Diseases of the Colon & Rectum

, Volume 36, Issue 2, pp 117–126 | Cite as

Patterns of recurrence following high-dose preoperative radiation and sphincter-preserving surgery for cancer of the rectum

  • Mohammed Mohiuddin
  • Gerald Marks
Original Contributions


High-dose preoperative radiation with new sphincter-preserving surgical options for the management of distal and unfavorable cancers of the rectum is gaining recognition as an alternative to abdominoperineal resection and permanent colostomy. From 1976 to 1989, 161 patients with cancer of the rectum were entered into a program of high-dose preoperative radiation and radical sphincter-preserving surgery. Selection was based on prospective clinical staging of unfavorability or tumor location at a low level in the rectum. All patients received a minimum dose of 4,000 to 4,500 cGy over 4 1/2 weeks in fractional doses of 180 to 250 cGy. Patients with tumor fixation were given an additional boost of 1,000 to 1,500 cGy for a total of 5,500 to 6,000 cGy using a coned-down field. Surgery was carried out four to eight weeks following completion of radiation. Fourteen patients, found at surgery to have liver metastasis, were treated by palliative resection. One hundred forty-seven patients underwent radical curative surgery with sphincter preservation. The surgical procedures performed were combined abdominotranssacral resection (63), transanal-abdominal-transanal resection (53), and anterior resection (31). Follow-up ranged from a minimum of two years to 15 years, with a median of five years. There was no perioperative mortality. Anastomotic failure occurred in three patients, two of whom were reconstituted. Late diversion was required in 10 other patients, primarily for recurrent disease. One hundred thirty-four of the 147 patients (91 percent) maintained long-term normal sphincter function. Pelvic-perineal recurrence was observed in 18 patients (12.4 percent), 12 of whom had fixed tumors located below the 6-cm level of the distal rectum. Median time to local recurrence was 24 months. Distant metastasis with or without local recurrence occurred in 35 patients, 22 of whom had fixed tumors below the 6-cm level of the rectum. Median time to distant metastasis was 17 months. Forty-three patients have died, 32 of disease. The overall five-year Kaplan-Meier actuarial survival for the total group of patients is 79 percent, with a disease-free survival of 73 percent. The findings of this study indicate that high-dose preoperative radiation used in combination with radical sphincter-preserving surgical techniques results in excellent local control of disease, improved survival, and enhanced quality of life with retention of normal anal sphincter function.

