Preoperative Radiochemotherapy and Sphincter-Saving Resection for T3 Carcinomas of the Lower Third of the Rectum

Abstract

ObjectiveTo evaluate the complications and oncologic and functional results of preoperative radiochemotherapy and sphincter-saving resection for T3 cancers of the lower third of the rectum. Summary Background DataCarcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdominoperineal resection, especially for T3 lesions. Few data are available evaluating concomitant chemotherapy with preoperative radiotherapy for increasing sphincter-saving resection in low rectal cancer. MethodsBetween 1995 and 1999, 43 patients underwent preoperative radiochemotherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors. Patients received preoperative radiotherapy with a mean dose of 50 Gy (range 40 -54) and concomitant chemotherapy with 5-FU in continuous infusion (n ϭ 36) or bolus (n ϭ 7). Sphinctersaving resection was performed 6 weeks after treatment, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patients had a protecting stoma. ResultsThere were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patients but one had closure of the stoma. Distal and radial surgical margins were respectively 23 Ϯ 8 mm (range 10 -40) and 8 Ϯ 4 mm (range 1-20) and were negative in 98% of the patients. Downstaging (pT0 -2N0) was observed in 42% of the patients (18/43) and was associated with a greater radial margin (10 vs. 6 mm; P ϭ .02). After a median follow-up of 30 months, the rate of local recurrence was 2% (1/43), and four patients had distal metastases. Overall and disease-free survival rates were both 85% at 3 years. Functional results were good (Kirwan continence I, II) in 79% of the available patients (n ϭ 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a colonic pouch (74 vs. 16%; P ϭ .01). ConclusionsThese results suggest that preoperative radiochemotherapy allowed sphincter-saving resection to be performed with good local control and good functional results in patients with T3 low rectal cancers that would have required abdominoperineal resection in most instances.Carcinomas of the rectum infiltrating the muscular layer and the perirectal adipose tissue and located in the lower third of the rectum (i.e., T3 tumors within 6 cm of the anal verge [or anal margin]) are traditionally treated by abdominoperineal resection (APR). Indeed, local excision and sphincter-saving resection (SSR) are proposed only in patients with well-differentiated T1-T2 disease. For T3 disease, APR is justified by the difficulties of achieving radial and distal negative margins because of the narrow shape of the distal pe...

Analysis of Clinical Factors Associated with Anal Function after Intersphincteric Resection for Very Low Rectal Cancer

“…In our study group, 6.7% of all patients had a CRM ≤1 mm, and similar results were reported in the range of 0% to 13.3% [18,26]. Preoperative CRT was considered useful for preventing local recurrence in low rectal cancer patients requiring ISR [14,23]. Kuo et al [26] reported a positive CRM rate of 13.3%, but a local recurrence rate of 7.7% in their ISR series of 26 patients; 88.5% of these patients had undergone preoperative CRT.…”

“…However, with this procedure, which involves dividing the rectum between the internal sphincter and the external sphincter or the levator ani, it remains unclear whether a secure circumferential resection margin (CRM) of the tumor can be obtained. Further, partial or total ISR procedures have been shown to possibly interfere with fecal continence [7,8,[14][15][16].…”

Excision of the Levator Muscles With External Sphincter Preservation in the Treatment of Selected Low T4 Rectal Cancers

“…This is because of the fact that it is impossible to obtain adequate margins from the tumor without damaging the sphincteric structures. Several recent experiences [10][11][12][13][14][15][16][17] suggest that, in selected tumors not infiltrating the levators or the external sphincter, it is possible to achieve a distal margin of 2 cm or more from the tumor, by extending the rectal excision to part of the whole of the internal sphincter and perform a coloanal anastomosis at, or below, the dentate line without major impairment of the anorectal function. The results of this operationknown as an "intersphincteric resection"-which is usually performed using an abdominoendoanal approach, seem to be satisfactory both oncologically and functionally.…”

“…The results of this operationknown as an "intersphincteric resection"-which is usually performed using an abdominoendoanal approach, seem to be satisfactory both oncologically and functionally. 14,16,17 Infiltration of the levator muscles and/or the external sphincter (T4 tumors), however, remains an absolute contraindication also for this advanced procedure 11,15 ; preservation of these muscles has been Figure 3. Opening of the pelvic floor with scissors at a distance from tumor after separation of the puborectalis muscle from the external anal sphincter.…”

Locally Advanced Rectal Cancer: What Is the Evidence for Induction Chemoradiation?

“…Longcourse CRT followed by a planned delay prior to surgery, may result in shrinkage back from the distal margin, and enable SPSS. Impressive results appear to have been achieved in phase II studies with CRT [31,32], and longterm follow-up has confirmed an excellent outcome if marked shrinkage of the distal tumor margin is demonstrated [33]. Subset analysis of randomized trials suggests that preoperative CRT offers a 10% [34] or even a 20% [2] higher chance overall of achieving SPSS.…”