Surgery which spares the rectum is gaining wide acceptance. But, many surgeons continue to remove the rectum, resulting in a permanent colostomy. The Texas Cancer Center encourages limited surgery, as practiced by Dr. N.A. Janjan at the UT M.D. Anderson Cancer Center in Houston. Additional medical research supporting our recommendations can be found in our "Medical Research" section. Most of this research is directly linked to the National Library of Medicine. There are no medical studies which refute this conservative treatment strategy.
INTRODUCTION
Cancers of the colon and rectum affect about 160,000 Americans every year, and represent about 15% of all cancers in the United States. Considered together they are second only to lung cancer as the leading cause of cancer death in the United States. They affect about one out of twenty (6%) Americans at some time during life. Rectal cancer affects about 45,000 Americans annually. Each year about 24,000 Americans die of this disease. Thus, almost half of all patients with rectal cancer are cured. They are cured almost exclusively with timely surgery.
(Return to Top)
STAGES OF DISEASE
In 1932, Dukes from England described a staging system for cancer of the colon and rectum. It is based primarily on the depth of tumor invasion. This system has been modified often, including changes by Dukes himself. This letter based system still bares his name. The TNM system has been accepted by the Union Internationale Contre Cancer (UICC) and the American Joint Committee for Cancer Staging and End Results (AJC).
Stage 0
Dukes' stage 0
TNM Tis or carcinoma in situ
The tumor is limited to the mucosa, the cell layer lining the rectum. The fiveyear survival rate is over 95%.
Stage I
Dukes' stage A or B1
TNM T12, N0, M0
The tumor is confined to the bowel wall. Penetration of the tumor into the muscle layer of the bowel is indicated by the higher designation in each system. (B1 or T2)
By altering these hormones it is possible to alter the growth of cancer cells. Hormonal therapy is often more effective in treating solid tumors than chemotherapy, and usually has fewer toxic side effects. Hormone therapy is almost never curative. It can decrease the rate of tumor growth, reduce pain, and increase the quality of life. These effects may persist for several months or a few years. But hormonal therapy is generally not able to significantly prolong life. If one form of hormonal treatment stops working, another my be tried. But each new hormone treatment becomes less effective. Like chemotherapy, response rates for hormonal therapy do not translate into survival rates. By altering these hormones it is possible to alter the growth of cancer cells. Hormonal therapy is often more effective in treating solid tumors than chemotherapy, and usually has fewer toxic side effects. Hormone therapy is almost never curative. It can decrease the rate of tumor growth, reduce pain, and increase the quality of life. These effects may persist for several months or a few years. But hormonal therapy is generally not able to significantly prolong life. If one form of hormonal treatment stops working, another my be tried. But each new hormone treatment becomes less effective. Like chemotherapy, response rates for hormonal therapy do not translate into survival rates. The fiveyear survival rates are about 90% for stage A and about 85% for stage B1.
Stage II
Dukes' stage B2 or B3
TNM T34, N0, M0
The tumor has spread through the entire bowel wall, but does not involve the lymph nodes. Involvement of adjacent structures or organs is indicated by the higher designation in each system. (B3 or T4) The five year survival rates are about 70% for stage B2 and about 30% for stage B3.
Stage III
Dukes' stage C13
TNM T04, N13, M0
The tumor has invaded the lymph nodes. The numbers 13 in the Dukes' system describe the extent of the primary tumor: (1) confined to the bowel, (2) outside the bowel, or (3) involving adjacent structures. The numbers 13 in the TNM system describe the progression of nodal disease: N1 Metastasis to 1 3 regional lymph nodes, N2 metastasis to 4 or more regional lymph nodes, N3 metastasis to a lymph node removed along the course of a named artery. The fiveyear survival rates: C1 45%, C2 20%, C3 15%.
Stage IV
Dukes' D
TNM T04, N13, M1
The disease has spread to distant organs. The fiveyear survival rate is less than 5%.
