Oncological outcome of T1 rectal cancer undergoing standard resection and local excision

Aim We studied the outcome and prognostic factors for T1 rectal cancer patients undergoing standard resection or transanal excision. Method One hundred and twenty‐four patients with T1 rectal cancer were included in the study, of whom 66 (53.2%) underwent standard resection and 58 (46.8%) underwent transanal excision. Survival analysis was performed to compare the outcome. Results The 5‐year local recurrence rate was 11.0% in the transanal excision group versus 1.6% in the standard resection group (P = 0.031) but the 5‐year disease‐free survival and overall survival rates were not significantly different between the two groups. Multivariate analysis suggested that a high tumour grade and perineural or lymphovascular invasion were independent risk factors for local recurrence and recurrence‐free survival. For high‐risk patients (with at least one of the above risk factors), the 5‐year local recurrence and 10‐year recurrence‐free survival rates were 21.2% and 74.5%, versus 1.2% and 92.0% in low‐risk patients (P = 0.00003 and P = 0.003). In patients undergoing transanal excision, none in the low‐risk group had local recurrence during follow up, while 40% (6 of 15) of patients in the high‐risk group developed local recurrence within 5 years after surgery. The 5‐year local recurrence rate was 45.0%. Conclusion Transanal excision in T1 rectal cancer may result in a high rate of local failure for patients with a high‐grade tumour, or perineural or lymphovascular invasion. Local excision should be avoided as a curative treatment in high‐risk patients.     

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.     

Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach

Aim Laparoscopic sphincter‐saving surgery has been investigated for rectal cancer but not for tumours of the lower third. We evaluated the feasibility and efficacy of laparoscopic intersphincteric resection for low rectal cancer. Method From 1990 to 2007, patients with rectal tumour below 6 cm from the anal verge and treated by open or laparoscopic curative intersphincteric resection were included in a retrospective comparative study. Surgery included total mesorectal excision with internal sphincter excision and protected low coloanal anastomosis. Neoadjuvant treatment was given to patients with T3 or N+ tumours. Recurrence and survival were evaluated by the Kaplan–Meier method and compared using the Logrank test. Function was assessed using the Wexner continence score. Results Intersphincteric resection was performed in 175 patients with low rectal cancer: 110 had laparoscopy and 65 had open surgery. The two groups were similar according to age, sex, body mass index, ASA score, tumour stage and preoperative radiotherapy. Postoperative mortality (zero) and morbidity (23%vs 28%; P = 0.410) were similar in both groups. There was no difference in 5‐year local recurrence (5%vs 2%; P = 0.349) and 5‐year disease‐free survival (70%vs 71%; P = 0.862). Function and continence scores (11 vs 12; P = 0.675) were similar in both groups. Conclusion Intersphincteric resection did not alter long‐term tumour control of low rectal cancer. The safety and efficacy of the laparoscopic approach for intersphincteric resection are suggested by a similar short‐ and long‐term outcome as obtained by open surgery.     

Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence,distant metastasis and reduced cancer‐specific survival?

Aim The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer‐specific survival was analysed. Method Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5‐year follow‐up were analysed with multivariate methods. Results After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour–node–metastasis stages I–III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5‐year cancer‐specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5‐year overall or 5‐year cancer‐specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy (P = 0.055) and rectal washout (P = 0.046) reduced the LR rate, but did not influence survival. Conclusion Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow‐up on the basis of the occurrence of AL after AR might not be justified.     

Clinical significance of macroscopic completeness of mesorectal resection in rectal cancer

