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Local Excision Techniques for Rectal Cancer After Neoadjuvant Chemoradiotherapy: What Are We Doing?

Smith, Fraser McLean M.D., F.R.C.S.I.; Ahad, Abdul M.R.C.S.; Perez, Rodrigo Oliva M.D.; Marks, John M.D.; Bujko, Krzysztof M.D.; Heald, Richard J. F.R.C.S.

doi: 10.1097/DCR.0000000000000749
Current Status

BACKGROUND: Recent evidence shows that the majority of rectal cancers demonstrate occult tumor scatter after neoadjuvant chemoradiotherapy that can extend for several centimeters under adjacent normal-appearing mucosa beside the residual mucosal abnormality or scar.

OBJECTIVE: This systematic review aimed to determine all of the published selection criteria and technical descriptions for local excision to date with regard to this phenomenon.

DATA SOURCES: PubMed, MEDLINE, and Embase were searched using the following key words: rectal cancer, local excision, radiotherapy, and neoadjuvant.

STUDY SELECTION: Studies that assessed local excision of rectal cancer after neoadjuvant chemoradiotherapy were included. Duplicate series were excluded from final analysis.

INTERVENTION: All of the data points were tabulated and analyzed using Microsoft Excel.

MAIN OUTCOME MEASURES: Criteria for patient selection, surgical technique, clinical restaging, pathologic assessment, and indications for completion surgery were analyzed.

RESULTS: After exclusions, data from 25 studies that in total evaluated local excision in 1001 patients were included. Compared with the single accepted technique of total mesorectal excision, described techniques for local excision after neoadjuvant therapy demonstrate significant variability in many critical technical issues, such as marking/tattooing original tumor margins before neoadjuvant therapy, using pretreatment tumor size/stage as exclusion criteria, and specifically stating lateral excision margins. Where detailed, the majority of local recurrences occurred in patients with clear pathological margins, yet significant variation existed for pathological assessment and reporting, with few studies detailing R status and some not reporting margin status at all. Significant variability also existed for adverse tumor features that mandated completion surgery, and, importantly, many series describe patients refusing completion surgery where indicated.

LIMITATIONS: We were unable to perform meta-analysis because studies lacked sufficient methodologic homogeneity to synthesize.

CONCLUSIONS: The observations from this study prompt additional study, standardization of technique, and cautious use of local excision of rectal cancer in the setting of neoadjuvant chemoradiotherapy.

1 Department of Surgery, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom

2 Epsom and St Helier University Hospitals National Health Service Trust, London, United Kingdom

3 Angelita and Joaquim Gama Institute and School of Medicine, University of São Paulo, São Paulo, Brazil

4 Marks Colorectal Associates, Lankenau Hospital, Philadelphia, Pennsylvania, USA

5 Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

6 Pelican Cancer Centre, Basingstoke, United Kingdom

Financial Disclosure: None reported.

Correspondence: Fraser McLean Smith, M.D., F.R.C.S.I., Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool L7 8XP, United Kingdom. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons