Transanal excision with radiation therapy for rectal adenocarcinoma

Objective: To evaluate the efficacy of transanal excision (TAE) combined with radiotherapy for rectal adenocarcinoma, assess the ability of pretreatment endoscopic ultrasound (EUS) to predict failures, and determine the prognostic value of downstaging and complete pathological response. Design: Retrospective outcomes study. Setting: Radiation oncology clinic. Participants: Thirty-eight patients with rectal adenocarcinoma. Methods: The medical records of patients treated with radiotherapy from 1998 to 2008 and followed for a median of 5.9 years were reviewed. Results: Kaplan-Meier estimates of freedom from selected endpoints at 5 years after treatment were: overall survival, 79%; cause-specific survival, 91%; local control, 90%; and freedom from distant metastasis, 76%. Seven patients (21%) had eventual abdominoperineal resection or lower anterior resection, four patients had local recurrence, and three patients had incomplete treatment or poor margins. T3 lesions clinically staged by EUS were a predictor of local failure (P=0.0110), but not distant metastasis (P=0.35). Patients with either a pathological or clinical T3 lesion did not have a significantly greater rate of metastasis (P=0.096). Patients who were downstaged did not have a significantly different rate of local recurrence or metastasis. Patients who experienced a complete pathological response did not have a significantly different rate of local control or distant metastasis. Conclusion: Patients with early-stage rectal lesions who undergo preoperative or postoperative radiation and TAE have similar outcomes to those who undergo abdominoperineal resection; local recurrence was higher for patients with T3 lesions when both were compared. Abdominal surgery should be considered for these patients. TAE is reasonable when patients are unwilling or unable to tolerate the morbidity of traditional transabdominal surgery.