Local excision for selected colorectal carcinomas

12 Local excision for selected colorectal carcinomas MALLORY STANLEY

A. LAWRENCE M. GOLDBERG

Colorectal carcinoma continues to be a major cause of death in Western civilizations. Age-adjusted death rates range from 24 to 33 per 100 000 for males and from 16 to 29 per 100000 for females (Silverberg and Lubera, 1989). In the United States, death rates have remained relatively unchanged over the last 50 years (Silverberg and Lubera, 1989). This has led to reassessment. of our capabilities to detect and manage colorectal carcinoma. Although the potential of adjuvant therapy modalities is being explored, surgery endures as the mainstay in the management of colorectal carcinoma. The efficacy of traditional radical surgery has come under intense scrutiny. Surgical goals are being directed towards individualizing treatment in such a manner that patient survival may be maximized while operative morbidity is minimized. In this regard, local excision, an accepted form of palliative therapy, has been gaining popularity as a primary mode of curative therapy for a select group of cancers of the colon and rectum. LOCAL

EXCISION

In dealing with cancers of the colon, local excision is primarily practised by the endoscopist. Endoscopic polypectomy is commonly utilized for the local excision of pedunculated polyps containing carcinoma. Colonoscopic management is discussed in some detail in Chapter 7; however, certain points merit repetition. If a carcinoma within a pedunculated polyp is moderately well or well differentiated, shows no evidence of venous or lymphatic invasion, and does not extend into the stalk of the polyp, regional lymph node involvement is unlikely (Colacchio et al, 1981; Morson et al, 1984; Haggitt et al, 1985). In this setting, extirpation of malignancy and minimal patient morbidity can be achieved with endoscopic polypectomy alone. Large (> 3 cm diameter), sessile, or grossly invasive tumours of the colon are more likely to have metastatic involvement of regional nodes and are best treated by resection of the involved colonic segment and its regional lymph nodes. An exception to this may be made if colonic resection is precluded by the patient’s co-existing medical problems. In this case, these Baillih?s

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tumours can often be endoscopically removed in a piecemeal fashion using snare excision. Following excision, fulguration of the base of the remaining tumour is recommended. Caution is advised since this palliative technique may be associated with an increased incidence of perforation. The earliest surgical treatments for rectal carcinoma were the sacral excision, popularized by Kraske (1885)) and the extended perineal excision, championed by Lockhart-Mummery (1920). These early techniques of local excision were replaced with the introduction of the abdominoperineal resection by Miles in 1908. Since that time, abdominoperineal resection has become the ‘gold standard’ for the treatment of carcinoma of the rectum. In the 1970s the advent of the circular intraluminal stapling devices and popularization of the coloanal anastomosis made it technically feasible to perform low anterior resection instead of abdominoperineal resection for some carcinomas in the upper, middle, and frequently even the lower one-third of the rectum. In the last two decades, there has been a renewal of interest in the use of local excision as a curative treatment for certain rectal carcinomas. Rectal tumours may be excised from a transanal, trans-sphincteric, transsacral, or transvaginal approach. The transanal approach is the most commonly utilized for local excision of rectal carcinomas. The other approaches are less popular because of their additional technical difficulty and associated complications, such as faecal fistula and wound infection. To compound this, these approaches introduce a significant potential for implantation of malignant cells within extrarectal tissue planes during the procedure. SELECTION

FOR LOCAL

EXCISION

It is the authors’ preference to limit local excision, in most cases, to certain carcinomas of the distal 10cm of the rectum. This is done for several reasons. Full thickness excision of the rectal wall proximal to this runs the risk of entering the peritoneal cavity. In addition, transanal excision is technically more difficult in the more proximal extent of the rectum. Poor exposure may not only hinder an adequate local excision of the tumour, but it may prevent a sound closure of the excision site, subjecting the patient to the possibility of a pelvic or retroperitoneal abscess. In most cases, the more proximal tumours can be better treated with low anterior resection. Certainly, if accessibility from a transanal approach is questionable, the surgical and anaesthetic teams should be ready to convert the procedure to a low anterior resection. Preoperatively, the patient should undergo a full mechanical and antibiotic bowel preparation. The prone ‘jack-knife’ position is preferred. Once the patient is positioned, a Pratt bivalved anoscope or Fansler operating anoscope is used to expose the tumour. A solution of local anaesthetic or saline containing 1:200 000 adrenaline (epinephrine) is infiltrated within a submucosal plane surrounding the tumour. Sutures are then placed in the mucosa just distal to the inferior edge of the tumour. Traction applied to these sutures facilitates dissection by prolapsing the tumour into

