Therapeutic Strategies

Once local and general staging have been completed, the decision to proceed with a curative LE should be taken after evaluating other important aspects (Fig. 3)

such as the size of the lesion, its position in the rectum, the functional status of the anal sphincters, and the route the surgeon intends to follow: either transsacral, trans-sphincteric or transanal. The advantage of LE over other local treatments is that the lesion can be retrieved at the end of the operation for thorough histological examination, allowing for further treatments should any adverse factor come up [10].

In the literature, local recurrence after curative LE is reported from 0 to 18% in T1 cancers and from 11 to 47% in T2, compared to 4-30% local recurrence after radical rectal resection [2, 5,10]. Mellgren et al., comparing the results of LE with respect to radical rectal resection showed 18% of local recurrence in T1 patients and survival rate significantly reduced in T2 after LE compared to radical surgery (65 vs. 81%), concluding that curative LE is contraindicated for T2 cancers, while in T1 there is a high risk of recurrence [5].

Fig. 3. Clinical evaluation flowchart

Both short- and long-term results seem unsatisfactory when surgical margins are involved, in cases of poor histology and when lymphovascular infiltration is present. In these cases the majority of Authors suggest an immediate radical rectal resection, with long-term results substantially similar to those after primary rectal resection. On the contrary, long-term results after salvage surgery, carried out only after the recurrence has occurred, are very poor. In fact, 5-year disease-free survival after immediate radical surgery is 94.1% vs. 55.5% after salvage surgery [2, 5, 24, 25]. The biological behaviour of the recurrence is probably different after LE and after rectal resection because in the former case the recurrence is related to the bowel wall, while in the latter it is related to the pelvis. As a matter of fact salvage surgery for recurrence after LE is higher with respect to salvage surgery after abdomino-perineal resection or anterior rectal resection [2]. Hershman et al. in a recent study on long-term results after LE [26], sustain that local recurrence rates are unacceptably high, with mortality rates that worsen with time as evidenced in 10-years, follow up, and advise against LE as a curative procedure.

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