Low rates of local recurrence after surgical resection of rectal cancer suggest a selective policy for preoperative radiotherapy

Aim Preoperative short‐course radiotherapy (SCRT) is increasingly recommended to reduce local recurrence after surgery for rectal cancer. Its avoidance may be beneficial, however, if the risk of local recurrence is low. We report a single centre experience which suggests that selective rather than uniform use of SCRT may be the best approach. Method Analysis was carried out on a prospectively collected unselected series of 1606 patients with rectal cancer treated in one centre. Follow‐up was 97% complete. SCRT was performed selectively and all patients had a mesorectal excision. Results Among 940 patients undergoing a potentially curative major resection the operative mortality was 4.6%, the permanent stoma rate 23% and the crude 5‐year survival 61%. The local recurrence rate after curative anterior resection was 2.9% and 7.7% after abdominoperineal excision. The overall local recurrence rate after a potentially curative major resection was 4.0%. Conclusion The routine use of preoperative radiotherapy for rectal cancer is probably not justified where local recurrence after curative rectal resection is uncommon.     

T3N0 rectal cancer: Results following sharp mesorectal excision and no adjuvant therapy

Adjuvant chemoradiation therapy following resection of T3N0 rectal cancer is recommended in order to reduce the incidence of local recurrence and improve survival. However, recent experience with rectal cancer resection utilizing sharp dissection and total mesorectal excision has resulted in a reduction in local recurrence rates to as low as 5% without adjuvant treatment. The purpose of this study was to determine if rectal cancer resection utilizing sharp mesorectal excision alone is adequate treatment for local control of T3N0 rectal cancer. Between July 1986 and December 1993, 95 patients with T3N0M0 rectal cancer underwent resection with sharp mesorectal excision and did not receive any adjuvant therapy. Various prognostic factors were analyzed for their association with local recurrence and survival. Seventy-nine patients had a low anterior resection, 10 of whom had a coloanal anastomosis, and 16 had an abdominoperineal resection. The median follow-up was 53.3 months. Six patients had local recurrence, 12 had distant recurrence, and three had local and distant recurrences. The overall local recurrence rate was 9% crude and 12% 5-year actuarial. The overall crude recurrence rate was 22%. The 5-year disease-specific survival rate was 86.6% with an overall survival of 75%. Postoperative complications occurred in 18 patients (19%). Five patients (6%) had a documented anastomotic leak. Perioperative mortality was 3%. No technical factors, including type of resection (low anterior vs. abdominoperineal), location of tumor, or extent of resection margin, were significant for determining local recurrence. The only histopathologic marker significant for determining local recurrence was lymphatic invasion (P <0.04). Sharp mesorectal excision with low anterior resection or abdominoperineal resection for T3N0M0 rectal cancer results in a local recurrence rate of less than 10% without the use of adjuvant therapy. Therefore, in select patients with T3N0M0 rectal cancer, the standard use of adjuvant therapy for local control may not be justified. Presented at the Thirty-Ninth Annual Meeting of The Society of Surgery for the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Recurrence and survival after surgical management of rectal cancer.

BACKGROUND: Reported local recurrence rates for rectal cancer are significantly reduced using a combination of superior surgical technique, in the form of total mesorectal excision, and routine radiotherapy. In an attempt to determine the effectiveness of current local management strategies, a review of Vancouver Island Cancer Centre patients with rectal cancer was performed and the overall local recurrence rate was identified. METHODS: We retrospectively reviewed the charts of 272 rectal cancer patients from 1988 to 1998. Two hundred and twenty-nine patients met inclusion criteria. Analysis of patient factors included age, gender, type of surgery, and adjuvant therapy. Tumors were assessed for level, stage, and grade. Local recurrence and distant metastases were also documented. Variables influencing local recurrence in this group were identified and disease-free and actuarial survival determined. RESULTS: Of 229 patients analyzed, 12.7% (29) had local recurrences. Variables influencing local recurrence were number of positive lymph nodes, vascular invasion, and neural invasion. There was no significant difference in local recurrence between patients having anterior resection and those having abdominoperineal resection. None of the patients who received preoperative radiotherapy had a local recurrence. Actuarial disease-free survival was 87% at 5 years. CONCLUSIONS: Limiting local recurrence is one of the most important goals in the treatment of rectal cancer. It is essential to identify those patients with "high risk" tumors as identified by endorectal ultrasound or pathologic features. These patients comprise the group most likely to benefit from a routine mesorectal excision combined with adjuvant radiotherapy.     