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the operative field. Beginning at its most distal aspect, the tumour is excised, together with a l-2cm rim of normal tissue at its margin, using the electrocautery. A full thickness of the rectal wall is excised to guarantee complete removal of the tumour. It is often helpful to place interrupted absorbable sutures serially to close the defect as the tumour is progressively excised. Traction on these sutures keeps the tumour prolapsed for easier excision and prevents the excision site from retracting out of the operative field. Following excision of the tumour, the sutures are tied and then cut, leaving their ends long. This facilitates identification of the site of excision in the event that postoperative bleeding requires reoperation. At the completion of the procedure, the surgeon should pin out and label the specimen so that the pathologist is properly oriented when examining the margins of the tumour.

ADVANTAGE OF LOCAL OF TREATMENT

EXCISION

OVER OTHER

FORMS

Unlike most other forms of local therapy (e.g. fulguration, endocavitary radiation), the technique of local excision provides the pathologist with an intact specimen for evaluation. The tumour is assessed for (1) depth of malignant invasion, (2) absence of malignancy at the tumour margins, (3) degree of histological differentiation, and (4) the presence of lymphatic or vascular invasion. As will be discussed below, these factors determine the need for additional surgery. Operative mortality rates for abdominoperineal resection range from 0.4-lo%, while those for low anterior resection range from 0.67% (Table 1). Both have mean operative mortality rates of approximately 5%. In contrast, operative mortality rates for local excision of carefully selected carcinomas of the rectum, as one would expect, approach zero (Table 1). This also holds true for ‘high-risk’ operative patients who undergo local excision as a means of palliation. Local excision of selected rectal cancers results in few complications. Conversely, low anterior resection and abdominoperineal resection are associated with significant immediate and long-term morbidity (Williams et al, 1985; Gillen and Peel, 1986). Specifically, both abdominoperineal resection and low anterior resection render the patient susceptible to intraoperative complications such as injury to ureters, spleen, bladder and presacral veins. Postoperatively, patients are subject to cardiopulmonary complications (e.g. myocardial infarction, pneumonia and pulmonary embolism), wound infection, and small bowel obstruction secondary to adhesions. With performance of a low anterior resection, the additional complications related to anastomotic leakage are introduced. On a long-term basis, the patient treated with abdominoperineal resection faces a significant likelihood of genitourinary dysfunction, the physical and psychological burden of living with a permanent colostomy, and the small risk of having a non-healing perineal wound. Some degree of permanent genitourinary dysfunction may

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also be experienced by patients undergoing low anterior resection. In addition, patients undergoing ‘extended’ low anterior resection may experience partial or even complete anal incontinence as a result of the removal of the rectum with its reservoir function, and/or damage to sphincters during resection of the rectum. This is particularly true if borderline incontinence is not appreciated prior to performance of low anterior resection or if a coloanal anastomosis is performed (Goligher et al, 1965).

Table

rectal

1. Operative cancer.

mortality

of surgical

Author

procedures Mortality

(%)

Abdominoperineal resection Mayo et al (1951) Gabriel (1957) Lloyd-Davies (1957) Deddish and Stearns (1961) Morgan (1965) Reynolds et al (1968) Zollinger and Shepard (1971) Slanetz et al (1972) Stearns (1974) Higgins et al (1975) Lockhart-Mummery et al (1976) Whittaker and Goligher (1976) Pate1 et al (1977) Enker et al (1979) Rothenberger et al (1979) Localio et al (1983)

4.1 9.2 8.6 2.0 3.1 6.7 6.5 5.4 3.5 10.0 2.1 12.5 2.9 6.4 0.4 2.0

Low anterior resection Deddish and Stearns (1961) Morgan (1965) Stearns (1974) Lockhart-Mummery et al (1976) Whittaker and Goligher (1976) Pate1 et al (1977) Keighley and Matheson (1980)* Parks and Percy (1982)* Rothenberger et al (1982) Localio et al (1983)

5.3 4.4 5.3 4.2 6.8 2.2 12.5 4.0 0.6 2.2

Local excision Morson et al (1977) Lock et al (1978) Cuthbertson and Kaye (1978) Hager et al (1983)t Stearns et al (1984)t Killingback (1984) Grigg et al (1984) Whiteway et al (1985)f Rothenberger and Finne (1988)

0 0 0 6.1 0 0 0 0 0

*With coloanal anastomosis. t Studies included ‘high-risk’

patients

treated

for

palliatively.