Key words

Rectal cancer Preoperative radiation Sphincter preservation 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Gunderson LL, Sosin H. Areas of failure found at reoperation (second or symptomatic look) following “curative surgery” for adenocarcinoma of the rectum. Cancer 1974;34:1278–92.PubMedGoogle Scholar
  2. 2.
    Pilipshen SJ, Heilweil M, Quan SH, Stemberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer 1984;53:1354–62.PubMedGoogle Scholar
  3. 3.
    Rao AR, Kagan AR, Chan PM,et al. Patterns of recurrence following curative resection alone for adenocarcinoma of the rectum and sigmoid colon. Cancer 1981;48:1492–5.PubMedGoogle Scholar
  4. 4.
    Stearns MW, Binkley GE. Influence of location of prognosis in operable rectal cancer. Surg Gynecol Obstet 1953;96:368–70.PubMedGoogle Scholar
  5. 5.
    Mohiuddin M, Marks G. High-dose preoperative radiation for cancer of the rectum: Thomas Jefferson University experience 1976–1988. Int J Radiat Oncol Biol Phys 1991;20:37–43.PubMedGoogle Scholar
  6. 6.
    Marks G, Mohiuddin M, Borenstein B. Preoperative radiation therapy and sphincter preservation by the combined abdominotranssacral technique for selected rectal cancers. Dis Colon Rectum 1985;28:565–71.PubMedGoogle Scholar
  7. 7.
    Marks GM, Mohiuddin M, Eitan A, Masoni L, Rakinic J. High-dose preoperative radiation and radical sphincter-preserving surgery for rectal cancer. Arch Surg 1991;126:1534–40.PubMedGoogle Scholar
  8. 8.
    Astler VS, Coller FA. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg 1954;139:846–51.PubMedGoogle Scholar
  9. 9.
    Kaplan E, Meier P. Non parametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.Google Scholar
  10. 10.
    Cox DR. Regression models and life tables. J R Stat Soc (Series B) 1972;34:187–220.Google Scholar
  11. 11.
    Adloff M, Arnaud JP, Schloegel M,et al. Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1985;28:413–5.PubMedGoogle Scholar
  12. 12.
    Falterman KW, Hill CB, Markey JC,et al. Cancer of the colon, rectum and anus: a review of 2313 cases. Cancer 1974;34:951–9.PubMedGoogle Scholar
  13. 13.
    Gilbertsen VA. Adenocarcinoma of the rectum: a fifteen-year study with evaluation of the results of curative therapy. Arch Surg 1960;80:135–43.Google Scholar
  14. 14.
    Gilbertsen VA. The results of the surgical treatment of cancer of the rectum. Surg Gynecol Obstet 1962;114:313–9.PubMedGoogle Scholar
  15. 15.
    Glenn F, McSherry CK. Carcinoma of the distal large bowel: 32-year review of 1,026 cases. Ann Surg 1966;163:838–49.PubMedGoogle Scholar
  16. 16.
    Liechty RD, Ziffren SE, Miller FE,et al. Adenocarcinoma of the colon and rectum: review of 2,261 cases over a 20-year period. Dis Colon Rectum 1968;11:201–8.PubMedGoogle Scholar
  17. 17.
    Duncan W, Smith AN, Freedman LF,et al. Clinicopathological features of prognostic significance in operable rectal cancer in 17 centres in the U.K. Br J Cancer 1984;50:435–42.PubMedGoogle Scholar
  18. 18.
    Fisher B, Wolmark N, Rockette H,et al. Postoperative adjuvant chemotherapy for rectal cancer; results from NSABP protocol R-01. J Natl Cancer Inst 1988;80:21–9.PubMedGoogle Scholar
  19. 19.
    Gastrointestinal Tumor Study Group. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315:1294–5.Google Scholar
  20. 20.
    Malcolm AW, Perencevich NP, Olseon RM, Hanley JA, Chaffey JT, Wilson RE. Analysis of recurrence patterns following curative resection for carcinoma of the colon and rectum. Surg Gynecol Obstet 1981;152:131–6.PubMedGoogle Scholar
  21. 21.
    Mendenhall WM, Million RR, Pfaff WW. Patterns of recurrence in adenocarcinoma of the rectum and rectosigmoid treated with surgery alone: implications in treatment planning with adjuvant radiation therapy. Int J Radiat Oncol Biol Phys 1983;9:977–85.PubMedGoogle Scholar
  22. 22.
    Neville R, Fielding LP, Amendola C. Local tumor recurrence after curative resection for rectal cancer. Dis Colon Rectum 1987;30:12–7.PubMedGoogle Scholar
  23. 23.
    Higgins GA, Humphrey EQ, Dwight RW, Roswit B, Lee LE, Keehn RJ. Preoperative radiation and surgery for cancer of the rectum: Veterans Administration Surgical Oncology Group Trial II. Cancer 1986;58:352–9.PubMedGoogle Scholar
  24. 24.
    Quan SH, Deddish MR, Stearns MW. The effect of preoperative roentgen therapy upon the 10- and 5-year results of the surgical treatment of cancer of the rectum. Surg Gynecol Obstet 1960;111:507–8.PubMedGoogle Scholar
  25. 25.
    Roswit B, Higgins GA, Keehn RJ. Preoperative irradiation for carcinoma of the rectum and rectosigmoid colon: report of a National Veterans Administration randomized study. Cancer 1975;35:1597–602.PubMedGoogle Scholar
  26. 26.
    Stockholm Rectal Cancer Study Group. Short-term preoperative radiotherapy for adenocarcinomas of the rectum. Am J Clin Oncol 1987;10:369–75.Google Scholar
  27. 27.
    Third report of the MRC trial on behalf of The Working Party. Clinico-pathological features of prognostic significance in operable rectal cancer in 17 centres in the U.K. Br J Surg 1984;50:435–42.Google Scholar
  28. 28.
    Fortier GA, Constable WC, Meyers H, Wanebo HJ. Preoperative radiation therapy for rectal cancer: an effective therapy in need of a clinical trial. Arch Surg 1986;121:1380–5.PubMedGoogle Scholar
  29. 29.
    Gerard A, Buyse M, Nordlinger B,et al. Preoperative radiotherapy as adjuvant treatment in rectal cancer—final results of a randomized study of the European Organization for Research and Treatment of Cancer (EORTC). Ann Surg 1988;208:606–14.PubMedGoogle Scholar
  30. 30.
    Kligerman MM, Urdaneta N, Knowlton A,et al. Preoperative irradiation of rectosigmoid carcinoma including its regional lymph nodes. Am J Roentgenol Radium Ther Nucl Med 1972;114:498–503.PubMedGoogle Scholar
  31. 31.
    Mendenhall WM, Million RR, Bland KI, Pfaff EE, Copeland EM. Preoperative radiation therapy for clinically resectable adenocarcinoma of the rectum. Ann Surg 1985;202:215–22.PubMedGoogle Scholar
  32. 32.
    Stevens KR, Allen CV, Fletcher WS. Preoperative radiotherapy for adenocarcinoma of the rectosigmoid. Cancer 1976;37:2866–74.PubMedGoogle Scholar
  33. 33.
    Krook JE, Moertel CG, Gunderson LL,et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709–15.PubMedGoogle Scholar
  34. 34.
    Pahlman L, Glimelius B. Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Ann Surg 1990;211:187–95.PubMedGoogle Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1993

Authors and Affiliations

  • Mohammed Mohiuddin
    • 1
  • Gerald Marks
    • 2
  1. 1.Departments of Radiation Oncology and Nuclear MedicineThomas Jefferson University HospitalPhiladelphia
  2. 2.Department of Surgery, The Comprehensive Rectal Cancer CenterThomas Jefferson University HospitalPhiladelphia

Personalised recommendations