Local Therapy

Local therapies include snare polypectomy, local excision (wedge resection of the tumor either by endo-anal approach or by transanal endoscopic microsurgery), or endocavitary radiation. There are many advantages of local therapies, including minimal postoperative morbidity and mortality and rapid postoperative recovery. Local therapy minimizes the impact of rectal cancer treatment on long term function and in some cases is the only alternative to permanent colostomy. However, by definition, local therapies leave all lymph node-bearing tissue in situ. Thus, the major concern with local therapy is undertreatment. Criteria for lesions appropriate for local therapy with curative intent are evolving and controversial. Today, most experts agree that < 10% of rectal cancers are appropriate for curative intent local therapy.

As screening colonoscopy becomes more commonplace, the diagnosis of invasive cancer in a polyp will undoubtedly be made more often, and appropriate management of such early-stage cancer will become increasingly important. Polypectomy and observation may be appropriate for cancer arising in a polyp if the lesion fits the favorable criteria noted in Table 98-2 (Rothenberger and Garcia-Aguilar, 2002). However, radical resection is generally recommended for less favorable situations as noted in Table 98-3. Similarly, local excision or endocavitary radiation may be appropriate for curative intent treatment of rectal cancers with highly favorable features, that is, T1, small (< 3 to 4 cm in diameter), exophytic lesions with favorable histology (moderate or well-differentiated, nonmucinous, nonsignet cell with no lymphovascular or neural invasion), involving less than one-third of the circumference of the rectum, and located such that local therapy is technically feasible and safe. The local recurrence rate after local therapy alone even for such favorable lesions is disappointingly high (5 to 18%) and for this reason, some centers have combined local excision with pre- or postoperative chemoradiation (Rothenberger, 2000). Whether this approach will improve outcomes awaits further research. A previously more liberal approach to local excision, with the inclusion of T2 lesions, resulted in an unacceptably high recurrence rate and is not advised. There is general consensus that using local therapy for more advanced or more aggressive disease will expose the patient to an increased rate of recurrence and decreased cancer specific survival. A radical resection should be performed in such patients, unless severe comorbidities preclude a safe operation.

TABLE 98-2. Suggested Criteria for Polypectomy and Observation for Cancer in a Polyp

• Complete excision of lesion

• Well or moderately differentiated

• No lymphovascular invasion

• Haggitt levels 1, 2, or 3 in pedunculated polyps

• Haggitt level 4 (pedunculated or sessile polyp) with Situ invasion

Adapted from Rothenberger and Garcia-Aguilar, 2002.

TABLE 98-3. Suggested Criteria for Radical Colorectal Resection for Cancer in a Polyp

Strong indicators

• Incomplete excision of lesion

• Microscopic cancer at resection margin

• Haggitt level 4 (pedunculated or sessile polyp) with Sm3 invasion Relative indicators

• Poorly differentiated

• Lymphovascular invasion

• Excision doubtfully complete

• Haggitt level 4 (pedunculated or sessile polyp) with Sm2 invasion

Adapted from Rothenberger and Garcia-Aguilar, 2002. Reproduced with permission from Humana Press.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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