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EXCISION

PATIENT

SURVIVAL

Decreased operative mortality and morbidity are of no advantage if patient survival is compromised by early local recurrence or systemic metastasis from an inadequate removal of existing carcinoma. Selection of the appropriate surgical procedure may be crucial in determining survival in patients with rectal carcinoma. In theory, treatment of cancers confined to the rectal wall (Dukes’ A and B) with local excision should be as efficacious as abdominoperineal resection or low anterior resection. In fact, numerous studies have demonstrated comparable, if not superior, local recurrence rates, and 5-year survival rates may be achieved using local excision (Table 2). Conversely, rectal carcinomas with nodal metastasis (Dukes’ C) are better managed with abdominoperineal resection or low anterior resection, since these procedures remove the reginal lymph nodes and mesorectum as well as the primary rectal carcinoma. In the case of unresectable hepatic Table

Author

Extent

Abdominooerineal resection Slanetz et al (1972)

Localio

Rosen

et al (1983)

et al (1982)

Low anterior resection Slanetz et al (1972)

Localio

et al (1983)

Pollett and Nicholls (1983) Local excision Grigg et al (1984) Hager et al (1983) Stearns

et al (1984)

Lock et al (1978) Whiteway et al (1985) Morson et al (1977) Deddish et al (1974) ’ Status staging.

of lymph

nodes

2. Local

recurrence

No. of patients

of invasion*

Local recurrence (%I

5-year survival uncorrected (%I

Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’

A B C A B C A B C

42 91 129 21 26 29 45 75 60

5.9 25 38 0 11.5 24.1 0 16 10

81 52 33 80.9 42.3 17.2 86 65 33

Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’ Dukes’

A B C A B C A B C

50 98 86 62 80 53 67 155 112

2.2 23 33 3.2 13.8 24.5 1.4 7.0 9.8

86 51 33 91.9 60 45.3 85 70.3 57

16 39 20 15 14 89 19 91 86

0 8 17

100 89 78 94 86 84.5 82 84

Submucosa Submucosa Muscularis propria Submucosa Muscularis propria and liver

and survival.

not usually

available

6.7 0 3.3 -

in local excision

groups

to assign

Dukes’

-

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metastases (Dukes’ ‘D’), ultimate survival will not be determined by the type of surgery performed upon the rectum. Taking these factors into consideration, choosing the appropriate procedure seems simple. Unfortunately, this scheme is complicated by our inability consistently to determine which cancers have nodal or local extrarectal metastases. LYMPH

NODE

INVOLVEMENT

In many cases, extensive extrarectal extension or enlarged perirectal lymph nodes can be palpated on performance of a digital examination. Nicholls and colleagues found that consultants at St Mark’s Hospital, using digital examination alone, determined the existence of local, extrarectal tumour spread in 48 patients examined with a 73-80% accuracy rate. They were able to detect cancer-bearing lymph nodes with only a 50% accuracy rate in patients subsequently proven to have rectal adenocarcinoma with Dukes’ C staging (Nicholls et al, 1982). Computerized tomography and magnetic resonance imaging are occasionally useful in evaluating the extrarectal spread of large, advanced rectal carcinomas or in the detection of enlarged lymph nodes. These diagnostic modalities are less useful in the assessment of early carcinomas as such tumours are more likely to have microscopic nodal metastasis without nodal enlargement (Dixon et al, 1981; Zaunbauer et al, 1981; Hodgman et al, 1986). Endoluminal ultrasound, in the hands of an experienced sonographer, can give precise determination of depth of malignant invasion within the rectal wall. In addition, accuracy rates in predicting the metastatic status of perirectal lymph nodes have been as high as 7588% (Saitoh et al, 1986; Senagore et al, 1988). Unfortunately, endoluminal ultrasound and experienced sonographers are still uncommom in most medical communities. TUMOUR RELATED METASTASES

FACTORS

PREDICTING

NODAL

In the absence of a consistently reliable diagnostic test to detect nodal metastases, clinicians must rely upon certain gross and histological characteristics of the tumour to predict the likelihood of nodal or extarectal involvement. Tumour mobility on digital or proctoscopic examination is perhaps one of the most helpful characteristics in determining extension beyond the rectal wall. York Mason (1975) devised a method of clinical staging based upon the degree of tumour mobility. With this staging system he was able to predict accurately the pathological stage in 75% of the cases examined (York Mason, 1976). Grigg and colleagues reported on 16 patients whose rectal tumours were actually mobile enough to be distracted from the rectal wall such that a ‘pseudostalk’ or pedicle could be produced prior to excision (Grigg et al, 1984). These tumours were found to penetrate no deeper than the submucosal layer. This further substantiated the value of tumour mobility in predicting depth of invasion and possible extrarectal extension.

