Treatment and survival outcome for molecular breast cancer subtypes in black women

OBJECTIVE: To analyze whether the local-regional surgical treatments (breast-conserving therapy, mastectomy) resulted in different overall survival, distant metastasis-free survival, and locoregional recurrence-free survival rates for the various molecular breast cancer subtypes. SUMMARY BACKGROUND DATA: Molecular gene expression profiling has been proposed as a new classification and prognostication system for breast cancer. Current recommendation for local-regional treatment of breast cancer is based on traditional clinicopathologic variables. METHODS: Retrospective analysis of 372 breast cancer cases with assessable immunohistochemical data for ER, PR, and Her-2/neu receptor status, diagnosed from 1998 to 2005. Molecular subtypes analyzed were luminal A, luminal B, basal like, and Her-2/neu. RESULTS: No substantial difference was noted in overall survival, and locoregional recurrence rate between the local-regional treatment modalities as a function of the molecular breast cancer subtypes. The basal cell-like subtype was an independent predictor of a poorer overall survival (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.28-4.97, P < 0.01) and a shorter distant metastasis-free survival time (HR = 3.61, 95% CI 1.27-10.2, P < 0.01), and showed a tendency toward statistical significance as an independent predictor of locoregional recurrence (HR = 3.57, 95% CI 0.93-13.6, P = 0.06). CONCLUSIONS: The basal cell-like subtype is associated with a worse prognosis, a higher incidence of distant metastasis, and may be more prone to local recurrence when managed with breast-conserving therapy.     

The significance of involvement of a free serosal surface for recurrence and survival following resection of clinicopathological stage B and C rectal cancer

OBJECTIVE: To determine whether the presence of tumour at a free serosal surface was independently associated with pelvic recurrence or survival in patients who had a resection for clinicopathological stage B or stage C rectal cancer and who had not received adjuvant therapy. METHOD: Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1971 to December 1998 with follow up to December 2003. Statistical analysis employed the chi(2) test or Fisher's exact probability, Kaplan-Meier estimation and proportional hazards regression, with a significance level of < or =0.05 and 95% confidence intervals (CI). RESULTS: In 665 patients with stages B or C tumour, 35 (5.3%; CI 3.7-7.2%) had tumour at a free serosal surface. These comprised 6/332 (1.8%; CI 0.8-3.7%) patients with stage B tumour and 29/333 (8.7%; CI 6.1-12.2%) with stage C tumour. After adjustment for other relevant variables, involvement of a free serosal surface was significantly associated with pelvic recurrence [hazard ratio (HR) 2.7; CI 1.3-5.5] and diminished survival (HR 1.6; CI 1.1-2.4) but not with systemic (only) recurrence. CONCLUSION: This study has confirmed that direct tumour spread to a free serosal surface independently predicts pelvic recurrence and diminished survival after resection of clinicopathological stage B and C rectal cancer. This feature should always be sought by the pathologist and reported when present, and noted by the surgeon and oncologist. Serosal involvement should be evaluated further for its utility in selecting patients for adjuvant therapy.     

Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision

BACKGROUND: The technique of total mesorectal excision (TME) increases the risk of anastomotic leakage. The impact of postoperative morbidity of TME on longterm survival has never been described. We retrospectively analyzed factors that might influence survival after TME for rectal cancer, including postoperative morbidity. STUDY DESIGN: From 1994 to 2001, 300 patients (192 men and 108 women; mean age, 64 years) had TME for rectal cancer. Preoperative radiotherapy was given in 202 patients. Age, gender, tumor height, size and circular invasion of the tumor, pathologic tumor and nodal status, distal and circumferential margins, number of lymph nodes analyzed, type of surgery, postoperative pelvic sepsis, preoperative radiotherapy, and adjuvant chemotherapy were examined; their association with overall and disease-free survival was evaluated by the log-rank test in univariate analysis and by multivariable Cox proportional hazards analysis. RESULTS: Postoperative morbidity was 38% (113 of 300 patients) and included 18% (54 of 300 patients) pelvic sepsis. The local recurrence rate was 6% (18 of 300 patients), and the distant metastasis rate was 24% (73 of 300 patients). Recurrence was three times more frequent distally than locally, including patients with pelvic sepsis The 5-year overall and disease-free survival rates were 72% and 60%, respectively. Independent predictors of overall survival were age older than 64 years (odds ration [OR]=2.19, 95% CI 1.32 to 4.17), pelvic sepsis (OR=2.06, 95% CI 1.10 to 3.87), circumferential surgical margin (OR=3.19, 95% CI 1.67 to 6.09), pathologic tumor (OR=2.69, 95% CI1.23 to 5.88), and nodal status (OR=3.18, 95% CI 1.79 to 5.64). Independent predictors of disease-free survival were pelvic sepsis (OR=2.17, 95% CI 1.31 to 3.58), circumferential surgical margin (OR=2.61, 95 CI 1.52 to 4.49), pathologic tumor (OR=1.82, 95% CI 1.04 to 3.20), and nodal status (OR=2.67, 95% CI 1.68 to 4.23). Patients with pelvic sepsis had a 5-year disease-free survival of 39% compared with 65% without pelvic sepsis (p<0.001). CONCLUSIONS: After TME for rectal cancer, pelvic sepsis is a common complication that is associated with increased risk of distant recurrence and decreased longterm survival. Efforts are necessary to decrease postoperative morbidity in surgical treatment of rectal cancer.     

Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour

BACKGROUND: Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour. METHODS: Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow-up to December 2003. RESULTS: The 5-year local recurrence rate was 15.9 (95 per cent confidence interval (c.i.) 11.0 to 22.8) per cent in 176 patients with tumours that had an anterior component compared with 5.8 (95 per cent c.i. 2.8 to 11.9) per cent in 132 patients with tumours without an anterior component (P = 0.009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2.4 (95 per cent c.i. 1.1 to 5.4)). Similarly, anterior position had a significant negative independent association with survival (HR 1.4 (95 per cent c.i. 1.0 to 2.00)). CONCLUSION: Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer.     

Impact of laparoscopic surgery on the long‐term outcomes for patients with rectal cancer

Background: This 20‐year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long‐term oncological outcomes for rectal cancer. Methods: We analysed survival data collected over 20 years for patients with rectal cancer (n= 407) according to surgical methods and tumour stage between those treated with laparoscopic surgery (n= 272) and those with open surgery (n= 135). Clinical factors were analysed to ascertain possible risk factors that might have been associated with survival from and recurrence of rectal cancer. A multivariate analysis was applied by using Cox's regression model to determine the impact of laparoscopic surgery on long‐term oncological outcomes. Results: Overall survival, disease‐specific survival and disease‐free survival rates were statistically higher in the laparoscopic group than in the open‐surgery group. The incidence of local recurrence in the laparoscopic group (7.9%; 95% confidence intervals (CI), 4.2–11.5) was significantly lower than that for the open‐surgery group (30.2%; 95% CI, 21.0–39.3; P < 0.001). By using a multivariate analysis, laparoscopic surgery for rectal cancer appeared not to be an independent factor for disease‐specific survival or disease‐free survival. However, the laparoscopic surgery was an independent factor associated with reduced local recurrence (Hazard ratio (HR), 3.408; 95% CI, 1.890–6.149; P < 0.001). Conclusion: Laparoscopic surgery did not adversely affect the long‐term oncological outcome for patients with rectal cancer.     

直肠癌腹腔镜与开腹手术肿瘤清除及远期疗效的随机对照试验荟萃分析

目的探讨腹腔镜手术治疗直肠癌的肿瘤清除情况及长期疗效。方法利用电子数据库和手工检索等方法检索Pubmed,Embase。WebofScience及CochraneLibrary截止至2010年6月30日的所有随机对照试验（RCT）文献。评价指标为淋巴结获取数、肿瘤长期疗效（局部复发、切口复发、总体复发、总体生存率及无病生存率）。采用固定效应模型和随机效应模型对直肠癌腹腔镜手术与开腹手术的肿瘤清除情况及长期疗效指标进行荟萃分析。结果符合入选标准的RCT文献有6项共计1033例患者．腹腔镜手术组与开腹手术组分别为577例和456例。两组的淋巴结获取数差异无统计学意义（WMD=-0．38,95％CI：-1．35～0．58,P=0．43）。腹腔镜组环周切缘阳性率（7．94％）高于开腹手术组（5．37％）,但差异无统计学意义[风险比（RR）=1．13,95％CI：0．69-1．85,P=0．63]。局部复发率比较。差异无统计学意义（RR=O．55,95％CI：0．22-1．40,P=0．21）。两组3年总体生存率比较[危险比（HR）=O．76,95％CI：0．54-1．07,P=0．11]。差异无统计学意义;两组3年无病生存率比较（HR=1．16,95％CI：0．61-2．20,P=0．64）,差异亦无统计学意义。结论直肠癌腹腔镜手术在肿瘤清除及长期疗效方面至少与开腹手术相当。     

Total mesorectal excision for rectal cancer – what can be achieved by a national audit?

