Is the increasing role of Transanal Endoscopic Microsurgery in curation for T1 rectal cancer justified? A systematic review

Figures & data

Table I.  Comparative series of local excision according to Parks (LE) versus radical surgery (RS) for T1 rectal carcinomas.

Author	LE vs. RS (no.)	R0: LE vs. RS (%)	LR: LE vs. RS (5-year [%])	OR: LE vs. RS (5-year [%])	OS: LE vs. RS (5-year [%])	Other survival: LE vs. RS (5-year [%])
Mellgren et al. [8] (2000)	69 vs. 30	100 vs.100	18 vs. 0‡	21 vs. 9	72 vs. 80	DSS: 95 vs. 95
Nascimbeni et al. [68] (2004)	70 vs. 74	NS	6.6 vs. 2.8‡	21 vs. 10‡	72 vs. 90‡	DSS: 89 vs. NS DFS: 67 vs. 84‡
Bentrem et al. [26] (2005)	151 vs. 168	NS	15 vs. 3‡	23 vs. 6‡	89 vs. 93*	DSS: 93 vs. 97*
Endreseth et al. [27] (2005)	35 vs. 256	83 vs. 100‡	12 vs. 6‡	12 vs. 13	70 vs. 80*‡	DFS: 64 vs. 77*‡
Ptok et al. [25] (2007)	105 vs. 312	100 vs. 100	6 vs. 2‡	10 vs. 6	84 vs. 92	DFS: 91 vs. 92
You et al. [22] (2007)	601 vs. 493	95 vs. 99	12.5 vs. 6.9‡	16 vs. 10‡	77 vs. 82	DSS: 93 vs. 97‡

R0=microscopic radical excision

LR=local recurrence

OR=overall recurrence

DSS=disease specific survival

DFS=disease free survival

OS=overall survival

Survival rates are 5-years, unless otherwise specified

‡Statistically significant (p<0.05)

*Patients who received neoadjuvant and/or adjuvant therapy were not excluded

NS=not stated

Table II.  Comparative series of TEM versus LE according to Parks and/or radical surgery (RS).

Author	Type of study	Inclusion criteria	Type of surgery	Number of T1 carcinomas	Level of evidence‡
Winde et al [28] (1996)	Randomized controlled trial	uT1, G1/2	TEM	26	IIb
			RS	26
Heintz et al. [29] (1998)	Retrospective	pT1	TEM	58	IIIb
			RS	45
Lee et al. [30] (2003)	Retrospective	cT1N0, G1/2	TEM	52	IIIb
			RS	17
Langer et al. [20] (2003)	Retrospective	pT1,G1/2	TEM	20	IIIb
			Parks	20
			RS	18

cT/N=clinical T/N-staging; uT/N=presumed T/N-stage based on endorectal ultrasound;

pT=T-stage based on histopathological investigation;

G1=well differentiated, G2=moderately differentiated, G3=poorly differentiated;

LVI=lymfvascular invasion;

TEM=transanal endoscopic microsurgery; RS=radical surgery;

‡=level of evidence according to Oxford Centre for Evidence-based Medicine Levels of Evidence

Table III.  Comparative series of TEM versus LE according to Parks and/or radical surgery (RS).

Authors	TEM vs. other (no.)	R0: (%)	LR: (5-years [%])	OR: (5-years [%])	OS (5-years [%])	Other survival: (5-years [%])
Winde et al. [28] (1996)	TEM 24	NS	4	4	NS	DSS: 96
	RS 26		0	4		DSS: 96
Heintz et al. [29] (1998)	TEM low risk 46	78	4	4	79	NS
	RS low risk 34	100	3	6	81
	TEM high risk 12	58	33	33	68	NS
	RS high risk 11	100	18	18	69
Lee et al. [30] (2003)	TEM 52	100	4	NS	100
	RS 17	100	0		93	DFS: 96
	100					DFS: 94
Langer et al.	TEM 20	76	10	NS	NS	100 (2-years)
[20] (2003)	Parks 20	47‡	15			100 (2-years)
	RS 18	100	0			93 (2-years)

TEM=Transanal Endoscopic Microsurgery;

Parks=LE according to Parks;

RS=radical surgery;

R0=microscopic radical excision;

LR=local recurrence;

OR=overall recurrence;

OS=overall survival;

DFS=disease free survival; DSS=disease specific survival; ‡=statistically significant (p<0.05)

Table IV.  Case series of TEM in T1 rectal carcinomas.