(Return to Top)
TYPES OF TREATMENT
Surgery
Abdominoperineal resection (APR) - Any operation which removes a segment of the intestine is called a resection. A segment is an entire tube shaped portion of the bowel of any length. Rectal cancer has traditionally been treated by a two phased operation performed from above (within the abdomen) and from below (the rectal area). The surgeon enters the abdominal cavity to free the colon and rectum from above. The entire rectum, the tumor, and surrounding tissue are removed through a second operation from below. This includes removal of the lymph nodes. There is usually a large defect, which requires several weeks or months to heal. The patient is left with a permanent colostomy.
Conservative surgery for cancer of the rectum focuses on preservation of the sphincter mechanism. This can be accomplished in two ways. First, a segment of intestine above and below the tumor is removed. The remaining upper segment is connected to the remaining rectum. The surgeon must remove a margin of normal appearing intestine above and below the tumor. Second, the tumor is simply excised or ablated, using a knife, electric current, cold probe, laser or radiation.
Intestinal Resection - This operation is usually called a low anterior resection, when it involves the rectum. The difficulty here concerns the length of rectum that the surgeon removes below the tumor without injuring the sphincter mechanism and without leaving tumor cells in the patient. Over the past several decades surgeons have been changing their opinion about the length of clinically healthy tissue which should be removed below the tumor the margin. This margin has slowly decreased from about 5 cm (2 inches) to 1 2 cm (3/8 3/4 inch). This change has allowed more patients to be treated with sphincter saving surgery. The rectal end of the resection is technically difficult, because the surgeon must operate deep inside the pelvis, where vision and room to operate are limited. Above the tumor the surgeon has no difficulty removing several inches of colon, because there are about seven feet remaining. The end of the colon is then connected to the remaining rectum. Originally these two pieces of intestine were sewn together by hand with sutures (stitches). Clinically significant leaks may occur where the segments of intestine are sewn together. This complication may occur is as many as 20% of patients. Therefore, a temporary colostomy is usually performed. After the two segments of bowel have healed together, the temporary colostomy is reversed and bowel movements return to normal.
Several different surgical techniques have been developed to connect the colon to the remaining rectum and its sphincter mechanism. In the 1970's a stapling device was invented which helped the surgeon join two segments of intestine. It worked particularly well inside the pelvis. It enabled surgeons to resect rectal tumors and staple the remaining colon to a short segment of remaining rectum, using a circular row of tiny metal staples.
The Pull through Procedure - In another operation the normal colon is pulled down through the rectum like one sleeve inside another. The mucosal lining of the rectum is stripped away so that the colon and rectum will stick together. No sutures and no colostomy are required. Incontinence and other problems with bowel habits occur in onethird or more of patients.
The Coloanal (Sleeve) Anastomosis - The lower colon is pulled down into and sewn to the lower rectum. Here too, the upper part of the rectum is stripped of mucosa. If the tumor has invaded near or into the sphincter muscles, these muscles may be partially removed and damaged. Patients will still have an external sphincter to maintain continence, but they may suddenly become aware of a large volume of feces, which suddenly falls into the rectum.
Local Excision or Ablation - Tumors, which are within 5 cm (about 2 inches) of the anus are removed by local excision. Surgeons have tried to save the rectum and avoid marring the patient with a permanent colostomy by treating these patients with local excision and radiation therapy. It is generally agreed that the surgeons should remove the tumor with a safety margin of 1 2 cm (3/8 3/4 inch) of visible normal tissue. It is generally agreed that tumors excised with narrow margins should be carefully checked by the pathologist to be sure that margins are all free of tumor cells. Different surgical approaches (incisions) have been used, e.g., through the anus, through the tail bone, or between the sphincter muscles in the buttocks.
