T2 low rectal cancer

[Grubbe-a-dub-dub]

Would anyone be inclined to treat a low rectal T2 adeno with XRT and a watch-and-wait approach, as opposed to a APR?

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[RickyScott]

If I was the pt would consider chemXrt and transanal microeccision

 

[Mandelin Rain]

I've done it if patient refuses APR. Otherwise, no.

 

[FrostyHammer]

The patient should be owed a fair, balanced discussion of the pros and cons of both approaches

 

[Mandelin Rain]

Definitely have been able to convert a handful to LAR with hand sewn anastomosis or transanal resection. Function is sometimes an issue, but whatever.

Not standard, but better than no treatment.

 

[deleted18755]

Definitely have been able to convert a handful to LAR with hand sewn anastomosis or transanal resection. Function is sometimes an issue, but whatever.

Not standard, but better than no treatment.

Ostomies have come a long way even within the past 10-15 years ... I worked with a nurse who had one (not due to cancer) who always joked that it’s easier to get used to a well functioning ostomy than a “crappy” anus!

In this case though potential impact on survival is obviously also an issue.

OP: how old is the patient/what’s his anticipated survival otherwise, any concerns with tolerating an APR, etc

 

[Mandelin Rain]

For sure. There is literature that QOL is better with an ostomy than a poor functioning anus. I try my best to impress this upon people, but they often don’t get it until they are soiling diapers 3-5 times per day.

 

[RickyScott]

For sure. There is literature that QOL is better with an ostomy than a poor functioning anus. I try my best to impress this upon people, but they often don’t get it until they are soiling diapers 3-5 times per day.

Had an Excon tell me that ostomy makes you a real target in prison.

 

[Mandelin Rain]

Had an Excon tell me that ostomy makes you a real target in prison.

That is the grossest thing I’ve heard in weeks.

 

[deleted205418]

Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial - PubMed

National Cancer Institute and Sanofi-Aventis.

www.ncbi.nlm.nih.gov

Could consider offering this approach if patient would have met eligibility criteria

 

[OnePunchBiopsy]

Neoadjuvant ChemoXRT is increasing in popularity for patients with low rectal cancers. Hope is to increase the odds of doing an LAR with good margins over an APR, especially for younger patients.

 

[Grubbe-a-dub-dub]

Thank you all for the feedback - I find this forum really helpful for these pesky questions that are not quite answered by trials or the guidelines.

Similar questions - when would you offer post-op RT for T1 with high risk features or T2 lesions removed by transanal excision? What are your high risk criteria and distance for a comfortable margin?

 

[Mandelin Rain]

Isn't there a rule of 2 for transanal excisions?

<T2
<2cm
>/= 2mm margins
</= sm2 invasion
</= Grade 2

 

[BobbyHeenan]

Thank you all for the feedback - I find this forum really helpful for these pesky questions that are not quite answered by trials or the guidelines.

Similar questions - when would you offer post-op RT for T1 with high risk features or T2 lesions removed by transanal excision? What are your high risk criteria and distance for a comfortable margin?

Often for a T2 lesion where patient is refusing standard of care APR, our surg oncs present them for consideration of adjuvant chemo-XRT no matter what margins are. There are relatively high (at least compared to TME/APR/LAR) recurrence rates with T2 trans anal surgery with XRT adjuvant, so I'd imagine without adjuvant XRT it's even higher.

So I typically offer adjuvant XRT in a T2 trans anal case regardless of any other path features if patient is refusing a more standard surgery.

If T2 up front on MRI or EUS and patient refusing APR/TME, then I think very reasonable to give the radiation pre-op like the other ACOSOG trial posted above.

Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984 - PubMed

Local excision alone for T1 rectal adenocarcinomas is associated with low recurrence and good survival rates that remain durable with long-term follow-up. T2 lesions treated via local excision and adjuvant therapy are associated with higher recurrence rates.

www.ncbi.nlm.nih.gov