Distinct Prognosis of High Versus Mid/Low Rectal Cancer: a Propensity Score–Matched Cohort Study

  • Lv-Jia Cheng
  • Jian-Hui Chen
  • Song-Yao Chen
  • Zhe-Wei Wei
  • Long Yu
  • Shao-Pu Han
  • Yu-Long He
  • Zi-Hao Wu
  • Chuang-Qi ChenEmail author
Original Article



Rectal cancers have long been treated as a single-entity disease; however, whether the prognosis of high rectal cancer (inferior margin located 10.1 to 15.0 cm from the anal verge) differs from that of mid/low rectal cancer (0 to 10.0 cm) remains disputed.


Patients with stages I–III rectal adenocarcinomas undergoing curative-intent surgery were enrolled between 2007 and 2013 in this retrospective analysis. Exclusion criteria were neoadjuvant therapy or concurrent cancers. Propensity score matching and Cox regression analysis were performed to compare a 5-year overall and cancer-specific survival between patients with high and mid/low rectal cancer.


Of 613 patients who met the inclusion criteria, 199 (32.5%) and 414 (67.5%) had high and mid/low rectal cancer, respectively. After propensity score matching (187 cases for each group), the high group showed a better overall survival (70.9 vs. 56.9%, p = 0.042) and cancer-specific survival (77.4 vs. 60.3%, p = 0.028) at 5 years compared with the mid/low group with stage III disease. However, high rectal cancer did not demonstrate prognostic superiority in stages I–II disease. Multivariate analysis identified high tumor location as an independent prognostic factor for cancer-specific survival (hazards ratio = 0.422, 95% confidence interval 0.226–0.786, p = 0.007) and overall survival (hazards ratio = 0.613, 95% confidence interval 0.379–0.991, p = 0.046).


Patients with stage III high rectal adenocarcinoma demonstrated better overall and cancer-specific survival than those with mid/low type, and tumor location was an independent prognostic factor for patients with rectal carcinomas.


High rectal cancer Mid/low rectal cancer Propensity score matching Survival 



The authors appreciate all the support from the staff of the Division of Gastrointestinal Surgery Center, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China. We also thank Prof. Jonathan B. Mitchem of University of Missouri Hospitals and Clinics, Columbia, MO 65212, USA, for linguistic assistance during the preparation of this manuscript.

Authors’ Contribution

Conception of the work: Chuang-Qi Chen, Lv-Jia Cheng, and Jian-Hui Chen.

Data acquisition: Lv-Jia Cheng, Song-Yao Chen, Long Yu, Shao-Pu Han, and Zhe-Wei Wei.

Data analysis and interpretation: Lv-Jia Cheng, Jian-Hui Chen, and Chuang-Qi Chen.

Manuscript drafting: Lv-Jia Cheng and Jian-Hui Chen.

Critical revision of manuscript: Chuang-Qi Chen, Zi-Hao Wu, and Yu-Long He.

Final approval: All authors.


Supported by the Science and Technology Planning Project of Guangdong Province (no. 2010B080701106 and no. 2013B021800131) and the Science and Technology Planning Project of Guangzhou City (no. 201604020003).

Compliance with Ethical Standards

Ethical Standards

An ethical subcommittee of the First Affiliated Hospital of Sun Yat-sen University approved this retrospective study. Written consent was obtained from the patients for their information to be stored in the hospital database and used for research.

Conflict of Interest

The authors declare that they have no competing interests.


