Late Side Effects of Short-Course Preoperative Radiotherapy Combined With Total Mesorectal Excision for Rectal Cancer: Increased Bowel Dysfunction in Irradiated Patients—A Dutch Colorectal Cancer Group Study

Peeters, Koen; Velde, Cornelis J.H. van de; Leer, J.W.H.; Martijn, Hendrik; Junggeburt, Jan M. C.; Kranenbarg, E. Klein; Steup, W. H.; Wiggers, Theo; Rutten, H.J.T.; Marijnen, Corrie A.M.

doi:10.1200/jco.2005.14.779

Cited by 824 publications

(550 citation statements)

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“…Although radiotherapy has been shown to improve outcome for patients with resectable rectal cancer, subgroup analysis from the Dutch trial showed that there is no benefit for patients with UICC tumour stage I or IV in the upper part of the rectum [6]. Therefore it is important to improve selection criteria for the application of preoperative radiotherapy to protect patients from the side effects of radiation without benefit [27,28]. In our analysis we could show that optimal TME quality is feasible in all stages of rectal cancer.…”

Section: Discussionmentioning

confidence: 99%

TME quality in rectal cancer surgery

et al. 2010

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Background The concept of total mesorectal excision has revolutionised rectal cancer surgery. TME reduces the rate of local recurrence and tumour associated mortality. However, in clinical trials only 50% of the removed rectal tumours have an optimal TME quality. Patients: During a period of 36 months we performed 103 rectal resections. The majority of patients (76%; 78/103) received an anterior resection. The remaining patients underwent either abdominoperineal resection (16%; 17/103), Hartmann's procedure (6%; 6/103) or colectomy (2%; 2/103). Results In 90% (93/103) TME quality control could be performed. 99% (92/93) of resected tumours had optimal TME quality. In 1% (1/93) the mesorectum was nearly complete. None of the removed tumours had an incomplete mesorectum. In 98% (91/93) the circumferential resection margin was negative. Major surgical complications occurred in 17% (18/103). 5% (4/78) of patients with anterior resection had anastomotic leakage. 17% (17/103) developed wound infections. Mortality after elective surgery was 4% (4/95). Conclusion Optimal TME quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature. Future studies should evaluate outcome and local recurrence in accordance to the degree of TME quality.

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Section: Discussionmentioning

confidence: 99%

TME quality in rectal cancer surgery

et al. 2010

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“…The TTM presented sequentially a short description of the two treatments and the respective probabilities of side effects as had been established at 2-year (sexual dysfunction; Marijnen et al, 2005) and 5-year (incontinence; Peeters et al, 2005) follow-up. Figure 1 depicts the male version.…”

Section: Methodsmentioning

confidence: 99%

“…Five-year follow-up trial data confirmed a reduced recurrence rate (from 11 to 6%), still with no survival benefit (Peeters et al, 2006). Irradiated patients reported higher rates of faecal incontinence compared to non-irradiated patients at 2-and 5-year follow-up Peeters et al, 2005). The Swedish Rectal Cancer Trial showed comparable results at a mean of 6 years follow-up (Dahlberg et al, 1998).…”

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confidence: 93%

“…It is presently questionable how strongly oncologists believe the benefit from PRT on local control to outweigh the risks. At the time of our study, PRT was the standard treatment in the Netherlands, but it was expected that the guideline might undergo changes, due to the publication of the above studies of Marijnen et al (2005) and Peeters et al (2005). Additionally, patients' views on the underlying risk/benefit tradeoff have never been assessed.…”

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Benefit from preoperative radiotherapy in rectal cancer treatment: disease-free patients' and oncologists' preferences

