Nucleotide-guided Mesorectal Excision (ngme) During Tem for Rectal Cancer: Preliminary Results

INTRODUCTION: TEM is used for local excision of T1N0 rectal cancer and in selected T2-T3 N0 cases after neoadjuvant radiochemotherapy. TEM usually removes few mesorectal lymph nodes adjacent to the tumor, which may leave the histopathological N parameter undefined. This may be a criticism to the use of TEM to treat T2-T3 patients. Aim is to evaluate the role of NGME during TEM to increase the lymphnode harvest and to improve staging.
METHODS: From September 2005 to June 2009, 23 patients (pts) (13 males, 10 females, mean age 65 years, range 37-87 years) underwent TEM with NGME for rectal adenocarcinoma. Pre-treatment staging was: T1 N0 11 pts, T2 N0 7 pts, T3 N0 2 pts, T3 N1 3 pts. Pre-treatment median tumor size was 3 cm (range 1-8 cm). Twelve pts underwent neoadjuvant radiochemotherapy, with tumor downsizing in all of them. Pre-operative staging was T1 N0 13 pts, T2 N0 8 pts, T3 N0 2 pts. At surgery, 99m-Technetium-marked nanocolloid was injected in the peritumoral submucosa 45 minutes before excision. After excision, the site was explored with a transanal probe in order to detect any residual radioactivity. If present this was marked with metal clips and excised by TEM. Hot lymphnodes were processed by immuno-histochemistry.
RESULTS: Median tumor distance (distal margin) from anal verge was 5.5 cm (3-15 cm). Mean operative time was 85.6 min (50-300 min). Median time to passage of stool was 2 days (1-4 days) and median hospital stay was 5.1 days (2-13 days). Morbidity included fever and pain in 4 pts each, and soiling in 3 cases. Mortality was nil. With improving experience in radioguided surgery the mesorectal lymphnode harvest has increased from 0 to 10. No micrometastases were observed. Final pathology report was Tis No 2 pt, T1 N0 9 pts, T2 N0 9 pts, T3 N0 2 pts, T2 N1 1 pt. The latter patient underwent low anterior resection with total mesorectal excision (TME), and pathological classification was N0. At mean follow up of 16.4 months (range 2-32 months) 22 pts are alive and disease-free. One patient died from unrelated causes 2 months after excision of T1 N0 rectal cancer.
CONCLUSIONS: NGME during TEM increases the lymphnode harvest and it may improve the accuracy of staging after TEM, although no conclusive data can yet be drawn.


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Program Number: P143

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