  1. 1.
    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(8):894–899.CrossRefGoogle Scholar
  2. 2.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. New Engl J Med. 2001;345(9):638–646.CrossRefGoogle Scholar
  3. 3.
    Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G. The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the "DISTANCE"? Radiology. 2013;268(2):330–344.CrossRefGoogle Scholar
  4. 4.
    Engelen SM, Maas M, Lahaye MJ, Leijtens JW, van Berlo CL, Jansen RL, Breukink SO, Dejong CH, van de Velde CJ, Beets-Tan RG, Beets GL. Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge. Eur J Cancer. 2013;49(10):2311–2320.CrossRefGoogle Scholar
  5. 5.
    Glynne-Jones R, Wyrwicz L, Tiret E, Brown G, Rodel C, Cervantes A, Arnold D, Comm EG. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017;28:22–40.CrossRefGoogle Scholar
  6. 6.
    NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Rectal Cancer, Version 1.2018. Available at Accessed 31 May 2018.
  7. 7.
    Park JS, Sakai Y, Simon NS, Law WL, Kim HR, Oh JH, Shan HC, Kwak SG, Choi GS. Long-Term Survival and Local Relapse Following Surgery Without Radiotherapy for Locally Advanced Upper Rectal Cancer: An International Multi-Institutional Study. Medicine (Baltimore). 2016;95(22):e2990.CrossRefGoogle Scholar
  8. 8.
    Kaser SA, Froelicher J, Li Q, Muller S, Metzger U, Castiglione M, Laffer UT, Maurer CA. Adenocarcinomas of the upper third of the rectum and the rectosigmoid junction seem to have similar prognosis as colon cancers even without radiotherapy, SAKK 40/87. Langenbecks Arch Surg. 2015;400(6):675–682.CrossRefGoogle Scholar
  9. 9.
    Chiang JM, Hsieh PS, Chen JS, Tang R, You JF, Yeh CY. Rectal cancer level significantly affects rates and patterns of distant metastases among rectal cancer patients post curative-intent surgery without neoadjuvant therapy. World J Surg Oncol. 2014;12:197.CrossRefGoogle Scholar
  10. 10.
    Marinello FG, Frasson M, Baguena G, Flor-Lorente B, Cervantes A, Rosello S, Espi A, Garcia-Granero E. Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary. Dis Colon Rectum. 2015;58(6):556–565.CrossRefGoogle Scholar
  11. 11.
    Rosenberg R, Maak M, Schuster T, Becker K, Friess H, Gertler R. Does a rectal cancer of the upper third behave more like a colon or a rectal cancer?, Dis Colon Rectum. 2010;53(5):761–770.CrossRefGoogle Scholar
  12. 12.
    Bondeven P, Laurberg S, Hagemann-Madsen RH, Ginnerup Pedersen B. Suboptimal surgery and omission of neoadjuvant therapy for upper rectal cancer is associated with a high risk of local recurrence. Colorectal Dis. 2015;17(3):216–224.CrossRefGoogle Scholar
  13. 13.
    Charlson ME, Pompei P, Ales KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383.CrossRefGoogle Scholar
  14. 14.
    Benson AB, 3rd, Schrag D, Somerfield MR, Cohen AM, Figueredo AT, Flynn PJ, Krzyzanowska MK, Maroun J, McAllister P, Van Cutsem E, Brouwers M, Charette M, Haller DG. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol. 2004;22(16):3408–3419.CrossRefGoogle Scholar
  15. 15.
    Fagard K, Casaer J, Wolthuis A, Flamaing J, Milisen K, Lobelle JP, Wildiers H, Kenis C. Postoperative complications in individuals aged 70 and over undergoing elective surgery for colorectal cancer. Colorectal Dis. 2017;19(9):329–338.CrossRefGoogle Scholar
  16. 16.
    Rosenbaum PR, Rubin DB. The Central Role of the Propensity Score in Observational Studies for Causal Effects. Biometrika. 1983;70(1):41–55.CrossRefGoogle Scholar
  17. 17.
    Heinze G, Juni P. An overview of the objectives of and the approaches to propensity score analyses. Eur Heart J. 2011;32(14):1704–1708.CrossRefGoogle Scholar
  18. 18.
    Kim TH, Jeong SY, Choi DH, Kim DY, Jung KH, Moon SH, Chang HJ, Lim SB, Choi HS, Park JG. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Ann Surg Oncol. 2008;15(3):729–737.CrossRefGoogle Scholar
  19. 19.