Objective The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986–88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five‐year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. Methods In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. Results The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow‐up the rate of local recurrence was 8%, and 5‐year overall survival was 71% for patients younger than 75 years. Conclusions An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.     

Clinical Significance of Occult Metastatic Melanoma in Sentinel Lymph Nodes and Other High-risk Factors Based on Long-term Follow-up

Selective sentinel lymphadenectomy (SSL) following preoperative lymphoscintigraphy is the most significant recent advance in the management of patients with primary melanoma. This study evaluates the prognostic value of sentinel lymph node (SLN) status and other risk factors in predicting survival and recurrence in patients with primary cutaneous melanoma. From October 1993 to July 1998 a series of 412 patients with primary invasive melanoma underwent SSL at the UCSF/ Mt. Zion Melanoma Center. The outcome of 363 evaluable patients is summarized in this study. The factors related to survival and disease recurrence were analyzed by Cox proportional hazard regression models. The overall incidence of patients with positive SLNs was 18%. Over a median follow-up of 4.8 years, the overall mortality rate in patients with primary cutaneous melanoma was 18.7%, and 74 recurrences occurred (20.4%). Mortality was significantly related to SLN status [HR = 2.06; 95% Confidence interval (CI) 1.18, 3.58], angiolymphatic invasion (HR = 2.21; 95% CI 1.08, 4.55), ulceration (HR = 1.79; 95% CI 1.02, 3.15), mitotic index (HR =1.38; 95% CI 1.01, 1.90), and tumor thickness (HR = 2.20, 95% CI 1.21, 3.99). Factors significantly related to disease-free survival included SLN status (HR = 2.09; 95% CI 1.31, 3.34), tumor thickness (HR = 1.89; 95%. CI 1.20,2.98), and age (HR= 1.26 95% CI 1.08, 1.47). SLN status was the most significant factor for melanoma recurrence and death. Other important predictors include tumor thickness, ulceration, lymphatic invasion, and mitotic index.     

The surgical management of rectal cancer: a comparison of treatment methods and outcomes over 2 time periods in the same geographic region

BACKGROUND: Preoperative radiotherapy combined with total mesorectal excision (TME) has provided excellent local control in the treatment of rectal cancer. This study is a review of patients treated at our regional cancer center from 1998 to 2004. The results were compared with a similar study carried out in our region from 1988 to 1998 to determine any changes in treatment methods, recurrence rates, and survival. METHODS: A retrospective review of 448 patients treated with definitive surgery for rectal cancer was conducted. Patient factors analyzed included sex, age, type of surgery, and adjuvant strategy. Tumor factors analyzed included level, stage, and grade. The presence of local recurrence was recorded and overall survival was determined. RESULTS: The local recurrence rate was 8.3% compared with 12.7% in the previous study. Patients treated with preoperative radiotherapy had a recurrence rate of 3.7%. The type of surgical therapy had no significant effect on local recurrence. There was no significant change in overall survival between the present study and the previous one. CONCLUSION: Preoperative radiotherapy is used more frequently in our region and has resulted in a decrease in the local recurrence rate compared to our previous retrospective review. There was no change in local recurrence seen in those patients treated with operative management alone. This study supports the use of preoperative radiotherapy in the management of rectal cancer.     

Risk Factors and Clinical Outcome for Anastomotic Leakage After Total Mesorectal Excision for Rectal Cancer

BACKGROUND: Anastomosis leakage is a major complication of rectal surgery. The aim of this study was to identify risk factors for anastomotic leakage after low anterior resection (LAR) in rectal cancer patients and study its impact on long-term prognosis and disease-free survival and overall survival in rectal cancer patients. METHODS: Consecutive patients who underwent rectal resection with primary anastomosis below the pelvic peritoneal reflexion for rectal cancer between October 1996 to February 2006 were included. RESULTS: Anastomosis leakage after LAR occurred in 51 patients (4.0%). The median time to leakage was 4 days (range = 2-30 days). In univariate analysis, gender, level of anastomosis less than 4 cm, preoperative concomitant chemoradiation (CCRT), and length of operation greater than 120 min were significantly associated with anastomosis leakage. In a multivariate analysis, gender (p = 0.041; relative risk = 2.007; 95% CI = 1.030-3.912) and preoperative CCRT (p = 0.003; relative risk = 2.861; 95% CI = 1.417-5.778) were identified as independent prognostic factors. The overall survival of the nonleakage group and the leakage group was 80.2% and 64.9%, respectively (p = 0.170). The 5-year disease-free survival rates were not significantly different between the nonleakage and leakage groups (78.1% vs. 65.9%, p = 0.166). CONCLUSIONS: The incidence of anastomotic leakage after low anterior resection is relatively low. Male gender and preoperative CCRT were associated with increased risk for anastomotic leakage after rectal cancer surgery. No effect of anastomosis leakage on local recurrence was found in this series.     

