title: Determining the need for radical surgery in patients with T1 rectal cancer.
abstract: OBJECTIVE
  In the era of modern preoperative staging of patients with rectal cancer, lymph node metastases can be reliably predicted by the histological features of the tumor and preoperative imaging. Local resection can then be safely offered to the patients who are at low risk of having malignant lymph nodes.
  
  
  METHODS
  We reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1N0 or T2N0 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients.
  
  
  METHODS
  Tertiary care referral center.
  
  
  METHODS
  Patients with preoperative imaging suggestive of T1N0 or T2N0 rectal cancer.
  
  
  METHODS
  To evaluate different clinical and pathologic tumor features as predictors of positive lymph nodes in T1 and T2 rectal cancers with negative radiographic nodes.
  
  
  BACKGROUND
  Local resection of T1 and T2 rectal cancer results in lower morbidity compared with radical resection. However, recurrence rates after local resection are higher, likely owing to unresected nodal metastasis. Reports on predictors of lymph node metastasis remain inconsistent in the literature. Although local resection may be appropriate for some rectal cancers, selection criteria remain unclear.
  
  
  RESULTS
  Despite indications of negative nodes on radiographic examination, 4 of 35 patients with T1 disease (11%) and 13 of 47 with T2 disease (28%) had positive nodes. On univariate analysis, the only significant predictor was depth of invasion: 24 of 65 patients with negative nodes (37%) vs 13 of 17 patients with positive nodes (76%) had tumors invading the lower third of the submucosa and beyond (P = .02). On logistic regression analysis accounting for depth of invasion (lower third of the submucosa and beyond), size, distance from anal verge, differentiation, and lymphovascular and small-vessel invasion, only depth of invasion remained a significant predictor.
  
  
  CONCLUSIONS
  In all, 89% of patients with T1 disease (31 of 35) and 72% of those with T2 disease (34 of 47) underwent unnecessary radical resection. Endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography, for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. Thus, local resection for T2 rectal cancer is not justified. Local resection should be offered only to patients with superficial T1 tumors who will adhere to aggressive postoperative surveillance.
authors.affiliation: Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
authors.forename: Harry M
authors.initials: HM
authors.lastname: Salinas
authors.forename: Abdulmetin
authors.initials: A
authors.lastname: Dursun
authors.forename: Coen L
authors.initials: CL
authors.lastname: Klos
authors.forename: Paul
authors.initials: P
authors.lastname: Shellito
authors.forename: Patricia
authors.initials: P
authors.lastname: Sylla
authors.forename: David
authors.initials: D
authors.lastname: Berger
authors.forename: Liliana
authors.initials: L
authors.lastname: Bordeianou
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology; D016015:Logistic Models; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis / Q000473:pathology*; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery; D009367:Neoplasm Staging; D011351:Proctoscopy; D011379:Prognosis; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D012007:Rectum / Q000473:pathology* / Q000601:surgery*; D016019:Survival Analysis; D019564:Unnecessary Procedures