Local recurrence and survival in patients with rectal cancer, diagnosed 1981-86: a community hospital-based study in the south-east Netherlands

The impact of age on rectal cancer treatment, complications and survival

BACKGROUND

The number of older patients with rectal cancer is increasing. Treatment outcome discrepancies persist, despite similar treatment guidelines. To offer the oldest patients optimal individually adjusted care, further knowledge is needed regarding treatment strategy and outcome. The present study aimed to evaluate treatment, postoperative complications, and survival in older patients treated for rectal cancer.

METHODS

This retrospective study included all 666 patients (n=255 females, n=411 males) treated for rectal cancer at Levanger Hospital during 1980-2016 (n=193 <65 years, n=329 65-79 years, n=144 ≥80 years). We performed logistic regression to analyse associations between complications, 90-day mortality, and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

RESULTS

Despite a similar distribution of cancer stages across age-groups, patients aged ≥80 years were treated with a non-curative approach more frequently than younger age groups. Among patients aged ≥80 years, 42% underwent a non-curative treatment approach, compared to 25% of patients aged <65 years, and 25% of patients aged 65-79 years. The 90-day mortality was 15.3% among patients aged ≥80 years, compared to 5.7% among patients aged <65 years, and 9.4% among patients aged 65-79 years. Among 431 (65%) patients treated with a major resection with curative intent, the 90-day mortality was 5.9% among patients aged ≥80 years (n=68), compared to 0.8% among patients aged <65 years (n=126), and 3.8% among patients aged 65-79 years (n=237). The rate of postoperative complications was 47.6%. Pneumonia was the only complication that occurred more frequently in the older patient group. The severity of complications increased with three factors: age, American Society of Anaesthesiologists score, and >400 ml perioperative blood loss. Among patients that survived the first 90 days, the relative long-term survival rates, five-year local recurrence rates, and metastases rates were independent of age.

CONCLUSION

Patients aged ≥80 years were less likely to undergo a major resection with curative intent and experienced more severe complications after surgery than patients aged <80 years. When patients aged ≥80 years were treated with a major resection with curative intent, the long-term survival rate was comparable to that of younger patients.

Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre

The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.

Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review

Elderly people represent almost all patients diagnosed with and treated for rectal cancer, and this trend is likely to become more apparent in the future. Surgical management and treatment decisions for this disease are becoming increasingly complex, but only a few reports deal specifically with older patients. In this systematic review, we provide an overview of published studies of outcomes after curative surgery for rectal cancer in elderly people (>70 years). We identified 48 studies providing information about postoperative results, survival, surgical approach, stoma formation, functional results, and quality of life after rectal resection for cancer. We found that advanced chronological age should not, by itself, exclude patients from curative rectal surgery or from other surgical options that are available for younger patients. Although overall survival is lower in elderly patients than in younger patients, cancer-specific survival does not decrease with age. However, the level of evidence for most studies was weak, emphasising the need for high-quality clinical trials for this population.

Use of adjuvant chemotherapy in stage C (III) rectal cancer: comparison of data from matched patients in a teaching hospital's clinico-pathological database

AIMS

Controversy continues regarding the treatment of patients with resectable rectal cancer, particularly in regard to the effects of adjuvant therapies on long-term survival. The benefits of adjuvant chemotherapy alone in patients with stage III rectal cancer after curative resection remain unclear. The aim of this study was to compare the overall survival of patients who had received adjuvant chemotherapy after resection of a stage III rectal cancer (111 patients) with the survival of a historical control group who had surgery alone before chemotherapy was introduced (129 patients).

METHODS

Treatment and outcomes data were drawn from a prospective hospital registry of consecutive patients who had a resection for stage III rectal cancer.

RESULTS

The estimated Kaplan-Meier overall 5-year survival rate in patients who received chemotherapy (68.7%, 95% CI 58.3-77.1%, log-rank P < 0.001) was improved compared with the historical controls (40.5%, 95% CI 31.4-49.5%, log-rank P < 0.001). No systematic differences between the treated and control group were found.

CONCLUSION

This study has shown improved survival after adjuvant chemotherapy in patients with stage III rectal cancer as compared with historical controls treated by surgery alone. Hence, there could be subsets of patients whom when treated with surgery in a specialized surgical unit, may benefit from chemotherapy and spared the toxicities of adjuvant radiotherapy. This should be explored further in a cooperative trial group setting.