Mortality Risk After Preoperative Versus Postoperative Chemotherapy and Radiotherapy in Lymph Node-Positive Rectal Cancer

Introduction

Persistent lymph node-positive disease after preoperative radiotherapy for rectal cancer is associated with adverse outcomes. We quantified mortality risks of persistent pathologic lymph nodes in lymph node-positive rectal cancer patients treated with preoperative versus postoperative chemoradiation.

Methods

This was a retrospective population-based analysis of 2,038 patients with stage III rectal cancer diagnosed 1994–2005 with follow-up through 2007 using data from the California Cancer Registry. Survival estimates were generated using the Kaplan–Meier method. Multivariate cancer-specific and overall mortality analyses were performed using Cox proportional hazard ratios with adjustment for age, gender, race/ethnicity, tumor grade, T stage, N stage, socioeconomic status, and time period (1994–1997, 1998–2001, and 2002–2005).

Results

Overall survival was higher among lymph node-positive patients receiving postoperative chemoradiation compared to lymph node-positive patients receiving preoperative chemoradiation (median overall survival?=?87 versus 62 months, P?=?0.0002). In adjusted analyses, patients with persistent lymph node-positive disease after preoperative chemoradiation treatment had increased overall (HR?=?1.69; 95 % CI, 1.42–2.01) and CRC-specific (HR?=?1.78; 95 % CI, 1.44–2.19) mortality risk compared to lymph node-positive disease after postoperative chemoradiation treatment.

Conclusions

Stage III rectal cancer patients with persistent pathologic lymph nodes after preoperative chemoradiation represent a high-risk group, with higher mortality than those treated with postoperative chemoradiation.     

Transanal endoscopic microsurgery for T1 and T2 rectal cancers: a meta-analysis and meta-regression analysis of outcomes

The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92, 95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.     

Intra‐operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer

Aim Abdominoperineal resection for rectal cancer is associated with higher rates of local recurrence and poorer survival than anterior resection. The aim of this study was to evaluate the outcome of conventional abdominoperineal resection in a large national series. Method The study was based on the Danish National Colorectal Cancer Database and included patients treated with abdominoperineal resection between 1 May 2001 and 31 December 2006. Follow up in the departments was supplemented with vital status in the Civil Registration System. The analysis included actuarial local and distant recurrence, and overall and cancer‐specific survival. Risk factors for local recurrence, distant metastases, overall survival and cancer‐specific survival were identified using multivariate analyses. Results A total of 1125 patients were followed up for a median of 57 (25–93) months. Intra‐operative perforation was reported in 108 (10%) patients. The cumulative 5‐year local recurrence rate was 11% [95% confidence interval (CI), 7–13)], overall survival was 56% (95% CI, 53–60) and cancer‐specific survival was 68% (95% CI, 65–71). Multivariate analysis showed that perforation, tumour stage and nonradical surgery were independent risk factors for local recurrence; tumour fixation to other organs, perforation and tumour stage were independent risk factors for distant metastases; and risk factors for impaired overall survival and cancer‐specific survival were age, tumour perforation, tumour stage, lymph node metastases and nonradical surgery. Conclusion Intra‐operative perforation is a major risk factor for local and distant recurrence and survival and therefore should be avoided.     

