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Zentralbl Chir 2003; 128(12 ): 1066-1074
DOI: 10.1055/s-2003-44846
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© Georg Thieme Verlag Stuttgart · New York

Stellenwert der lokalchirurgischen Therapie beim Rektumkarzinom

Eine LiteraturanalyseValue of Local Surgical Therapy for Rectal CancerA Literature AnalysisT. Borschitz1 , T. Junginger1
  • 1Klinik und Poliklinik der Allgemein- und Abdominalchirurgie Universitätsklinik der Mainz
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Publication History

Publication Date:
29 January 2004 (online)

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Zusammenfassung

Hintergrund: Die lokale Exzision ist als kurative Therapieform beim pT1 Rektumkarzinom anerkannt, wohingegen die Indikation bei pT2 Tumoren nicht geklärt ist. Ferner ist der Wert prognostisch histologischer Bewertungskriterien und der Einfluss adjuvanter und neoadjuvanter Maßnahmen offen.
Methodik: In unserer Literaturrecherche gingen Untersuchungen ab dem Erscheinungsdatum 1990 zur lokalen Exzision mit wenigstens 30 Patienten und einer Nachbeobachtungsdauer von mindestens 24 Monaten, mit und ohne adjuvanter oder neoadjuvanter Therapie, ein. Wir analysierten die Beurteilungskriterien Lokalrezidiv, Überlebensrate, Tumorgrading sowie die Beschaffenheit der Absetzungsränder.
Ergebnisse: Nach R0-Resektion sind bei „low grade” Tumoren der pT1-Kategorie Lokalrezidivwerte im Mittel von 8 % und im Stadium pT2 im Mittel von 22 % zu erwarten. Schlecht differenzierte pT1-Tumore weisen nach R0-Resektion über 18 % und nach R1-Resektion, trotz adjuvanter Radio-(Chemo)-Therapie, bis zu 26 % Rezidive auf. Bei pT 2 „high grade” Tumoren sind im Mittel 50 % und für pT2 „low grade” Tumoren nach R0-Resektion und adjuvanter Radiatio im Mittel 6 % Lokalrezidive zu erwarten. Adjuvante Maßnahmen können bei pT2-Tumoren nach R1-Resektion das Lokalrezidivrisiko nicht unter 20 % senken.
Diskussion: Die lokale R0-Exzision stellt bei pT 1 „low grade” Tumoren eine adäquate Therapieform dar. Künftige prospektive Studien sind notwendig um zu klären, ob die adjuvante Radio-(Chemo)-Therapie bei pT2 „low grade” Tumoren nach R0-Resektion eine kurative Therapieoption darstellt.

Abstract

Background: Local excision of pT1 rectal cancer is recognized as curative treatment, whereas the indication is not clarified for pT2-tumours. In addition the prognostic histological analysis criteria and the influence of adjuvant and neoadjuvant measures are open.
Method: Starting form the publication date 1990 investigations on the local excision, with and without adjuvant or neoadjuvant therapy, were included in our literature search and analysed if they comprised at least 30 patients and a follow up of at least 24 months. We studied the assessment criteria local recurrence, survival rate, histological grading, and the conditions of resection margins.
Results: After complete resection of “low grade” rectal cancers local recurrences are expected for the pT1-category of mean 8 % and for pT2-tumours of mean 22 %. Poor differentiated pT1-tumours exhibit after complete resection over 18 % and after incomplete, despite adjuvant radio (chemo)-therapy, up to 26 % recurrences. For pT2 “high grade” tumours in mean 50 % local recurrences and for pT2 “low grade” tumours after complete resection and adjuvant irradiation in mean 6 % have to be expected. Adjuvant measures cannot lower the local recurrence rate for pT2 tumours after incomplete resection under 20 %.
Conclusion: Local excision with clear margins represents for pT1 “low grade” cancer an adequate therapy. Further prospective investigations are necessary to clarify whether adjuvant radio (chemo)-therapy represents a curative therapeutic option for pT 2 “low grade” tumours after complete resection.