Aim Local recurrence after resection of rectal cancer is usually regarded as being due to a ‘failure’ of surgery. The completeness of resection of the mesorectum has been proposed as an indicator of the ‘quality’ of the resection. We determined the prognostic value of macroscopic evaluation of rectal cancer resection specimens and the circumferential resection margin (CRM) after curative surgery. Method From 1999 to 2006, the macroscopic quality of the mesorectum and the CRM were prospectively assessed in 127 patients who underwent rectal cancer resection with curative intent (R0+R1). Chemoradiotherapy was administered for 61 tumours staged as locally advanced tumours (T3, T4 and N+). Univariate analysis of time to local recurrence and cancer‐free survival were tested (Kaplan–Meier) and multivariate analysis calculated with a Cox regression model. Results The mesorectum was incomplete in 34 (26.8%) patients. At a median follow up of 34 months (range, 9–96 months), in the group with an adequate mesorectal excision, the cumulative risk of local recurrence at 5 years was 10%. This was 25% if the mesorectum was incomplete (P < 0.01). Five‐year cancer‐free survival was 65% if the mesorectal excision was adequate and 47% if it was not (P < 0.05). Multivariate analysis identified T status, the CRM and the mesorectal score as independent factors for local recurrence, and T and N status and the mesorectal score as independent factors for disease‐free survival. Conclusion The outcome of surgical treatment of rectal cancer is related to the completeness of mesorectal excision. It is a more discriminative prognostic factor than the classic tumour–node–metastasis (TNM) system.     

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.     

Effect of Adjuvant Radiotherapy on Local Recurrence in Stage II Rectal Cancer

Background Prospective trials have demonstrated that chemotherapy combined with radiotherapy decreases local recurrence rates in stage II and stage III rectal cancer. Some patients with stage II lesions, however, have relatively low risks of local recurrence. We evaluated the effect of radiotherapy on local recurrence in patients with stage IIA rectal cancer. Methods From the colorectal cancer database, we identified 390 stage IIA rectal cancer patients who underwent curative resection followed by adjuvant therapy from 1995 to 2002; a total of 72 patients who received preoperative chemoradiotherapy and who did not receive adjuvant therapy were excluded. Mean follow-up period was 65 months (range, 2–133 months). Results Of the 390 patients, 110 had primary tumors in the upper rectum, 136 in the midrectum, and 144 in the lower rectum. Lymphovascular invasion was observed in 35 patients (9.0%). Mean (± SD) number of examined lymph nodes was 18 (± 12). Adjuvant chemotherapy was provided to 180 patients (46.2%), and chemotherapy plus radiotherapy was provided to 210 patients (53.8%). Radiotherapy was significantly more common in younger patients (P = .01) and those with lower rectal cancer (P < .001). Local recurrence rate did not differ between patients who did and did not receive radiotherapy. In patients with mid and lower rectal cancer, the local recurrence rate was not affected by radiotherapy. Conclusions Radiotherapy did not seem to provide additional benefit in decreasing local recurrence rate of stage IIA rectal cancers. In selected patients, however, the role of radiotherapy needs to be carefully evaluated.     

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.     

Adjuvant radiochemotherapy – what is the patients benefit?

Background: Local relapse is a major problem after potentially curative rectal cancer surgery. Although the incidence of local recurrences may be reduced by specialized surgical techniques such as total mesorectal excision (TME), local relapse rates of 20% or higher are the surgical reality today. Studies using adjuvant postoperative radiotherapy, chemotherapy, radiochemotherapy or immunotherapy have tried to reduce local relapse rates and distant progression. Postoperative radiochemotherapy has been the recommended standard, after complete resection of Union Internationale Contra la Cancrum (UICC) stages II and III rectal cancers. In view of recent positive results with preoperative radiotherapy of TME without adjuvant therapy, we found it important to review the literature to update the recommendable adjuvant procedure in rectal cancer. Method/Patients: The literature from 1985 to May 1998 was reviewed for studies trying to either confirm or improve adjuvant therapy in rectal cancer. Only randomized controlled trials were analyzed with regard to their effectiveness in reducing the absolute rates of local recurrence and improving survival. Results: Two trials applying adjuvant radiotherapy were able to demonstrate the reduction of local relapse rates, one trial with marginal significance, both without impact on survival. Four trials involving 1104 patients with rectal cancer stages UICC II–III compared postoperative radiochemotherapy with either surgical controls, adjuvant radiotherapy or conventional radiochemotherapy. In these trials, local relapse rates were significantly reduced by 11–18%, and survival rates significantly improved by 10–14%. Severe acute toxicities occurred in 50–61% of the patients, compromising compatibility, and caused death in 0–1%. Small-bowel obstruction leading to surgery was noted in 2–6% and to death in up to 2% of the patients. Intraoperative radiotherapy (IORT) improved local control and survival after surgery of locally advanced disease/local relapse. Conclusion: In view of four trials demonstrating a significant benefit of postoperative radiochemotherapy and with regard to recent still-debatable results of preoperative short-term radiotherapy optimal surgery with lowest local relapse rates plus postoperative radiochemotherapy remains the actual recommendable standard for rectal cancer surgery in R0 resected tumors stages UICC II+III. Received: 1 September 1998 / Accepted: 15 September 1998     