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Although some surgeons find tumour size to be a less significant factor in predicting extrarectal tumour spread (Greaney and Irvin, 1977; Lock et al, 1978), most studies demonstrate a lower local recurrence rate when local excision is limited to rectal cancers < 3 cm in diameter (Morson et al, 1977; Hager et al, 1983; Stearns et al, 1984; Killingback, 1985). It is well recognized that the technical difficulty of local excision increases proportionately with the size of the tumour. Similarly, a greater degree of difficulty might be expected in the local excision of rectal tumours incorporating greater than one-quarter of the rectal circumference. Polypoid, exophytic carcinomas have been noted to have a better chance of being cured with various forms of local therapy than do ulcerated tumours (Papillon, 1975; Greaney and Irvin, 1977; Hughes et al, 1982; Michelassi et al, 1988). Of note, Greaney found that ulcerated rectal carcinomas were associated with a 50% incidence of regional nodal metastasis (Greaney and Irvin, 1977). Following local excision, full histopathological examination of the specimen gives the best prognostic information concerning the likelihood of regional lymph node metastases. Certain histological features may lead the surgeon to consider additional radical surgery. The depth of transmural malignant invasion has a close correlation with the probability of lymph node involvement. Carcinoma confined to the mucosa, or carcinoma-insitu, has essentially no potential for lymph node involvement. Cancer confined to the submucosa is associated with a 6-11% incidence of nodal involvement (Morson, 1966; Morson et al, 1977; Hager et al, 1983; Stearns et al, 1984; DeLeon et al, 1987). Invasion into the muscularis propria has been associated with a l&20% incidence of regional nodal involvement (Morson, 1966; Hager et al, 1983; Killingback, 1985). Once the carcinoma penetrates the muscularis and invades the immediate perirectral fat, lymph node involvement can be expected to occur with a 33-70% incidence (Morson, 1966; Nicholls et al, 1982; Hager et al, 1983; Whiteway et al, 1985). Although each case must be judged individually with respect to risks and benefits, the increased incidence of nodal involvement associated with carcinomas invading the muscularis propria generally justifies the need for further surgery. The degree of differentiation of the carcinoma has predictive value for the incidence of lymph node metastases. Lymph node metastases are found in 25% of well differentiated carcinomas, 50% of moderately well differentiated carcinomas, and up to 80% of poorly differentiated tumours (Morson, 1988; Stearns et al, 1984). Regardless of Dukes’ staging, poorly differentiated adenocarcinomas are associated with crude 5-year survival rates of about 25% (Morson, 1988). Local excision is generally considered to be inadequate as the ultimate curative therapy for poorly differentiated carcinomas as it is their nature to metastasize early. Ten to twenty per cent of all colorectal adenocarcinomas are of the mutinous variety (Symonds and Vickery, 1976; Sunblad and Paz, 1982). Mutinous adenocarcinomas are difficult to grade histologically; however, they carry an increased incidence of nodal metastases in comparison to non-mutinous adenocarcinomas (Sunblad and Paz, 1982). The signet cell

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type, which retains its mucus intracellularly, is the most virulent of the mutinous adenocarcinomas. It has been associated with crude 5-year patient survival rates of about 5% (Morson, 1988). Accordingly, these carcinomas should be treated with a more radical resection to encompass regional lymph nodes. The prognostic significance of venous invasion by carcinoma is controversial. Some researchers have found malignant venous invasion to be associated with decreases in 5-year survival rates by as much as 50% when compared with tumours of equivalent Dukes’ staging without venous invasion (Morson, 1988; Copeland et al, 1968). This finding is thought to correspond with earlier and more frequent blood borne metastases. Others have found this factor to have no influence upon survival (Jass et al, 1987). Recently, the absence of an inflammatory cellular response at the tumour-host interface has been linked to an increased metastatic potential and reduced 5-year survival rates (Jass et al, 1987). Although this characteristic may add weight to the argument for further surgery in patients whose locally excised carcinomas reveal other unfavourable histological features, this trait alone should not be used to determine the need for further surgery. Cytometric DNA analysis has allowed clinicians to identify tumours with respect to their diploid or non-diploid status. Researchers have found a correlation between non-diploid status and increased incidence of local recurrence and metastases as well as decreased survival rates (Forsslund et al, 1984; Banner et al, 1985; Kokal et al, 1986). This method holds promise in helping to identify carcinomas with a higher probability of having lymph node metastases. Unfortunately, its current limited availability for clinical application has made it of academic interest only. ADJUVANT

