Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236-242. [PMID: 19212176 DOI: 10.1097/sla.0b013e318195e17c]

Systematic review of outcomes after intersphincteric resection for low rectal cancer

BACKGROUND

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer.

METHODS

A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011.

RESULTS

Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7.

CONCLUSION

Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.

Laparoscopic versus open intersphincteric resection and coloanal anastomosis for low rectal cancer: intermediate-term oncologic outcomes

OBJECTIVE

To compare the surgical outcome and intermediate oncological outcomes for laparoscopic versus open intersphincteric resection (ISR).

BACKGROUND

Intersphincteric resection has been proposed as an alternative to abdominoperineal resection for selected low rectal cancer cases, but the oncological adequacy of laparoscopic ISR has not been established.

METHODS

A total of 210 consecutive patients with low rectal cancer who underwent ISR between 1997 and 2009 in 2 institutions were evaluated retrospectively. Patients were classified into an open surgery (OS, n = 80) group and a laparoscopy (LAP, n = 130) group. The primary endpoint was 3-year disease-free survival.

RESULTS

The major complication rates were similar in the LAP and OS groups (5.4% vs 3.8%, respectively; P = 0.428). However, the LAP group had a shorter hospital stay and time to bowel movement compared with the OS group. In the LAP group, operating time was 16 minutes shorter (P = 0.230) and intraoperative blood loss was less (P = 0.002). Median follow-up was 34 months (interquartile range: 20.0-42.5 months). The local recurrence rates were similar in the 2 groups (LAP, 2.6% vs OS, 7.7%; P = 0.184). The combined 3-year disease-free survival for all stages was 82.1% (95% CI: 73.7-90.2%) in the LAP group and 77.0% (95% CI: 66.9%-86.9%) in the OS group (P = 0.523).

CONCLUSIONS

Laparoscopic ISR can be performed safely and offers a minimally invasive sphincter-sparing alternative. The oncological adequacy of laparoscopic ISR requires long-term follow-up data, but the intermediate-term outcomes seem equivalent to those achieved with OS.

Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only?

BACKGROUND

Previous reports suggest that patients with rectal cancer undergoing abdominoperineal resection have worse oncologic outcomes in comparison with those undergoing restorative rectal resection.

OBJECTIVE

This study aimed to assess factors influencing oncologic outcomes for patients undergoing surgery for rectal cancer.

DESIGN

This study is a retrospective review of prospectively gathered data.

SETTING

Data were gathered from a prospective cancer database.

PATIENTS

Patients were included who underwent radical resection for mid and lower third rectal cancer (1991-2006).

MAIN OUTCOME MEASURES

The primary outcomes measured were the impact of various factors on perioperative outcomes, local recurrence, and disease-free survival for patients undergoing abdominoperineal resection.

RESULTS

Four hundred thirteen (29%) patients underwent abdominoperineal resection and 993 (71%) underwent restorative resection for rectal cancer. Patients with abdominoperineal resection were older (p < 0.0001), had a higher mean ASA score (p < 0.001), worse tumor differentiation (p < 0.001), and higher tumor stage (p = 0.0001). Although overall morbidity was lower in the abdominoperineal resection group (p = 0.001), the length of stay was greater (p < 0.001). After a similar period of follow-up (5.2 ± 3.9 vs 5.3 ± 3.4 y, p = 0.58), local recurrence (7% vs 3%, p = 0.02) was higher after abdominoperineal resection, but overall survival (56% vs 71%, p < 0.001) and disease-free survival (54% vs 70%, p < 0.001) were lower. On multivariate analysis, higher stage, poor tumor differentiation, involved margins, and older age were associated with worse survival, whereas higher stage, poor tumor differentiation, and abdominoperineal resection were associated with greater recurrence. These worse oncologic outcomes persisted even when the groups were stratified based on the location of the cancer in mid or distal rectum and for patients with a clear circumferential margin.

LIMITATION

This study was limited by its retrospective nature.

CONCLUSION

Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection in comparison with restorative resection. A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes. Because patients undergoing abdominoperineal resection represent a high risk for poor outcomes, management strategies need to consider all these factors during treatment.

Acceptance of a 5-mm distal bowel resection margin for rectal cancer: is it safe?

