title: Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome.
abstract: OBJECTIVE
  The outcome of patients undergoing full-thickness local excision (LE) of rectal cancers may be compromised if poor prognostic features are found in the LE specimen. Our aim was to evaluate the long-term results of radical surgery performed after LE because poor prognostic factors are identified.
  
  
  METHODS
  Patients with biopsy-proven rectal cancer who had undergone full-thickness LE followed by radical surgery because of a positive margin, T stage ≥3, lymphovascular invasion, poor differentiation or mucinous histology were identified from a prospective database. Their records were retrospectively reviewed and follow up was updated.
  
  
  RESULTS
  Between 1995 and 2003, 17 patients underwent LE followed by radical surgery because of poor prognostic features. Combined chemotherapy and radiotherapy was given to 11 (65%) patients before radical surgery. Patients underwent radical surgery after a median of 14 (range: 0-40) weeks from LE. Nine underwent a low anterior resection and eight an abdominoperineal resection. At the time of radical surgery, residual disease was found in six (35%) patients (in lymph nodes in three; intramural in two; and both lymph nodes and intramural in one). Four of the patients with residual disease had undergone neoadjuvant therapy before radical surgery. The mean follow up was 110 (95% CI: 92-129) months. Recurrence-free survival at 10 years was 88%. There was no case of local recurrence, and two patients died of metastatic disease.
  
  
  CONCLUSIONS
  In this series patients who underwent early radical surgery because of poor prognostic features found at LE had good overall and cancer-specific long-term survival. Even after neoadjuvant therapy, more than a third of patients had residual disease at the time of radical surgery. We therefore recommend radical surgery with neoadjuvant therapy when poor prognostic features are found at LE.
authors.affiliation: Division of Colorectal Surgery, University of Texas Medical School, Houston, Texas, USA.
authors.forename: G
authors.initials: G
authors.lastname: Gagliardi
authors.forename: T R
authors.initials: TR
authors.lastname: Newton
authors.forename: H R
authors.initials: HR
authors.lastname: Bailey
mesh_terms: D002288:Adenocarcinoma, Mucinous / Q000601:surgery*; D000328:Adult; D000368:Aged; D001808:Blood Vessels / Q000473:pathology; D059186:Chemoradiotherapy, Adjuvant; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D042601:Lymphatic Vessels / Q000473:pathology; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D012004:Rectal Neoplasms / Q000473:pathology* / Q000601:surgery* / Q000628:therapy; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Rectal cancer; local excision; neoadjuvant therapy; radiotherapy; transanal excision