Beenumehta wrote:Just got diagnosed wiith low rectal cancer 3-4 cm from anal verge. Looking for options divided between local anal excision and total mesorectal excision. Confused and scared? Anyone out there who has done local anal excision and had good outcome?
Your signature says:
Female age 51 at diagnosis
Blood in stool March 2022
Colonoscopy May 11,2022
Rectum polypectomy 2 cm polyp
Pathology report Mucinous adenocarcinoma, moderately differentiated, involving colonic mucosa with positive margin
MRI and ct scan clear
Looking for options?
Previous thyroidectomy at age 50 for papillary carcinoma surgery Jan 21 partial April 21 complete .
RAI August 21
In the diagram below you can see that there are 4 layers in the rectum wall:
1. Mucosa (innermost layer)
4. Serosa (outermost layer)
According to your signature, your 2 cm polyp involved the innermost layer, the "mucosa". You can see from the diagram below that this layer does not have a lot of large blood vessels or neural connections. It's the deeper layers that have the major lymphovascular and neural connections. Thus, you could assume that this polyp, although malignant, was probably not involved with shedding many cancer cells to other parts of the body. So it is probably "only" a Stage I tumor, and probably amenable to some kind of endoscopic excision or endoscopic dissection to remove what was left in the "positive margin" after the polypectomy.
But there is always the possibility that a few malignant cells left the polyp and traveled elsewhere before the bulk of the polyp was removed, or even that some cancerous cells were "dropped" during the procedure while the polyp was being removed. So, this is where the dilemma is: Do you decide to do a simple excision now to scoop out just that area of the mucosa where the polyp was found, or do you do a more extensive removal involving other, deeper, layers of the rectum wall, just in case the cancerous polyp had grown deeper than what the colonoscopy biopsy suggested. In the most extreme case you could do a full-blown TME-based LAR which would likely remove everything that might have been infiltrated, including nearby lymph nodes.
One possible problem with just doing a local excision is that the outer rectum wall and the adjacent lymph nodes would not be removed, thus the pathology report of the surgery would not have any information at all on these outer areas since they weren't part of the specimen sent to the pathologist.
So, this is where you need to get the best advice possible, and do whatever additional scans or tests necessary to determine just how invasive the polyp was. I don't know what additional procedures or technology might need to be involved, but it could be something like an MRI with contrast, or a trans-anal ultrasound, or something else to get additional data on the likely depth of the polyp root. Also, it could be important to know exactly what type of polyp was removed, e.g., a flat (sessile) polyp, or a pedunculated polyp with a central root, or a donut-shaped polyp, etc. It might make a difference in how deeply into the wall the polyp was growing. Also important is to know the type of growth pattern in the polyp, e.g., "tubular" vs. "tubulovillous" vs. "villous", etc.
So, it seems to me that quite a lot of additional research and testing will need to be done before you can safely proceed with something like a simple local excision. You may need to get second and third opinions on how best to proceed, especially since the recent polypectomy was essentially a failure since it had positive margins and no doubt left left some difficult scar tissue behind as well as some cancer cells, which will be more troublesome to deal with now than just a simple local excision for a polyp.
Also, it would be good if you could have a look at the two articles that roadrunner mentioned earlier (first two listed below), plus a third summary article.Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4397248/When is local excision appropriate for "early" rectal cancer?https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194025/Endoscopic management of complex colorectal polyps: Current insights and future trendshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811151/
I would also suggest reading the article below, in addition, since it addresses the current (2020) standards for managing malignant colorectal polyps:Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancerhttps://www.gastrojournal.org/article/S0016-5085(20)35122-2/fulltext