Laparoscopic total mesorectal excision

After total mesorectal excision for rectal cancer was introduced in 1982, local recurrence rates decreased to 5%. These results were found to be reproducible; therefore, the technique became standard for the treatment of rectal cancer. Laparoscopic surgery for curable colorectal malignancy is still considered investigational. Indeed, the United States National Cancer Institute (NCI) trial excludes rectal carcinoma. The application of laparoscopy to rectal carcinoma must compete with total mesorectal excision, which has obtained favorable results in the last decade. In this review, we assess the adequacy of laparoscopic total mesorectal excision, describe the techniques (both anterior resection and abdominoperineal resection), and discuss their potential advantages.     

Carcinoma of the rectum: a 10-year experience

A consecutive series of 303 patients with carcinoma of the rectum and distal sigmoid colon treated by a single surgeon over a 10-year period are reported. Of these, 202 underwent an anterior resection, 85 an abdominoperineal excision of the rectum and 16 a coloanal anastomosis. Surgery was considered palliative in 52 patients undergoing anterior resection and 24 undergoing abdominoperineal resection. The 30-day hospital mortality rate was six patients (3 per cent) for anterior resection and two patients (2 per cent) for abdominoperineal resection. Peroperative anastomotic testing demonstrated leakage in five stapled anastomoses; these were rectified and no clinical sequelae occurred. Two patients (1 per cent) developed a clinical anastomotic leak, one of which proved fatal; in each case the intraoperative test was negative. The overall 5-year survival rate was 64 per cent after anterior resection and 52 per cent after abdominoperineal resection; the median follow-up was 64 months. The incidence of local pelvic recurrence was 6.4 per cent after anterior resection and 14 per cent after abdominoperineal (not significant). These results confirm the success of sphincter-saving anterior resection combined with total mesorectal excision, routine full mobilization of the splenic flexure and cancercidal lavage of the distal rectum in the treatment of low rectal carcinomas; morbidity, local recurrence and survival are not compromised.     

Transsacral exenteration of fixed primary and recurrent anorectal cancer

BACKGROUND: Posteriorly fixed anorectal cancer is often considered incurable, but may be resectable using transsacral approaches. METHODS: We reviewed 45 patients undergoing transsacral exenteration for this problem since 1983 to determine outcome of such surgery. RESULTS: The group consisted of 38 men and 7 women; 17 had primary tumors, 28 had recurrent cancer: local excision, 1; low anterior resection, 11; or abdominoperineal resection, 16. Thirty-nine had prior XRT. Operative mortality was 4%. Severe pain was relieved in 16 of 22 (72%) patients. Crude recurrence rates are local 22%, local plus distant 11%, distant 16%. Five-year disease-free survival is 31% for primary disease, 32% for recurrence. Median survival is abdominoperineal resection recurrence, 24 months; primary cancer, 30 months; low anterior resection recurrence, 37 months. CONCLUSIONS: Transsacral exenteration relieved pain in 70% of patients with fixed anorectal cancer, and led to long-term survival in 31% to 32%. Prognosis trended toward benefit for recurrence after low anterior resection.     

The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma

OBJECTIVE: To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery. SUMMARY BACKGROUND DATA: Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years. METHODS: One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control. RESULTS: Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P < 0.001). Overall survival at 5 years was 64.2% and 63.5%, respectively (P = 0.902). Subgroup analyses showed significant effect of radiotherapy in reducing local recurrence risk for patients with nodal involvement, for patients with lesions between 5 and 10 cm from the anal verge, and for patients with uninvolved circumferential resection margins. CONCLUSIONS: With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.     

Local recurrence following surgical treatment for carcinoma of the lower rectum

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).     

低位Ⅰ期直肠癌患者的外科治疗与预后分析

目的探讨低位Ⅰ期直肠癌的外科治疗效果及影响复发和预后的因素。方法回顾性分析166例低位Ⅰ期直肠癌患者的临床资料。结果本组根治性手术138例，均按直肠全系膜切除（TME）手术原则进行；其中93例行腹会阴联合根治术，45例行保肛手术；肿瘤局部切除术28例。局部复发率根治性手术者为5．1％（7／138），其中腹会阴联合根治术组为6．5％（6／93），保肛术组为2．2％（1／45）；局部切除术组为17．9％（5／28）。X^2检验显示，肿瘤分化程度（P=0．009）和手术方式（P=0．039）与局部复发相关。腹会阴联合根治术组5年生存率为90．4％，保肛术组为95．5％。局部切除术组为82．6％。单因素分析显示，肿瘤分化程度（P=0．000）和局部复发（P=0．000）与预后相关；多因素分析显示，局部复发是影响预后的主要因素（P=0．000）。结论低位Ⅰ期直肠癌根治性手术切除复发率低、预后好。局部切除术的选择应严格把握指征。     

Curative surgery for local pelvic recurrence of rectal cancer

BACKGROUND/AIMS: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. METHODS: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. RESULTS: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. CONCLUSIONS: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.     

