International Journal of Colorectal Disease

, Volume 33, Issue 4, pp 383–391 | Cite as

Are we doing too much?: local excision before radical surgery in early rectal cancer

  • Sun Min Park
  • Bong-Hyeon Kye
  • Min Ki Kim
  • Heba E. Jalloun
  • Hyeon-Min Cho
  • In Kyu Lee
Original Article



In early rectal cancer cases, the use of local excision is increasing. The general indication for local excision is based on the preoperative stage, but there is often a discrepancy between pre and postoperative stages. We sought to determine the indications for local excision in T1 rectal adenocarcinoma patients by comparing the preoperative clinical and postoperative pathological stages. A second aim was to compare the oncologic outcomes between local excision and radical resection.


Between 2004 and 2014, 152 T1 rectal adenocarcinoma patients were enrolled. We divided the subjects into two groups, local excision and radical resection, depending on the modality of treatment the patients initially received. The group of patients who underwent radical resection was subsequently subdivided into “excisable” and “non-excisable” groups based on the postoperative pathology.


Of 152 patients, 28 patients (18.4%) underwent local excision, while 124 patients (81.6%) underwent radical resection. Of 124 patients, in clinically suspected T2 or less and N0 (93) cases, 50 patients (53.8%) needed treatment beyond local excision, and local excision was sufficient for 43 patients (46.2%). The 3-year overall survival (p = 0.393) and 3-year disease-free survival (p = 0.076) between the local excision and radical resection groups showed no significant difference.


The clinical T stage was overestimated in more than half of the cases. Therefore, if cT1/2 tumors with cN0 are suspected preoperatively, local excision is initially recommended and will allow for determination of underlying pathology. The clinician can then decide whether to monitor or intervene with radical resection.


Early rectal cancer Treatment Local excision Preop stage Indication 


Compliance with ethical standards

This study was approved by the Institutional Review Board of the Ethical Committee of the College of Medicine, The Catholic University of Korea (XC15RIMI0107K).