et al. 2007

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Preoperative radiotherapy (PRT) in resectable rectal cancer improves local control but increases probability of faecal incontinence and sexual dysfunction. Consensus was reached in 2001 in the Netherlands on a guideline advising PRT to new patients. Purpose was to assess at what benefit oncologists and rectal cancer patients prefer PRT followed by surgery to surgery alone, and how oncologists and patients value various treatment outcomes. Sixty-six disease-free patients and 60 oncologists (surgical, radiation, medical) were interviewed. Minimally desired benefit from PRT (local control) was assessed using the Treatment Tradeoff Method. Importance of survival, local control, faecal incontinence, and sexual dysfunction in determining treatment outcome preferences was assessed using Adaptive Conjoint Analysis. The range of required benefit from PRT varied widely within participant groups. Seventeen percent of patients would choose PRT at a 0% benefit; 11% would not choose PRT for the maximum benefit of 11%. Mean minimally desired benefit excluding these two groups was 4%. For oncologists, the required benefit was 5%. Also, how strongly participants valued treatment outcomes varied widely within groups. Of the four outcomes, participants considered incontinence most often as most important. Relative treatment outcome importance differed between specialties. Patients considered sexual functioning more important than oncologists. Large differences in treatment preferences exist between individual patients and oncologists. Oncologists should adequately inform their patients about the risks and benefits of PRT, and elicit patient preferences regarding treatment outcomes.

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“…Bladder problems were observed in 2% [36]. In the TME trial, bowel dysfunction impairing daily life occurred in 34%, daily incontinence in 14% [30]. Radiation toxicity has been substantially reduced since data of large studies analyzing the pattern of local failure permitted a reduction of field size [26].…”

Section: Should the Level Of Evidence Be Neglected?mentioning

confidence: 99%

Rectal cancer

et al. 2013

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When is the local recurrence risk low enough to refrain from the aim to prevent it?Local recurrence (LR) of rectal cancer is a devastating incident for each affected individual [2,21]. Thus, along with the attempt of improving survival, local tumor control has been an essential goal in the management of rectal cancer. Adjuvant radiotherapy (RT) with or without chemotherapy (ChT) reduced local recurrence and became a standard treatment in the 1980s [14], which was later on gradually replaced by preoperative RT (nRT) [9,45] or neoadjuvant radiochemotherapy (nRCT) [3,4,10,34,37]. Further substantial progress in terms of local recurrence reduction was achieved with the advent of quality-assured total mesorectal excision (TME; [15]). The next step was the introduction of magnetic resonance imaging (MRI) as a routine preoperative staging tool [1] facilitating the visualization of the distance between tumor and mesorectal fascia. If this distance is ≥1 mm on MRI, a negative circumferential resection margin (CRM) is assumed, provided that total mesorectal excision surgery is performed adequately. A negative CRM (defined as ≥1 mm on pathological work-up) has consecutively been identified and validated as an important surrogate parameter to predict the individual LR risk [12]. Results of the MERCURY study group (Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study) whose authors propagated and investigated MRI-based treatment for rectal cancer were encouraging [23,43] and promoted similar attempts in the German-speaking community such as the OCUM study (optimized surgery and MRI-based multimodal therapy of rectal cancer). Preliminary results were recently published [22,42] and are commented in this editorial.Altogether, 230 patients with rectal cancer clinically staged as cT2-4, any cN, cM0 were included in this observational study. The anticipated CRM assessed by MRI (mrCRM) was used as a decision tool for selecting patients (n=230) either to undergo primary surgery (n=134) or to receive nRCT (n=96). For the lower third of the rectum (defined as <6 cm from the anal verge, 37%), nRCT was performed in all cT3 and cT4 tumors, irrespective of the anticipated CRM status; tumors of the middle third (i.e., 6 to <12 cm) were treated by nRCT in case of positive mrCRM only. For the upper third (12-16 cm), the decision was left to the discretion of the treating center. Clinically positive lymph nodes did not influence the choice of therapy; in patients with pathologically positive lymph nodes, chemotherapy was offered according to the standard of the respective centers. Postoperative RCT was restricted to patients with an involved CRM (pCRM ≤1 mm) [42].The mrCRM was positive in 74/230 patients, 72 in the nRCT group and 2 of the patients selected for surgery alone. A pathologically positive CRM (pCRM) occurred in 5.7% of all patients (nCRT: 11%, primary surgery: 1.5%). Pathology revealed complete remission (ypT0N0) after nRCT in 15% of patients, a partial remission in 67%. Even in patients whose margins were involv...

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Late Side Effects of Short-Course Preoperative Radiotherapy Combined With Total Mesorectal Excision for Rectal Cancer: Increased Bowel Dysfunction in Irradiated Patients—A Dutch Colorectal Cancer Group Study

Cited by 824 publications

References 25 publications

TME quality in rectal cancer surgery

TME quality in rectal cancer surgery

Benefit from preoperative radiotherapy in rectal cancer treatment: disease-free patients' and oncologists' preferences

Rectal cancer

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