Local excision of rectal carcinoma

The purpose of this study was to identify the recurrence rate, the salvage rate after recurrence, and the overall survival after local excision of rectal adenocarcinomas. A retrospective medical chart review was performed in 31 consecutive patients with rectal adenocarcinoma who underwent local excision at Roswell Park Cancer Institute from January 1990 through December 1999. After excision nine patients were excluded from further analysis because they were found to have advanced stage on pathologic examination (T2 primary tumors with vascular invasion or T3 tumors). Eight of the nine patients underwent abdominoperineal resection as definitive therapy. In the remaining 22 patients who underwent transanal excision as definitive surgical therapy there were 13 patients with T1 tumors and nine patients with T2 tumors. Overall seven patients (32%) developed local recurrences after local excision. This included four patients with T1 and three patients with T2 primary tumors. All recurrences occurred in the seven patients who did not receive adjuvant chemoradiation. All patients underwent salvage resection of the recurrence. Four patients who underwent salvage resection of the recurrence remain without evidence of disease at a median follow-up of 19.5 months. Local excision without adjuvant therapy has an unacceptably high rate of local recurrence. Although most patients who recur locally are salvaged by radical resection the long-term results after resection remain unknown. The use of adjuvant chemoradiation appears to reduce this high recurrence rate and may eventually become a standard adjunct to local excision of rectal cancer.     

Centralization of rectal cancer surgery improves long‐term survival

Aim In 1996, rectal cancer surgery in the Swedish county of Västmanland was centralized to a single colorectal unit. At the same time, total mesorectal excision and multidisciplinary team meetings were introduced. The aim of this audit was to determine the long‐term results before and after centralization. Method All consecutive rectal cancer patients who underwent curative or palliative surgery at one of the county’s four hospitals between 1993 and 1996 (n = 133, group 1) were compared with patients operated at the new centralized colorectal unit between 1996 and 1999 (n = 144, group 2). Results Preoperative radiotherapy was common in both groups, but in group 2, it was planned using MRI. Local recurrences were detected in 8% of all patients operated in group 1 vs 3.5% in group 2 (P = 0.043). The overall 5‐year survival for all patients in group 1 was 38 vs 62% in group 2 (P = 0.003). According to multivariate analysis, the new colorectal unit was an independent predictor for improved long‐term survival. Conclusion This population‐based audit shows reduced local recurrence rate and prolonged overall survival for rectal cancer patients after centralization to a single colorectal unit with multidisciplinary management and increased subspecialization.     

Long-term results of local excision for rectal cancer

OBJECTIVE: To review the authors' experience with local excision of early rectal cancers to assess the effectiveness of initial treatment and of salvage surgery. SUMMARY BACKGROUND DATA: Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome. METHODS: Patients with T1 and T2 adenocarcinomas of the rectum treated by local excision as definitive surgery between 1969 to 1996 at the authors' institution were reviewed. Pathology slides were reviewed. Among 125 assessable patients, 74 were T1 and 51 were T2. Thirty-one patients (25%) were selected to receive adjuvant radiation therapy. Fifteen of these 31 patients received adjuvant radiation in combination with 5-fluorouracil chemotherapy. Median follow-up was 6.7 years. One hundred fifteen patients (92%) were followed until death or for greater than 5 years, and 69 patients (55%) were followed until death or for greater than 10 years. Recurrence was recorded as local, distant, and overall. Survival was disease-specific. RESULTS: Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.     