进展期直肠癌新辅助放疗与化放疗联合TME随机对照试验的Meta分析

目的评价新辅助放疗组与新辅助化放疗组联合全直肠系膜切除术(TME)治疗局部进展期直肠癌的安全性与疗效。 方法检索2002年至2017年PubMed、OVID、Cochrane图书馆、中国生物医学文献数据库(CBM)、中国知网全文数据库(CNKI)、万方数据库关于新辅助治疗联合TME手术治疗局部进展期直肠癌的文献,对符合纳入标准的文献进行质量评价,采用Revman5.0软件检验异质性,进行meta分析。 结果共4个随机对照试验共2 272例直肠癌患者纳入研究,新辅助放疗组1 133例患者,新辅助化放疗组1 139例患者。与新辅助化放疗组相比,单纯新辅助放疗组的完全病理缓解率更低(OR＝0.32, 95%CI: 0.22～0.44, P<0.05),5年局部复发率更高(OR＝2.13, 95%CI: 1.62～2.79, P<0.05),严重不良反应更少(OR＝0.38, 95%CI: 0.17～0.82, P＝0.01),差异有统计学意义。但保肛率、术后并发症发病率、5年无病生存率和总生存率差异无统计学意义。 结论新辅助化放疗总体上优于单纯新辅助放疗治疗进展期直肠癌,但临床应用中仍需要根据患者的耐受情况选择合适的新辅助治疗方案。     

术前放疗联合全直肠系膜切除术治疗可切除性直肠癌临床疗效的系统评价

目的评价术前放疗联合全直肠系膜切除术（TME）治疗局部可切除直肠癌的临床疗效。方法全面检索1982年1月至2009年4月间发表的评价术前放疗的前瞻性临床随机对照试验研究,按纳入和排除标准筛选,提取人选试验的基本特征和临床疗效数据。对研究目的相同的多项随机对照试验的临床数据采用RevMan4．2软件进行定量合并．对不符合定量合并要求的数据作统计描述。结果符合选择标准的临床随机对照试验9项。短程术前放疗联合规范的TME手术组治疗直肠癌的2年局部复发率为2．4％,低于单纯TME手术组的8．2％（P〈0．01）。术前放疗患者的4年总生存率和无病生存率与术前常规分割放化疗患者相比,差异无统计学意义（P〉0．05）：两组患者的局部复发率差异也无统计学意义（RR=1．16,95％C10．37～3．61,P=0．80）。术前高剂量放疗组完全缓解率显著高于低剂量组（16．0％比2．0％,P〈0．05）．保肛手术率提高3．9％。结论TME术前放疗可降低直肠癌术后局部复发的风险。     

Use of adjuvant,preoperative chemo-radiotherapy in patients with locally advanced rectal cancer

Background: The objective of this study was to perform a non‐randomised prospective examination of the efficacy of adjuvant, preoperative chemo‐radiotherapy in patients with locally advanced rectal cancer. Methods: Between 1996 and 2001, patients presenting with biopsy‐proven, locally advanced, rectal cancers within 12 cm of the anal verge were referred for a long course of adjuvant chemo‐radiotherapy prior to their surgery. Locally advanced lesions were defined by either: (i) endoanal ultrasound showing at least full thickness penetration of the rectal wall (i.e. T3, T4); (ii) abdominal computed tomography scan showing infiltration of adjacent structures, or; (iii) clinical examination demonstrating a fixed lesion. All patients were followed through the hospital colorectal unit. A Kaplan?Meier survival analysis was used to determine survival and local recurrence rates. Results: There were 60 patients with a mean age of 61.5 years (range 33?77 years) with a sex distribution of males to females of 1.7?1.0. Curative resections were performed in 81% of these patients. The remainder (n = 12) were found to have either metastatic disease at operation (n = 5), inoperable disease (n = 2), or had positive resection margins on histology (n = 7). The mean follow up was 2.1 years (maximum 5.1 years). The overall 2‐year survival rate was 86.1% (95% CI ±5.4%). In patients undergoing curative resections, the overall 2‐year survival rate was 91.4% (95% CI ±4.8%), and the 2‐year disease free survival rate was 85.1% (95% CI ±6.2%). The 2‐year local recurrence rate was 7.5%. Conclusions: The use of adjuvant, preoperative, chemo‐radiotherapy in patients with locally advanced rectal cancer is associated with high short‐term survival and a low recurrence rate.     

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.     

Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: a nationwide cohort study from the National Cancer Database

OBJECTIVE: Determine rates of local excision (LE) over time, and test the hypothesis that LE carries increased oncologic risks but reduced perioperative morbidity when compared with standard resection (SR). SUMMARY BACKGROUND DATA: Despite the lack of level I/level II evidence supporting its oncologic adequacy, LE is performed for stage I rectal cancer. METHODS: Surgical therapy for 35,179 patients with stage I rectal cancer diagnosed in 1989 to 2003 was examined over time, utilizing the National Cancer Database. A special study then analyzed perioperative outcomes, local recurrence and survival in 2124 patients diagnosed between 1994 and 1996, including 765 (T1, 601; T2, 164) treated by LE and 1359 (T1, 493; T2, 866) treated by SR. RESULTS: From 1989 to 2003, the use of LE has increased (T1, 26.6-43.7%; T2, 5.8-16.8%; P < 0.001 both). The special study demonstrated significantly lower 30-day morbidity after LE versus SR (5.6% vs. 14.6%; P < 0.001). After adjusting for patient and tumor characteristics, the 5-year local recurrence after LE versus SR was 12.5 versus 6.9% (P = 0.003; hazard ratio = 0.38; 95% CI, 0.23-0.62) for T1 tumors, and 22.1 versus 15.1% (P = 0.01; hazard ratio = 0.69; 95% CI, 0.44-1.07) for T2 tumors. The 5-year overall survival (T1, 77.4% vs. 81.7%, P = 0.09; T2, 67.6% vs. 76.5%, P = 0.01) was influenced by age and comorbidities but not the type of surgery. CONCLUSIONS: This study provides the best evidence for both the increasing use and the associated risks of LE versus SR. For each individual patient, the benefits of LE must be balanced against the heightened risk of local failure.     

Baseline Mortality-Adjusted Survival in Resected Rectal Cancer Patients

Background

This investigation assessed the baseline mortality-adjusted 5-year survival after open rectal cancer resection.

Methods

The 5-year survival rate was analyzed in 885 consecutive American Joint Committee on Cancer (AJCC) stage I–IV rectal cancer patients undergoing open resection between 2002 and 2011 using risk-adjusted Cox proportional hazards regression models adjusted for population-based baseline mortality.

Results

The 5-year relative and overall survival rates were 80.9 %(95 % confidence interval (CI): 77.0–85.0 %) and 71.9 %(95 % CI, 68.4–75.5 %), respectively. The 5-year relative survival rates for stage I, II, III, and IV cancer were 97.8 % (95 % CI, 93.1–102.8 %), 90.9 %(95 % CI, 84.3–98.1 %), 72.0 % (95 % CI, 64.7–80.1 %), and 24.4 % (95 % CI: 16.0–37.0 %), respectively. After the curative resection of stage I–III rectal cancer, fewer than every other observed death was cancer-related. The 5-year relative survival rate for stage I cancer did not differ from the matched average national baseline mortality rate (P?=?0.419). Higher age (hazard ratio (HR) 0.94, 95 % CI: 0.92–0.95, P?P?P?=?0.014).

Conclusion

The analysis of relative survival in a large cohort of rectal cancer patients revealed that stage I rectal cancer is fully curable. The findings regarding age and gender may explain the conflicting results obtained to date from studies based on overall survival.     

Prognostic Impact of Circumferential Resection Margin in Rectal Cancer Treated with Preoperative Chemoradiotherapy

Background

The circumferential resection margin (CRM) is a strong prognostic factor in rectal cancer. The purpose of this study was to investigate the relationship between CRM distance and recurrence in patients with locally advanced rectal cancer who received preoperative chemoradiotherapy (CRT).

Methods

We analyzed data for 561 patients who underwent preoperative CRT and curative surgery for locally advanced rectal cancer between August 2001 and December 2008. CRM was divided into four groups: group 1, CRM > 2 mm; group 2, 1.1–2.0 mm; group 3, 0.1–1.0 mm; and group 4, 0 mm. We assessed the associations of CRM with local recurrence and disease-free survival.

Results

Groups 1, 2, 3, and 4 comprised 487, 36, 20, and 18 patients, respectively. The local recurrence rate was highest and the disease-free survival rate was lowest in group 4, followed by groups 3, 2, and 1. Survival was similar between groups 2 and 1. Local recurrence rates were lower in groups 3, 2, and 1 than in group 4 [hazard ratio (HR) 0.28, 95 % confidence interval (CI) 0.09–0.91, P = 0.035; HR 0.11, 95 % CI 0.03–0.46, P = 0.002; HR 0.18, 95 % CI 0.08–0.42, P < 0.0001, respectively]. Disease-free survival rates were higher in groups 3, 2, and 1 than in group 4 (HR 0.32, 95 % CI 0.13–0.75, P = 0.009; HR 0.24, 95 % CI 0.10–0.54, P = 0.001; HR 0.26, 95 % CI 0.14–0.48, P < 0.0001, respectively).

Conclusions

After preoperative CRT, CRM distance provides useful information for risk stratification in the recurrence of rectal cancer.