Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer.
A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6–8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated.
Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival.
Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.
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Havenga K, Enker WE, Norstein J, Moriya Y, Heald RJ, van Houwelingen HC, et al. Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients. Eur J Surg Oncol. 1999; 25:368–74.
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg. 1998; 133:894–9.
Andreola S, Leo E, Belli F, Bonfanti G, Sirizzotti G, Greco P, et al. Adenocarcinoma of the lower third of the rectum surgically treated with a <10-mm distal clearance: preliminary results in 35 N0 patients. Ann Surg Oncol. 2001; 8:611–5.
Minsky BD, Cohen AM, Enker WE, Paty P. Sphincter preservation with preoperative radiation therapy and coloanal anastomosis. Int J Radiat Oncol Biol Phys. 1995; 31:553–9.
Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, et al. Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys. 1999; 44:1027–38.
Rouanet P, Fabre JM, Dubois JB, Dravet F, Saint Aubert B, Pradel J, et al. Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results. Ann Surg. 1995; 221:67–73.
Wagman R, Minsky BD, Cohen AM, Guillem JG, Paty PP. Sphincter preservation in rectal cancer with preoperative radiation therapy and coloanal anastomosis: long term follow-up. Int J Radiat Oncol Biol Phys. 1998; 42:51–7.
Tytherleigh MG, Mc CMNJ. Options for sphincter preservation in surgery for low rectal cancer. Br J Surg. 2003; 90:922–33.
Kim NK, Baik SH, Seong JS, Kim H, Roh JK, Lee KY, et al. Oncologic outcomes after neoadjuvant chemoradiation followed by curative resection with tumor-specific mesorectal excision for fixed locally advanced rectal cancer: impact of postirradiated pathologic downstaging on local recurrence and survival. Ann Surg. 2006; 244:1024–30.
Crane CH, Skibber JM, Feig BW, Vauthey JN, Thames HD, Curley SA, et al. Response to preoperative chemoradiation increases the use of sphincter-preserving surgery in patients with locally advanced low rectal carcinoma. Cancer. 2003; 97:517–24.
Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH. Analysis of anal sphincter preservation rate according to tumor level and neoadjuvant chemoradiotherapy in rectal cancer patients. J Gastrointest Surg. 2008; 12:176–82.
Rothenberger DA, Wong WD. Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg. 1992; 16:478–85.
Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004; 47:48–58.
Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005; 242:74–82.
Law WL, Chu KW. Abdominoperineal resection is associated with poor oncological outcome. Br J Surg. 2004; 91:1493–9.
Chuwa EW, Seow-Choen F. Outcomes for abdominoperineal resections are not worse than those of anterior resections. Dis Colon Rectum. 2006; 49:41–9.
Chiappa A, Biffi R, Zbar AP, Luca F, Crotti C, Bertani E, et al. Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003. Int J Colorectal Dis. 2005; 20:221–30.
Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Hölzel D. Quality of life in rectal cancer patients: a four-year prospective study. Ann Surg. 2003; 238:203–13.
Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001; 345:638–46.
Rullier E, Goffre B, Bonnel C, Zerbib F, Caudry M, Saric J. Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum. Ann Surg. 2001; 234:633–40.
Luna-Perez P, Rodriguez-Ramirez S, Rodriguez-Coria DF, Fernández A, Labastida S, Silva A, et al. Preoperative chemoradiation therapy and anal sphincter preservation with locally advanced rectal adenocarcinoma. World J Surg. 2001; 25:1006–11.
Gavioli M, Losi L, Luppi G, Iacchetta F, Zironi S, Bertolini F, et al. Preoperative therapy for lower rectal cancer and modifications in distance from anal sphincter. Int J Radiat Oncol Biol Phys. 2007; 69:370–5.
Kim NK, Baik SH, Min BS, Pyo HR, Choi YJ, Kim H, et al. A comparative study of volumetric analysis, histopathologic downstaging, and tumor regression grade in evaluating tumor response in locally advanced rectal cancer following preoperative chemoradiation. Int J Radiat Oncol Biol Phys. 2007; 67:204–10.
Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005; 23:9257–64.
Kim NK. Anatomic basis of sharp pelvic dissection for curative resection of rectal cancer. Yonsei Med J. 2005; 46:737–49.
Kim NK. Sharp pelvic dissection for abdominoperineal resection for distal rectal caner based on anatomical and MRI knowledge. J Korean Soc Coloproctol. 2005; 21: 258–67.
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004; 351:1731–40.
Uzcudun AE, Batlle JF, Velasco JC, Sánchez Santos ME, Carpeño Jde C, Grande AG, et al. Efficacy of preoperative radiation therapy for resectable rectal adenocarcinoma when combined with oral tegafur-uracil modulated with leucovorin: results from a phase II study. Dis Colon Rectum. 2002; 45:1349–58.
Guillem JG, Chessin DB, Cohen AM, Shia J, Mazumdar M, Enker W, et al. Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer. Ann Surg. 2005; 241:829–36; discussion 836–8.
This work was supported by a grant from the Korea Health 21 R&D Project, Ministry of Health and Welfare, Republic of Korea (0412-CR01-0704-0001, 0405-BC01-0604-0002).
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Kim, J.S., Hur, H., Kim, N.K. et al. Oncologic Outcomes After Radical Surgery Following Preoperative Chemoradiotherapy for Locally Advanced Lower Rectal Cancer: Abdominoperineal Resection Versus Sphincter-Preserving Procedure. Ann Surg Oncol 16, 1266–1273 (2009). https://doi.org/10.1245/s10434-009-0338-3
- Anal Sphincter
- Anterior Resection
- Total Mesorectal Excision
- Oncologic Outcome
- Circumferential Resection Margin