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. 2022 Mar;125(3):475-483.
doi: 10.1002/jso.26734. Epub 2021 Oct 27.

Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis

Katherine A Hrebinko  1 , Katherine M Reitz  1 , Maryam K Mohammed  1 , Ibrahim Nassour  2 , Andrew R Watson  3 , Kellie E Cunningham  3 , David S Medich  3 , James P Celebrezze  3 , Jennifer M Holder-Murray  3
Affiliations

Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis

Katherine A Hrebinko et al. J Surg Oncol. 2022 Mar.

Abstract

Background: Current guidelines favor transabdominal radical resection (RR) over transanal local excision (TAX) followed by adjuvant therapy (TAXa) for pT1N0 rectal tumors with high-risk features. Comparison of oncologic outcomes between these approaches is limited, although the former is associated with increased postoperative morbidity. We hypothesize that such treatment strategies result in equivalent long-term survival.

Methods: A retrospective cohort study was conducted using the National Cancer Database (2010-2016) to identify patients with pT1N0 rectal adenocarcinoma with high-risk features who underwent TAX or RR for curative intent. The primary outcome was 5-year overall survival (OS), evaluated with log-rank and Cox-proportional hazards testing.

Results: A total of 1159 patients (age 67.4 ± 12.9 years; 56.6% male; 83.3% White) met study criteria, of which 1009 (87.1%) underwent RR and 150 (12.9%) underwent TAXa. Patients undergoing TAXa had shorter lengths of stay (RR = 6.5 days, TAXa = 2.7 days, p < 0.001). The 5-year OS was equivalent between groups. TAX without adjuvant therapy was associated with an increased risk of mortality (hazard ratio 1.81, 95% confidence interval 1.17-2.78, p = 0.01).

Conclusions: This is the largest study to demonstrate equivalent 5-year OS between TAXa and RR for T1N0 rectal cancer with high-risk features. These findings may guide the development of prospective, randomized trials and influence changes in practice recommendations for early-stage rectal cancer.

Keywords: adenocarcinoma; digestive system surgical procedures; morbidity; rectal neoplasms.

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Figures

FIGURE 1
FIGURE 1
Flowchart illustrating cohort accrual
FIGURE 2
FIGURE 2
(A) Five-year overall survival for patients in the primary cohort undergoing RR versus TAX_A. (B) Five-year overall survival for patients in the secondary cohort undergoing TAX_A, RR, or TAX. RR, radical resection; TAX_A, transanal excision without adjuvant therapy
FIGURE 3
FIGURE 3
(A) Five-year overall survival for patients with lymphovascular invasion undergoing RR versus TAX_A. (B). Five-year overall survival for patients with positive resection margins undergoing RR versus TAX_A. (C) Five-year overall survival for patients with poorly differentiated or undifferentiated tumors undergoing RR versus TAX_A. RR, radical resection; TAX_A, transanal excision without adjuvant therapy
See this image and copyright information in PMC

References

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