Fulguration uses an electric current to burn the tumor. The term electrocoagulation suggests complete ablation of the full thickness of the tumor. The defect is allowed to heal without closure. In addition the tumor can be treated with cryotherapy; a probe freezes the tumor. Since the margins of the tumor are destroyed by these techniques, they cannot be checked by a pathologist, and are not widely practiced. These techniques are use primarily on patients who are medically unsuitable for extensive surgery. Patients must be examined four to six weeks for recurrence. Often two to four treatments are required to eliminate the tumor. Laser therapy has also been used. It is primarily used in patients with advanced disease, e.g., to remove tumor, which is obstructing the intestinal tract.
Radiation Therapy
Radiation can be administered with devices placed into the rectum (intraluminal or intracavitary). Often 6,000 cGy of intracavitary radiation is followed by 4,500 6,000 cGy of external beam radiation. When radiation is given as the only therapy, treatment requires four to six weeks of outpatient treatment to administer 9,000 cGy to 15,000 cGy. For larger tumors supplemental external beam radiation can also be given.
Radiation therapy can also eradicate microscopic cells that may remain after a local excision of the primary lesion. Usually 5,000 to 6,000 cGy is administered. Adjuvant radiation therapy can successfully reduce local recurrence rates, but it does not increase survival. One study demonstrated decreased local recurrence and increased survival for patients who had low dose radiation therapy prior to an abdominoperineal resection. Local recurrence following abdominoperineal resection (APR) is found deep within the pelvis. It is very difficult to detect and treat. The recurrent disease could grow to a large size and become the source of disseminating tumor cells. Radiation therapy can also be used to shrink tumors preoperatively, making them suitable for more conservative excision.
Early complications such as proctitis and bleeding occur primarily in patients who receive over 6,300 cGy. Late complications include intestinal obstruction, inflammation of the intestines and bladder contraction.
Chemotherapy
For over twenty-five years 5 fluorouracil (5-FU) has been the standard drug for cancers of the colon and rectum. This is the same drug used in lotion form to treat skin cancers (Efudex). It can reduce the size of tumors in about 25% of patients. But, used alone, it does not reduce local recurrence after surgery or increase survival.
Levamisole has been used widely around the world to treat worms in both humans and animals. It can stimulate the immune system. In one recent study levamisole and 5-FU in combination increased survival in patients with stage C colon cancer. This study did not include patients with rectal cancer, but the tumors are similar. Adjuvant chemotherapy has been reported to prolong the lives of some patients with advanced disease, who also receive postoperative XRT. European trials have disputed this. Other chemotherapy and immunotherapy have been tested.
Leucovorine is a compound which can stabilize the molecular structure 5-FU. There is evidence that these two drugs together can prolong survival better than 5-FU alone.
(Return to Top)
TCC ANALYSIS
Surgical procedures which spare the rectum are gaining acceptance and are available at most large medical centers. One is the debates concerns the width of the margin of excision. Many surgeons are now accepting margins of 1 cm. This represents a rapid change is surgical opinion during the past twenty years. The NSABP randomized trial determined that a narrow margin of excision increased local recurrence to from 12% to 22%, but did not decrease survival. The authors concluded,"There are unmistakable parallels between the evolution of the operative strategy of carcinoma of the rectum and that of breast cancer." Promptly treated local recurrence does not reduce survival. Therefore, surgeons can prudently perform one of the conservative operations discussed above without compromising the patient's survival.
As with breast cancer, local recurrence following radical surgery (abdominoperineal resection) is a worrisome event, and is associated with a decreased survival. Local recurrence following conservative surgery (local persistence) has a much better prognosis. By reading Chapter 7 Breast Cancer, and the section of the appendix devoted to rectal cancer, you should gain confidence in surgical procedures would spare the rectum.
(Return to Top)
LIMITED SURGERY
Conservative surgery for cancer of the rectum is widely practiced. You should have little difficulty finding a surgeon who is familiar with the operations described here. But, much of the therapy recommended here is in the developmental stages. You will want to be treated by surgeons who are familiar with these new techniques.
