PURPOSE: This study was designed to assess the local recurrence rate and prognostic factors for local recurrence in patients undergoing curative anterior or abdominoperineal resections without radiotherapy. METHODS: From January 1980 to December 1996, 514 consecutive patients underwent curative resections for rectal cancer. We excluded those with preoperative radiotherapy (n=23), postoperative radiotherapy (n=27), local resection (n=36), and 11 (2.1 percent) patients who died postoperatively. The remaining 417 patients (249 males) with a median age of 64 (range, 21–90) years were analyzed. For upper third lesions, mesorectal tissue was excised down to at least 5 cm below the tumor. Total mesorectal excision was performed for lower and middle tumors. Postoperative chemotherapy was limited to patients with Stage III lesions. Median follow-up (and 95 percent confidence interval) was (5.2 4.3–5.9) years, with 87.7 percent of patients followed up longer than 24 months. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis. RESULTS: Five-year local recurrence rate(and 95 percent confidence interval) was 9.7 (6.4–13) percent, with a median time to diagnosis of 15 (10–23) months. Local recurrence rates in Stages I, II, and III were: 3.1, 4.1, and 24.1 percent, respectively (P < 0.0001). In relation to node status, local recurrence rates were N0, 4.1 (1.7–6.5) percent; N1, 12.6 (4.6–20.6) percent; N2, 32.1 (12.1–52.1) percent; and N3, 59.3 (22.5–96.1) percent; (P < 0.00001). Lower third tumors had a higher local recurrence rate than middle and upper third tumors: 17.9, 7.1, and 5.1 percent, respectively (P=0.002). Adjusted by stage, this difference was maintained only in Stage III tumors. Among lower tumors, those at 6 and 7 cm from the anal verge had a lower local recurrence rate than those below 6 cm (6.7vs. 26.2 percent, respectively;P=0.02). Accidental rectal perforation at or near the tumor site occurred in 12 cases (2.9 percent), showing a strong correlation with local recurrence (P < 0.0001). Multivariate analysis showed significant higher risk for lower third tumors (hazard ratio, 2.98) and positive nodes (hazard ratio, 4.78). CONCLUSIONS: Appropriate surgery without irradiation achieves excellent local control in N0 rectal cancers. Node metastasis, lower third localization (especially below 6 cm), and accidental rectal perforation at or near the tumor site are significantly associated with a higher local recurrence rate.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Karanjia ND, Schache DJ, North WR,et al. “Close shave” in anterior resection. Br J Surg 1990;77:501–12.
Nilsson E, Gregersen N-P, Hartvig B,et al. Carcinoma of the colon and rectum. Acta Chir Scand 1984;150:177–82.
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer. The Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 1998;133:894–99.
Holm T, Johansson H, Cedemark B, Ekelund G, Rutqvist L. Influence of hospital and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy. Br J Surg 1997;84:657–63.
McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival BMJ 1991; 302:1501–05.
Phillips RK, Hittinger R, Blesovsky L. Local recurrence following “curative” surgery large bowel cancer: II. the rectum and rectosigmoid. Br J Surg 1988;71:17–20.
Soreide O, Norstein J. Local recurrence after operative treatment of rectal carcinoma: a strategy for change. J Am Coll Surg 1997;184:84–92.
Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997;336:980–7.
Chari RS, Tyler DS, Anscher MS,et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 1996;221:778–87.
Stryker SJ, Kiel KD, Rademaker A,et al. Preoperative chemoradiation for stages II and III rectal carcinoma. Arch Surg 1996;131:514–9.
Hyams DM, Mamounas EP, Petrelli N,et al. A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of National Surgical Breast and Bowel Project Protocol R-03. Dis Colon Rectum 1997;40:131–9.
Rich TA, Skibber JM, Ajani JA,et al. Preoperative infusional chemoradiation therapy for stage T3 rectal cancer. Int J Radiat Oncol Biol Phys 1995;32:1025–9.
Grann A, Minsky BD, Cohen AM,et al. Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer. Dis Colon Rectum 1997;40:515–22.
Påhlman L, Glimelius B. Pre-operative and post-operative radiotherapy and rectal cancer. World J Surg 1992;16:858–65.
Arbman G, Nilsson E, Hallböök O, Sjödahl R. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 1996;83:375–79.
Zaheer S, Pemberton JH, Farouk R,et al. Surgical treatment of adenocarcinoma of the rectum. Ann Surg 1998;227:800–11.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 1982;69:613–16.
Cohen AM, Shank B, Friedman MA. Colorectal Cancer. In: De Vita VT, Hellman S, Rosenberg S, eds. Principles and practice of oncology. 3rd ed. Philadelphia: JB Lippincott, 1989:910.
Lane R, Thompson M, Whatleyet al. Effect of specialization on outcome in patients having surgery for rectal cancer [meeting abstract]. Dis Colon Rectum 1999;42:A6.
García-Granero E, Martí-Obiol R, Gómez J,et al. Impact of surgeon organization and specialization in rectal cancer outcome [meeting abstract]. Dis Colon Rectum 1999; 42:A30
Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factor and outcome in rectal cancer. Ann Surg 1998;227:157–67.
McCall JL, Cox MR, Wattchow DA. Analysis of local recurrence rates after surgery alone for rectal cancer. Int J Colorectal Dis 1995;10:126–32.
Lopez-Kostner F, Lavery IC, Hool GR, Rybicki LA, Fazio VW. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery 1998;124:612–18.
Killingback M. Local recurrence after restorative resection for carcinoma of the rectum (without total mesorectal excision)[abstract]. Int J Colorectal Dis 1996;11:129.
Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995;181:335–46.
Willet CG, Badizadegan K, Ancukiewicz M, Shellito PC. Prognostic factors in Stage T3N0 rectal cancer: do all patients require postoperative pelvic irradiation and chemotherapy? Dis Colon Rectum 1999;42:167–73.
McDermott ST, Hughes ES, Pihl WR,et al. Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Surg 1985;72:34–7.
Morson BC, Vaughan EG, Bussey HJ. Pelvic recurrence after excision of the rectum for carcinoma. BMJ 1963;2:13–8.
Moosa AR, Ree PC, Marks JE. Factor influencing local recurrence after abdominoperineal resection for cancer of the rectum and rectosigmoid. Br J Surg 1975;62:727–30.
Patel SC, Tovee EB, Langer B. Twenty-five years experience with radical surgical treatment of carcinoma of the extraperitoneal rectum. Surgery 1977;82:365–73.
Zringibl H, Husemann B, Hermanek P. Intra-operative spillage of tumor cells in surgery for rectal cancer. Dis Colon Rectum 1990;33:610–4.
Grinnell RS. Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg Gynecol Obstet 1954;99:421–30.
Williams NS, Dixon ME, Johnson D. Reappraisal of the 5 cm rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and patients' survival. Br J Surg 1983;70:150–4.
Corman ML, Jagelman D, Salvati EP, Beart RW Jr. Sphincter-saving operation for rectal cancer. Contemp Surg 1982;21:59–78.
Hughes TG, Jenevein EP, Poulos E. Intramural spread of the colon carcinoma. Am J Surg 1983;146:697–9.
About this article
Cite this article
Bonadeo, F.A., Vaccaro, C.A., Benati, M.L. et al. Rectal cancer. Dis Colon Rectum 44, 374–379 (2001). https://doi.org/10.1007/BF02234736
- Rectal cancer
- Local recurrence
- Mesorectal excision