Surgical treatment of rectal cancer: results of a strategy for selective preoperative radiotherapy

The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results

PURPOSE

To investigate the influence of the introduction of total mesorectal excision (TME) on local recurrence rate and survival in patients with rectal cancer.

METHODS

A total of 171 consecutive patients underwent anterior or abdominoperineal resection for primary rectal cancer. When the TME technique was introduced, the clinical setting, including the surgeons, remained the same. Group 1 (1993-95, n =53) underwent conventional surgery and group 2 (1995-2001, n = 118) underwent TME. All patients were followed for 7 years or until death.

RESULTS

Between the two groups, no statistically significant differences were present with regards to patient-, treatment-, or tumor-related characteristics apart from the time point of radiotherapy. The total local recurrence rates were 11 of 53 (20.8%) in group 1 and 7 of 118 (5.9%) in group 2, and the rates of isolated local recurrences were 6 of 53 (11.3%) in group 1 and 2 of 118 (1.7%) in group 2. Both differences were highly statistically significant. The disease-free survival in groups 1 and 2 was 60.4 and 65.3% at 5 years, and 58.5 and 65.3% at 7 years, respectively. Excluding patients with synchronous or metachronous distant metastasis from the analysis, both the disease-free survival and the cancer-specific survival were statistically significantly better in group 2 than in group 1. No statistically significant difference between the two groups was detected regarding the overall survival.

CONCLUSIONS

The introduction of TME led to an impressive reduction of the local recurrence rate. Survival is mainly determined by the occurrence of distant metastasis, but TME seems to improve survival in patients without systemic disease.

Individualized magnetic resonance imaging-based neoadjuvant chemoradiation for middle and lower rectal carcinoma

AIM

In most institutions neoadjuvant chemoradiation for middle and lower rectal carcinoma is currently given to patients with tumours of clinical stages II or III (cT3,4 and/or N1,2). The possibility of a reduction in the use of neoadjuvant chemoradiation by an individualized magnetic resonance imaging (MRI)-based indication for neoadjuvant chemoradiation was analysed.

METHOD

Assessment of the pathological and oncological principles indicating for neoadjuvant treatment was used to determine the prognostic importance of the distance between the tumour and the circumferential resection margin and pretherapeutic assessment using modern MRI.

RESULTS

Based on the results of pretreatment MRI scanning, a proposal is presented for the treatment of middle and lower rectal carcinoma with neoadjuvant chemoradiation. Adopting this proposal, the frequency of neoadjuvant chemoradiation decreased from 70% to 35% and the early and late adverse effects of this therapy were reduced. In contrast, the expected locoregional recurrence rate increased from 6% to 11% if all quality criteria were met and to 18% if not.

CONCLUSION

An MRI-based indication for neoadjuvant chemoradiation is justified only for centres with regular quality assurance of MRI, surgery, radiotherapy and pathology. The proposal needs confirmation by long-term follow up and by prospective studies with larger numbers of patients.

Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME [corrected] surgery. Implications for treatment decisions

BACKGROUND AND AIMS

For rectal carcinoma treated according to the concept of total mesorectal excision (TME surgery), the independent influence of regional lymph node metastasis on the locoregional recurrence risk is still in discussion. A reliable assessment of this risk is important for an individualised selective indication for neoadjuvant radio-/radiochemotherapy.

METHODS

Analysis of literature, especially of the last 20 years, and consideration of pathological and oncological basic research. Multivariate analysis of data of the Erlangen Registry of Colorectal Carcinoma.

RESULTS

The clinical assessment of the pretherapeutic regional lymph node status by the present available imaging methods is still unreliable. The analysis of the association between pretherapeutic regional lymph node status and locoregional recurrence risk has to be based on follow-up data of patients treated by primary surgery and has to be distinguished between patients treated by conventional and optimised quality-assured TME surgery, respectively. Data from Erlangen show an increase of the local recurrence risk for patients with at least four involved regional lymph nodes.

CONCLUSIONS

For patients with at least four involved regional lymph nodes, a neoadjuvant radiochemotherapy may be indicated. However, today, the pretherapeutic diagnosis is uncertain and results in overtherapy in 40%. Thus, in case of positive lymph node findings by imaging methods, the benefits and risk of neoadjuvant therapy in such situations should always be discussed with the patient in the sense of informed consent and shared decision.

Surgery-predominant combined treatment for colorectal cancer

Colorectal cancer (CRC) is the third most common cancer and the fifth leading cause of cancer-related mortality in China with an increasing trend, which is emphasizing the need for improvements in therapeutic options. The 5-year survival rate of surgery, the first-line treatment for CRC, is just about 50 percent. In recent years many patients with CRC have benefited from the combined treatment with surgery for CRC, which integrates chemotherapy, radiotherapy, concurrent chemoradiotherapy, biotherapy, traditional Chinese medicine, etc., especially patients at advanced stage. This paper highlighted current situation for combined treatment with surgery for CRC.