直肠癌全直肠系膜切除术系膜切缘微转移的临床研究

目的 对直肠癌患者系膜切缘微转移灶进行检测,研究其对局部复发的影响.方法 对52例Dukes A、B和C期直肠癌患者实施伞直肠系膜切除术,用RT-PCR技术检测系膜切缘组织细胞中角质蛋白CK20 mRNA.结果 本组52例直肠癌旁系膜中,21例CK20 mRNA呈阳性,31例为阴性,总阳性率为40%.Dukes A、B和C期阳性率分别为17%、30%和54%,直肠系膜切缘微转移发生率随肿瘤分期升高而增加,组间比较差异有统计学意义,P<0.05;高、中、低与未分化癌阳性表达率分别为43%、38%、40%和50%,病理分级之间CK20 mRNA表达阳性率差异无统计学意义(P>0.05).全组患者局部复发率为12%,CK20 mRNA阳性组和阴性组局部复发率分别为24%和3%,两组比较差异有统计学意义,P<0.05.结论 直肠系膜切缘微转移与局部复发有关,提示系膜CK20mRNA可能是一个潜在的局部复发标志物.     

全直肠系膜切除术安全远切端距离的临床研究

目的 探讨全直肠系膜切除术(TME)原则下直肠癌低位前切除术的安全远切端距离.方法 回顾性分析5年间412例TME原则下直肠癌低位前切除术患者的临床资料,比较不同远切端距离(DML)分组间并发症发生率、远处转移率、复发率和生存率的差异.结果 DML＜2 cm组,2～3 cm(含2 cm和3 cm)组,＞3 cm组患者术后并发症发生率和远处转移率差异均无统计学意义(P=0.494和P=0.906).DML＜2 cm组局部复发率(19.30%)显著高于DML2～3 cm组(8.37%,P=0.015)和DML＞3 cm组(7.69%,P=0.029),后两组局部复发率差异无统计学意义(P=0.833).DML＜2 cm组,2～3 cm组,＞3 cm组3年生存率依次为69.4%,86.5%,89.9%;5年生存率依次为63.0%,70.7%,71.1%.DML＜2 cm组总生存率显著低于2～3 cm组和＞3 cm组,差异有统计学意义(P=0.030和P=0.040).DML2～3 cm组和＞3 cm组总生存率之间差异无统计学意义(P=0.707).结论 遵循TME原则下的直肠癌低位前切除术,＜2 cm的远切端距离是不足够的;对于分化较好的直肠腺癌,≥2 cm是可接受的远切端安全距离.     

Impact of total mesorectal excision on the results of surgery of distal rectal cancer.

BACKGROUND: This study reviewed the results of surgery for distal rectal cancer (tumours within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. METHODS: Two hundred and five patients who had undergone surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected prospectively. Comparisons were made between patients who had different surgical procedures. RESULTS: Abdominoperineal resection (APR) was performed in 27.8 per cent of patients, falling from 36.0 per cent in the first 3 years to 20.0 per cent in the last 3 years of the study. The overall operative mortality rate was 1.5 per cent and the morbidity rate 30.2 per cent. With a mean follow-up of 36 months, local recurrence occurred in 28 of the 185 patients who had curative resection. The 5-year actuarial local recurrence rates for double-stapled anastomosis, peranal coloanal anastomosis and APR were 11.2, 34.6 and 23.5 per cent respectively. The local recurrence rate was significantly lower for double-stapled low anterior resection than for the other types of operation. The overall 5-year survival rate in patients with low anterior resection and APR was 69.1 and 51.1 per cent respectively (P = 0.12). CONCLUSION: With the practice of total mesorectal excision, APR was necessary in only 27.8 per cent of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was much lower in patients with double-stapled low anterior resection than in those treated with APR or peranal anastomosis.     

