Stellenwert der lokalchirurgischen Therapie beim Rektumkarzinom

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
• 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
• 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
• 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
• 6 Baron P L, Sigurdson E R. Local surgical treatment of rectal cancer.  Cancer Invest. 1995;  13 612-616
• 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
• 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
• 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
• 10 Billingham R P. Conservative treatment of rectal cancer. Extending the indications.  Cancer Supp. 1992;  70 1355-1363
• 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
• 12 Buess G F. Local surgery treatment of rectal cancer.  Eur J Cancer. 1995;  31 1233-1237
• 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
• 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
• 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
• 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
• 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
• 18 Graham R A, Garnsey L, Jessup L M. Local excision of rectal cancer.  Am J Surg. 1990;  160 306-312
• 19 Grinnell R S. Distal intramural spread of carcinoma of the rectum and rectosigmoid.  Surg Gynecol Obstet. 1954;  99 421-430
• 20 Heintz A, Braunstein S, Menke H. Lokale Exzision von Rektumtumoren. Indikationen, präoperative Diagnostik, Operationstechnik und Ergebnisse.  Med Klin. 1992;  5 236-241
• 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
• 22 Hermanek P, Gall F P. Early (microinvasive) colorectal carcinoma.  Int J colorect Dis. 1986;  1 79-84
• 23 Klingensmith W, Dickinson W E, Hays R S. Posterior resection of selected rectal tumors.  Arch Surg. 1975;  110 647-651
• 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
• 25 Kim D G, Madoff R D. Transanal treatment of rectal cancer: ablative methods and open resection.  Semin Surg Oncol. 1998;  15 101-113
• 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
• 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
• 28 Mason A Y. Trans-sphincteric surgery of the rectum.  Prog Surg. 1974;  13 66-97
• 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
• 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
• 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
• 32 Ng A K, Recht A, Busse P M. Sphincter preservation therapy for distal rectal carcinoma.  Cancer. 1996;  79 671-683
• 33 Nivatvongs S. Surgical management of early colorectal cancer.  World J Surg. 2000;  24 1052-1055
• 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
• 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
• 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
• 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
• 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
• 39 Said S, Müller J M. TEM-minimal invasive therapy of rectal cancer?.  Swiss Surg. 1997;  3 248-254
• 40 Sengupta S, Tjandra J J. Local excision of rectal cancer: what is the evidence?.  Dis Colon rectum. 2001;  44 1345-1361
• 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
• 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
• 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
• 44 Thompson B W, Tucker W E. Transsphincteric approach to lesions of the rectum.  South Med J. 1987;  80 41-43
• 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
• 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
• 48 Willett C G. Local excision followed by postoperative radiation therapy.  Semin Radiat Oncol. 1998;  8 24-29
• 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
• 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
• 51 Wilson S E, Gordan H E. Excision of rectal lesions by the Kraske approach.  Am J Surg. 1969;  118 213-217
• 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