Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum.
OBJECTIVE
To 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.


BACKGROUND
Carcinomas 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.


METHODS
Between 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 = 36) or bolus (n = 7). Sphincter- saving 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.


RESULTS
There 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 +/- 8 mm (range 10-40) and 8 +/- 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 =.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 = 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 =.01).


CONCLUSIONS
These 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.
Rullier
E
E
Department of Surgery, Saint-Andre Hospital, Bordeaux, France. eric.rullier@chu-bordeaux.fr
Goffre
B
B
Bonnel
C
C
Zerbib
F
F
Caudry
M
M
Saric
J
J
D000230:Adenocarcinoma / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D003106:Colon / Q000601:surgery; D003131:Combined Modality Therapy; D003672:Defecation; D005260:Female; D005472:Fluorouracil / Q000009:adverse effects / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016737:Proctocolectomy, Restorative; D011446:Prospective Studies; D011878:Radiotherapy / Q000009:adverse effects; D011879:Radiotherapy Dosage; D012004:Rectal Neoplasms / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D012007:Rectum / Q000601:surgery; D015996:Survival Rate
D000970:Antineoplastic Agents; D005472:Fluorouracil