Locally Excised T1 Rectal Cancers: Need for Specialized Surveillance Protocols

BACKGROUND: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision. OBJECTIVE: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer. DESIGN: This study is a retrospective review. SETTINGS: Patients treated by University of Minnesota-Affiliated physicians, 1994 to 2014, were selected. PATIENTS: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up. INTERVENTIONS: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence. RESULTS: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed. LIMITATIONS: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available. CONCLUSIONS: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979.