Preoperative staging and treatment options in T1 rectal adenocarcinoma

Figures & data

Figure 1.  Haggit's sub-classification of polyp-cancers. The stage is related to the extent of penetration into the stalk of the polyp.

Figure 2.  Sub-classification of T1 cancers based upon depth of invasion into the submucosal layer.

Table I.  Elements to be included in the pathological report on T1 rectal adenocarcinoma.

Tumour	– Histological type of adenoma
	– Histological type and grade of carcinoma
	– Location in rectum
	– Depth of infiltration including Haggitt level and sm-level
	– Infiltration of tumour into vessels
Resection margins	– shortest distance from carcinoma to resection margin in the depth and to the side
Lymph nodes	– number of lymph nodes
	– number of lymph nodes with metastasis
	– number of lymph nodes with extranodal growth of tumour
Staging	– TNM
	– Dukes

Table II.  Accuracy of T and N staging by endoscopic ultrasound in patients with rectal cancer.

Author	Year	No of patients	T-stage accuracy	N-stage accuracy
Orrom	1990	77	75	82
Glaser	1990	86	88	80
Katsura	1992	112	92
Herzog	1993	111	89
Fedyaev	1995	109	95
Massari	1998	75	91	76
Kim	1999	89	81	64
Akasu	2000	154	96	72
Marusch	2002	422	63	80
Garcia-Aguilar	2002	545	69	64
Harewood	2002	80	91	82
Nesbakken	2003	81	74	65
Mackay	2003	433	89	66
Bali	2004	33	79	59
Kauer	2004	458	69	68
Knaebel	2005-1	424	81
	2005-2	332	72
Ptok	2006	3501	66	ns
Doornebosch	2007	210	84

Figure 3.  The conventional 10 MHz B mode ultrasound picture is shown to the right and the sonoelastographic picture to the left. Note the colour scale indicating the strain as hard (blue to soft (red). The read and green colour of the tumour indicates that it is softer than the surrounding normal bowel wall, which is blue.

Figure 4.  Endoscopic submucosal dissection of adenomas and polypoid low risk T1 cancers of Haggits stage 1 or 2.

Figure 5.  The TEM equipment for transanal stereomicroscopic dissection of low risk T1 cancers.

Table III.  Reported local recurrence rates after TEM-resection of T1 cancer. Non-comparative case-series including at least 20 patients.

	Year	No of patients	Local recurrence	Observation time (months)
Whitehouse	2008	23	26%	34
Ptok	2007	99	5%*	43
Maslekar	2007	27	0	36
Bretagnol	2007	28	11%	34
Lesoche	2007	51	0	63
Borschitz	2005	66	6%
Stipa S	2006	39	13%	37
Ganai	2006	21	26%	60
Guerrieri	2006	58	0	35
Floyd	2006	37	11%	34
Duck	2005	25	0
Jotautas	2005	22	0	3–17
Duck	2005	25	0
Palma	2004	21	5%	30
De Graaf	2002	21	18%	10
Lezoche E	1998	10	0	34
Said S	1997	19	0	12
Mentges B	1997	52	4%	28
Smith LE	1996	30	10%
Lirici	1994	21	5%	12
Buess	1993	29	4%	12

Table IV.  Factors indicating a good prognosis in T1 cancer.

Tumour diameter less than 3.0 cm
High or intermediate differentiation of tumour
Tumour infiltration no deeper than the middle layer of the submucosa (sm1 or sm2)
No sign of lymphovascular infiltration