  1. 1.
    Lev-Chelouche D, Margel D, Goldman G, Rabau MJ (2000) Transanal endoscopic microsurgery. Dis Colon Rectum 43(5):662–667CrossRefPubMedGoogle Scholar
  2. 2.
    Bailey HR, Huval W, Max E, Smith K, Butts D, Zamora L (1992) Local excision of carcinoma of the rectum for cure. Surgery 111(5):555–561PubMedGoogle Scholar
  3. 3.
    Killingback M (1992) Local excision of carcinoma of the rectum: indications. World J Surg 16(3):437–446CrossRefPubMedGoogle Scholar
  4. 4.
    Minsky BD (1993) Clinical experience with local excision and postoperative radiation therapy for rectal cancer. Dis Colon Rectum 36(4):405–409CrossRefPubMedGoogle Scholar
  5. 5.
    Minsky BD, Enker WE, Cohen AM, Lauwers G (1994) Local excision and postoperative radiation therapy for rectal cancer. Am J Clin Oncol 17(5):411–416CrossRefPubMedGoogle Scholar
  6. 6.
    Ota D, Skibber J, Rich TA (1992) MD Anderson Cancer Center experience with local excision and multimodality therapy for rectal cancer. Surg Oncol Clin North Am 1(1):147–152Google Scholar
  7. 7.
    Taylor RH, Hay JH, Larsson SN (1998) Transanal local excision of selected low rectal cancers. Am J Surg 175(5):360–363CrossRefPubMedGoogle Scholar
  8. 8.
    Bleday R, Breen E, Jessup JM, Burgess A, Sentovich SM, Steele G Jr (1997) Prospective evaluation of local excision for small rectal cancers. Dis Colon Rectum 40(4):388–392CrossRefPubMedGoogle Scholar
  9. 9.
    You YN, Baxter NN, Stewart A, Nelson H (2007) 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 245(5):726–733. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR (2002) Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 45(2):200–206CrossRefPubMedGoogle Scholar
  11. 11.
    Gagliardi G, Newton TR, Bailey HR (2013) Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome. Color Dis: Off J Assoc Coloproctology of G B Irel 15(11):e659–e664. CrossRefGoogle Scholar
  12. 12.
    Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43(8):1064–1071 discussion 1071-1064 CrossRefPubMedGoogle Scholar
  13. 13.
    Nascimbeni R, Nivatvongs S, Larson DR, Burgart LJ (2004) Long-term survival after local excision for T1 carcinoma of the rectum. Dis Colon Rectum 47(11):1773–1779CrossRefPubMedGoogle Scholar
  14. 14.
    Hahnloser D, Wolff GB, Larson WD, Ping J, Nivatvongs S (2005) Immediate radical resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum 48(3):429–437. CrossRefPubMedGoogle Scholar
  15. 15.
    Bikhchandani J, Ong GK, Dozois EJ, Mathis KL (2015) Outcomes of salvage surgery for cure in patients with locally recurrent disease after local excision of rectal cancer. Dis Colon Rectum 58(3):283–287. CrossRefPubMedGoogle Scholar
  16. 16.
    Weiser MR, Landmann RG, Wong WD, Shia J, Guillem JG, Temple LK, Minsky BD, Cohen AM, Paty PB (2005) Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum 48(6):1169–1175CrossRefPubMedGoogle Scholar
  17. 17.
    You YN, Roses RE, Chang GJ, Rodriguez-Bigas MA, Feig BW, Slack R, Nguyen S, Skibber JM (2012) Multimodality salvage of recurrent disease after local excision for rectal cancer. Dis Colon Rectum 55(12):1213–1219CrossRefPubMedGoogle Scholar
  18. 18.
    Salinas HM, Dursun A, Klos CL, Shellito P, Sylla P, Berger D, Bordeianou L (2011) Determining the need for radical surgery in patients with T1 rectal cancer. Arch Surg (Chicago, Ill : 1960) 146(5):540–543. CrossRefGoogle Scholar
  19. 19.
    Bentrem DJ, Okabe S, Wong WD, Guillem JG, Weiser MR, Temple LK, Ben-Porat LS, Minsky BD, Cohen AM, Paty PB (2005) T1 adenocarcinoma of the rectum: transanal excision or radical surgery? Ann Surg 242(4):472–477 discussion 477–479PubMedPubMedCentralGoogle Scholar
  20. 20.
    Brodsky JT, Richard GK, Cohen AM, Minsky BD (1992) Variables correlated with the risk of lymph node metastasis in early rectal cancer. Cancer 69(2):322–326CrossRefPubMedGoogle Scholar
  21. 21.
    Blumberg D, Paty PB, Picon AI, Guillem JG, Klimstra DS, Minsky BD, Quan SH, Cohen AM (1998) Stage I rectal cancer: identification of high-risk patients. J Am Coll Surg 186(5):574–580CrossRefPubMedGoogle Scholar
  22. 22.
    Cooper HS, Deppisch LM, Gourley WK, Kahn EI, Lev R, Manley PN, Pascal RR, Qizilbash AH, Rickert RR, Silverman JF (1995) Endoscopically removed malignant colorectal polyps: clinicopathologic correlations. Gastroenterology 108(6):1657–1665CrossRefPubMedGoogle Scholar
  23. 23.
    Goldstein N, Hart J (1999) Histologic features associated with lymph node metastasis in stage T1 and superficial T2 rectal adenocarcinomas in abdominoperineal resection specimens. Identifying a subset of patients for whom treatment with adjuvant therapy or completion abdominoperineal resection should be considered after local excision. Am J Clin Pathol 111(1):51–58CrossRefPubMedGoogle Scholar
  24. 24.
    Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki R, Fujiyoshi T, Uchida Y (1995) Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum 38(12):1286–1295CrossRefPubMedGoogle Scholar
  25. 25.
    Tanaka S, Haruma K, Teixeira CR, Tatsuta S, Ohtsu N, Hiraga Y, Yoshihara M, Sumii K, Kajiyama G, Shimamoto F (1995) Endoscopic treatment of submucosal invasive colorectal carcinoma with special reference to risk factors for lymph node metastasis. J Gastroenterol 30(6):710–717CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Sun Min Park
    • 1
  • Bong-Hyeon Kye
    • 1
  • Min Ki Kim
    • 1
  • Heba E. Jalloun
    • 1
  • Hyeon-Min Cho
    • 2
  • In Kyu Lee
    • 1
  1. 1.Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaSeoulKorea
  2. 2.Division of Colorectal Surgery, Department of Surgery, St. Vincent’s Hospital, College of MedicineThe Catholic University of KoreaSuwonKorea

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