AIM

Acceptance of a short distal bowel margin results in a higher rate of anterior resection but may compromise oncological safety. This study aimed to evaluate the safety of a 5-mm distal margin.

METHOD

A retrospective analysis was carried out of 412 consecutive patients with rectal cancer treated with anterior resection with a negative circumferential resection margin. Radiotherapy was given to 63% of patients with an advanced tumour. The median follow up was 75 months.

RESULTS

Fewer patients in the group with a distal margin of ≤ 5 mm had a tumour with an advanced pT stage compared to patients in the group with a distal margin of > 5 mm (P = 0.033). Two patients were converted to abdominoperineal resection because of a positive 'doughnut', leaving 410 patients, in whom 5.4% (95% CI, 0-11.3%) of the group with a distal margin of ≤ 5 mm had local recurrence at 5 years compared with 4.2% (95% CI, 2.1-6.3%) of the group with a distal margin of > 5 mm (P = 0.726). The corresponding figures for the 5-year overall survival were 82.4% (95% CI, 72.6-92.2%) vs 76.3% (95% CI, 71.8-80.8%) (P = 0.581). All four anastomotic recurrences occurred in the group with a distal margin of > 5 mm.

CONCLUSION

A distal margin of ≤ 5 mm did not compromise oncological safety in patients undergoing preoperative radiation for an advanced rectal cancer.

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.

Does long-course radiotherapy influence postoperative perineal morbidity after abdominoperineal resection of the rectum for cancer?

AIM

The aim of the study was to define risk factors for perineal wound complications after abdominoperineal resection (APR), with particular reference to preoperative radiotherapy.

METHOD

Patients undergoing APR at our institution between 1985 and 2009 were reviewed. Wound complications were classified according to the Center for Disease Control and Prevention classification of surgical site infection (SSI). Perineal complications were identified in patients who had preoperative long-course radiotherapy (Group 1) and those who had surgery alone (Group 2).

RESULTS

One hundred and fifty-seven patients met the inclusion criteria. Preoperative radiotherapy was performed in 68 (44.7%) patients (Group 1), and 89 (65.3%) patients (Group 2) underwent surgery alone. The overall rate of perineal wound complications was 14.8%. The wound infection rate was similar in each group (Group 1, 10/68, 14.7%; Group 2, 13/89, 14.9%; P = 0.9). An elevated BMI (>30) was the only factor correlated with perineal morbidity on univariate analysis (P = 0.01).

CONCLUSION

Preoperative radiotherapy does not influence perineal healing other than in patients with obesity.

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.

Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview

BACKGROUND

After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence.

METHODS

A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics.

RESULTS

In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups.

CONCLUSION

This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.

How low is low? Evolving approaches to sphincter-sparing resection techniques

Although advances in rectal cancer staging may ultimately be accurate enough to reliably exclude disease outside the rectal wall (thereby allowing local approaches to be more widely and safely applied) and advances in the use of neoadjuvant chemo- and radiation therapy may ultimately produce more "complete responders" that can be accurately identified and spared surgery altogether, as it stands, radical resection forms the basis of curative treatment for rectal cancer. However, the concepts that guide the surgeon in choosing the optimal approach in radical resection are changing. In the past, the decision as to how to proceed surgically with radical resection was based primarily on the level of the tumor above the anal verge or anorectal ring. The issue was primarily "How low is the tumor?" and "Is the distal margin safe?" A more modern approach focuses attention on achieving a negative circumferential margin despite what historically may seem to be a very minimal distal margin, the current issue is not "How low is the tumor?" so much as it is "How deep does the tumor go?". This shift in focus has been a major impetus in the evolution of sphincter sparing resection techniques.

Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review

Background

Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of <1 cm jeopardizes oncologic safety.

Methods

A systematic review of the literature identified 17 studies showing results in relation to margins of approximately <1 cm (948 patients) versus >1 cm (4626 patients); five studies in relation to a margin of ≤5 mm (173 patients) versus >5 mm (1277 patients), and five studies showing results in a margin of ≤2 mm (73 patients). In most studies, pre- or postoperative radiation was provided.

