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Background <p>Transanal endoscopic microsurgery (TEM) enables the local excision of rectal neoplasms with minimal invasiveness; however, the long-term oncologic safety for pTis and pT1 lesions, as well as the significance of traditional histopathological risk factors, remains controversial.</p> Methods <p>A retrospective cohort of 170 consecutive patients undergoing en bloc, R0 full-thickness TEM for rectal pTis or pT1 adenocarcinoma between 1994 and 2025 at a single tertiary centre was analysed. Pathological review included Vienna classification, submucosal invasion (sm1 vs sm2–3), tumour grade (G1–2 vs G3), lymphovascular invasion (LVI), mucinous histotype, tumour budding, perineural invasion (PNI), and tumour diameter (&gt; 3&#xa0;cm). Patients with adverse features were recommended salvage radical surgery or adjuvant radiotherapy. Disease-free (DFS) and overall survival (OS) were estimated using Kaplan–Meier analysis and log-binomial regression.</p> Results <p>The median age was 71&#xa0;years (IQR, 62–77), and the median follow-up was 24&#xa0;months (IQR, 24–53). Lesion distribution was Vienna 4.2 (<i>n</i> = 21), Vienna 4.4 (<i>n</i> = 21), pT1sm1 (<i>n</i> = 48), pT1sm2 (<i>n</i> = 40), and pT1sm3 (<i>n</i> = 40). All patients achieved R0 excision. No recurrences were observed in the Vienna 4.2/4.4 groups. For pT1 tumours, recurrence rates were 4.2% (sm1), 37.5% (sm2), and 20.0% (sm3). On multivariate analysis, submucosal invasion (sm2–3; HR 5.67, p = 0.021), high grade (G3; HR 3.58, <i>p</i> = 0.004), and LVI (HR 3.58, <i>p</i> = 0.003) were independent predictors of DFS. Other factors were not significant. In OS analysis, older age (&gt; = 71&#xa0;years) and tumour diameter &gt; 3&#xa0;cm were associated with poorer survival, whereas classical high-risk pathological factors (sm2–3, G3, LVI) were not.</p> Conclusion <p>TEM affords excellent long-term disease control for Vienna 4.2/4.4 lesions. In pT1 adenocarcinoma, only submucosal invasion beyond sm1, high grade, and LVI independently predict recurrence, underscoring the need for risk-adapted, multidisciplinary management.</p>

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Which prognostic factors for recurrence after transanal endoscopic microsurgery for early rectal cancer?

  • 期刊论文

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  • 发表日期：

    2026年2月18日

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  • Alberto Arezzo,
  • Carlo Alberto Ammirati,
  • Giovanni Distefano,
  • Michele Barbiero,
  • Francesca Sbuelz,
  • Roberto Passera,
  • Mario Morino

摘要

Background

Transanal endoscopic microsurgery (TEM) enables the local excision of rectal neoplasms with minimal invasiveness; however, the long-term oncologic safety for pTis and pT1 lesions, as well as the significance of traditional histopathological risk factors, remains controversial.

Methods

A retrospective cohort of 170 consecutive patients undergoing en bloc, R0 full-thickness TEM for rectal pTis or pT1 adenocarcinoma between 1994 and 2025 at a single tertiary centre was analysed. Pathological review included Vienna classification, submucosal invasion (sm1 vs sm2–3), tumour grade (G1–2 vs G3), lymphovascular invasion (LVI), mucinous histotype, tumour budding, perineural invasion (PNI), and tumour diameter (> 3 cm). Patients with adverse features were recommended salvage radical surgery or adjuvant radiotherapy. Disease-free (DFS) and overall survival (OS) were estimated using Kaplan–Meier analysis and log-binomial regression.

Results

The median age was 71 years (IQR, 62–77), and the median follow-up was 24 months (IQR, 24–53). Lesion distribution was Vienna 4.2 (n = 21), Vienna 4.4 (n = 21), pT1sm1 (n = 48), pT1sm2 (n = 40), and pT1sm3 (n = 40). All patients achieved R0 excision. No recurrences were observed in the Vienna 4.2/4.4 groups. For pT1 tumours, recurrence rates were 4.2% (sm1), 37.5% (sm2), and 20.0% (sm3). On multivariate analysis, submucosal invasion (sm2–3; HR 5.67, p = 0.021), high grade (G3; HR 3.58, p = 0.004), and LVI (HR 3.58, p = 0.003) were independent predictors of DFS. Other factors were not significant. In OS analysis, older age (> = 71 years) and tumour diameter > 3 cm were associated with poorer survival, whereas classical high-risk pathological factors (sm2–3, G3, LVI) were not.

Conclusion

TEM affords excellent long-term disease control for Vienna 4.2/4.4 lesions. In pT1 adenocarcinoma, only submucosal invasion beyond sm1, high grade, and LVI independently predict recurrence, underscoring the need for risk-adapted, multidisciplinary management.