Author	Type of study	Inclusion criteria	No. of T1 carcinomas	Comments	LR	OS	DSS	Level of evidence‡
Smith et al. [43] (1996)	retrospective	NS	30	No pre-/postoperative adjuvant therapy	3/30 (10%)	NS	NS	IV
Mentges et al. [35] (1997)	prospective	G1/2 curative intent (N=60) G3 in selected patients (N=4)	64	No pre-/postoperative adjuvant therapy	2/52 (4%)	NS	NS	IV
Demartines et al. [33] (2001)	prospective	G1/2, LVI -	9	One patient adjuvant therapy, type not mentioned	1/7 (14%)	NS	NS	IV
De Graaf et al. [46] (2002)	retrospective	NS	21	No pre-/postoperative adjuvant therapy	2/19 (11%)	NS	NS	IV
Dafnis et al. [44] (2004)	retrospective	NS	10	No pre-/postoperative adjuvant therapy	1/10 (10%)	NS	NS	IV
Stipa et al.[38] (2004)	retrospective	uT1-T3,<3 cm	39	Overall 43% of patients pre-/postoperative RT	5/39 (13%)	92%	92%	IV
Duek et al. [45] (2005)	retrospective	G1/2,<3 cm, <10 cm from dentate line, cN0	25	No pre-/postoperative adjuvant therapy	0/25 (0%)	NS	NS	IV
Endreseth et al. [40] (2005)	retrospective	NS	8	No pre-/postoperative adjuvant therapy	0/8 (0%)	NS	NS	IV
Floyd et al. [39] (2005)	retrospective	NS	53	No pre-/postoperative adjuvant therapy	4/53 (8%)	100%	100%	IV
Ganai et al. [42] (2006)	retrospective	NS	21	One patient postoperative CRT	4/21 (19%)	73%	89%	IV
Borschitz et al. [34] (2006)	prospective	pT1	105	21 patients immediate radical surgery No pre-/postoperative adjuvant therapy	11/84 (13%)	93% (low-risk, R0)	94% (low-risk, R0)	IV
Stipa et al. [37] (2006)	retrospective	uT1/T2, uN0	23	2 patients preoperative CRT 2 patients postoperative RT	2/23 (9%)	91%	91%	IV
Bretagnol et al.[36] (2007)	retrospective	G1/2,<3 cm	31	3 patients immediate radical surgery	3/28 (11%)	79%	81%	IV
Whitehouse et al. [41] (2007)	retrospective	NS	25	2 patients immediate radical surgery Pre-/postoperative CRT not clear	6/23 (26%)	NS	NS	IV
Lezoche et al. [31] (2007)	prospective	uT1N0	51	Pre-/postoperative CRT not mentioned	0/51 (0%)	94%	100%	IV
Maslekar et al. [32] (2007)	prospective	G1/2 en 3	27	No pre-/postoperative adjuvant therapy	0/27 (0%)	NS	NS	IV

uT/N=presumed T/N-stage based on endorectal ultrasound

pT=T-stage based on histopathological investigation

G1=well differentiated, G2=moderately differentiated, G3=poorly differentiated

NS=not stated

LR=local recurrence

OS=overall survival

DSS=disease specific survival

‡=level of evidence according to Oxford Centre for Evidence-based Medicine Levels of Evidence

CRT=chemoradiotherapy

RT=radiotherapy

Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 2000;43:1064–71; Discussion 1071–4.

 PubMed Web of Science ®Google Scholar

Nascimbeni R, Nivatvongs S, Larson DR, Burgart LJ. Long-term survival after local excision for T1 carcinoma of the rectum. Dis Colon Rectum 2004; 47: 1773–9

 PubMedGoogle Scholar

Bentrem DJ, Okabe S, Wong WD, Guillem JG, Weiser MR, Temple LK, et al. T1 adenocarcinoma of the rectum: Transanal excision or radical surgery? Ann Surg 2005;242:472–7; Discussion 477–9.

 PubMed Web of Science ®Google Scholar

Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A. Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum 2005; 48: 1380–8

 PubMed Web of Science ®Google Scholar

Ptok H, Marusch F, Meyer F, Schubert D, Koeckerling F, Gastinger I, et al. Oncological outcome of local vs.radical resection of low-risk pT1 rectal cancer. Arch Surg 2007;142:649–55; Discussion 656.