Results

A multifactorial process was identified resulting in selection of favorable tumors for anterior resection with the short bowel margin and unfavorable tumors for abdominoperineal resection or for anterior resection with the long margin. In total, the local recurrence rate was 1.0% higher in the <1-cm margin group compared to the >1-cm margin group (95% confidence interval [CI] −0.6 to 2.7; P = 0.175). The corresponding figures for ≤5 mm cutoff point were 1.7% (95% CI −1.9 to 5.3; P = 0.375). The pooled local recurrence rate in patients having ≤2 mm margin was 2.7% (95% CI 0 to 6.4).

Conclusions

In the selected group of patients, <1 cm margin did not jeopardize oncologic safety.

Proximal and distal rectal cancers differ in curative resectability and local recurrence

AIM: To evaluate patients with proximal rectal cancer (PRC) (> 6 cm up to 12 cm) and distal rectal cancer (DRC) (0 to 6 cm from the anal verge).

METHODS: Two hundred and eighteen patients (120 male, 98 female, median age 58 years, range 19-88 years) comprised 100 with PRC and 118 with DRC. The proportion of T1, T2 vs T3, T4 stage cancers was similar in both groups (PRC: T1+T2 = 29%; T3+T4 = 71% and DRC: T1+T2 = -31%; T3+T4 = 69%). All patients had cancer confined to the rectum - those with synchronous distant metastasis were excluded. Surgical resection was with curative intent with or without pre-operative chemoradiation (c-RT). Follow-up was for a median of 35 mo (range: 12 to 126 mo). End points were: 30 d mortality, complications of operation, microscopic tumour- free margins, resection with a tumour-free circumferential margin (CRM) of 1 to 2 mm and > 2 mm, local recurrence, survival and the permanent stoma rate.

RESULTS: Overall 30-d mortality was 6% (12): PRC 7 % and DRC 4%. Postoperative complications occurred in 14% with PRC compared with 21.5% with DRC, urinary retention was the complication most frequently reported (PRC 2% vs DRC 9%, P = 0.04). Twelve percent with PRC compared with 37% with DRC were subjected to preoperative c-RT (P = 0.03). A tumour-free CRM of 1 to 2 mm and > 2 mm was reported in 93% and 82% with PRC and 88% and 75% with DRC respectively (PRC vs DRC, P > 0.05). However, local recurrence was 5% for PRC vs 11% for DRC (P < 0.001). Three and five years survival was 65.6% and 60.2% for PRC vs 67% and 64.3% for DRC respectively. No patient with PRC and 23 (20%) with DRC received an abdomino-perineal resection.

CONCLUSION: PRC and DRC differ in the rate of abdomino-perineal resection, post-operative urinary retention and local recurrence. Survival in both groups was similar.

Risk factors for fecal incontinence after intersphincteric resection for rectal cancer

BACKGROUND

Restoration of bowel continuity is a major goal after surgical treatment of rectal cancer. Intersphincteric resection allows sphincter preservation in low rectal cancer but may have poor functional results, including frequent bowel movements, urgency, and incontinence.

OBJECTIVE

This study aimed to evaluate long-term functional outcome after intersphincteric resection to identify factors predictive of good continence.

DESIGN

Descriptive observational study.

SETTING

Follow-up of surgery in tertiary care university hospital.

PATIENTS

Eligible patients were without recurrence 1 year or more after surgery for low rectal cancer.

INTERVENTION

Intersphincteric resection.

MAIN OUTCOME MEASURES

: Bowel function was assessed with a standardized questionnaire sent to patients. Functional outcome was considered as good if the Wexner score was 10 or less. Univariable and multivariable regression analyses were used to evaluate impact of age, gender, body mass index, tumor stage, tumor location, distance of the tumor from the anal verge and from the anal ring, type of surgery, colonic pouch, height of the anastomosis, pelvic sepsis, and preoperative radiotherapy on functional outcome.

RESULTS

Of 125 eligible patients, 101 responded to the questionnaire. Median follow-up was 51 (range, 13-167) months. In multivariate analyses, the only independent predictors of good continence were distance of the tumor greater than 1 cm from the anal ring (OR, 5.88; 95% CI, 1.75-19.80; P = .004) and anastomoses higher than 2 cm above the anal verge (OR, 6.59; 95% CI, 1.12-38.67; P = .037).

