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Local Excision
Symposium on Surgical Oncology
local Excision
Michael R. Deddish, M.D. *
Probably the least appreciated fact in the diagnosis and treatment of precancerous and early malignant lesions of the low sigmoid and rectum is that they are superficial in origin and limited to the mucosal glands. Furthermore, they may be present from 5 to 20 years before becoming invasive cancer. In this early stage, cancer may be cured by local excision. After this type of treatment, a strict follow-up is mandatory. This latter discipline is necessary because some marginal residual tissue (transitional zone) may be left after excision. Our study of the natural history of these mucosal changes shows that other similar lesions may occur on the adjacent mucosa. Early hyperplastic areas have been followed at regular inspection intervals and it has been noted that excrescences on the mucosa of approximately 3 mm represent benign hyperplasia while those of 6+ mm may show atypia and later, in situ carcinoma or invasive carcinoma. In other words, cancers of the lower intestinal tract are generally preceded by precancerous lesions. So-called cancer de novo is exceedingly rare and difficult to substantiate. Something should be said concerning multiple and deep biopsies of sessile mucosal lesions. Experience has shown that when superficial cancer is present it may be implanted into the underlying muscle by a punch biopsy whereas complete initial removal of a suspicious lesion by means of the cautery snare or surgical excision will allow the pathologist to determine the extent of malignant change if any is present, and to determine the margin of excision. Other clinical complications should be mentioned briefly, as secondary to multiple biopsies. When referred for consultation and/or for definitive treatment, clinical evaluation is usually difficult because of secondary infection. Massive hemorrhage may also occur, and when given transfusions the patient may have his problem further complicated by various reactions, including hepatitis. A random biopsy may not provide diagnostic tissue. In this discourse it should be sufficient to say that despite the pro and con arguments as to the existence of precancerous lesions, if early cancers are removed totally, lower colon and rectal cancer should be cured more frequently. ':'Attending Surgeon, Rectum and Colon Service, Memorial Sloan-Kettering Cancer Center, New York, New York
Surgical Clinics of North Americu- Vol. 54, No.4, August 1974
877
878
MICHAEL
R.
DEDDISH
Despite different names assigned to mucosal lesions of the lower intestine and rectum, they are the same histologically and their clinical appearance is greatly influenced by their environment. They are usually sessile in the rectum or, at most, have a short pedicle. In the more active peristaltic areas such as the rectosigmoid they become pedunculated quite early. A biopsy taken from the apex of any pedunculated lesion may present a real diagnostic problem to the pathologist. The removal of the entire lesion with a margin of essentially normal tissue is necessary to determine invasion of the deeper structures. The techniques of wide local excision are relatively simple and should preserve normal bowel control in most instances. Low rectal tumors may be approached more easily by posterior sphincterotomy and elliptical full thickness excision of the area bearing the tumor. For tumors in the midrectum, the approach may either be transcoccygeal posteriorly or through the perineal body anteriorly. The rectal wall is readily dissected from the presacral fascia, the prostatic bed, or the posterior vaginal wall. (Again, a full thickness excision of the rectal wall is required and closure is in the transverse plane. An adjuvant posterior sphincterotomy facilitates healing with fewer fistulae, which are only temporary.) Mucosal lesions at the rectosigmoid and above are best removed by means of the cautery snare. Snare wires size 30 monofilament stainless steel are most selective and have produced the least complications. It is not necessary to remove an entire sessile lesion by a single grasp of the snare. Also, complete removal does require good lighting, and the clinically normal appearing marginal mucosa should be well fulgurated for at least 5 to 7 mm. This same technique applies for short pedicled tumors. Submitting all of the excised tissue with adequate description of the lesion and the procedure will aid the pathologist substantially in determining the degree of involvement. If tumor has been transected, either additional local excision or radical extirpation must be done. (Again, a strict follow-up of the area treated is mandatory, which will also rule out other neoplasms which may develop in the lower intes tinal tract.) Preoperative x-radiation therapy in this series of local excisions has Table 1.
Follow-up of 86 Patients with Invasive Carcinoma of the LoweT Intestinal Tract Treated by Local Excision 5
Total number exposed to risk Alive at end of interval Treated without clinical evidence of disease since initial treatment after treatment for reappearance of disease Died durin g interval of disease of other cause Lost to follow-up
YEARS
10
YEARS
86
71
71
63
69
59
2
4
14
6
5 9
6 2
LOCAL EXCISION
Table 2.
