MUSC Colorectal Surgeons Treating Cancer Report Success by Beginning with a Non-Operative Approach

Colorectal cancer is the third most common cancer in the world, according to the World Health Organization. The management of colorectal cancer is rapidly evolving. Surgeons at the Medical University of South Carolina (MUSC) are achieving outstanding outcomes with an organ-sparing approach that avoids immediate surgery and may avoid surgery altogether, reports colorectal surgeon Virgilio George, M.D., Director of the Division of Colorectal Surgery, MUSC. This approach follows the standard of care guidelines recommended by the National Accreditation Program for Rectal Cancer (NAPRC). MUSC's colorectal surgery program is the only NAPRC-accredited program in South Carolina.

Non-Operative Management

Patients with locally advanced colorectal cancer are advised to proceed with total neoadjuvant therapy (TNT). This means patients receive both chemotherapy and radiation prior to surgery in an effort to shrink the tumor and, in some cases, eradicate it completely. By giving patients all needed chemotherapy and radiation before surgery, the multidisciplinary colorectal cancer team at MUSC has seen a complete clinical response rate (no evidence of cancer) in up to 40 percent of patients. These patients may not require surgery at all. However, they do require monitoring with MRI and sigmoidoscopy every three months for three years to ensure there are no signs of any disease regrowth, says Dr. George. This "watch and wait" approach depends on close adherence to the surveillance regimen to detect any tumor regrowth early. With early detection, patients can still be treated with curative intent surgery.

When Surgery is Required

In cases in which the tumor is still present after TNT, the surgical treatment will depend on the stage of the cancer and the tumor's location within the rectum.

• Local excision, for small stage I rectal cancers that are less than three centimeters in size, involves removal of the tumor through the anal canal. Preservation of the rectum may be considered.
• Low anterior resection with anastomosis involves removing the portion of the rectum where the tumor is located, including the fatty tissue that envelopes the rectum (mesorectum) and houses the lymph nodes. A new connection is made between the colon and lower rectum. This may require a temporary diverting ostomy to allow the new connection to heal completely.
• Abdominoperineal resection is generally reserved for tumors that have invaded the anal sphincter muscles. This procedure removes the anal canal, sphincter muscles, and rectum, and creates a permanent colostomy. This may be considered in patients with advanced tumors involving the sphincter muscle or patients with pre-existing incontinence who may prefer a colostomy.

Methods of Surgical Treatments

At MUSC, the surgical treatments described above are most often performed with minimally invasive techniques (i.e., using small incisions), which permit a faster recovery and improved quality of life. These approaches include:

• Robotic surgery deploys advanced surgical instruments through small incisions, using 3D imaging and wristed instruments to enable delicate maneuvering in small spaces. The robotic platform is particularly well-suited for surgery within the confines of the pelvis, which can be especially challenging in male patients and obese patients with colorectal cancer.
• Laparoscopy also uses small incisions to deploy multiple instruments to accomplish all the goals of traditional large-incision surgery while offering a faster patient recovery and equivalent oncological outcomes.
• Transanal Minimally Invasive Surgery (TAMIS) is laparoscopic surgery through the anal canal, rather than through abdominal incisions, to remove the tumor and keep the rectum in place. This approach frequently allows patients to go home on the same day as their surgery. TAMIS may be appropriate for selected small, early cancers that historically may have required removal of the rectum.
• Transanal Total Mesolectal Excision (TaTME) is a hybrid minimally invasive surgery using a combined transanal and transabdominal approach for low colorectal tumors in an attempt to preserve the anal sphincter muscles and prevent a permanent ostomy.

Maximizing Quality of Life

In all cancer therapies, the goal is to avoid post-surgical complications, avoid a colostomy, and maximize the patient's quality of life. Individualized treatment plans must consider both the stage and location of the tumor, but sometimes more importantly, the overall values and goals of the patient. This involves the patient's functional status, current bowel function, social support, and network. An individualized treatment plan begins with a dialogue between patient and surgeon, in which the surgeon explains the rationale for each treatment and the potential outcomes, enabling the patient to make an informed decision and take ownership of his or her cancer care.

To refer a patient to MUSC Hollings Cancer Center, please call 843-792-9300.