Local excision of T2 and T3 rectal cancers after downstaging chemoradiation

Objective To evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been down-staged by preoper ative chemoradiation. Summary Background Data T2 and T3 cancers treated by local excision alone a re associated with unacceptably high recurrence rates. The authors hypothes ized that preoperative chemoradiation might downstage both T2 and T3 lesion s and significantly expand the indications for local excision. Methods Local excision was performed after preoperative chemoradiation on p atients with a complete clinical response or on patients who were either in eligible for or refused to undergo abdominoperineal resection. Local excisi on was approached transanally by removing full-thickness rectal wall and th e underlying mesorectum. Results From 1994 to 2000, 95 patients with rectal cancers underwent preope rative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44-90), underwent local excision. Pretreatment endoscopic ultrasound classi fications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic part ial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65% ) patients, respectively. Two of nine partial responders underwent immediat e abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6-77). The only recurrence was in a patient who refused to undergo ab dominoperineal resection after a partial response. There was one postoperat ive death from a stroke. This treatment was associated with a low rate of c omplications. Conclusion Local excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T 2 and T3 adenocarcinomas of the distal rectum who show a complete pathologi c response to preoperative chemoradiation.