Time to locoregional recurrence after curative resection of rectal carcinoma is prolonged after neoadjuvant treatment: a systematic review and meta-analysis

AIM

A systematic review of the literature with meta-analysis was performed to evaluate the time to locoregional recurrence after curative resection of rectal carcinoma, assuming that this time is prolonged after neoadjuvant radiochemotherapy and/or present day surgery.

METHOD

English and German language peer-reviewed articles published between 1980 and 2007 were selected. Twenty-five of 118 studies fulfilled the defined inclusion and exclusion criteria. For some special questions, data of the Erlangen Registry of Colorectal Carcinoma (ERCRC) from 1985 to 1997 are reported.

RESULTS

After conventional surgery of rectal carcinoma, 75% (range 66-84%) of locoregional recurrence presented during the first 2 years after resection. Following the introduction of total mesorectal excision surgery and the use of neoadjuvant treatment, a general reduction of the frequency of local recurrence combined with a prolongation of the time to local recurrence was observed. In the practice of today, in particular after neoadjuvant long-course radiochemo-or radiotherapy, 24% (range 8-40%) of all local recurrences present later than 5 years after primary therapy. In contrast, such late local recurrences are observed in only 8% (range 5-9%) following primary surgery alone.

CONCLUSION

For a definite assessment of the therapeutic results regarding local control, a minimal follow up of 7-8 years either after neoadjuvant long-course radiochemo- or radiotherapy and a minimum of 5 years after surgery alone is necessary. For patients with primary surgery followed by adjuvant therapy, it is not possible to make a clear statement.

Patterns of recurrence following liver resection for colorectal metastases: effect of primary rectal tumor site

HYPOTHESIS

Patients with rectal adenocarcinoma are at increased risk of locoregional recurrence compared with patients with colon cancer. This may affect the pattern of recurrence and survival rates following hepatic resection of liver metastases from rectal adenocarcinoma.

DESIGN

Retrospective review of a prospectively collected cancer center database.

PATIENT AND METHODS

From April 1, 1984, to December 31, 2005, 582 patients with liver metastases from a primary colorectal adenocarcinoma underwent hepatic resection. Clinical and pathological factors were analyzed using Cox regression analyses and log-rank tests.

RESULTS

Of 582 patients, 141 (24.2%) had liver metastases from a primary rectal tumor site. Treatment of the primary rectal tumor most frequently included chemoradiation therapy (59.6%) and low anterior resection (63.1%). Most rectal tumors were pathological stage T3/T4 (85.8%) and N1 (68.1%). Treatment directed at the hepatic metastases included resection only (81.5%), resection plus radiofrequency ablation (17.8%), or radiofrequency ablation only (0.7%). With a median follow-up time of 30.7 months, 80 of 141 patients (56.7%) developed recurrence; 23 patients (16.3%) developed recurrence in the pelvis. Of 23 patients with pelvic recurrence, 56.5% also developed recurrence in the liver. The 3- and 5-year survival rates for all patients were 62.4% and 36.4%, respectively. Of 80 patients who had a recurrence following hepatic metastectomy, 23 (28.8%) underwent another operation. Following repeat metastectomy, 3- and 5-year survival rates were 76.7% and 38.6%, respectively.

CONCLUSIONS

Following resection of hepatic rectal metastases, pelvic recurrence is relatively common, and most patients with pelvic recurrence will also develop recurrence in the liver. Surgery for recurrent disease following hepatic resection of rectal metastases is warranted among well-selected patients.

Total mesorectal excision and management of rectal cancer

Treatment of rectal cancer over the last two decades has evolved with changes in techniques of surgery and radiation based on national and international trials. Preoperative adjuvant radiation is now preferred over postoperative adjuvant radiation, and total mesorectal excision with preservation of pelvic nerves is the gold standard for surgical treatment of rectal cancer. Preservation of the anal sphincter without compromising oncological outcome is an additional benefit for patients with carcinoma in the distal rectum. Further progress in imaging and a multidisciplinary team approach will facilitate individualization of treatment strategy with more focus on quality of life.

The influence of total mesorectal excision on local recurrence and survival in rectal cancer patients: a population-based study in Greater Amsterdam

BACKGROUND AND OBJECTIVES

To determine retrospectively in a population-based setting, the influence of the introduction of total mesorectal excision (TME) on local recurrence and survival in patients with rectal carcinoma.