LIMITATIONS

The study is limited by its retrospective, observational design and potential bias due to possible differences between those who responded to the questionnaire and those who did not.

CONCLUSIONS

Patient characteristics do not appear to influence functional outcome at long-term follow-up after intersphincteric resection. The risk of fecal incontinence depends mainly on tumor level and height of the anastomosis.

Neoadjuvant therapy in rectal cancer

BACKGROUND

The optimal type of neoadjuvant therapy regimen in rectal cancer is contentious.

OBJECTIVE

This study aimed to review the impact of neoadjuvant therapy on oncological outcomes and complications (short and long term) in patients undergoing total mesorectal excision for rectal cancer.

DATA SOURCES

An electronic search of MEDLINE, PubMed, EMBASE, and the Cochrane Database of Collected Reviews was performed through March 2010.

STUDY SELECTION

Key-word combinations including rectal cancer, total mesorectal excision, radiotherapy, chemotherapy, endorectal ultrasound, and magnetic resonance imaging were used to identify randomized control trials where chemotherapy and/or radiotherapy were deployed before resectional surgery.

INTERVENTION(S)

Patients underwent total mesorectal excision for rectal cancer who did and did not receive preoperative chemotherapy and/or radiotherapy.

MAIN OUTCOME MEASURES

The main outcome measures comprised the impact of the addition of neoadjuvant therapy to total mesorectal excision on the perioperative complication rate, the pathological complete response rate, the rate of local recurrence, and long-term treatment-related complications.

RESULTS

A total of 12 randomized control trials involving 9410 patients were included. Both short-course radiotherapy and long-course chemoradiation can offer a relative risk reduction of 50% in local recurrence in appropriately selected patients with stage II and III rectal cancer. This oncological benefit comes at the cost of a relative risk increase of 50% in both acute treatment-related toxicity and long-term anorectal dysfunction.

LIMITATIONS

Preoperative staging provides only an estimate of the "true" tumor stage that can only be determined by histological assessment of the tumor specimen which renders appropriate patient selection challenging.

CONCLUSIONS

The current treatment trade-off of a relative risk reduction of local recurrence of 50% at the cost of a relative increase of 50% in treatment-related complications underpins the need for more accurate patient staging and more precise delivery of neoadjuvant therapy.

Review of histopathological and molecular prognostic features in colorectal cancer

Prediction of prognosis in colorectal cancer is vital for the choice of therapeutic options. Histopathological factors remain paramount in this respect. Factors such as tumor size, histological type and subtype, presence of signet ring morphology and the degree of differentiation as well as the presence of lymphovascular invasion and lymph node involvement are well known factors that influence outcome. Our understanding of these factors has improved in the past few years with factors such as tumor budding, lymphocytic infiltration being recognized as important. Likewise the prognostic significance of resection margins, particularly circumferential margins has been appreciated in the last two decades. A number of molecular and genetic markers such as KRAS, BRAF and microsatellite instability are also important and correlate with histological features in some patients. This review summarizes our current understanding of the main histopathological factors that affect prognosis of colorectal cancer.

Oncological and functional outcomes of intersphincteric resection for low rectal cancer

BACKGROUND

The intersphincteric resection technique has been used to extend the opportunity for sphincter preservation in patients with very low rectal cancer. The aim of this study is to assess the long-term oncological and functional outcomes of intersphincteric resection.

METHODS

Patients with extraperitoneal rectal cancer were treated and retrospectively chart reviewed. The oncological and functional outcomes were evaluated. Comparisons of the overall disease-free survival and recurrence were analyzed for the different surgical procedures.

RESULTS

From July 2002 to August 2009, 162 patients with extraperitoneal rectal cancer were retrospectively chart reviewed. One-hundred one patients (62.3%) underwent low anterior resection, 26 patients (16%) received radical proctectomy and intersphincteric resection with coloanal anastomosis, and 23 (14.2%) had abdominoperineal resection. The sphincter preservation rate was 80%. In the intersphincteric resection group, overall survival rates at 3 and 5 y were 83% and 83%, and disease-free survival at 3 and 5 y were 82% and 76%, respectively. The mean stool frequency was 4.7 per 24 h. There were 38.1% of patients suffering from stool fragmentation, and 23.8% had nocturnal defecation. About one-third of the patients required antidiarrheal medications. Overall, 90.8% of patients were satisfied with the functional results of surgery.