Indicators of quality in surgical treatment of rectal carcinoma]

INTRODUCTION: For the assessment of surgical therapy for rectal cancer, perioperative and oncological as well as aspects of quality of life have to be taken into consideration. The objective of the present analysis was to identify indicators allowing assessment of the quality of the surgical intervention. PATIENTS AND METHODS: Between March 1997 and August 1998,50 patients with adenocarcinoma of the rectum were operated on by five surgeons according to the concept of total or partial mesorectal excision. In 4 patients an anterior, in 35 a low anterior resection, and in 11 an abdominoperineal resection was performed. There was a stage IV (UICC) present in 9 cases, and in 18 patients the tumor extension was restricted to the wall. The demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 44 months (5-57). RESULTS: Intraoperative parameters showed no differences concerning the individual operating surgeons. General complications arose in 9 (50%) and surgical complications in 34 (68%) patients. Anastomotic leakage (5/39), perineal wound infection, and bladder dysfunction (requiring catheterization for bladder emptying) occurred as frequent complications and there were differences with regard to the surgeon. The rate of local recurrence was different and was between 0% and 75% for the individual surgeons. CONCLUSIONS: For the assessment of surgery for rectal carcinoma, only a few parameters are necessary. As indicators of quality after rectal resection, the rate of anastomotic leakage should be registered; after abdominoperineal resection, the rate of perineal wound infection, the ratio of postoperative bladder dysfunction, and the locoregional rate of recurrence should be registered.     

The current abdominoperineal resection: oncological problems and surgical modifications for low rectal cancer

Abdominoperineal resection is the one of the oldest surgical procedures for rectal cancer. Outcome after abdominoperineal resection for rectal carcinoma is not as good as anterior resection as the risk of local recurrence is higher and survival is poorer. During abdominoperineal resection, the rate of rectal perforation is high and the circumferential margin is often involved. Recently the concept of cylindrical abdominoperineal resection has been reintroduced. It allows a large excision and the initial results are encouraging. The purpose of this article was to analyse the oncological results of abdominoperineal resection and to develop the potential technical modifications of the procedure.     

Preoperative radiotherapy improves survival for patients undergoing total mesorectal excision for stage T3 low rectal cancers

OBJECTIVE: To examine the effect of preoperative radiotherapy (PRT) on patients who undergo rectal resection with total mesorectal excision (TME) for stage T3 low rectal cancers. SUMMARY BACKGROUND DATA: Evidence for the value of PRT before rectal cancer surgery is weakened by variability in the use of TME. Many surgeons have concluded that PRT is unnecessary for small rectal tumors if TME is performed, but there are no prospective data to support this opinion. METHODS: Since 1980, 2,200 patients with rectal cancer have been enrolled in a prospective database. Of these, 259 underwent curative anterior or abdominoperineal resection with TME for pathologically confirmed T3 lesions within 8 cm of the anal verge. Patients were grouped by receiving PRT (n = 92) or not receiving PRT (n = 167). Five-year overall survival and 5-year local recurrence rates were evaluated. RESULTS: Overall survival was increased from 52% in patients not receiving PRT to 63% in those receiving PRT. PRT increased overall survival for node-negative patients from 58% to 82%, with no benefit for node-positive patients. There was no significant difference in local recurrence rates. When categorized by tumor size, there was no difference in overall survival or local recurrence for 0- to 2-cm tumors or those larger than 5 cm, but PRT increased overall survival from 50% to 72% for patients with 2- to 5-cm tumors. Similar results were observed for patients with tumors staged as T3 on preoperative endoluminal ultrasound. CONCLUSIONS: Patients with pT3 low rectal cancers undergoing resection with TME have an improved survival with PRT. The effect is most beneficial for patients with node-negative and 2- to 5-cm tumors, although this group may include larger and node-positive tumors that have been downstaged by PRT. PRT should be advocated for all patients with T3 rectal cancers less than 8 cm from the anal verge, even if the surgery includes a properly performed TME.     

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND: Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented. METHODS: Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group. RESULTS: The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001). CONCLUSION: Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.     

Impact of radiotherapy on local recurrence of rectal cancer in Norway

BACKGROUND: The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). METHODS: This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. RESULTS: The proportion of patients who had radiotherapy before or after operation increased from 4.6 per cent in 1994 to 23.0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16.2 to 10.7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0.59 (95 per cent confidence interval 0.39 to 0.87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0.003); cumulative 5-year local recurrence rates for these patients were 10.6 and 15.8 per cent respectively (P < 0.001). CONCLUSION: Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.     

Prospective phase I trial of conservative management of low rectal lesions

The purpose of this study was to assess and function and to compare the morbidity of local excision and postoperative radiotherapy for rectal adenocarcinoma with the morbidity of abdominoperineal resection. A posterior parasacral approach was used for local excision. All patients had negative margins, and all but one were continent after completion of radiotherapy. Seven patients (29%) had either a wound infection or a fistula in the local excision group. No local failures occurred, although follow-up was only 13 months. Thirteen (50%) of the 26 patients who underwent an abdominoperineal resection developed at least one complication. Combined treatment that spares the rectal sphincters may be preferable in selected patients with low rectal cancer, if long-term disease-free survival is maintained.