Low rectal tumor surgical options - LAR vs. APR

[weisssoccermom]

Like Terry I also had a transanal excision. To answer your questions, I was dxd as a T3 but there has been some discrepancy about that - late T2 or potential T3??? To this day, the opinions still differ. I also had neoadjuvant chemoradiation. Just 'celebrated' three years since my last treatment. I am ecstatic about my quality of life issues - there are none. No 'accidents', perfectly normal BMs, etc. but.......everyone is different and to be truthfully honest, even with me being on the cusp of a stage I/II (because of the T2/T3 thing), a full thickness transanal excision isn't for everyone or every situation.

After reading all the different posts, I don't know what I would do in your case. Honestly, I do feel, in my opinion, that the two surgeries - LAR v APR - are probably equal in 'risk' but if your tumor truly is that low, then you may want to seriously think about the quality of life aspect. One of my biggest questions would have to be with the LAR ...just how likely is it that there wouldn't be bowel issues??? That was a HUGE factor for me and my tumor wasn't located as close to the sphincter as yours is. Certainly none of this is what any of us expected or wanted but it's the hand we are dealt. I also am not sure just how realistic the surgeon can be about a patient's quality of life afterwards because I truly don't think they know when...even when the tumor is located higher up. Let's face it....you take out the majority of all of the rectum and your life is bound to be different. This truly is a tough decision and only you can decide what factors are important for you.

Good luck.
Jaynee

[Surroundedbylove]

I haven't commented on this thread much but I thought I'd mention my experience in case it helps make a decision. My tumor wasn't nearly as low. It was 10 cm from the anal verge approximately. It was a 6 cm T3 tumor that shrunk to 1cm with chemoradiation and was a virtually complete response - there were only a few minute foci of cancer cells left in the tumor sprinkled throughout that 1 cm. My LAR was successful and I've had a decent adaptation to bowel movements after my reversal surgery. I'm one of the "success" stories for adaptation. That being said, I still have to very, very, very carefully plan my food, my bathroom availability, and plan for urgency and frequency. I can live a very normal life but there still is an impact. For example, we have friends who have a wonderful party boat - like a houseboat. It can hold about 30 people and they frequently have great parties on the boat. There is one bathroom. Normally not a problem in a party context. However, I really can't do that right now because I have clustering and frequency from time to time and you never know when it is going to hit.

Just some thoughts.

[dschreffler]

<<added 6/10/2010: I had new data since this and choose TAE, see my posts later in this thread for a complete perspective!>>
Since you all shared so much with me, I'll try to return the favor and share where my head is at and how I got to the decision.

It took a while, and I was lucky enough to be in a postion to research the possibilities and provide guidance to the surgen on my wishes, not leave it up to them entirely.
However, I also know that once the surgeon begins their work, may find that based on cancer/anatomy, your only option may be APR. So I prepared and have accepted this as a possible outcome.

But assuming I have a choice, here is my process and what I decided - your mileage will vary.

1) Get opinions of 2-3 surgeons - experts in the field - I know insurance coverage will constrain who, where, and how many. Don't settle for 1 perspective. In my case I chose the top colorectal folk in Scranton, Johns Hopkins, and MSKCC.
2) Understand standard of care for stage and location of your cancer - readily avaiable on http://www.cancer.org, http://www.cancer.gov.
3) Ask the hard questions about both short and long term risks of each treatment option. Setting the expecation before the surgury will help deal with what actually is reality after surgery. Ignoring them will not change the odds of your outcome.
4) Get statisicial information from clinical studies with large numbers in the study. http://www.ncbi.nlm.nih.gov/pubmed/
5) Look and ask for first hand accounts from reputable internet forums like this Colonclub.com, uoaa.org, csn.cancer.org, to consider risks, results, and complicartions that you may not have thought of. This first hand informaiton is good, but always counter with statical studies as responses on the boards are only one perspective and not a scientific study. In fact, take what i write with a grain of salt and do your own dang homework!
6) Know thyself - what are your priorities - what can you deal with - what is the worse case. Again, setting expectations before hand.
7) Don't rush the decision and bounce it off a loved one - preconceptions about treatment, emotion, can have you deciding before you should. I found trying to explain to my wife and a good friend why i thought something was a good idea exposed helped me to really decide if I was right. The danger is their fears/prejudices can cause more confusion I pushed my decision to the edge of when I should as I am looking at 10-12 weeks post neoadjuctive vs 6-8 that is normal.