CONCLUSIONS

Our data show intersphincteric resection for low rectal cancer is feasible and safe. Preoperative radiotherapy may negatively affect symptom-specific quality of life.

A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era

PURPOSE

It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE.

METHODS

A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected.

RESULTS

Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE.

CONCLUSIONS

Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.

Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy

AIM: To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China.

METHODS: Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared.

RESULTS: The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049).

CONCLUSION: MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.

Clinical characteristics of rectal cancer involving the anal canal

BACKGROUND

This study evaluates the clinical characteristics of rectal cancer involving the anal canal.

METHODS

A total of 346 consecutive patients with primary low rectal cancer located below the peritoneal reflection were reviewed in this study. Patients were divided into two groups according to whether the lower edge of the tumor came in contact with the anal canal (P group, n = 78) or not (Rb group, n = 268). Clinical and pathological parameters, recurrence rates, and survival rates were compared between the two groups.

RESULTS

The occurrence of uncommon histological types of tumor was significantly higher in the P group than in the Rb group. P group patients also had a significantly higher lateral pelvic node metastasis rate (p < 0.001), lower 5-year overall survival rate (p = 0.0491), and higher 5-year local recurrence rate (p = 0.0171) than Rb group patients. Multivariate analysis revealed that tumor location was a significant risk factor for local recurrence. In the P group, multivariate analysis showed that uncommon histological tumor types were a significant prognostic factor.

CONCLUSION

Rectal cancer involving the anal canal should be treated with special care, considering the particularly high lateral pelvic lymph node metastasis rate and high local recurrence rate.

Sphincter preservation for distal rectal cancer - a goal worth achieving at all costs?

To assess the merits of currently available treatment options in the management of patients with low rectal cancer, a review of the medical literature pertaining to the operative and non-operative management of low rectal cancer was performed, with particular emphasis on sphincter preservation, oncological outcome, functional outcome, morbidity, quality of life, and patient preference. Low anterior resection (AR) is technically feasible in an increasing proportion of patients with low rectal cancer. The cost of sphincter preservation is the risk of morbidity and poor functional outcome in a significant proportion of patients. Transanal and endoscopic surgery are attractive options in selected patients that can provide satisfactory oncological outcomes while avoiding the morbidity and functional sequelae of open total mesorectal excision. In complete responders to neo-adjuvant chemoradiotherapy, a non-operative approach may prove to be an option. Abdominoperineal excision (APE) imposes a permanent stoma and is associated with significant incidence of perineal morbidity but avoids the risk of poor functional outcome following AR. Quality of life following AR and APE is comparable. Given the choice, most patients will choose AR over APE, however patients following APE positively appraise this option. In striving toward sphincter preservation the challenge is not only to achieve the best possible oncological outcome, but also to ensure that patients with low rectal cancer have realistic and accurate expectations of their treatment choice so that the best possible overall outcome can be obtained by each individual.

Neoadjuvant vs adjuvant pelvic radiotherapy for locally advanced rectal cancer: Which is superior?

The treatment of locally advanced rectal cancer including timing and dosage of radiotherapy, degree of sphincter preservation with neoadjuvant radiotherapy, and short and long term effects of radiotherapy are controversial topics. The MEDLINE, Cochrane Library databases, and meeting proceedings from the American Society of Clinical Oncology, were searched for reports of randomized controlled trials and meta-analyses comparing neoadjuvant and adjuvant radiotherapy with surgery to surgery alone for rectal cancer. Neoadjuvant radiotherapy shows superior results in terms of local control compared to adjuvant radiotherapy. Neither adjuvant or neoadjuvant radiotherapy impacts overall survival. Short course versus long course neoadjuvant radiotherapy remains controversial. There is insufficient data to conclude that neoadjuvant therapy improves rates of sphincter preserving surgery. Radiation significantly impacts anorectal and sexual function and includes both acute and long term toxicity. Data demonstrate that neoadjuvant radiation causes less toxicity compared to adjuvant radiotherapy, and specifically short course neoadjuvant radiation results in less toxicity than long course neoadjuvant radiation. Neoadjuvant radiotherapy is the preferred modality for administering radiation in locally advanced rectal cancer. There are significant side effects from radiation, including anorectal and sexual dysfunction, which may be less with short course neoadjuvant radiation.

