We have read with great interest the article by Johnston et al,1 who suggest a decision analysis for patients with T1 adenocarcinoma of the low rectum. We believe that the article presents 2 major drawbacks. In Table 1, the authors 1 include in local excision (LE) both transanal endoscopic microsurgery (TEM) and classical transanal local excision (TLE), techniques that we do not consider comparable. International literature has demonstrated the superiority of TEM vs TLE. Moore et al 2 and de Graaf et al 3 showed that TEM was more likely to yield clear margins (90% vs 71%, p = 0.001 and 88% vs 50%, p < 0.001) and a nonfragmented specimen (94% vs 65%, p < 0.001 and 98.6% vs 76.2%, p < 0.001) than TLE. Moore et al 2 (5% vs 27%), Middleton et al 4 (6% vs 22%), and de Graaf et al 3 (6.1% vs 28.7%) reported a significantly reduced recurrence rate for TEM in comparison with TLE. Moreover, T1 rectal cancer is an heterogeneous clinical entity, presenting 3 depths of invasion: sm1 to sm3.5,6 The depth of submucosal invasion represents a major prognostic factor of recurrence after LE: 0% for sm1 vs 22.7% for sm2 to sm3.7,8 In addition, pT stage, grading,7 and size >3 cm 8 are independent predictors of recurrence. Therefore, although we agree that LE plays a fundamental role in the modern treatment of early rectal cancer, we believe that, when LE is indicated, TEM should be the technique of choice. Furthermore, different clinical strategies should be proposed for T1sm1 compared with T1sm2/3, aside from decision analysis.
Comments on Decision Analysis for Patients With T1 Adenocarcinoma of the Low Rectum
AREZZO, Alberto;MORINO, Mario
2013-01-01
Abstract
We have read with great interest the article by Johnston et al,1 who suggest a decision analysis for patients with T1 adenocarcinoma of the low rectum. We believe that the article presents 2 major drawbacks. In Table 1, the authors 1 include in local excision (LE) both transanal endoscopic microsurgery (TEM) and classical transanal local excision (TLE), techniques that we do not consider comparable. International literature has demonstrated the superiority of TEM vs TLE. Moore et al 2 and de Graaf et al 3 showed that TEM was more likely to yield clear margins (90% vs 71%, p = 0.001 and 88% vs 50%, p < 0.001) and a nonfragmented specimen (94% vs 65%, p < 0.001 and 98.6% vs 76.2%, p < 0.001) than TLE. Moore et al 2 (5% vs 27%), Middleton et al 4 (6% vs 22%), and de Graaf et al 3 (6.1% vs 28.7%) reported a significantly reduced recurrence rate for TEM in comparison with TLE. Moreover, T1 rectal cancer is an heterogeneous clinical entity, presenting 3 depths of invasion: sm1 to sm3.5,6 The depth of submucosal invasion represents a major prognostic factor of recurrence after LE: 0% for sm1 vs 22.7% for sm2 to sm3.7,8 In addition, pT stage, grading,7 and size >3 cm 8 are independent predictors of recurrence. Therefore, although we agree that LE plays a fundamental role in the modern treatment of early rectal cancer, we believe that, when LE is indicated, TEM should be the technique of choice. Furthermore, different clinical strategies should be proposed for T1sm1 compared with T1sm2/3, aside from decision analysis.
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