Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Abstract

Background: Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers.Methods: Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. Results: Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82⋅8 per cent (298 patients) and the local recurrence rate was 12⋅5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4⋅49, 95 per cent c.i. 1⋅99 to 10⋅14; P = 0⋅002) and lymphovascular invasion (HR 2⋅02, 1⋅08 to 3⋅77; P = 0⋅032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease.Conclusion: This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

En bloc resection of locally perforated colonic malignancy with removal of iliopsoas and femoral nerve and primary anastomosis

“…Using a combination of neoadjuvant chemoradiotherapy for advanced colonic malignancies has only been explored in a few small case series, which report successful R0 resection rates between 91% and 100% 3–5 . These rates are consistent with those reported in other advanced gastrointestinal malignancies 6–9 and are again demonstrated in this case. Furthermore, the reduction in the incidence of local recurrence is further evidence to support the use of neoadjuvant therapy prior to resection 10 .…”

Outcomes of extended radical resections for locally advanced and recurrent pelvic malignancy involving the aortoiliac axis

“…The technique for extended radical pelvic resection at our institution has previously been described [6,10].…”

An International Multicenter Prospective Study Evaluating the Long-term Oncological Impact of Adjuvant Chemotherapy in ypN+ Rectal Cancer

“…It is established that high-quality surgery in the form of a complete total mesorectal excision (TME) is the cornerstone of surgical management for locally advanced rectal cancer (LARC) 1–3. Neoadjuvant therapy, either chemoradiotherapy (NACRT) or short course radiotherapy can further confer maximum oncological benefit 4–6. More recently, total neoadjuvant therapy (TNT), that is, additional treatment with up-front or consolidation chemotherapy with NACRT or short course radiotherapy is gaining popularity with favorable outcomes 7–10…”