    Nakamura T, Watanabe M. Lateral lymph node dissection for lower rectal cancer. World J Surg. 2013;37(8):1808–1813.CrossRefGoogle Scholar
  20. 20.
    Wang XT, Li DG, Li L, Kong FB, Pang LM, Mai W. Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer. Pathol Oncol Res. 2015;21(1):19–27.CrossRefGoogle Scholar
  21. 21.
    Guinney J, Dienstmann R, Wang X, de Reynies A, Schlicker A, Soneson C, Marisa L, Roepman P, Nyamundanda G, Angelino P, Bot BM, Morris JS, Simon IM, Gerster S, Fessler E, De Sousa EMF, Missiaglia E, Ramay H, Barras D, Homicsko K, Maru D, Manyam GC, Broom B, Boige V, Perez-Villamil B, Laderas T, Salazar R, Gray JW, Hanahan D, Tabernero J, Bernards R, Friend SH, Laurent-Puig P, Medema JP, Sadanandam A, Wessels L, Delorenzi M, Kopetz S, Vermeulen L, Tejpar S. The consensus molecular subtypes of colorectal cancer. Nat Med. 2015;21(11):1350–1356.CrossRefGoogle Scholar
  22. 22.
    Mouradov D, Domingo E, Gibbs P, Jorissen RN, Li S, Soo PY, Lipton L, Desai J, Danielsen HE, Oukrif D, Novelli M, Yau C, Holmes CC, Jones IT, McLaughlin S, Molloy P, Hawkins NJ, Ward R, Midgely R, Kerr D, Tomlinson IP, Sieber OM. Survival in stage II/III colorectal cancer is independently predicted by chromosomal and microsatellite instability, but not by specific driver mutations. Am J Gastroenterol. 2013;108(11):1785–1793.CrossRefGoogle Scholar
  23. 23.
    Dudley JC, Lin MT, Le DT, Eshleman JR. Microsatellite Instability as a Biomarker for PD-1 Blockade. Clin Cancer Res. 2016;22(4):813–820.CrossRefGoogle Scholar
  24. 24.
    Hong SP, Min BS, Kim TI, Cheon JH, Kim NK, Kim H, Kim WH. The differential impact of microsatellite instability as a marker of prognosis and tumour response between colon cancer and rectal cancer. Eur J Cancer. 2012;48(8):1235–1243.CrossRefGoogle Scholar
  25. 25.
    Bhangu A, Rasheed S, Brown G, Tait D, Cunningham D, Tekkis P. Does rectal cancer height influence the oncological outcome?, Colorectal Dis. 2014;16(10):801–808.CrossRefGoogle Scholar
  26. 26.
    Ishikubo T, Nishimura Y, Yamaguchi K, Khansuwan U, Arai Y, Kobayashi T, Ohkura Y, Hashiguchi Y, Tanaka Y, Akagi K. The clinical features of rectal cancers with high-frequency microsatellite instability (MSI-H) in Japanese males. Cancer Lett. 2004;216(1):55–62.CrossRefGoogle Scholar
  27. 27.
    Cho H, Mariotto AB, Mann BS, Klabunde CN, Feuer EJ. Assessing non-cancer-related health status of US cancer patients: other-cause survival and comorbidity prevalence. Am J Epidemiol. 2013;178(3):339–349.CrossRefGoogle Scholar
  28. 28.
    Duraes LC, Stocchi L, Steele SR, Kalady MF, Church JM, Gorgun E, Liska D, Kessler H, Lavryk OA, Delaney CP. The Relationship Between Clavien-Dindo Morbidity Classification and Oncologic Outcomes After Colorectal Cancer Resection. Ann Surg Oncol. 2018;25(1):188–196.CrossRefGoogle Scholar
  29. 29.
    Boeckx N, Koukakis R, Op de Beeck K, Rolfo C, Van Camp G, Siena S, Tabernero J, Douillard JY, Andre T, Peeters M. Primary tumor sidedness has an impact on prognosis and treatment outcome in metastatic colorectal cancer: results from two randomized first-line panitumumab studies. Ann Oncol. 2017;28(8):1862–1868.CrossRefGoogle Scholar
  30. 30.
    Tejpar S, Stintzing S, Ciardiello F, Tabernero J, Van Cutsem E, Beier F, Esser R, Lenz HJ, Heinemann V. Prognostic and Predictive Relevance of Primary Tumor Location in Patients With RAS Wild-Type Metastatic Colorectal Cancer: Retrospective Analyses of the CRYSTAL and FIRE-3 Trials. JAMA Oncol. 2017; 3(2):194–201.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  1. 1.Division of Gastrointestinal Surgery CenterThe First Affiliated Hospital of Sun Yat-Sen UniversityGuangzhouChina
  2. 2.Department of Colorectal SurgeryThe First Affiliated Hospital of Sun Yat-sen UniversityGuangzhouChina
  3. 3.Department of SurgeryUniversity of Missouri Hospitals and ClinicsColumbiaUSA

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