METHODS

All rectal carcinomas diagnosed during 1988-1991 (979 patients, conventional surgery with blunt dissection of the rectum) and 1998-2000 (890 patients, TME resection) were selected from the Amsterdam Cancer Registry. For all patients who underwent a macroscopically radical resection in the absence of distant dissemination, information on the occurrence of local recurrent disease and distant metastasis was collected.

RESULTS

The cumulative 5-year recurrence rate decreased significantly from 20% for patients diagnosed in 1988-1991 to 11% in 1998-2000. Stage (T-category, nodal status), period of diagnosis (conventional surgery vs. TME resection), radiotherapy, and chemotherapy were independent variables of local recurrence in multivariate analysis. There was a non-significant trend for improved 5-year relative survival for all rectal carcinoma cases from 52% (95% CI 48-55) for patients diagnosed in 1988-1991 to 59% (95% CI 55-63) in 1998-2000.

CONCLUSIONS

A significant decrease in local recurrence and a trend for improved relative survival were observed. The broad introduction of TME and the shift towards preoperative radiotherapy are the most plausible explanations for these observations.

Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour

Background

Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour.

Methods

Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow-up to December 2003.

Results

The 5-year local recurrence rate was 15·9 (95 per cent confidence interval (c.i.) 11·0 to 22·8) per cent in 176 patients with tumours that had an anterior component compared with 5·8 (95 per cent c.i. 2·8 to 11·9) per cent in 132 patients with tumours without an anterior component (P = 0·009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2·4 (95 per cent c.i. 1·1 to 5·4)). Similarly, anterior position had a significant negative independent association with survival (HR 1·4 (95 per cent c.i. 1·0 to 2·00)).

Conclusion

Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer.

The long term survival of rectal cancer patients following abdominoperineal and anterior resection: results of a population-based observational study

AIMS

The surgical management of rectal cancer is not uniform. Both abdominoperineal (APR) and anterior resection (AR) are used in potentially curative surgery but there is no definitive evidence regarding comparative survival outcomes and no randomised controlled trials. We sought to determine if any differences in survival existed between patients who received AR or APR. In addition, we sought to determine how variations in surgical management relate to the degree of specialisation and caseload of the managing consultant.

PATIENTS AND METHODS

A retrospective study of population-based data collected by the Northern and Yorkshire Cancer Registry and Information Service was undertaken. All patients (3521) diagnosed with rectal cancer in the former Yorkshire Regional Health Authority (population 3.6 million) between 1986 and 1994 who received either an APR or AR were included. Survival was assessed in relation to the surgical methods adopted. In addition, we determined whether the extent of specialisation of the managing consultant influenced the type of operation adopted.

RESULTS

A Log Rank test, stratified for sex and age, showed a statistically significant 6.7% 5-year survival advantage for patients receiving AR (p=0.0064). AR was more likely to be performed by more specialist colorectal cancer surgeons (p<0.001).

CONCLUSIONS

This evidence suggests that the outcomes of the two main surgical procedures used in curative surgery for rectal cancer are different and that, when possible, AR should be the operation of choice. Our results show no indication of excess risk associated with this procedure compared with APR.

Stable overall referral rates of primary radiotherapy for newly diagnosed cancer patients in the ageing population of South-Eastern Netherlands, 1975–1998

BACKGROUND AND PURPOSE

To determine the primary radiotherapy (RT) consumption in a population of almost one million inhabitants, served by one RT centre. Primary RT was defined as being planned, started or finished within 4-6 months of diagnosis. Application was evaluated according to tumour category, stage and year of diagnosis during three 8-year periods: 1975-1982, 1983 -1990 and 1991-1998.

RESULTS

Most patients were between 60 and 75 years. The number of patients receiving primary RT increased with 3% annually over the whole studied period, but remained proportionally stable for males at 30% and decreased for females from 36.2 to 34.6%. A decrease of referral rates for patients with gynaecological cancer was observed. The introduction of breast-conserving therapy in 1981 and of population screening for women aged 50-69 years in 1992 led to a considerable increase of primary RT. The eightfold increase in number of irradiated patients with localised prostate cancer rather reflected a higher detection rate than an increased referral rate. Except for an important increase of irradiated patients with rectal cancer, largely due to the shift to preoperative RT since 1994, and of patients with brain cancer, only slight alterations in referral rates were observed for the other cancers.

