Transanal endoscopic microsurgery after radiation or chemoradiation therapy for rectal cancer — peculiarities and results

INTRODUCTION: the standard treatment for patients with locally advanced rectal cancer is the use of chemoradiotherapy (CRT) or intensive radiation therapy (RT) regimens with delayed surgery. Moreover, in 10–25% of cases, patients experience complete disappearance of the tumor during treatment. Current approaches to the management of cases with a good response involve organ-sparing treatment in patients with a complete clinical response (cCR), which means dynamic observation of the patient, or local excision of the scar at the site of a pre-existing tumor in cases of a near complete clinical response (nCR).

AIM: to analyze the results of treatment of patients with rectal cancer who had a good response to RT/CRT and who underwent transanal endoscopic microsurgery (TEM).

PATIENTS AND METHODS: from 2019 to 2023, 20 patients with rectal adenocarcinoma underwent TEM after RT/CRT. In all patients, the tumors were located in the distal rectum, which required either abdominoperineal resection or ultra low anterior rectal resection. The median interval between RT and surgery was 22 (12–78) weeks. In 5 (25.0%) patients included in the study, a cCR was registered for neoadjuvant treatment. In 15 cases, TEM was performed in patients with nCR. RESULTS: operation time was 117 minutes, the blood loss was 40 ml. A complicated postoperative period was observed in 4 (20.0%) patients, among whom the most serious complication was suture failure of the sutured intestinal defect — in 3 (15.0%) patients. Unfavorable prognosis factors were identified in 7 (35%) patients, while final TEM was performed in only 2 (28.6%) of them. In other clinical situations, active follow-up of patients was performed — local tumor recurrence was not detected in any case. With a median follow-up of 31.5 (3-54) months, signs of distant metastases were recorded in 2 (10.0%) cases. Local relapse at 12.3 months was detected in one case (5.0%). The cumulative three-year local recurrence rate was 6.2 ± 6.1%. Overall and disease-free three-year survival rates were 83.3 ± 10.8% and 80.4 ± 10.4%, respectively, and stoma-free survival was 92.9 ± 6.9%.

CONCLUSION: despite the fact that TEM in patients with rectal cancer after RT is an effective and safe method of treatment, its use in patients with cCR to confirm a complete response is inappropriate and carries an unnecessary risk of postoperative complications and possible functional dysfunction. The main indication for the use of TEM after RT/CRT is nCR, when local excision of the scar at the site of a pre-existing tumor allows not only to determine their pathological nature and treatment approach, but also for most patients it is a radical surgical intervention with a relatively low risk of local relapse.

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