Conservative Surgery for Low Rectal Carcinoma After High-Dose Radiation Functional and Oncologic Results

Abstract

ObjectiveUsing a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after highdose radiation. Summary Background DataColo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship. MethodsSince June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3). ResultsMortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients. ConclusionsThese first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.Currently, abdominoperineal resection (APR) repre-rence,3 the need for a 2-cm distal margin,4'5 and the sents the standard surgical treatment of lower-third rec-desirability of complete removal of the perirectal fat.6'7 tal carcinoma. 1"2 The justification for this lies in the nat-In recent years, improvements in surgical technique ural history ofthese tumors-the high risk oflocal recur-have made sphincter conservation for low rectal carci-67

Local staging of rectal cancer using combined pelvic phased‐array and endorectal coil MRI

“…A well known result of preoperative chemoradiotherapy is downsizing of tumors and involved lymph nodes, which leads to a lower pathological staging (5)(6)(7)(8)(9). It is likely that the downstaging effect of preoperative chemoradiotherapy contributed to some of the false-positive results in our study, since all of the overstaged patients in terms of mesorectal fat invasion and the majority (six of eight) of the overstaged patients in terms of nodal involvement received preoperative radiochemotherapy.…”

“…Traditional surgical methods, such as low anterior resection (LAR) and abdominoperineal resection (APR), have high recurrence rates, leading to a poor prognosis (4). Recent findings from large, randomized trials indicate that preoperative chemoradiotherapy substantially reduces the frequency of local recurrence and improves survival (5)(6)(7)(8)(9). In addition, preoperative chemoradiotherapy may reduce the size of a tumor, facilitate a curative resection, and enable sphincter-preserving surgery in tumors located near the anorectal junction (6,7).…”

“…Recent findings from large, randomized trials indicate that preoperative chemoradiotherapy substantially reduces the frequency of local recurrence and improves survival (5)(6)(7)(8)(9). In addition, preoperative chemoradiotherapy may reduce the size of a tumor, facilitate a curative resection, and enable sphincter-preserving surgery in tumors located near the anorectal junction (6,7). Preoperative chemoradiotherapy is not offered for stage I tumors (confined to the rectal wall, no nodal involvement: T1-2/N0), but is recommended as a standard treatment for stage II (extent beyond the rectal wall, no nodal involvement: T3/N0) and stage III (regional lymph node involvement, regardless of T stage: Tx/N1-2) tumors (5,8,9).…”

Multidisciplinary case teams: an approach to the future management of advanced colorectal cancer

“…Results expressed as percentages of patients who were evaluable at each dosage level are shown above each bar (Minsky et al, 1992a) need to monitor the results of treatment and respond appropriately. The need for more effective liaison between different clinical disciplines is illustrated by the observation that preoperative radiation therapy or combined modality therapy in patients with rectal cancer who undergo surgery may be associated with a more favourable outcome (reduced toxicity and better preservation of sphincter function) than post-operative therapy (Minsky et al, 1992ci;Rouanet et al, 1995;Hyams et al] 1997;Maghfoor et al, 1997). An example of how patient-centred end-points such as reduced incidence of acute side-effects and the avoidance of permanent colostomy might be used to improve the overall effectiveness of treatment is shown by the following data from the Memorial Sloan-Kettering Cancer Center (Minsky et al, 1992a).…”

“…The traditional rationale for this procedure lies in the natural history of these tumours, with their high risk of local recurrence (Domergue et al, 1988), the need for a 2-cm distal margin (Pollett and Nicholls, 1983;Williams et al, 1983) (Wagman et al, 1997) and 'perfect' in 71% (Rouanet et al, 1995) of evaluable patients. Although the phase I/II data that suggest that preoperative therapy has lower acute toxicity and enhances sphincter preservation need to be confirmed in a randomized trial, the results are nonetheless illustrative of qualityof-life end points.…”