CONCLUSIONS

Use of primary RT remained proportionally steady and modest. The marked increase in workload was mainly due to more and earlier detection of breast and prostate cancer and treatment changes in rectal cancer. Decreases were observed for each of the gynecological cancers.

Quality assurance of surgery in gastric and rectal cancer

Multimodality and quality controlled treatment result in improved treatment outcome in patients with solid tumours. Quality assurance focuses on identifying and reducing variations in treatment strategy. Treatment outcome is subsequently improved through the introduction of programs that reduce treatment variations to an acceptable level and implement standardised treatment. In chemotherapy and radiotherapy, such programmes have been introduced successfully. In surgery however, there has been little attention for quality assurance so far. Surgery is the mainstay in the treatment of patients with gastric and rectal cancer. In gastric cancer, the extent of surgery is continuously being debated. In Japan, extended lymph node dissection is favoured whereas in the West this type of surgery is not routinely performed with two large European trials concluding that there is no survival benefit from regional lymph node clearance. Post-operative chemoradiation is part of the standard treatment in the United States, although its role in combination with adequate surgery has not been established yet. These global differences in treatment policy clearly relate to the extent and quality of surgical treatment. As for gastric cancer, surgical treatment of rectal cancer patients determines patient's prognosis to a large extent. With the introduction of total mesorectal excision, local control and survival have improved substantially. Most rectal cancer patients receive adjuvant treatment, either pre- or post-operatively. The efficacy of many adjuvant treatment regimens has been investigated in combination with conventional suboptimal surgery. Traditional indications of adjuvant treatment might have to be re-examined, considering the substantial changes in surgical practise. Quality assurance programs enable the introduction of standardised and quality controlled surgery. Promising adjuvant regimens should be investigated in combination with optimal surgery.

Reirradiation and hyperthermia in rectal carcinoma: a retrospective study on palliative effect

BACKGROUND

The objective of this study was to evaluate the palliative effect of reirradiation and hyperthermia in patients with unresectable, recurrent colorectal carcinoma.

METHODS

The medical records of 54 patients with unresectable, recurrent colorectal carcinoma that caused pain and who were treated with reirradiation and hyperthermia, were evaluated retrospectively. Previous radiotherapy was given up to a total dose ranging from 25-70 grays (Gy). The median interval between prior radiotherapy and reirradiation was 22 months (range, 4-97 months). The total reirradiation dose varied from 24 Gy to 32 Gy given in fractions of 4 Gy twice weekly. Three or four hyperthermia treatments were given once weekly. Toxicity was registered. The influence of World Health Organization (WHO) performance status, maximum tumor dimension, and time between first radiotherapy and reirradiation on therapeutic outcome was evaluated. The results of this study were compared with published results on patients who received radiotherapy with or without hyperthermia.

RESULTS

Forty-seven patients (87%) completed the planned treatment schedule. The maximum toxicity was Grade 2. All patients were evaluated for palliative effect. The median follow-up was 10 months. A good or complete palliative effect was achieved in 72% of patients for a median duration of 6 months. Patients who had a better WHO performance status, smaller tumors, and a longer interval between first radiotherapy and reirradiation had slightly better outcomes, although none of those parameters reached statistical significance.

CONCLUSIONS

The described combined treatment was feasible and well tolerated. Comparison of results from radiotherapy plus hyperthermia with results after radiotherapy alone suggested that additional hyperthermia prolonged the duration of palliation. Firm proof of the contribution of hyperthermia will require performing a Phase III study.

Improved survival of patients with rectal cancer since 1980: a population-based study

The treatment of rectal cancer has changed over the last two decades as far as surgical techniques and radiotherapy are concerned. We studied the changes in patterns of care for patients with rectal cancer and the effect on prognosis. All patients with cancer of the rectum or rectosigmoid in South-east Netherlands, diagnosed in the period of 1980-2000, were included in our analyses (n=3635). The use of surgery as the only treatment decreased from 62% in the period of 1980-1989 to 42% in the period of 1995-2000, whereas the combination of surgery and radiotherapy increased from 26 to 40%. The use of postoperative radiotherapy decreased from 25 to 4%, while preoperative radiotherapy increased from 1 to 35%. Patients aged 75 years or older were less likely to receive radiotherapy. After adjustment for age, gender, tumour stage and tumour site, significant improvements in the relative risk of death were observed between the periods of 1995-2000 and 1980-1989 for patients under 60 years of age (Relative Risk (RR)=0.45; 95% Confidence Interval (CI)=0.35-0.58) and those 60-74 years old (RR=0.62; 95% CI 0.53-0.72). No improvement in the risk of death was found for patients aged 75 years and over. No improvements in the distribution of tumour stage were observed, making it very likely that the continuing increase in population-based survival among patients aged <75 years results from the shift from postoperative to preoperative radiotherapy, the development of the total mesorectal excision technique and the related tendency to subspecialisation of surgeons in colorectal cancer surgery.

