The Study: Yes, that’s T-E-M not T-M-E. As a reminder, transanal excisions are typically recommended only for the smallest cT1 tumors <3 cm involving <30% of the rectal circumference. The previously reported Dutch feasibility CARTS study enrolled 55 patients with node-negative rectal cancers with cT1-3 tumors that would traditionally require abdominoperineal resection (APR) or low anterior resection (LAR) and treated them neoadjuvantly with conventionally-fractionated radiation with concurrent capecitabine in an attempt to downgrade resection to a TEM. The breakdown was 10 patients with T1 tumors, 29 with T2, and 16 with T3—meaning 39 patients received chemoradiation who otherwise wouldn’t. 47 patients (85%) were downgraded to criteria making them eligible for TEM and 39 of these (71%) required no further surgery, i.e., they had ypT0-1 tumors with negative margins. Long-term results with a median follow-up of 4.5 years reveal only one of these 39 patients developed a local recurrence. Sounds great until you realize half suffered bowel symptoms equivalent that seen after LAR, begging the question of what we’re really preserving with organ preservation.
Bottom Line: Roughly two-thirds of patients with node-negative rectal cancers initially ineligible for organ preservation can safely undergo TEM, but this buys a lot more patients chemoradiation without a clear advantage in quality of life. | Stijins, JAMA Surg 2018