[Local recurrence and survival rate after rectal cancer operations and multimodal therapy].
BACKGROUND
In the guidelines of the German specialist medical societies, postoperative chemoradiotherapy is recommended for rectal carcinomas in stages II and III. In the meantime, there are important study findings favoring preoperative radiotherapy as against postoperative irradiation. In the present unicentric study, the clinical results after preoperative irradiation and postoperative chemotherapy are to be determined. In period I, sandwich radiation without total mesorectal excision was applied. In period II, the treatment was developed further with exclusive preoperative radiation and total mesorectal excision. Since from 1994 the therapy regimen has changed with the introduction of total mesorectal excision and improved radiotherapy, the present study was carried out to check whether this has led to better results of therapy.


METHODS
Over a period of 7 years, data from 607 patients with rectal carcinoma were recorded and stored in an Excel file. The carcinomas were grouped into lower, middle and upper segment levels and classified endosconographically. Multimodal treatment was administered in stage uT3. In period I, sandwich radiation was carried out with 24 Gy preoperatively and 24 Gy postoperatively, followed by adjuvant chemotherapy. Total mesorectal excision was not performed. In period II, 50.4 Gy were applied preoperatively, followed by adjuvant chemotherapy. The operation comprised total mesorectal excision of the lower two thirds of the rectum. Calcium folinate and 5-fluoroucil were administered in six chemotherapy cycles. Primarily inoperable patients received preoperative irradiation with up to 50.4 Gy in both periods to attain down-staging. The following surgical procedures were applied: abdominal perineal extirpations, deep anterior resections, coloanal anastomoses, colon pouch anal anastomoses and transanal microsurgical resections.


RESULTS
In 469 curatively operated patients, including primarily inoperable patients after down-staging radiotherapy, the rates of local recurrence were 5.8% with a mean follow-up observation of 4.29 years, and the carcinoma-specific 4-year actuarial survival was 84%. The rate of recurrence was highest in the lowest segment level of the rectum (7.6 as compared to 2.4%, P = 0.042). The rates of local recurrence were 7.4% in period I and 4.3% in period II (P = 0.44). The carcinoma-specific 4-year actuarial survivals were 81% in period I and 87% in period II (P = 0.202). Investigation of the subgroups of irradiated patients showed complete freedom from recurrence after a mean follow-up observation time of 3.58 years for patients in stage uT3 with total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy (n = 51). The difference from patients without postoperative chemotherapy was significant (P = 0.018). After radiotherapy, the complication observed was a raised rate of sacral cavity infections after total resection of the rectum (p = 0.039).


CONCLUSIONS
Total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy can effectively influence the rate of local recurrences after rectal carcinoma operations (0-4.3% after a mean period of follow-up observation of 3.58 years). No appraisal can be made with regard to the benefit resulting from the individual measures.
Thomschke
D
D
Klinik für Allgemein- und Visceralchirurgie der Dr.-Horst-Schmidt-Kliniken GmbH, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden.
Kyau-Ummen
B
B
Halbfass
H J
HJ
D000206:Actuarial Analysis; D000368:Aged; D002423:Cause of Death; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery*; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000532:radiotherapy / Q000601:surgery*; D012086:Reoperation; D015996:Survival Rate