My priorities
1) Cure the dang cancer
2) Quality of life - as in functional urinary, sexual and fecal control.
3) Balance surgery and recovery time vs benefit of surgery. How much time do you want to spent in a hospital/recovery vs how much time living a life vs how much time will you be managing your decsion for rest of life?

My options
All 3 recommended neoadjuctive chemo/radiation and post surgery chemo. In my case I responded very well to chemo/radiation with tumor no longer visible in the scoping 5 weeks after chemo/rad.
Given the tumor downstaging, my age 45, good health, no medications, I got 3 very different options for surgery.

1) Transanal excision (TAE), do a pathology, and if no signs of cancer monitor closley, else perform APR. Really attractive as TAE is outpaient, with low surgical risk or complications. Ruled out as not standard of care for T3, no significant study that show this option has low reoorrance or high long term surivcal rates. Also, if fails, then LAR no longer an option in my case.
2) APR + TME - the standard for removal of cancerous tissue in colon. Enables larger margins for tissue removal. Very tempting given less surgeries, a little shorter recovery time, and controlled incontinece (into a bag) better then in your pants should LAR not work out. Downside is bag maintence for life.
3) LAR + TME - emerging standard as recent studies show onocological results similar to APR. Depending upon the patient, this provides a mean to remove cancer and not have to have a colostomy. Need to weigh the possibility of fecal incontinence and a longer recovery time - 6-18 months. Some possibility of never being continent and need to do APR.

And my choice is: LAR + TME.
1) cancer removal - Onocological results for APR and LAR the same, TAE too risky - even for stage 1 appears unreliable
2) quality of life - recent sudies showing LAR with j-pouch has good return of continence at 6 months post surgery and improving over time. If it would not work in my case, then can revert to APR.
3) balance surgery and recovery time vs benefit of surgery.

Ideally I'd like to do LAR+TME, do the reversal, then the chemo as I think bowel recovery will be quicker, but will depend upon pathology from surgery and if I can get agreement from Sloan.

Below are some of the studies I used:

OVERVIEWS:
2009: M. McCourt - Rectal cancer
http://www.ncbi.nlm.nih.gov/pubmed/19580180

2006: Geibel - Modern management of rectal cancer: A 2006 update
http://www.wjgnet.com/1007-9327/12/3186.pdf

2004: Chessin - Surgical Issues in Rectal Cancer: A 2004 Update
http://www.ncbi.nlm.nih.gov/pubmed/15555204

2003: McNamara - Methods and Results of Sphincter-Preserving Surgery for Rectal Cancer
http://www.ncbi.nlm.nih.gov/pubmed/12794619

1997: Surgical Treatment of Colorectal Cancer
http://caonline.amcancersoc.org/cgi/rep ... /2/113.pdf

2005: Rengan - Distal cT2N0 Rectal Cancer: Is There an Alternative to Abdominoperineal Resection?
http://www.ncbi.nlm.nih.gov/pubmed/16051945

Outcome/Quality of life - TME and preoperative radiation, LAR, APR:

2010: The relation between illness cognitions and quality of life in people with and without a stoma following rectal cancer treatment
http://www3.interscience.wiley.com/jour ... 0/abstract

2009: Krouse - Health-related quality of life among long-term rectal cancer survivors with an ostomy: manifestations by sex.
http://www.ncbi.nlm.nih.gov/pubmed/19720920

