title: Changing operative strategy from abdominoperineal resection to sphincter preservation in T3 low rectal cancer after downstaging by neoadjuvant chemoradiation: a preliminary report.
abstract: OBJECTIVE
  The objective of this study is to assess oncological outcome after changing operative strategy from abdominoperineal resection (APR) to sphincter preservation (SP) in T3 low rectal carcinomas downstaged by neoadjuvant chemoradiation (nCRT).
  
  
  METHODS
  This was a prospective observational study performed at academic medical centers. Patients with T3 rectal carcinoma, (<1 cm from the top of anal sphincter) received long-course neoadjuvant chemoradiation. Decision before chemoradiation was APR in all patients. Patients who had successful downstaging were included in the study. Low anterior resection (LAR) was performed after 8-11 weeks from completion of nCRT. Follow-up duration ranged from 4 to 6 years. Salvage surgery was done for local recurrence when possible. The primary endpoint of the study was disease-free survival. Secondary endpoints were morbidity, mortality, continence, and oncologic results of salvage surgery after recurrence.
  
  
  RESULTS
  LAR with colorectal or coloanal anastomosis were done in 9 and 36 patients, respectively. After a mean follow-up of 57 months (range 48-70), local recurrences was reported in 4 patients (8.8 %), one of them had also distant metastasis while 2 patients (4.4 %) had only distant metastasis. Disease-free and overall survival rates were 87 and 89 %, respectively. Three of 4 patients with local recurrence (the fourth had liver metastasis) underwent salvage APR with free safety margins. Follow-up after salvage surgery for 31, 33, and 37 months revealed no recurrences. Wexner continence score ≤4 was noted in 39 patients; while major incontinence (Wexner score >12) was noted in 2 patients.
  
  
  CONCLUSIONS
  For selected patients of T3 low rectal cancer, changing operative strategy from APR to SP after downstaging by nCRT can be done in motivated patients with good sphincter function. Disease-free survival rates and continence are comparable to patients had APR and to previous publications with decision made before nCRT. With strict follow-up, early diagnosis of recurrence and salvage surgery with free resection margins can be achieved.
authors.affiliation: Department of Surgery, University of Alexandria, El Raml Station, Alexandria, Egypt, khaled.madbouly@alexmed.edu.eg.
authors.forename: Khaled M
authors.initials: KM
authors.lastname: Madbouly
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Hussein
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary / Q000601:surgery* / Q000628:therapy; D000328:Adult; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical / Q000009:adverse effects; D059186:Chemoradiotherapy, Adjuvant; D003106:Colon / Q000601:surgery; D003125:Colostomy; D013505:Digestive System Surgical Procedures / Q000009:adverse effects; D018572:Disease-Free Survival; D005242:Fecal Incontinence / Q000209:etiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D009367:Neoplasm Staging; D059351:Organ Sparing Treatments; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D012007:Rectum / Q000601:surgery; D016879:Salvage Therapy; D015996:Survival Rate