The role of total mesorectal excision in the management of rectal cancer

During the past decade, it has been clearly demonstrated that adjuvant treatment has the potential of improving not only prognosis in terms of local recurrence, but also in terms of overall survival. However, one of the largest improvements in the outcome of rectal cancer has been the introduction of total mesorectal excision. TME, with its large decline in local recurrence rate, has become the new standard of operative management for rectal cancers, replacing conventional resection technique [68]. In addition, current clinical trials examining the role of adjuvant therapy in patients who are undergoing standardized operations are now setting the standard of surgical care in several countries.

Surgical trials in oncology. the importance of quality control in the TME trial

Results from randomised trials provide the best scientific evidence of efficacy or inefficacy of the therapy. The evaluation of surgical procedures involves problems in addition to those associated with medical experimentation. Surgery, unlike a pill, is not a standardised, reproducible entity, but a unique product whose details are defined by, for example, the skill of the surgeon. Quality assurance is important for treatment and also for data handling. The different treatments (surgery, pathology, radiotherapy, etc.) should be familiar to all participating physicians prior to the start of the trial. Instructions can be given by means of a well-written protocol, videotapes, workshops and instructors at the dissection table. The data collection and data check should be done by data managers and co-ordinators for the separate disciplines. Errors and missing data should be completed and feedback to the physician is essential. Close contact between an active co-ordinating data centre, including co-ordinators for the separate disciplines, and all participating physicians is essential to conduct a quality controlled multicentre, multidisciplinary trial. Continuous enthusiasm can be maintained by the organisation of regular workshops, distribution of newsletters and trial up-dates at scientific meetings. The efforts from all of the involved co-ordinators, data managers, instructors and physicians have resulted in a very successful trial with rapid accrual, good quality treatments and procedures, good quality data, and a high participation rate among hospitals and patients. Quality control is expensive and labour-intensive, but it is worthwhile.

Developments and quality assurance in rectal cancer surgery

One of the main problems in the treatment of rectal cancer is the development of local recurrences. In the last decades, major improvements have been realized in the surgical treatment of rectal cancer. The introduction of TME-surgery has led to a large reduction in local recurrence rates and improved survival. TME-based operations are now established as the standard of care for rectal cancer, and should form the basis for trials concerning the role of (neo)adjuvant therapy. However, training and quality control are prerequisites to obtain good results in all surgeons' hands. Furthermore, standardization in the description of operations and reporting of pathology specimens should be implemented as important features of quality control. In general, it is thought that high volume and specialist care produces superior results to low volume and non-specialist care, especially for those less frequent forms of cancer and in technically difficult operations, like those for rectal cancer. However, limiting the performance of rectal cancer surgery to highly specialized surgeons or to only those general surgeons who perform more than a certain volume is impractical in view of the prevalence of rectal cancer. This article reviews developments in the treatment of especially mobile rectal cancer and pays attention to variability in outcomes and quality assurance of surgery.

Methodology and reporting in studies of local recurrence after curative excision of the rectum for cancer

BACKGROUND

Widely varying rates have been reported in the extensive literature published in the English language on local recurrence after curative excision of rectal carcinoma. These variations may be attributable to differences in the case mix of pathological factors influencing recurrence, differences in surgical technique or expertise, differences in the administration of adjuvant therapy and various combinations of these. They may also arise from methodological differences among studies.

METHODS

This paper reviews the adequacy of methodology and reporting in 21 recent studies of local recurrence after curative resection of rectal cancer.

RESULTS

Many flaws in reporting and apparent inadequacies in methodology were identified. On an index of 26 criteria examined, eight studies scored no more than 8 and only three studies scored more than 11.

CONCLUSION

To date, the value of reports of local recurrence rates following curative excision of rectal cancer has been limited by inadequacies in documentation and methodology. Suggestions are made for preferred procedures to be followed in the reporting of future studies.