879
Survival in 86 Patients with Invasive Carcinoma of the Lower Intestinal Tract Treated by Local Excision
5 year survival: 71/85 or 83,5 per cent 10 year survival: 63/85 or 72,2 per cent 15 patients alive and well at 10 to 15 years 15 patients alive and well at 15 to 24 years 75 per cent died of other causes: 5 of other neoplasms 10 of heart disease
been used in small doses with several ideas in mind. First, since many of these were re-excisions, x-ray therapy of approximately 2000 rads was used to clear up the local infection. Second, a localization has been observed in infected or ulcerated lesions, and third, a recurrence of benign mucosal lesions has been noted to cease, particularly in a few papillary adenomas. Local excision should not be done for at least 2 weeks after the completion of x-radiation. This will allow sufficient interval for cell damage within the tumor, and possibly lessen local implantation at time of excision. Finally, a few malignant adenocarcinomas have disappeared completely with this small dosage of x-radiation. (Needless to say, a strict follow-up is mandatory in such patients.) An analysis of 86 invasive cancers treated by local excision with subsequent follow-up is presented in Tables 1 and 2, as determined by the Direct Method for Reporting Cancer Survival and End Results. Discussion Local excision of malignant mucosal lesions has to be a highly selective procedure, requiring knowledge of the natural history of the disease and clinical judgment before utilizing such treatment. These statistics represent what has been learned by the removal of several thousands of polyps containing foci of cancer. The structure of these lesions has been studied by the same staff of the Department of Pathology at the Memorial Cancer Center. Local excision is not generally recommended as a curative procedure for invasive cancer. However, these cases are being reported to supplement the standard radical excisions of cancer as originally described by Miles' in 1908. Later anterior resection was popularized by Dixon3 for upper rectal and distal sigmoid cancers. (In general practice the radical surgical procedures still produce t.pe better cure rates.) Many local techniques have been described without regard to accurate pathologic studies or the gentle handling of tissue-bearing cancer. Such techniques and results will never be accurately evaluated and the procedures themselves can hardly be classified as surgical. Local excision of the lower bowel mucosa or bowel wall containing a superficial mucosal cancer or a pedunculated polyp showing an invasive disease may be utilized in highly selected instances, such as extremely poor operative risks, varied patient disabilities, and some cases of refusal to undergo radical surgery. The tissue so removed should be studied adequately and a strict follow-up is mandatory. When a routine local excision of a lower intestinal lesion containing invasive cancer is found, consulta-
880
MICHAEL
R.
DEDDISH
tion with the pathologist usually determines one's management of the problem. This series is being presented because it pretty well approximates the cure rates of the radical treatment of Dukes' A, and many Dukes' B, lesions. (Strict follow-up and clinical evaluation for possible residual disease cannot be emphasized too strongly because these observations usually determine the end result.) It is also interesting to note that only 5 patients in this series died of their disease during the 1 to 5 year interval, and for the 5 to 10 year period, 5 patients developed other neoplasms and 10 patients died of heart disease. Conclusions 1. Local excision may be utilized in selected invasive rectal and colon cancers. 2. Survival rates are reported in 86 patients and are comparable to radical excision of early invasive cancer of the distal colon and rectum. 3. The diligent study of the excised specimen, the clinical evaluation of the lesion preoperatively, and a strict follow-up regimen are mandatory. 4. The 5-year survival rate for local excision is 83.5 per cent. 5. The IO-year survival rate is 72.2 per cent. 6. Seventy-five per cent of the deaths during the first IO-year interval were due to causes other than the original disease.