2004: Marijen - Impact of Short-Term Preoperative Radiotherapy on Health-Related Quality of Life and Sexual Functioning in Primary Rectal Cancer: Report of a Multicenter Randomized Trial
http://journal.shouxi.net/qikan/article.php?id=214507

2003: Engel - Quality of Life in Rectal Cancer Patients
http://www.ncbi.nlm.nih.gov/pubmed/12894013

2001: Grumann - Comparison of Quality of Life in Patients Undergoing Abdominoperineal Extirpation or
Anterior Resection for Rectal Cancer
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421194/

2008: Lange - Faecal and Urinary Incontinence after Multimodality Treatment of Rectal Cancer
case study and discussion ofpossible issues and how to address.

http://www.ncbi.nlm.nih.gov/pmc/article ... ool=pubmed

2002: Minsky - Sphincter Preservation for Rectal Cancer: Fact or Fiction?
http://jco.ascopubs.org/cgi/content/full/20/8/1971

2004: Rauch - Quality of Life Among Disease-Free Survivors of Rectal Cancer
http://www.ncbi.nlm.nih.gov/pubmed/14722043

2007: Chamiou - Long-term results of intersphincteric resection for low rectal cancer.
http://www.ncbi.nlm.nih.gov/pubmed/18043092

2000: Gamagami - Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses.
http://www.ncbi.nlm.nih.gov/pubmed/10715984

2005: DAI - Preservation of the continence function after intersphincteric resection using a prolapsing technique in the patients with low rectal cancer and its clinical prognosis.
http://www.cmj.org/Periodical/PDF/2008101650923570.pdf

2005: Schiessel - Technique and long-term results of intersphincteric resection for low rectal cancer.
http://www.ncbi.nlm.nih.gov/pubmed/16086223 (NEED)

2005: Rullier - Sphincter Saving Resection End of the 2 cm Rule?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1409892/

2001: Rullier - Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum.
http://www.ncbi.nlm.nih.gov/pubmed/11685026

[PGLGreg]

My 2a rectal cancer was 5cm above the anus. Is that "low"? From reading the thread, I don't think so, so maybe my experience is not relevant. But I get the impression that some think incontinence issues are likely after an LAR, so I thought I'd note here that I never did have any such problems.

[Surroundedbylove]

I pushed my decision to the edge of when I should as I am looking at 10-12 weeks post neoadjuctive vs 6-8 that is normal.

Actually, the newer studies (sorry - don't have the quotes - my surgeon sharted them with me though - at least one was British Journal of Cancer and one was s surgical journal) are showing benefit in waiting to 10-12 weeks post neoadjuvant treatment rather than the 6-8 weeks. The tumor continues to shrink and the residual chemo radiation is still working. By waiting longer, the tumor may be smaller to resect and the surrounding tissue healthier so the surgery is easier on the patient. Also the docs have a better assessment of complete response, near-complete response, or other less responsive categories. These have significant prognostic meaning. So, you're just where you should be it sounds like!

Good luck with the surgery and you did many people in the years to come the favor of your detailed approach to your decision. Good decision "tree"

SBL

[BrownBagger]

My tumor was not terribly low. I had an LAR with a colonic j-pouch following chemo-radiation. All that was left of the T3 tumor was .7 mm--seven tenths of a millimeter, so the chemo/rad worked pretty well.

My bowel function has steadily improved post-reversal. I recently started taking Metamucil and that's been a quantum leap forward. No more constipation and more accomplished at each sitting. I still have days when I cluster, but I like to think of it as productive clustering.

My bottom line lately is that the only issue I have relating to my bowel function is comfort: I use the bathroom at my convenience, but "holding it" is not always as comfortable as one might like. In that respect, it's not much different than before I had the tumor. I'm averaging about 2-3 times a day, vs. 1-2 before.