European trials with total mesorectal excision

The outcome after surgery for rectal cancer differs markedly between patient series regarding local recurrence rates and survival. A high incidence of local recurrence is associated with conventional, nonstandardized procedures. To improve results of surgery, various additional treatments, such as radiotherapy, chemotherapy, and immunotherapy, have been tested. The Swedish Rectal Cancer Trial (SRCT) was the first trial to show that better local control achieved with preoperative radiotherapy resulted in improved survival. In recent years local control and survival have been further improved by the introduction of standardized total mesorectal excision (TME) surgery. A major problem of published studies on adjuvant therapy is that surgery was not standardized in these studies. Furthermore, quality control of the surgical technique by standardized pathological examination of the specimen is absent in most studies. In Europe, TME has become the preferred standard of operative management for rectal cancer. Adjuvant therapy studies should now be reexamined based on a platform of standardized, optimal surgery and pathology. We studied the European trials in which TME surgery is intentionally performed. Most of these trials are still in progress, with follow-up too short for definitive results, apart from interim analyses. However, the Dutch TME trial has already shown that performing a large, multicenter trial with quality control of both surgery and pathology is feasible.

Intraoperative electron beam radiation therapy for locally recurrent rectal carcinoma

PURPOSE

Treatment results for locally recurrent rectal cancers are poor. This is a result of the fact that surgery is hampered due to the severance of the anatomical planes during the primary procedure and that radiotherapy is limited by normal tissue tolerance, especially after previous irradiation. This paper describes the results of a combined treatment modality in this patient group.

METHODS AND MATERIALS

From 1994 to 1998, 37 patients with locally recurrent rectal cancer, but without distant metastatic disease, received a combined treatment consisting of 50.4 Gy preoperative irradiation or, in case of previous radiotherapy, 30 Gy reirradiation or no irradiation, followed by radical surgery and intraoperative electron beam radiotherapy boost.

RESULTS

Fifteen patients received a radical resection (R0), eight a microscopic irradical resection (R1), and 14 a macroscopic irradical resection (R2). The overall 3-year local control (LC), disease-free survival (DFS), and overall survival rates were 60%, 32%, and 58% respectively. Radicality of resection (R0/R1 vs. R2) turned out to be the significant factor for improved survival (p < 0.05), DFS (p = 0.0008), and LC (p = 0.01). Preoperative (re-)irradiation is the other significant factor in survival (p = 0.005) and DFS (p = 0.001) and was almost significant for LC (p = 0.08). After external beam radiation therapy (EBRT) a significantly higher resection rate was obtained (R0/R1 vs. R2 p = 0.001). Symptomatic peripheral local recurrences have a significantly worse prognosis and higher rate of R2-resection (p = 0.0005).

CONCLUSION

Centralization of locally recurrent rectal cancer patients enabled the development of an aggressive multimodality treatment, which in turn led to promising results. Distant failure is still a drawback.

Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population-based study in the west Netherlands

AIMS

We carried out a population-based study of local recurrence rates in curatively resected patients with rectal cancer, diagnosed between 1988 and 1992. The first objective was to make an inventory of the overall local recurrence rate after non-standardized conventional surgery, inter-institutional recurrence rate variability, and correlations between patient- and tumour-related factors and recurrence rate. A second objective was to investigate the compliance to guidelines for post-operative radiotherapy.

METHODS

Data were obtained from the Comprehensive Cancer Centre West. The study comprised 1105 patients from 12 hospitals. Of these patients, 437 were ineligible because of missing medical records, no carcinoma, incorrect registration, no laparotomy, non-curative resection, or loss to follow-up.

RESULTS

The overall local recurrence rate was 22.5% with a range of 9-36% between the hospitals. These differences were not significant. Dukes' Astler-Coller stage, tumour location, and residual tumour were significant independent prognostic factors for the risk of local recurrence. Indications for post-operative radiotherapy were Dukes' Astler-Coller B2 and C tumours, positive surgical margins, and tumour spill. Compliance to the guidelines for radiotherapy was only 50%. However, no significant difference in recurrence rate was found between patients treated according to the guidelines and those not treated according to the guidelines.

CONCLUSION

This study shows a large variability in local recurrence rate between the participating hospitals and confirms that the risk of recurrence in primary rectal cancer is dependent on Dukes' Astler-Coller stage, tumour location and residual tumour. Furthermore, this study contributes to the discussion about the feasibility of guidelines for post-operative radiotherapy.