THERAPY

There is evidence to suggest that perioperative radiotherapy may decrease the rate of local recurrence of carcinoma of the rectum following low anterior resection and abdominoperineal resection (Gastrointestinal Tumour Study Group, 1985; Gerard et al, 1988). There are those who have advocated the use of endocavitary or external beam radiotherapy as an adjunct to local excision as well (Fleshman et al, 1985; Ellis et al, 1988; McCready et al, 1989). The rationale for this is puzzling. Moderately well or well differentiated carcinomas of the rectum that are completely excised and found to extend no further than the submucosa should be adequately treated by local excision alone in 89-94% of cases. Under these circumstances, the use of endocavitary radiation seems excessive, in that the rectal wall carcinoma that this form of radiotherapy is designed to treat has already been removed. Conversely, one can hardly justify giving potentially harmful pelvic radiotherapy to treat the lymph nodes which have only a 611% chance of containing carcinoma. If transmural involvement or severe anaplasia is revealed on histopathological examination of the excised specimen, the potential for regional lymphatic involvement and local extrarectal exten-

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sion of the carcinoma must be dealt with. In this setting, radiotherapy may be a reasonable adjunct to low anterior resection or abdominoperineal resection; however, radiotherapy is not advocated as a substitute for further surgery. An exception to this may be encountered when dealing with the patient who refuses or is medically unfit to undergo more radical surgery. SUMMARY In summary, local excision is a useful tool in the management of selected colorectal carcinomas. The advent of the fibreoptic colonoscope has revised the cycept of local excision when dealing with carcinoma-containing polyps of the colon. The clinician now has the means of locally excising certain carcinomas which would have required laparotomy in the not so distant past. In dealing with carcinoma of the rectum, local excision is not advocated for all rectal carcinomas. In fact, when the previously discussed tumour related factors are considered, local excision should be the ultimate procedure in less than 5% of operations performed for rectal carcinomas. However, when appropriately used, local excision provides a less morbid alternative to more radical procedures without compromising patient survival rates or local recurrence rates. REFERENCES Banner BF, Tomas-DeLaVega JE, Roseman DL et al (1985) Should flow cytometric DNA analysis precede definitive surgery for colon carcinoma? Annuls of Surgery 202: 740-744. Colacchio TA, Forde KA & Scantlebury VP (1981) Endoscopic polypectomy: inadequate treatment for invasive colorectal carcinoma. Annals ofSurgery 194: 704-707. Copeland EM, Miller LD & Jones RS (1968) Prognostic factors in carcinoma of the rectum. American Journal of Surgery 116: 875-881. Cuthbertson AN & Kaye AH (1978) Local excision of carcinomas of the rectum, anus and anal canal. Australian and New Zealand Journal of Surgery 48: 412-415. Deddish NR (1974) Local excision. Surgical Clinics of North America 54: 877-880. Deddish MR & Stearns MW Jr (1961) Anterior resection for carcinoma of the rectum and rectosigmoid area. Annals of Surgery 154: 961-966. DeLeon ML, Schoetz DJ, Coller JA et al (1987) Colorectal cancer: Lahey Clinic experience, 1972-1976. Diseases of the Colon and Rectum 30: 237-242. Dixon AK, Kelsey-Fry I, Morson BC et al (1981) Preoperative tomography of carcinoma of the rectum. British Journal of Radiology 54: 655-659. Ellis LM, Mendenhall WH, Bland KI & Copeland EM III (1988) Local excision and radiation therapy for early rectal cancer. American Surgeon 54(4): 217-220. Enker WE, Laffrer UT & Block GE (1979) Enhanced survival of patients with colon and rectal cancer is based upon wide anatomical resection. Annals of Surgery 189: 488-492. Fleshman JW, Kodner IJ, Fry RD et al (1985) Adenocarcinoma of the rectum: results of radiotherapy and resection, endocavitary &radiation, local excision, and preoperative clinical staging. Diseases of the Colon and Rectum 28(11)1 81@815. Forsslund G, Cedermark B, Onman U et al (1984) The significance of DNA distribution patterns in rectal carcinoma: a preliminary study. Diseases of the Colon and Rectum 27: 579-584. Gabriel WB (1957) Discussion on major surgery in carcinoma of the rectum, with or without colostomy, excluding the anal canal and including the rectosigmoid. Proceedings of the Royal Society of Medicine 50: 1047.

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