title: Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence.
abstract: BACKGROUND
  Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM.
  
  
  METHODS
  Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with "near" complete response to CRT (≤3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence.
  
  
  RESULTS
  A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53-100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %.
  
  
  CONCLUSIONS
  Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil. rodrigo.operez@gmail.com.|Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil. rodrigo.operez@gmail.com.|São Paulo Branch, Ludwig Institute for Cancer Research, São Paulo, Brazil. rodrigo.operez@gmail.com.
authors.forename: Rodrigo Oliva
authors.initials: RO
authors.lastname: Perez
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.|University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Angelita
authors.initials: A
authors.lastname: Habr-Gama
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.
authors.forename: Guilherme Pagin
authors.initials: GP
authors.lastname: São Julião
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.
authors.forename: Igor
authors.initials: I
authors.lastname: Proscurshim
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.
authors.forename: Laura Melina
authors.initials: LM
authors.lastname: Fernandez
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.|University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Rafael Ulysses
authors.initials: RU
authors.lastname: de Azevedo
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.
authors.forename: Bruna B
authors.initials: BB
authors.lastname: Vailati
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.|University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Felipe Alexandre
authors.initials: FA
authors.lastname: Fernandes
authors.affiliation: Angelita and Joaquim Gama Institute, São Paulo, Brazil.|University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Joaquim
authors.initials: J
authors.lastname: Gama-Rodrigues
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D059248:Chemoradiotherapy; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D011379:Prognosis; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D016879:Salvage Therapy; D015996:Survival Rate; D000067369:Transanal Endoscopic Microsurgery