Long-term survival and recurrence outcomes following surgery for distal rectal cancer

BACKGROUND

Treatment of distal rectal cancer remains clinically challenging and includes proctectomy and coloanal anastomosis (CAA) or abdominoperineal resection (APR). The purpose of this study is to evaluate operative and pathologic factors associated with long-term survival and local recurrence outcomes in patients treated for distal rectal cancer.

METHODS

A retrospective consecutive cohort study of 304 patients treated for distal rectal cancer with radical resection from 1993 to 2003 was performed. Patients were grouped by procedure (CAA or APR). Demographic, pathologic, recurrence, and survival data were analyzed utilizing chi-square analysis for comparison of proportions. Survival analysis was performed using Kaplan-Meier method and log-rank test for univariate and Cox regression for multivariate comparison.

RESULTS

The median tumor distance from the anal verge was 2 cm [interquartile range (IQR) 0.5-4 cm]. Margins were negative in all but four patients (one distal, 0.3%; three radial, 1%). The 5-year overall survival rate was 82% (88.6% stage pI, 80.5% stage pII, 67.9% stage pIII). Older age, advanced pathologic stage, presence of lymphovascular or perineural invasion, earlier treatment period, and APR surgery type were associated with worse survival on multivariate analysis. The 5-year local recurrence rate was 5.3% after CAA and 7.9% after APR (p = 0.33).

CONCLUSIONS

Low rates of local recurrence and good overall survival can be achieved after treatment of distal rectal cancer with stage-appropriate chemoradiation and proctectomy with CAA or APR. Sphincter preservation can be achieved even with distal margins less than 2 cm.

Close distal margin and rectal cancer recurrence after sphincter-preserving rectal resection

PURPOSE

Negative surgical margins are important for local control of rectal cancer treated with sphincter-preserving surgery. However, the association of rectal cancer recurrence with close distal margin is not well established.

METHODS

Data were extracted from a prospective database of patients collected between 1991 and 2003. Included were 627 patients who underwent curative low anterior resection with total mesorectal excision for rectal cancer 2 to 12 cm from the anal verge. Three hundred ninety-nine patients received neoadjuvant therapy, 65 received postoperative adjuvant therapy alone, and 163 were treated with surgery alone. Median follow-up was 5.8 years.

RESULTS

On multivariable analysis, overall recurrence was associated with pathologic stage, lymphovascular invasion, and distal margin. Mucosal recurrence was uncommon; only 16 events were recorded, and of those only 8 were at the initial site of isolated tumor recurrence; 7 of the 8 were surgically salvaged. On univariable analysis, mucosal recurrence was associated with close distal margin (5 vs 2% at 5 y) and lymphovascular invasion (7 vs 2%). Pelvic recurrence, other than isolated mucosal recurrence, was associated with distal location (6 vs 4% at 5 y) and lymphovascular invasion (11 vs 4%). Distal margin as a continuous variable was associated with overall recurrence (excluding isolated mucosal recurrence).

CONCLUSIONS

Close distal resection margin identifies patients with increased risk of mucosal and overall cancer recurrence. Although neither causality nor a minimally acceptable margin length can be defined, the data support the importance of achieving a clear distal resection margin in the surgical management of rectal cancer.

Do all locally advanced rectal cancers require radiation? A review of literature in the modern era

Potentially curable rectal cancer is primarily treated with surgical resection. Adjuvant or neoadjuvant radiotherapy is often utilized for patients deemed to be at unacceptable risk for local recurrence. The purpose of this article is to review the pertinent literature and elucidate the role of radiotherapy in patients with an intermediate risk of local recurrence. The addition of chemoradiotherapy is recommended in the majority of patients with transmural or node positive rectal cancer. However, some patients with favorable characteristics may have only a small incremental benefit from the addition of radiotherapy. The decision to treat or not to treat should take into consideration the patient and physician tolerance of risk of recurrence and risk of treatment related toxicity. The primary factors identified for determining low risk patients are circumferential radial margin (CRM), location within the rectum, and nodal status. Patients at lowest risk have widely negative CRM (>2mm), proximal lesions (>10cm from the anal verge), and no nodal disease. Patients with all three low risk factors have an absolute reduction in local recurrence that is <5% and may be eligible to forego radiotherapy. Additional factors identified which may impact local recurrence risk are elevated serum CEA level, lymphovascular space invasion, pathologic grade, and extramural space invasion.

Effects of obesity in rectal cancer surgery

BACKGROUND

Increased local recurrence after total mesorectal excision (TME) in obese rectal cancer patients has been attributed to technical difficulties associated with adiposity. In this study, we evaluate whether higher body mass index (BMI) compromises surgical resection in patients with locally advanced, mid-to-low rectal cancer after neoadjuvant therapy, adversely affecting long-term oncologic outcomes.

STUDY DESIGN

Five-hundred and ninety-six patients with uT3/4 and/or uN1 rectal adenocarcinoma were treated from 1998 to 2007 with neoadjuvant therapy, followed by radical resection using TME. Outcomes were analyzed according to BMI: obese (BMI >or=30) and nonobese (BMI <30). Median follow-up was 39 months.

RESULTS

In all, 26.7% of patients were obese. The rate for positive circumferential margin in nonobese was 4.9% versus 2.5% in obese (p = 0.21). The sphincter-sparing rate in nonobese was 79.5% versus 80.5% in obese (p = 0.77). Five-year overall survival for nonobese was 84% versus 90% for obese (p = 0.92). Five-year disease-free survival for nonobese was 76% versus 73% for obese (p = 0.75). Operative time was longer in obese than nonobese; 4.3 versus 3.7 hours, respectively (p < 0.01). Length of stay was longer in obese than nonobese; 8 versus 7 days, respectively (p < 0.01). Similar results were obtained in analysis stratified by gender.

CONCLUSIONS

After neoadjuvant therapy for mid-to-low rectal cancer, higher BMI did not compromise sphincter preservation or complete resection or negatively affect long-term outcomes. These findings might be related to the fact that resection was performed in a specialty center with dedicated oncologic surgeons. However, higher BMI was associated with longer operative time, indicating a more technically demanding procedure and longer hospital stay.

Ressecção anterior ultrabaixa e interesfinctérica do reto com anastomose coloanal por videolaparoscopia

O autor apresenta, detalhadamente, a técnica de ressecção anterior ultrabaixa e interesfinctérica com anastomose coloanal por videolaparoscopia para tratamento do câncer do reto distal. São descritos os principais passos da operação: 1 - Posição do Paciente; 2 - Posicionamento do Equipamento e Equipe; 3 - Posicionamento dos Trocartes e Exploração da Cavidade Abdominal; 4 - Exposição do Campo Operatório; 5 - Ligadura dos Vasos Mesentéricos Inferiores pelo acesso medial; 6 - Mobilização do Ângulo Esplênico e do Colon Sigmóide; 7 - Excisão total do mesorreto, preservação dos nervos pélvicos e mobilização do reto pela técnica de Rullier; 8- Secção do reto distal e anastomose coloanal;9-Ressecção interesfinctérica (RI) e anastomose coloanal com coloplastia transversa, bolsa colónica em J ou anastomose latero-terminal. A utilização desta técnica, apesar de ser um procedimento complexo, mostrou-se viável e segura, pois apresentou baixo índice de complicação pós-operatória e mortalidade.

Multidisciplinary treatment of locally advanced rectal cancer: a literature review. Part 1

In Western countries, colorectal cancer is the third most common cancer in terms of incidence and mortality. The management of rectal cancer has undergone and continues to undergo significant evolutions. In the last two decades, new multimodality strategies have been developed. Multimodality treatments have improved the prognosis of locally advanced rectal cancer with local recurrences decreasing from 40% to < 10% and overall survival increasing from 50% to 75% in the last 40 years. This review discusses the role of neoadjuvant chemoradiotherapy regimens used in the standard combined modality treatment programs for rectal cancer and focuses on the ongoing research to improve these regimens.