Local excision results in comparable survival to radical resection for early-stage rectal carcinoid

Background: Controversy exists regarding current National Comprehensive Cancer Network guidelines, which recommend local excision for rectal carcinoids <= 2 cm and radical resection for tumors > 2 cm. Given the limited data examining optimal surgical approach for these lesions, we queried a national database to determine the impact of extent of resection on survival. Methods: Patients undergoing treatment for clinical stage I and II rectal carcinoid (RC) were identified from the National Cancer Data Base (1998-2012). The association between extent of surgery, tumor size, and the likelihood of pathologic lymph node positivity was examined. Kaplan-Meier analysis was used to compare overall survival. Results: In total, 1900 patients were identified, of whom 1644 (86.5%) were treated with local excision, and 256 (13.5%) were treated with radical resection. A significant majority of patients with tumors <= 2.0 cm (89.0%) and nearly half with tumors 2.1-4.0 cm (44.8%) or > 4.0 cm (45.8%) underwent local excision. Nodal positivity was correlated with tumor size (7.1% positivity with <= 2.0 cm tumors, 31.3% with 2.1-4.0 cm tumors, and 50.0% with > 4 cm tumors). However, 5-y survival was equivalent between surgical approaches for tumors <= 2 cm (93.0% versus 93.0%) and tumors 2.1-4.0 cm (76.0% versus 76.0%). Conclusions: We demonstrate in early-stage RC that nearly half of intermediate and large tumors are being treated with local excision outside National Comprehensive Cancer Network guidelines. In addition, radical resection does not appear to be associated with improved overall survival for tumors of any size. These findings suggest that the preferred approach to early-stage RCs without aggressive biological characteristics is local excision due to the decreased morbidity and mortality versus radical resection. (C) 2018 Elsevier Inc. All rights reserved.