Previous transanal full‐thickness excision increases the morbidity of radical resection for rectal cancer

Aim The aim of the study was to determine the impact of primary full‐thickness transanal excision (TAE) on the morbidity rate following radical rectal resection for cancer. Method Fourteen consecutive patients underwent radical resection for lower third rectal cancer following full‐thickness TAE without closure of the defect. They were compared with 25 matched patients from a prospective database of 275 rectal resections who had undergone radical resection without previous TAE for lower third rectal cancer (control group). The confounding factors were: age, sex, body mass index (BMI), classification according to the American Society of Anaesthesiologists, administration of neoadjuvant radiotherapy before rectal resection, tumour stage and type of surgical procedure. Results There were no deaths. Overall morbidity was 64.3% in the TAE group and 32% in the control group (P = 0.112). Surgical complications were significantly more frequent in the former (57.1%vs 20%; P = 0.048). The frequency of specific surgical site complications, including anastomotic complications and pelvic abscess formation requiring surgical drainage, was significantly higher in the TAE group than in the control group (42.8%vs 8%; P = 0.032). In univariate analysis, the only factors associated with specific surgical site complications were BMI > 27 and TAE before rectal resection. Conclusion This case‐matched study suggests that previous full‐thickness TAE increases the risk of surgical complications after radical resection for lower third rectal cancer, including anastomotic dehiscence and pelvic sepsis.     

1ADJUVANT RADIOTHERAPY IS AN INDEPENDENT RISK FACTOR FOR SMALL BOWEL OBSTRUCTION AFTER CURATIVE RECTAL CANCER SURGERY

Aim: Small bowel obstruction (SBO) as a complication is not uncommon after curative rectal cancer surgery; adjuvant radiotherapy (RT) may have a contributory role. This study aimed at determining the prevalence and risk factors for this complication. Methods: The medical records of 260 consecutive patients with rectal cancer (excluding rectosigmoid cancer) who underwent curative surgery at our institution between January 1995 and December 2000 were retrospectively reviewed to determine the prevalence of SBO requiring hospitalization and intervention. Possible risk factors for SBO were recorded and analysed using univariate and multivariate analysis. Results: The median duration of follow up was 76.1 months (range, 3.3–141.8 months). Forty‐four patients (16.9%) developed SBO and 19 of them required surgical intervention. Three patients (6.8%) died as a consequence of SBO. Seventy‐eight patients (30%) received adjuvant RT with a median dose of 50 Gy (range 30–64 Gy). Patients receiving RT were more likely to develop SBO (25.6% vs 13.2%, P = 0.014). The median duration between adjuvant RT and the first episode of SBO was 23.5 months (range, 5.7–99.4 months). Multivariate analysis showed that adjuvant RT was the only independent risk factor for SBO (OR = 2.27, 95% CI = 1.17–4.42, P = 0.016). Gender, operative approach (open vs laparoscopic), abdominoperineal resection, perioperative blood transfusion, postoperative intra‐abdominal sepsis, tumour stage, and disease recurrence were not associated with the development of SBO. Conclusion: Adjuvant RT is the only independent risk factor for SBO after curative surgery for rectal cancer. Patients should be well informed of this potential complication when they are offered adjuvant RT.     

Prognostic implications of circumferential location of distal rectal cancer

Aim This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. Method All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. Results Two hundred and five patients with distal rectal cancer were operated on for a uT2‐T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty‐three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. Conclusion Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.     

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis

Aim The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. Method The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. Results Five nonrandomized studies including a total of 5012 patients were identified. Meta‐analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43–0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39–0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42–0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39–0.98). Conclusion Taking into account the limitations of the design of the included studies the meta‐analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.     

直肠癌局部切除术的外科疗效与预后分析

目的 分析局部切除术治疗直肠癌的疗效及影响复发和预后的因素.方法 回顾性分析采用局部切除术治疗的46例中低位直肠癌患者临床资料,并对其预后影响因素进行单因素及多因素分析.结果 46例患者中经肛门局部切除38例,经骶尾部切除8例;术后并发症发生率为10.9%,围手术期病死率为0;局部复发率为17.4%,Tis、T1及T2期病变的局部复发率分别为0,12.0%,33.3%.肿瘤大体类型、肿瘤直径和分化程度与术后局部复发相关.总体5年生存率为83.3%,Tis、T1、T2期5年生存率分别为100%、90.9%、66.7%.单因素分析显示,肿瘤大小、分化程度、术后放化疗、脉管癌栓和局部复发是影响预后的因素.多因素分析显示,局部复发是影响预后的主要因素.结论 早期（Tis、T1期）高中分化癌,病灶直径≤3 cm,无脉管浸润的隆起型直肠癌,局部切除术是有效的治疗方法.T2期及以上的肿瘤应首选根治性手术,不能耐受根治术者或拒行腹壁人工肛门者,可考虑姑息性局部切除术后加行辅助放、化疗.     

Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre

Aim Extralevator abdominoperineal excision (APE) for low rectal tumours has been introduced to achieve improved local radicality. Fewer positive margins and intraoperative perforations have been reported compared with standard APE. The aim of this retrospective study was to compare short‐term complications and results of the two techniques in our institution. Method Consecutive patients with rectal cancer undergoing APE between 2004 and 2009 were included. They were divided into two groups of 79 patients in extralevator APE and 79 in standard APE. Patients with recurrence and those having a palliative procedure were excluded. Data were collected from hospital records and the colorectal cancer registry. Main endpoints were wound infection, perineal wound revision, oncological data and length of hospital stay. Results Circumferential resection margin positivity did not differ significantly between groups (17% extralevator APE; 20% standard APE). Intraoperative perforation (13%vs 10%) or local recurrence (seven in each group) were no different. Perineal wound infection was more common after extralevator APE (46%vs 28%, P < 0.05) as was perineal wound revision (22%vs 8%, P < 0.05). Hospital stay was longer after extralevator APE (median 12 vs 11 days, P < 0.05). Tumour height (median 4 cm) and pTNM classification did not differ. Conclusion The results do not show any advantage for extralevator APE. The oncological data were no better and postoperative morbidity was increased. Further studies are needed before extralevator APE is widely adopted in clinical practice.     

Prognostic Significance of Circumferential Resection Margin Following Total Mesorectal Excision and Adjuvant Chemoradiotherapy in Patients with Rectal Cancer

Background This study was designed to evaluate the prognostic value of circumferential resection margin (CRM) in rectal cancer patients who underwent curative resection with adjuvant chemoradiotherapy (CRT). Methods We studied 504 patients who underwent total mesorectal excision with adjuvant CRT for rectal cancer between 1997 and 2001. The patients were divided into two groups: a negative CRM group (CRM > 1 mm) and a positive CRM group (CRM ≤ 1 mm). The survival rates, local recurrence rates, and systemic recurrence rates were compared between groups. Results The negative CRM group had 460 patients and the positive CRM group had 44 patients. The 5-year local and systemic recurrence rates were 11.3 and 25.3%, respectively, in the negative CRM group and 35.2 and 60.8% in the positive CRM group, respectively. The cancer-specific 5-year survival rates for the two groups were 72.5 and 26.9% (P < .001), respectively. CRM was found to be an independent prognostic factor by multivariate analyses which were adjusted for known outcome predictors (P < .001). Conclusion Oncological outcome for patients in the positive CRM group is less favorable than for those in the negative CRM group. Adjuvant CRT is not a definite treatment modality that can be used to compensate for a positive CRM following TME and adjuvant CRT in patients with TNM stage II or III rectal cancer.     

Local recurrence of cancer of the rectum.

BACHGROUND: Although radiotherapy or total mesorectal excision decreases the risk of local recurrence of rectal cancer, this risk remains around 10%. METHODS: Of 80 patients having a local recurrence, 38 (48%) underwent a re-resection combined in 10 cases with resection of mestastases. RESULTS: The incidence of asymptomatic detected recurrence was higher after anterior resection (39%) than after abdominoperineal resection (18%). Re-resection was performed more often (P <0.01) in the past 2 decades after anterior or Hartman first procedure than after abdominoperineal resection (67% versus 21%), and more often in asymptomatic patients than in symptomatic patients (71% versus 38%). The actuarial 5-year survival rate after re-resection was 20%. CONCLUSIONS: Early detection of local recurrence, with PET scan using (18)F-fluorodeoxyglucose (8 cases in the present series), leads to an improved re-resection rate. In patients who did not undergo radiotherapy (all patients but 1) re-resection can be achieved safely (no postoperative mortality). The place for radiation in the treatment of rectal cancer has to be revaluated and compared with total mesorectal excision and results of re-resection for local recurrence.