REFERENCES 1. Binkley, G. E., Sunderland, D. A., and Miller, C. J.: Treatment of papillary adenomas of the
rectum. New York State J. Med., 49: 1949. 2. Binkley, G. E., Sunderland, D. A., Miller, C. J., Stearns, M., Jr., and Deddish, M. R.: Carcinoma arising in adenomas of the colon and rectum. J.A.M.A., 148:1465-1469, 1952. 3. Dixon, C. F.: Surgical removal of lesions occurring in the sigmoid and rectosigmoid. Amer. J. Surg., 46: 12, 1939. 4. Miles, W. E.: A method of performing abdominoperineal excision for carcinoma of the rec· tum and terminal portion of the pelvic colon. Lancet, 2:812,1908. Memorial Sloan-Kettering Cancer Center 1275 York Avenue New York, New York 10021
local Excision
Michael R. Deddish, M.D. *
Probably the least appreciated fact in the diagnosis and treatment of precancerous and early malignant lesions of the low sigmoid and rectum is that they are superficial in origin and limited to the mucosal glands. Furthermore, they may be present from 5 to 20 years before becoming invasive cancer. In this early stage, cancer may be cured by local excision. After this type of treatment, a strict follow-up is mandatory. This latter discipline is necessary because some marginal residual tissue (transitional zone) may be left after excision. Our study of the natural history of these mucosal changes shows that other similar lesions may occur on the adjacent mucosa. Early hyperplastic areas have been followed at regular inspection intervals and it has been noted that excrescences on the mucosa of approximately 3 mm represent benign hyperplasia while those of 6+ mm may show atypia and later, in situ carcinoma or invasive carcinoma. In other words, cancers of the lower intestinal tract are generally preceded by precancerous lesions. So-called cancer de novo is exceedingly rare and difficult to substantiate. Something should be said concerning multiple and deep biopsies of sessile mucosal lesions. Experience has shown that when superficial cancer is present it may be implanted into the underlying muscle by a punch biopsy whereas complete initial removal of a suspicious lesion by means of the cautery snare or surgical excision will allow the pathologist to determine the extent of malignant change if any is present, and to determine the margin of excision. Other clinical complications should be mentioned briefly, as secondary to multiple biopsies. When referred for consultation and/or for definitive treatment, clinical evaluation is usually difficult because of secondary infection. Massive hemorrhage may also occur, and when given transfusions the patient may have his problem further complicated by various reactions, including hepatitis. A random biopsy may not provide diagnostic tissue. In this discourse it should be sufficient to say that despite the pro and con arguments as to the existence of precancerous lesions, if early cancers are removed totally, lower colon and rectal cancer should be cured more frequently. ':'Attending Surgeon, Rectum and Colon Service, Memorial Sloan-Kettering Cancer Center, New York, New York
Surgical Clinics of North Americu- Vol. 54, No.4, August 1974
877
878
MICHAEL
R.
DEDDISH
Despite different names assigned to mucosal lesions of the lower intestine and rectum, they are the same histologically and their clinical appearance is greatly influenced by their environment. They are usually sessile in the rectum or, at most, have a short pedicle. In the more active peristaltic areas such as the rectosigmoid they become pedunculated quite early. A biopsy taken from the apex of any pedunculated lesion may present a real diagnostic problem to the pathologist. The removal of the entire lesion with a margin of essentially normal tissue is necessary to determine invasion of the deeper structures. The techniques of wide local excision are relatively simple and should preserve normal bowel control in most instances. Low rectal tumors may be approached more easily by posterior sphincterotomy and elliptical full thickness excision of the area bearing the tumor. For tumors in the midrectum, the approach may either be transcoccygeal posteriorly or through the perineal body anteriorly. The rectal wall is readily dissected from the presacral fascia, the prostatic bed, or the posterior vaginal wall. (Again, a full thickness excision of the rectal wall is required and closure is in the transverse plane. An adjuvant posterior sphincterotomy facilitates healing with fewer fistulae, which are only temporary.) Mucosal lesions at the rectosigmoid and above are best removed by means of the cautery snare. Snare wires size 30 monofilament stainless steel are most selective and have produced the least complications. It is not necessary to remove an entire sessile lesion by a single grasp of the snare. Also, complete removal does require good lighting, and the clinically normal appearing marginal mucosa should be well fulgurated for at least 5 to 7 mm. This same technique applies for short pedicled tumors. Submitting all of the excised tissue with adequate description of the lesion and the procedure will aid the pathologist substantially in determining the degree of involvement. If tumor has been transected, either additional local excision or radical extirpation must be done. (Again, a strict follow-up of the area treated is mandatory, which will also rule out other neoplasms which may develop in the lower intes tinal tract.) Preoperative x-radiation therapy in this series of local excisions has Table 1.
Follow-up of 86 Patients with Invasive Carcinoma of the LoweT Intestinal Tract Treated by Local Excision 5
Total number exposed to risk Alive at end of interval Treated without clinical evidence of disease since initial treatment after treatment for reappearance of disease Died durin g interval of disease of other cause Lost to follow-up
YEARS
10
YEARS
86
71
71
63
69
59
2
4
14
6
5 9
6 2
LOCAL EXCISION
Table 2.