[dschreffler]

Serendipity - TAE chosen over APR and LAR - scheduling miscues and insurance hassles allowed me to continue my research and meeting again with local surgeon and oncologists; read a couple more studies, and got some more first hand accounts from folk.

Recap on the options:
1) Transanal excision (TAE), do a pathology, and if no signs of cancer monitor closely for years (key!), else perform more radical surgery. Really attractive as TAE is outpaient, with low surgical risk or complications. Not standard of care for T3, but studies starting to show outcomes in line with other options, and chemo before/after the key. If fails, then LAR no longer an option in my case.
2) APR + TME - the standard for removal of cancerous tissue in colon. Enables larger margins for tissue removal. Very tempting given less surgeries, a little shorter recovery time, and controlled incontinece (into a bag) better then in your pants should LAR not work out. Downside is bag maintence for life.
3) LAR + TME - emerging standard as recent studies show onocological results similar to APR. Depending upon the patient, this provides a mean to remove cancer and not have to have a colostomy. Need to weigh the possibility of fecal incontinence and a longer recovery time - 6-18 months (or more). Some possibility of never being continent and need to do APR.

And my choice is: TAE + more chemo
This approach was heavily favored by both my local surgeon and oncologist given my reponse to the chemo and radiation so far, as well as my youthful age of 45.
1) cancer removal - Onocological results in line with other options provided post surgery chemo and with proper surveillance (scope/ultra sound every 3 months for 2 years. CT every 6 months.)
2) quality of life - Expecting little impact on fecal control or impact to sexual/urinary function short term and more importantly long term..
3) Balance surgery and recovery time vs benefit of surgery. The least recovery time due to surgeries or any option.

Surgery is scheduled for 6/15/10.

Supporting studies:
These studies have a small sample size, so I know this is not standard of care as generally APR or LAR the recommendation.

2008: Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum
26 men and 18 women. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively.

2004: Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients
Actuarial overall survival at 5 years was 86% in the local-excision group compared with 81% among mesorectal-excision patients (p = NS), and 85% in patients with a complete clinical response to chemoradiation followed by mesorectal excision by APR or LAR (p = NS).
26 patients.
In an experience stimulated by patient refusal of APR, highly selected patients who responded well to conventional external-beam radiotherapy (CXRT) were selected to undergo local excision. Most of these patients had pathologic complete response. Local control and survival rates are comparable to those achieved with chemoradiation followed by mesorectal excision. This strategy should be prospectively studied in a group of patients with low rectal cancer who have no clinical evidence of tumor after chemoradiation.

2002: Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy
11 patients
CONCLUSIONS: In patients who have initial bulky (T3) lesions, and experience significant downstaging after neoadjuvant chemoradiotherapy, transanal excision appears to be a safe and effective treatment, preserving sphincter function and avoiding laparotomy.

[rickker20]

T3 is a serious tumor it's on the last layer of Rectum. I decide to have the LAR because I felt I would be taking a big risk with TAE. I did not want this cancer to come back. The TAE sound all good but the risky is to high.

[weisssoccermom]

Rickker20,

I don't want to start something here but I am going to disagree with you at least on part of what you said. There have been studies done - Dr. David Medich in Pittsburg, Dr. Angelita Habr-Gamma that have shown that when certain criteria are met, the full thickness transanal excision is a viable and equal option. The difficulty is in finding those patients who meet the criteria. Unfortunately, too many surgeons only like to quote the statistics for the excision recurrence from 20+ years ago when the excision was the only treatment. And yes, then it was risky and the risk of recurrence was high - there's no disputing that. HOWEVER, what is neglected to be mentioned is when: neoadjuvant chemoradiation with a good response + full thickness transanal excision + adjuvant chemo is undertaken, the rates are comparable to the more radical surgery.