Schlüsselwörter

Rektumkarzinom - transanale Resektion - lokale Exzision - adjuvante Therapie - neoadjuvante Therapie

Key words

Rectal cancer - transanal resection - local excision - adjuvant therapy - neoadjuvant therapy

Literatur

  • 1 Ambacher T, Kasperk R, Schumpelick V. Tumor recurrence after transanal excision of stage I rectal cancer in comparison with radical resection.  Chirurg. 1990;  70 1469-1474
    PubMedSearch in Google Scholar
  • 2 American Joint Committee on Cancer .Manual for staging cancer. 3rd ed. Lippincott JB, Philadelphia 1988; 75-80
  • 3 Arnaud J P, Eloy M R, Clendinnen G, Adloff M. The posterior approach for villous tumors of the rectum: report of eleven cases.  Am J Surg. 1978;  136 273-275
    CrossrefPubMedSearch in Google Scholar
  • 4 Bailey H R, Huval W V, Max E, Smith K W, Butts D R, Zamora L F. Local excision of carcinoma of the rectum for cure.  Surgery. 1992;  111 555-561
    PubMedSearch in Google Scholar
  • 5 Baron P L, Enker W E, Zakowski M E, Urmacher C. Immediate vs. salvage resection after local treatment for early rectal cancer.  Dis Colon Rectum. 1995;  38 177-181
    PubMedSearch in Google Scholar
  • 6 Baron P L, Sigurdson E R. Local surgical treatment of rectal cancer.  Cancer Invest. 1995;  13 612-616
    PubMedSearch in Google Scholar
  • 7 Benoist S, Panis Y, Martella L, Nemeth J, Hautefeuille P, Valleur P. Local excision of rectal cancer for cure: should we always regard rigid pathologic criteria?.  Hepato-Gastroenterology. 1998;  45 1546-1551
    PubMedSearch in Google Scholar
  • 8 Benson R, Wong C S, Cummings B J, Brierley J, Catton P, Ringashi J, Abdolell M. Local excision and postoperative radiotherapy for distal rectal cancer.  Int J Radiat Oncol Biol Phys. 2001;  50 1309-1316
    CrossrefPubMedSearch in Google Scholar
  • 9 Bleday R, Breen E, Jessup J M, Burgess A, Sentovich S M, Steel G D. Prospective evaluation of local excision for small rectal cancers.  Dis Colon Rectum. 1997;  40 388-392
    PubMedSearch in Google Scholar
  • 10 Billingham R P. Conservative treatment of rectal cancer. Extending the indications.  Cancer Supp. 1992;  70 1355-1363
    PubMedSearch in Google Scholar
  • 11 Bouvet M, Milas M, Geoffrey G, Giacco G G, Cleary K R, Janjan N A, Skibber J M. Predictors of recurrence after local excision and postoperative chemoradiation therapy of adenocarcinoma of the rectum.  Ann Surg Oncol. 1999;  6 26-32
    CrossrefPubMedSearch in Google Scholar
  • 12 Buess G F. Local surgery treatment of rectal cancer.  Eur J Cancer. 1995;  31 1233-1237
    CrossrefPubMedSearch in Google Scholar
  • 13 Chakravarti A, Compton C C, Shellito P C, Wood W C, Landry J, Machuta S R, Kaufman D, Ancukiewicz M, Willett C G. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation.  Ann Surg. 1999;  230 49-54
    CrossrefPubMedSearch in Google Scholar
  • 14 Coco C, Magistrelli P, Granone P, Roncolini G, Picciocchi A. Conservative surgery for early cancer of the rectum.  Dis Colon Rectum. 1992;  35 131-136
    PubMedSearch in Google Scholar
  • 15 Faivre J, Chaume J -C, Pigot F, Trojani M, Bonichon F. Transanal electroresection of small rectal cancer: a sole treatment?.  Dis Colon Rectum. 1996;  39 270-278
    PubMedSearch in Google Scholar
  • 16 Friel C M, Cromwell J W, Marra C, Madoff R D, Rothenberger D A, Garcia-Aguilar J. Salvage radical surgery after failed local excision for early rectal cancer.  Dis Colon Rectum. 2002;  45 875-879
    CrossrefPubMedSearch in Google Scholar