879
Survival in 86 Patients with Invasive Carcinoma of the Lower Intestinal Tract Treated by Local Excision
5 year survival: 71/85 or 83,5 per cent 10 year survival: 63/85 or 72,2 per cent 15 patients alive and well at 10 to 15 years 15 patients alive and well at 15 to 24 years 75 per cent died of other causes: 5 of other neoplasms 10 of heart disease
been used in small doses with several ideas in mind. First, since many of these were re-excisions, x-ray therapy of approximately 2000 rads was used to clear up the local infection. Second, a localization has been observed in infected or ulcerated lesions, and third, a recurrence of benign mucosal lesions has been noted to cease, particularly in a few papillary adenomas. Local excision should not be done for at least 2 weeks after the completion of x-radiation. This will allow sufficient interval for cell damage within the tumor, and possibly lessen local implantation at time of excision. Finally, a few malignant adenocarcinomas have disappeared completely with this small dosage of x-radiation. (Needless to say, a strict follow-up is mandatory in such patients.) An analysis of 86 invasive cancers treated by local excision with subsequent follow-up is presented in Tables 1 and 2, as determined by the Direct Method for Reporting Cancer Survival and End Results. Discussion Local excision of malignant mucosal lesions has to be a highly selective procedure, requiring knowledge of the natural history of the disease and clinical judgment before utilizing such treatment. These statistics represent what has been learned by the removal of several thousands of polyps containing foci of cancer. The structure of these lesions has been studied by the same staff of the Department of Pathology at the Memorial Cancer Center. Local excision is not generally recommended as a curative procedure for invasive cancer. However, these cases are being reported to supplement the standard radical excisions of cancer as originally described by Miles' in 1908. Later anterior resection was popularized by Dixon3 for upper rectal and distal sigmoid cancers. (In general practice the radical surgical procedures still produce t.pe better cure rates.) Many local techniques have been described without regard to accurate pathologic studies or the gentle handling of tissue-bearing cancer. Such techniques and results will never be accurately evaluated and the procedures themselves can hardly be classified as surgical. Local excision of the lower bowel mucosa or bowel wall containing a superficial mucosal cancer or a pedunculated polyp showing an invasive disease may be utilized in highly selected instances, such as extremely poor operative risks, varied patient disabilities, and some cases of refusal to undergo radical surgery. The tissue so removed should be studied adequately and a strict follow-up is mandatory. When a routine local excision of a lower intestinal lesion containing invasive cancer is found, consulta-
880
MICHAEL
R.
DEDDISH
tion with the pathologist usually determines one's management of the problem. This series is being presented because it pretty well approximates the cure rates of the radical treatment of Dukes' A, and many Dukes' B, lesions. (Strict follow-up and clinical evaluation for possible residual disease cannot be emphasized too strongly because these observations usually determine the end result.) It is also interesting to note that only 5 patients in this series died of their disease during the 1 to 5 year interval, and for the 5 to 10 year period, 5 patients developed other neoplasms and 10 patients died of heart disease. Conclusions 1. Local excision may be utilized in selected invasive rectal and colon cancers. 2. Survival rates are reported in 86 patients and are comparable to radical excision of early invasive cancer of the distal colon and rectum. 3. The diligent study of the excised specimen, the clinical evaluation of the lesion preoperatively, and a strict follow-up regimen are mandatory. 4. The 5-year survival rate for local excision is 83.5 per cent. 5. The IO-year survival rate is 72.2 per cent. 6. Seventy-five per cent of the deaths during the first IO-year interval were due to causes other than the original disease.
REFERENCES 1. Binkley, G. E., Sunderland, D. A., and Miller, C. J.: Treatment of papillary adenomas of the
rectum. New York State J. Med., 49: 1949. 2. Binkley, G. E., Sunderland, D. A., Miller, C. J., Stearns, M., Jr., and Deddish, M. R.: Carcinoma arising in adenomas of the colon and rectum. J.A.M.A., 148:1465-1469, 1952. 3. Dixon, C. F.: Surgical removal of lesions occurring in the sigmoid and rectosigmoid. Amer. J. Surg., 46: 12, 1939. 4. Miles, W. E.: A method of performing abdominoperineal excision for carcinoma of the rec· tum and terminal portion of the pelvic colon. Lancet, 2:812,1908. Memorial Sloan-Kettering Cancer Center 1275 York Avenue New York, New York 10021