ReviewOutcomes following completion and salvage surgery for early rectal cancer: A systematic review
Introduction
Four major goals exist in the treatment of a patient with rectal cancer: disease control, long-term survival, preservation of anal sphincter, urinary, and sexual functions, and maintenance or improvement in quality of life [1]. Historically, aside from improvements in neo-adjuvant treatment, surgical approaches mainly focused on radical oncological resection by either low anterior resection (LAR) or abdominoperineal excision (APE) even for early rectal cancer (ERC). More recently, local excision (LE) of ERC by either transanal endoscopic microsurgery (TEM) or transanal minimally-invasive surgery (TAMIS) has become an accepted treatment in selected patients, with the advantages of reduced post-operative morbidity and mortality, and less impairment of quality of life. The increase in LE has raised two particular issues. Firstly, current pre-operative staging is imperfect; histopathology may show cancers to be more advanced than anticipated and/or reveal unfavourable features, raising the question of whether and when a completion procedure should be undertaken. The second issue is how best to salvage the situation if local recurrence occurs. These two situations can be considered as ‘completion’ and ‘salvage’ surgery respectively.
However these terms are not consistently used in the current literature. We define ‘completion surgery’ as a procedure with curative intent undertaken on the basis of histopathology showing a more advanced cancer than anticipated. We use ‘salvage surgery’ for a surgical procedure with curative intent following the development of local recurrence. Some papers refer to completion surgery as ‘early salvage’; this is confusing as it does not sufficiently differentiate between the two different situations of a) performing more extensive surgery to remove the mesorectum and regional lymph nodes as part of the primary treatment strategy to reduce the risk of later recurrence, and b) dealing with local recurrence once it has occurred.
The literature on completion and salvage surgery is limited as these procedures are relatively rare; most series lack both a sufficient number of patients and adequate follow-up. Furthermore, historical data can be misleading due to different patient populations and poor definition. Our impression is that these techniques carry greater risk than is recognised in the literature, and therefore LE may be undertaken without adequate consideration of the potential consequences. As ERC and LE become more common, a good evidence base of outcomes is necessary to inform both surgeons and patients when deciding to proceed with further surgery. Our objective is to establish the outcomes after completion and salvage surgery in the recent literature to inform decision-making in this situation.
Section snippets
Methods
The review was registered with PROSPERO (number CRD42014014758) and published on the database on 4th November 2014.
Study selection
The PRISMA diagram is shown in Fig. 1. Only records providing specific outcome information for patients having completion and/or salvage surgery after LE of rectal cancer were included. A few studies included both completion and salvage surgery patients but only provided specific outcome information for the salvage surgery patients; completion surgery patients without outcome data in these studies were not included in this review.
In total, 23 cohort studies were included [3], [4], [5], [6], [7]
Completion surgery
Of the ten studies [4], [5], [6], [7], [10], [16], [17], [18], [19], [25] covering completion surgery, four [5], [6], [7], [25] looked specifically at completion surgery, although only two [5], [6] used this term; operations were otherwise referred to as early or immediate salvage, or just additional radical surgery.
Salvage surgery
Of the 15 studies covering salvage surgery, two [3], [24] focussed specifically on salvage surgery.
Discussion
Few studies involving completion surgery used this term. An important first step in generating usable data on outcomes after radical surgery following LE is international agreement about terminology. We propose the terms ‘completion’ and ‘salvage’ surgery. The Oxford group defined completion surgery as ‘surgery carried out after local excision to complete surgical treatment of the primary tumour. This is applied to patients with an inadequate or unclear resection margin following local
Conflicts of interest and source of funding
None declared.
Funding and support
Nil.
Author contribution
H Jones: study conception and design, analysis and interpretation of data, writing manuscript and final approval of version to be published.
C Cunningham: study conception and design, critical revision and final approval of version to be published.
G Nicholson: study conception and design, acquisition of data, drafting article and final approval of version to be published.
R Hompes: study conception and design, critical revision and final approval of version to be published.
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2022, European Journal of Surgical OncologyCitation Excerpt :This was previously addressed by our study group [24]. Finally, there is no consensus on the specified time interval for when to still define additional surgery as ‘completion surgery’ or when to define it as ‘salvage surgery’ [33]. A 6-month cut-off has been described previously [18,19].
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2022, Surgical OncologyCitation Excerpt :The proportion of salvageable recurrences is varies between 73% and 92% [66–70]. However, overall survival in case of local recurrence seems poor and is estimated on 50% [71]. If treatment of high-risk tumours consists of local excision only, close surveillance should aim for early detection of local recurrence and the subsequent opportunity of salvage surgery.
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2021, Cirugia EspanolaCitation Excerpt :This may negate sphincter preservation and patients may instead opt for cCRT owing to the possibility of an organ-preserving strategy with no survival detriment and without incurring an unreasonable risk of LR. CRT after LE is associated with a trend toward a reduced rate of LR, even for high-risk disease.76 The toxicity of CRT needs to be taken into account and also communicated to the patient prior to any treatment decision.
Preoperative radiotherapy and local excision of rectal cancer: Long-term results of a randomised study
2018, Radiotherapy and OncologyCitation Excerpt :It is thus likely that LE of residual scar reduces the risk of local recurrence compared to a watch-and-wait strategy. The rate of successful salvage surgery is however higher after a watch-and-wait approach [28,29] than after LE [31]. It is therefore likely that survival and the final rates of an uncontrolled primary tumour are similar in both strategies.
Prognostic value of the ratio of pretreatment carcinoembryonic antigen to tumor volume in rectal cancer
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