The difficulty lies in determining who is a good candidate - and what constitutes a good response to the neoadjuvant chemoradiation but it is like comparing apples to oranges to quote stats from excision alone surgery with the more thorough treatment plan listed above and what dschreffler is having done (exactly what I had done). No, it's not for everyone and each person should have the correct facts to make an informed decision - and from my experience, the surgeons tend to just ignore the fact that other treatments such as neoadjuvant chemoradiation and adjuvant chemo are being added to the "equation".

Just to let you know, there is no guarantee that a rectal cancer treated with an LAR or APR won't return either - regardless of which surgery any of us have, there is always a chance that the cancer will return.

[wombat]

Hey gang,

Had my surgery last week. Got back from the hospital yesterday. To recap, I choose the LAR procedure and was pretty excited and happy with my decision. Based on my research, the local recurrence rates between LAR and APR seemed comparable and it seemed like there was a fair chance that I would be happy with the performance of a partial sphincter. And, of course, the opportunity to avoid having a bag was attractive.

However, surgery did not go quite as planned. I'm sitting here at home with a colostomy - I got an APR. Here's what happened. One reason I was comfortable with signing up for an LAR procedure was that my surgeon assured me that if at any point he felt he couldn't get all the cancer out, or that he couldn't perform the LAR procedure due to various other constraints (my body type, etc.), he would switch over to an APR. His utmost concern, as was mine, was to get all of the cancer out. One of his decision points was whether he felt there was sufficient distal margin. After chemo/radiation, he did a rigid proctoscopy to take a look at things, he felt there was enough margin (but wouldn't know for sure until surgery) and said that I was a candidate for an LAR. In my case, once he got in there, he didn't feel there wasn't enough margin, and he went ahead and did the APR. I'm not too surprised by this as all three doctors at the Mayo Clinic came to this conclusion IMMEDIATELY after feeling where my tumor was.

On the bright side, it appears I had a complete pathological response to chemo/radiation. This is very, very good news! NONE of the harvested lymph nodes (0/46) showed signs of cancer (my initial diagnoses showed that the cancer had spread to 3-4 nodes) and there was no signs of cancer in the remnants of the thumor. (On a side note, 46 nodes seems to be a LOT. I asked my surgeon if he went fishing for extra lymph nodes and he said no, that's the number of lymph nodes that happened to be in the excised tissue. He said the combination of me having a strong immune system and the hospital having eager-beaver med techs who search extra hard for lymph nodes was responsible for the result.)

That I had a complete response is bittersweet news. It seems cruel that you can only learn that neoadjuvant therapy was completely effective after you have surgery. But, I also understand that you can't draw the conclusion that there's been a complete response based on a limited number of post-chemo/radiation biopsies that come back clean.

But, yeah, It's a bummer to be sitting here with a colostomy, especially when I had done all that work and research between the two options, and after I had gotten myself all excited about NOT having a bag. I'm still focusing on healing and getting through all the physical pain I'm still in, so I haven't started wrapping my mind around the idea of it yet. I try to look at the bag as little as possible right now, and I haven't even looked at the stoma yet. I'm wondering if my surgeon didn't leave me a bit astray with offering me the option of getting an LAR. He said from the get-go that the tumor was located pretty low, and that the if the tumor shrunk, I'd be eligible for sphincter-saving surgery. However, he also said that he assumes that all scar tissue he comes across during surgery is cancerous (for the most part, surgeons can't tell the difference between cancerous tissue and scar tissue from CRT). So, although he never really said it, I think my surgeon, all along, had the same mind set as the Mayo surgeon (take out all tissue wherever there has been cancer - it's the only way to know for sure.)

So, anyways, here I sit, "cancer free", with a colostomy bag. That sentence captures both the highs and lows of how I'm feeling right now. Being cancer free is wonderful news! But, having a bag - bummer. I know I'm not going to enjoy having to deal with the bag, but I do know that I'm going to enjoy life. As I sat in my wheelchair at the hospital entrance waiting for my ride, I saw at least several people who would probably be willing to trade their condition for merely having a colostomy bag. I feel fortunate that cancer (or something else) didn't take much, much more from me.

