Surgical Treatment Options for Rectal Carcinoid Cancer: Trans-Anal Excision Versus Low Anterior Total Mesorectal Excision

Yz Wang, MD, A E Diebold, BS, J P Boudreaux, MD, D Raines, MD, R Campeau, MD, L Anthony, MD, E A Woltering, MD. Louisiana State University Health Sciences Center


Background: The biological behavior of rectal carcinoids has not been fully studied and appreciated due to the rarity of the disease and thus, the optimal surgical treatment remains controversial. Oftentimes, primary tumors less than 2cm are assumed to be indolent and are treated by trans-anal excision. We hypothesized that rectal carcinoids are more malignant than previously described and small tumors may warrant more aggressive surgery than what has been traditionally recommended.

Methods: The charts of 62 consecutive rectal carcinoid patients seen at our institution between 10/2006 and 8/2011 were retrospectively reviewed. The size of the primary tumors, the extent of disease and basic survival data was collected for analysis.

Results: Thirty-two patients had localized disease only and three patients had lymph node metastasis without distant disease. All 35 patients are alive. Twenty-seven patients were found to have distant disease; 10/27 (37%) had succumbed to the disease. Stratified by size of the primary tumor, the chances of lymph node metastases are as follows: <1cm: 2/26 (8%); 1.1-2cm: 9/13 (69%); 2.1-3cm: 4/5 (80%) and >3cm: 7/12 (58%). Twelve (12/27, 44%) patients with distant disease were initially treated with trans-anal excision and two of them have died. One of these patients had a primary tumor size of only 1cm.

Conclusions: Rectal carcinoids are more malignant than previously portrayed. Primary tumors greater than 1 cm have a much higher rate of lymph node metastasis than what has been previously reported. We believe that tumors larger than 1cm should have a Low Anterior Resection (LAR) with Total Mesorectal Excision as their initial definitive treatment. For tumors less than 1cm, surgical treatment should be individualized. Trans-anal excision with a lifelong follow up is a reasonable choice. LAR with TME, in contrast, might be considered for young patients. Since, tumors of this size still carry an 8% chance of lymph node metastasis, and the potential of death from distant spread.

Session Number: SS20 – Colorectal
Program Number: S110

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