Predictors of recurrence after local excision.

Local management of rectal cancer has been used for over 5 decades. This technique has established itself as a viable alternative. During these 5 decades, however, there has been increasing attention to more clearly define the patients who are best served by this technique. Physical examination has been the mainstay of this evaluation. The astute surgeon has learned to evaluate tumors and accurately predict their depth of invasion. Our previous work suggested that tumors which were ,3 cm and well differentiated were managed preferably by local excision. The authors of this study in this issue of Annals of Surgical Oncology, Dr. Bouvet and co-workers, support this finding. Clearly T1 lesions are best managed by transanal local excision with minimal morbidity in a long-term salvage. The authors point out the importance of complete removal. The most significant predictor of failure is a positive surgical margin. The second lesson that can be learned from this article is that positive surgical margins cannot be corrected by radiotherapy. Complete surgical extirpation is a hallmark of adequate treatment. The authors take earlier studies, however, and carry them further by characterizing the tumors by the newer tumor, node, metastasis (TNM) classification, which is helpful. They point out that T2 and T3 lesions are at increased risk for recurrence. They have confirmed the feelings which many of us have had, that radiotherapy may help to treat a T2 and T3 lesion. This is an observation that will never be adequately subjected to randomized prospective study, and therefore, large series such as this one become very important in understanding the role of radiotherapy. Finally, the authors point out that T3 lesions are not managed best by local excision with or without radiotherapy. In this group of patients, and perhaps in many T2 patients, one will selectively choose to do a proctectomy with lymphadenectomy. Also of significance is the fact that the patterns of recurrence suggest that two thirds of the patients will relapse with distant disease. This pattern of failure most likely will not be affected by proctectomy and lymphadenectomy. When tumors return locally, most of these patients can be salvaged. Therefore, if one is going to treat a patient with local techniques, then close follow-up is mandatory. Local management of colorectal cancer needs to be in the armamentarium of anyone managing rectal cancer. It has an important role. Historically, we have managed about 10% of our patients with this technique. However, with increasing understanding of the relative advantages and role of radiotherapy to augment traditional local surgical techniques, it is likely that this technique will play an even more important role in the management of our patients. Received September 17, 1998; accepted September 25, 1998. From the University of Southern California School of Medicine, Department of Surgery, Los Angeles, California. Address correspondence to: Robert W. Beart, Jr., MD, University of Southern California School of Medicine, Department of Surgery, 1510 San Pablo Street, #514, Los Angeles, CA 90033-4612. Annals of Surgical Oncology, 6(1):2 Published by Lippincott Williams & Wilkins © 1999 The Society of Surgical Oncology, Inc.