 PubMedGoogle Scholar

You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: A nationwide cohort study from the National Cancer Database. Ann Surg 2007; 245: 726–33

 PubMed Web of Science ®Google Scholar

Winde G, Nottberg H, Keller R, Schmid KW, Bunte H. Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum 1996; 39: 969–76

 PubMedGoogle Scholar

Heintz A, Morschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 1998; 12: 1145–8

 PubMed Web of Science ®Google Scholar

Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc 2003; 17: 1283–7

 PubMedGoogle Scholar

Langer C, Liersch T, Suss M, Siemer A, Markus P, Ghadimi BM, et al. Surgical cure for early rectal carcinoma and large adenoma: Transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int J Colorectal Dis 2003; 18: 222–9

 PubMedGoogle Scholar

Smith LE, Ko ST, Saclarides T, Caushaj P, Orkin BA, Khanduja KS. Transanal endoscopic microsurgery. Initial registry results. Dis Colon Rectum 1996; 39(10 Suppl)S79–S84

 PubMed Web of Science ®Google Scholar

Mentges B, Buess G, Effinger G, Manncke K, Becker HD. Indications and results of local treatment of rectal cancer. Br J Surg 1997; 84: 348–51

 PubMedGoogle Scholar

Demartines N, von Flue MO, Harder FH. Transanal endoscopic microsurgical excision of rectal tumors: Indications and results. World J Surg 2001; 25: 870–5

 PubMedGoogle Scholar

de Graaf EJ, Doornebosch PG, Stassen LP, Debets JM, Tetteroo GW, Hop WC. Transanal endoscopic microsurgery for rectal cancer. Eur J Cancer 2002; 38: 904–10

 PubMedGoogle Scholar

Dafnis G, Pahlman L, Raab Y, Gustafsson UM, Graf W. Transanal endoscopic microsurgery: Clinical and functional results. Colorectal Dis 2004; 6: 336–42

 PubMedGoogle Scholar

Stipa F, Lucandri G, Ferri M, Casula G, Ziparo V. Local excision of rectal cancer with transanal endoscopic microsurgery (TEM). Anticancer Res 2004; 24(2C)1167–72

 PubMedGoogle Scholar

Duek SD, Krausz MM, Hershko DD. Transanal endoscopic microsurgery for rectal cancer. Isr Med Assoc J 2005; 7: 435–8

 PubMedGoogle Scholar

Endreseth BH, Wibe A, Svinsas M, Marvik R, Myrvold HE. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal Dis 2005; 7: 133–7

 PubMed Web of Science ®Google Scholar

Floyd ND, Saclarides TJ. Transanal endoscopic microsurgical resection of pT1 rectal tumors. Dis Colon Rectum 2006; 49: 164–8

 PubMedGoogle Scholar

Ganai S, Kanumuri P, Rao RS, Alexander AI. Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol 2006; 13: 547–56

 PubMed Web of Science ®Google Scholar

Borschitz T, Heintz A, Junginger T The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: Results of local excision (Transanal Endoscopic Microsurgery) and immediate reoperation. Dis Colon Rectum 2006.

 Google Scholar

Stipa F, Burza A, Lucandri G, Ferri M, Pigazzi A, Ziparo V, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: A 5-year follow-up study. Surg Endosc 2006; 20: 541–5

 PubMed Web of Science ®Google Scholar

Bretagnol F, Merrie A, George B, Warren BF, Mortensen NJ. Local excision of rectal tumours by transanal endoscopic microsurgery. Br J Surg 2007; 94: 627–33

 PubMedGoogle Scholar

Whitehouse PA, Armitage JN, Tilney HS, Simson JN. Transanal endoscopic microsurgery: Local recurrence rate following resection of rectal cancer. Colorectal Dis 2008; 10: 187–93

 PubMedGoogle Scholar

Lezoche E, Baldarelli M, De Sanctis A, Lezoche G, Guerrieri M. Early rectal cancer: Definition and management. Dig Dis 2007; 25: 76–9

 PubMedGoogle Scholar

Maslekar S, Pillinger SH, Monson JR. Transanal endoscopic microsurgery for carcinoma of the rectum. Surg Endosc 2007; 21: 97–102

 PubMed Web of Science ®Google Scholar