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Original Article |
1
Clinic of General and Abdominal Surgery, Johannes Gutenberg-University Hospital, Mainz, Germany
2
Coordination Center for Clinical Trials, Johannes Gutenberg-University, Mainz, Germany
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First Department of Internal Medicine, Johannes Gutenberg-University Hospital, Mainz, Germany
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Clinic of Radiation Oncology and Radiation Therapy, Johannes Gutenberg-University Hospital, Mainz, Germany
Correspondence: Address correspondence and reprint requests to: Thomas Borschitz, MD; E-mail: borschit{at}mail.uni-mainz.de
Background: Local excision (LE) of T1 low-risk (G1–2/L0/V0) rectal cancer is an established approach with local recurrence (LR) rates of ~5%, whereas LE of 
T2 high-risk tumors or inadequate resections (R1/RX/R 
1 mm) showed high recurrence rates. Because of the favorable results after neoadjuvant chemoradiotherapy (nCRT) and radical surgery of disease that completely responds (CR) with almost absent LR even of T3–4 tumors, an extension of the indication for LE is controversially discussed, and therefore, we assessed this therapeutic option.
Methods: Including our own data, seven studies about LE after nCRT of cT2–3 tumors (n = 237) were analyzed after a PubMed search for cT categories, tumor height, nCRT regimens, schedule and technique of surgery, complications, freedom of stoma, response rates (ypT0–3), length of follow-up, LR, and metastases.
Results: Subgroups that we formed (retrospective vs. prospective/retractor vs. transanal endoscopic microsurgery) showed differences in the distribution of cT categories. However, neither the studies we considered nor our own patients showed LR in CR (ypT0). In addition, patients with ypT1 tumor consistently showed low LR rates of 2% (range, 0%–6%), whereas in ypT2 findings, less favorable LR rates of 6% to 20% were observed, and disease that did not respond to therapy (ypT3) displayed LR rates in up to 42%.
Conclusions: Despite of a highly selected patient collective, an extended indication for LE of cT2–3 rectal cancer after nCRT may be considered. The strongest prognostic factors were a CR (ypT0) or responses on submucosa level (ypT1). These first results will have to be confirmed in a prospective trial with an appropriate sample size to ensure high statistical power.
Key Words: Rectal cancer • Neoadjuvant chemoradiation • Local excision • Tumor response
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