O. K. Jawitz1, M. Adam2, M. Turner1, J. Migaly1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA
Introduction: Despite clinical guidelines classifying T2 rectal cancer as a contraindication for transanal local excision due to unacceptably high rates of local recurrence, it is a practice that persists clinically. It is unknown how this practice has changed in recent years.
Methods: The 2004-2015 National Cancer Database (NCDB) was queried for patients with pathologic stage T2 rectal adenocarcinoma who underwent surgical intervention. Patients were stratified into transabdominal resection and transanal local excision cohorts on univariate and multivariate analyses. Postoperative survival was compared between groups using Kaplan-Meier and Cox Proportional Hazard models. The proportion of cases performed as local excision was evaluated by year.
Results: A total of 34,243 patients met inclusion criteria, including 30,507 patients (89.1%) who underwent resection and 3,736 patients (10.9%) who underwent transanal local excision. In unadjusted analysis, patients who underwent local excision were older (median age 69.7 vs. 63.2, p<0.001), more likely to have government insurance (64.0% vs. 49.6%, p<0.001), and were less likely to undergo radiation therapy (41.5% vs 59.7%, p<0.001) or chemotherapy (37.8% vs. 63.1%, p<0.001). Transabdominal resection patients had improved postoperative survival on Kaplan-Meier analysis (Figure, p<0.001). On multivariate Cox Proportional Hazard regression, local excision remained an independent predictor of patient mortality (HR 1.28, p<0.001).
Conclusion: Transanal local excision for T2 rectal cancer is associated with decreased survival and is not supported by national clinical guidelines. Despite this fact, it is a practice that has persisted at a relatively stable frequency over the past twelve years. Patients who undergo transanal local excision with the addition of chemoradiation may achieve survival rates similar to those who undergo transabdominal resection without the addition of chemoradiation.