Here's to having had a successful surgery and looking forward to getting back to doing all the things that I love to do!!!

Doug

[CRguy]

As I sat in my wheelchair at the hospital entrance waiting for my ride, I saw at least several people who would probably be willing to trade their condition for merely having a colostomy bag. I feel fortunate that cancer (or something else) didn't take much, much more from me.
Here's to having had a successful surgery and looking forward to getting back to doing all the things that I love to do!!!
Doug

Hey bro' thanks for the update, and from where I sit, sounds like you have captured what I value most from my martial arts training : Indomitable spirit. I salute your courage.

" I cried because I had no shoes. Then, I met a man with no legs. "

You may have no shoes, but you have what cancer could NOT take from you : Indomitable spirit.

Sending you "I-5's" down the highway from BC.

Stay well on your journey of recovery, my friend.

In Harmony
CRguy

[dschreffler]

So, anyways, here I sit, "cancer free", with a colostomy bag. That sentence captures both the highs and lows of how I'm feeling right now. Being cancer free is wonderful news! But, having a bag - bummer. I know I'm not going to enjoy having to deal with the bag, but I do know that I'm going to enjoy life. As I sat in my wheelchair at the hospital entrance waiting for my ride, I saw at least several people who would probably be willing to trade their condition for merely having a colostomy bag. I feel fortunate that cancer (or something else) didn't take much, much more from me.

Here's to having had a successful surgery and looking forward to getting back to doing all the things that I love to do!!!

Doug

You rock man!!!!
I had the chance to meet Linda Hamilton at a Comic convention this weekend (I'm a geek yes) and had her sign a photo with "There is NO Fate but what we make..", her terminator 2 quote, but YOU ARE the cancer terminator!!!

Glad to hear from you!!!!

[Terry]

Jaynee, I have disagree with you. After my surgery they downstaged me to a stage I which I don't think should EVER be done! Due to that I didn't have neoadjuvant chemo. That was thanks to my surgeon who is a good surgeon but he shouldn't have stuck his nose into the staging issue or chemo decision.

Dan I reread my post to you earlier.. I said I had a transanal excision and what I wrote sounded like I have bathroom issues,, however, do not have an problems with that. I guess it doesn't matter because the more I think about it I believe you said your a stage III so it doesn't matter.

[weisssoccermom]

Hey Terry, just trying to figure out what you disagree with me on - fill me in, ok?? You're right - no surgeon/onc should ever have downstaged you - the fact is, according to the ACS, a patient is never 'downstaged' - the tumor may be downgraded but unless there was an error or something on the original ultrasound, a patient is not downstaged. And, Terry, I agree with you that you should have had adjuvant chemotherapy - always have maintained that as well.

I'm only guessing you're looking at my last post. Maybe I typed something incorrectly. Let me make sure I'm clear. I only feel that a patient should be allowed to have a full thickness excision under the following criteria.

1. clincical complete response to neoadjuvant chemoradiation (i.e. - tumor appears to be totally or almost totally GONE) - the good response part
2. the pathology report comes back with nothing more than a T1
3. adjuvant chemo is given

In my opinion, it's an all or nothing - you can't just do, for example, #1 & #2 without #3 or any other combination. It's got to be the whole shebang which is why there isn't generally a large 'population' of people who fit the criteria. Of course, if a patient wants an excision and doesn't care about any of the 'criteria' then I suppose that that is he/her decision.

Let me know what I typed Terry that we're not agreeing on, ok??

Jaynee

[rickker20]

T3 tumor has grown pass the Subserosa. TAE is not good for this kind of tumor matter of fact many surgeon's would not even try this operation on this kind of tumor. I agree if the tumor is T1 then yes TAE is good option. Second you don't remove any Lympn nodes with a TAE so how do you know if cancer is not in the Lymph nodes?