Locally Excised T1 Rectal Cancers: Need for Specialized Surveillance Protocols

BACKGROUND: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision. OBJECTIVE: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer. DESIGN: This study is a retrospective review. SETTINGS: Patients treated by University of Minnesota-affiliated physicians, 1994 to 2014, were selected. PATIENTS: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up. INTERVENTIONS: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence. RESULTS: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed. LIMITATIONS: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available. CONCLUSIONS: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979. CANCERES RECTALES T1 EXTIRPADOS LOCALMENTE: NECESIDAD DE PROTOCOLOS DE VIGILANCIA ESPECIALIZADOS: La escision local de los canceres de recto T1 ayuda a evitar una cirugia mayor, pero la frecuencia y el patron de recurrencia pueden ser diferentes a los de los pacientes tratados con escision mesorectal total. OBJETIVO: Evaluar el patron, la frecuencia y los medios de deteccion de recidiva en una cohorte de pacientes con cancer de recto T1 extirpado localmente bajo un regimen de seguimiento especifico. DISENO:: Revision retrospectiva. AJUSTES: Pacientes tratados por hospitales afiliados a la Universidad de Minnesota, 1994-2014 PACIENTES:: Pacientes con cancer de recto T1 confirmado patologicamente, tratados con escision local y con al menos 3 meses de seguimiento. INTERVENCIONES: Extirpacion local del cancer de recto T1, con un seguimiento multimodal incluyendo examen fisico, antigeno carcinoembrionario (CEA), TC, ecografia endorrectal y proctoscopia. PRINCIPALES MEDIDAS DE RESULTADO: Presencia de recurrencia local y medios de deteccion de recurrencia. RESULTADOS: Un total de 114 pacientes cumplieron con los criterios de inclusion. La tasa de recurrencia local fue del 11,4% y la tasa de metastasis a distancia fue del 2,6%. Las recurrencias locales se presentaron hasta 7 anos despues de la escision local. De los 14 pacientes con recurrencia, 10 de las recurrencias se detectaron por ultrasonido y / o proctoscopia en lugar de los metodos tradicionales de vigilancia, como CEA o imagenes. De estos diez pacientes, cuatro tenian una cicatriz aparente en la proctoscopia y el ultrasonido solo revelo hallazgos relacionados con tumores malignos recurrentes. En una ecografia se demostro malignidad recurrente, pero no se realizo proctoscopia concurrente. LIMITACIONES: Revision retrospectiva; estudio realizado en una institucion donde se dispone facilmente de ultrasonido endorrectal CONCLUSIONES:: Los canceres de recto T1 extirpados localmente deben tener una vigilancia especifica distinta de los canceres en etapa I tratados con TME. El regimen de seguimiento debera de extender mas alla del intervalo tradicional de 5 anos de vigilancia. Tambien se debe considerar la posibilidad de realizar una ecografia o una resonancia magnetica (IRM) ademas de la sigmoidoscopia flexible o la proctoscopia. Vea el Resumen del video en http://links.lww.com/DCR/A979.