  • 17 Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff R D, Rothenberg D A. Local excision of rectal cancer without adjuvant therapy: a word of caution.  Ann Surg. 2000;  231 345-351
    CrossrefPubMedSearch in Google Scholar
  • 18 Graham R A, Garnsey L, Jessup L M. Local excision of rectal cancer.  Am J Surg. 1990;  160 306-312
    CrossrefPubMedSearch in Google Scholar
  • 19 Grinnell R S. Distal intramural spread of carcinoma of the rectum and rectosigmoid.  Surg Gynecol Obstet. 1954;  99 421-430
    PubMedSearch in Google Scholar
  • 20 Heintz A, Braunstein S, Menke H. Lokale Exzision von Rektumtumoren. Indikationen, präoperative Diagnostik, Operationstechnik und Ergebnisse.  Med Klin. 1992;  5 236-241
    PubMedSearch in Google Scholar
  • 21 Heintz A, Mörschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum.  Surg Endosc. 1998;  12 1145-1148
    CrossrefPubMedSearch in Google Scholar
  • 22 Hermanek P, Gall F P. Early (microinvasive) colorectal carcinoma.  Int J colorect Dis. 1986;  1 79-84
    CrossrefPubMedSearch in Google Scholar
  • 23 Klingensmith W, Dickinson W E, Hays R S. Posterior resection of selected rectal tumors.  Arch Surg. 1975;  110 647-651
    PubMedSearch in Google Scholar
  • 24 Kim C J, Yeatman T J, Coppola D, Trotti A, Williams B, Barthel J S, Dinwoodie W, Karl R C, Marcet J. Local excision of T2 and T3 rectal cancer after downstaging chemoradiation.  Ann Surg. 2001;  234 352-359
    CrossrefPubMedSearch in Google Scholar
  • 25 Kim D G, Madoff R D. Transanal treatment of rectal cancer: ablative methods and open resection.  Semin Surg Oncol. 1998;  15 101-113
    CrossrefPubMedSearch in Google Scholar
  • 26 Lamont J P, McCarty T M, Digan R D, Jacobson R, Tulanon P, Lichliter W E. Should locally excised T1 rectal cancer receive adjuvant chemoradiation?.  Am J Surg. 2000;  180 402-406
    CrossrefPubMedSearch in Google Scholar
  • 27 Lezoche E, Guerrieri M, Paganini A M, Feliciotti F. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision.  World J Surg. 2002;  26 1170-1174
    CrossrefPubMedSearch in Google Scholar
  • 28 Mason A Y. Trans-sphincteric surgery of the rectum.  Prog Surg. 1974;  13 66-97
    PubMedSearch in Google Scholar
  • 29 Mellgren A, Sirivong P, Rothenberg D A, Madoff R D, Garcia-Aguilar J. Is local excision adequate therapy or rectal cancer?.  Dis Colon Rectum. 2000;  43 1064-1074
    CrossrefPubMedSearch in Google Scholar
  • 30 Mentges B, Buess G, Effinger G, Manncke K, Becker H D. Indications and results of local treatment of rectal cancer.  Br J Surg. 1997;  84 348-351
    CrossrefPubMedSearch in Google Scholar
  • 31 Minsky B D, Enker W E, Cohen A M, Lauwers G. Local excision and postoperative radiation therapy for rectal cancer.  Am J Clin Oncol. 1994;  17 411-416
    PubMedSearch in Google Scholar
  • 32 Ng A K, Recht A, Busse P M. Sphincter preservation therapy for distal rectal carcinoma.  Cancer. 1996;  79 671-683
    PubMedSearch in Google Scholar
  • 33 Nivatvongs S. Surgical management of early colorectal cancer.  World J Surg. 2000;  24 1052-1055
    CrossrefPubMedSearch in Google Scholar
  • 34 Oh C, Kark A E. The transsphincteric approach to mid and low rectal villous adenoma: anatomic basis of surgical treatment.  Ann Surg. 1972;  176 605-612
    PubMedSearch in Google Scholar
  • 35 Ota D M, Skibber J, Rich T A. Anderson cancer centre experience with local excision and multimodality therapy for rectal cancer.  Surg Oncol Clin North Am. 1992;  1 147-152
    PubMedSearch in Google Scholar
  • 36 Paty P B, Nash G M, Baron P, Zakowski M, Minsky B D, Blumberg D, Nathanson D R, Guillem J G, Enker W E, Cohen A M, Wong W D. Long-term results of local excision for rectal cancer.  Ann Surg. 2002;  236 522-530
    CrossrefPubMedSearch in Google Scholar
  • 37 Quer E A, Dahlin D C, Mayo C W. Retrograde intramural spread of carcinoma of the rectum and rectosigmoid: a microscopic study.  Surg Gynecol Obstet. 1953;  96 24-30
    PubMedSearch in Google Scholar
  • 38 Russell A H, Harris J, Rosenberg P J, Sause W T, Fisher B J, Hoffmann J P, Karybill W G, Byhardt R. Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89-02.  Int J Radiat Oncol Biol Phys. 2000;  46 313-322
    CrossrefPubMedSearch in Google Scholar
  • 39 Said S, Müller J M. TEM-minimal invasive therapy of rectal cancer?.  Swiss Surg. 1997;  3 248-254
    PubMedSearch in Google Scholar
  • 40 Sengupta S, Tjandra J J. Local excision of rectal cancer: what is the evidence?.  Dis Colon rectum. 2001;  44 1345-1361
    CrossrefPubMedSearch in Google Scholar
  • 41 Slisow W, Moesta K T, Schlag P M. Local excision of rectal cancer through windowed specula: long-term results.  Recent Result Cancer Res. 1998;  146 114-123
    PubMedSearch in Google Scholar
  • 42 Steel G D, Herndon J E, Bleday R, Russell A, Benson A, Hussain M, Burgess A, Tepper J E, Mayer R J. Sphincter-sparing treatment for distal rectal adenocarcinoma.  Ann Surg Oncol. 1999;  6 433-441
    CrossrefPubMedSearch in Google Scholar
  • 43 Taylor R H, Hay J H, Larsson S N. Transanal local excision of selected low rectal cancer.  Am J Surg. 1998;  175 360-363
    CrossrefPubMedSearch in Google Scholar
  • 44 Thompson B W, Tucker W E. Transsphincteric approach to lesions of the rectum.  South Med J. 1987;  80 41-43
    PubMedSearch in Google Scholar
  • 45 UICC .TNM Classification of malignant tumours. 3rd ed. In: Hermanek P, Scheibe O, Spiessl B, Wagner G (eds). Springer, Berlin, Heidelberg, New York, Tokio 1987
  • 46 Varma M G, Rogers S J, Schrock T R, Welton M L. Local excision of rectal cancer.  Arch Surg. 1999;  134 863-868
    PubMedSearch in Google Scholar
  • 47 Wagman R, Minsky B D, Cohen A M, Saltz L, Paty P B, Guillem J G. Conservative management of rectal cancer with local excision and postoperative adjuvant therapy.  Int J Radiat Oncol Biol Phys. 1999;  44 841-846
    CrossrefPubMedSearch in Google Scholar
  • 48 Willett C G. Local excision followed by postoperative radiation therapy.  Semin Radiat Oncol. 1998;  8 24-29
    PubMedSearch in Google Scholar
  • 49 Willett C G, Compton C C, Shellito P C, Efird J T. Selection factors for local excision or abdominoperineal resection of early stage rectal cancer.  Cancer. 1994;  73 2716-2720
    PubMedSearch in Google Scholar
  • 50 Williams N S, Dixon M F, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patient's survival.  Br J Surg. 1983;  70 150-154
    CrossrefPubMedSearch in Google Scholar
  • 51 Wilson S E, Gordan H E. Excision of rectal lesions by the Kraske approach.  Am J Surg. 1969;  118 213-217
    CrossrefPubMedSearch in Google Scholar
  • 52 Winde G, Nottberg H, Keller R, Schmid K W, Bünte H. Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs. anterior resection.  Dis Colon Rectum. 1996;  39 969-976
    CrossrefPubMedSearch in Google Scholar

Prof. Dr. med. T. Junginger

Univ.-Klinik für Allgemein- und Abdominalchirurgie

Langenbeckstraße 1

55101 Mainz