Stage 0 Carcinoma in situ
Local excision is the primary therapy.
Stage I - The tumor is confined to the bowel wall.
Upper 10 cm of the rectum - Tumors which are more than about 5 cm (2 inches) above the anus can often be removed with a low anterior resection. The margin must be free of tumor cells. If the margins are inadequate for the size of the tumor, consider the treatment below.
Lower 5 cm of the rectum - Small tumors can often be locally excised with a full thickness of the rectal wall. If the lesion is less than 3 cm in diameter, well or moderately differentiated, and has been completely excised, postoperative radiation therapy may not be needed.
Larger tumors may by treated with a pull through or Coloanal Anastomosis. The surgeon can remove the tumor within a segment of bowel. He can even remove a small portion of involved muscle. Preoperative radiation therapy and chemotherapy may shrink the tumor enough to allow complete excision. If there are grave signs, e.g., high grade or blood vessel or lymphatic invasion, postoperative radiation therapy should be considered to reduce the chances of local recurrence.
Stage II - The tumor has penetrated through the bowel wall.
Upper 10 cm of the rectum - Same as stage I. Margins must be free of tumor as determined by a pathologist. Preoperative radiation therapy or chemotherapy may shrink the tumor enough to allow surgical removal of the tumor and reduce local recurrence. Preoperative treatment may shrink the tumor sufficiently to permit a sphincter preserving operation. Postoperative chemotherapy may reduce local recurrence and increase survival. If the tumor invades adjacent structures, such as the bladder, a partial cystectomy may be necessary.
Lower 5 cm of the rectum - Some T3 lesions can be excised locally or treated with resection and coloanal anastomosis. Resection is preferable. Preoperative chemotherapy and/or radiation therapy may allow complete excision and a coloanal anastomosis. Postoperative radiation therapy and chemotherapy may be considered.
Stage III - The tumor has spread to the lymph nodes.
Upper 10 cm of the rectum - Surgical excision should be considered, as described above. Postoperative chemotherapy may be added, particularly for patients with more than four positive lymph nodes.
Lower 5 cm of the rectum - Large tumors should be treated with preoperative radiation therapy and/or chemotherapy. Sphincter saving procedures may be employed if technically possible. Large tumors, which fail to respond to preoperative radiation or chemotherapy may require an abdominoperineal resection. Postoperative chemotherapy may be added, particularly for patients with more than four positive lymph nodes. After curative surgery continuous infusion chemotherapy may be somewhat more successful than conventional intermittent intravenous injections in prolonging overall survival.
Stage IV - The tumor has spread to distant organs.
The primary tumor should be removed locally if possible. More extensive surgery including radiation therapy is appropriate if intestinal obstruction may occur. One to three liver metastases or isolated lung or ovarian metastases may be removed. Chemotherapy or immunotherapy may be attempted.
(Return to Top)
MEDICAL RESEARCH
Ernest Miles developed the abdominoperineal resection in 1908 at a time when radical surgical procedures where developing for cancer of the
breast, head and neck, and cervix. At this time surgeons at St. Mark's Hospital in London were trying to improve patient survival by increasing the number of lymph nodes they removed.(1) Their operation was extended significantly to remove lymph nodes throughout the abdomen. (This was comparable to the supraradical mastectomy for breast cancer.) They found no survival advantage for extended surgery.
In 1939, Dixon introduced the low anterior resection. Surgeons have devised several techniques to transfer a normal colon to a normal sphincter mechanism. In the early 1940's H.E. Bacon began to use the pull-through procedure, a technique first described in the late 1880's.
For most of this century surgeons have tried to remove at least 5 cm (2 inches) of normal rectum below the tumor. This was first suggested by Cole in 1913. In the 1970's and 80's, more surgeons tried to preserve normal bowel function. Margins of 2 cm were tried and became accepted. Some surgeons now accept a margin of one cm below the tumor, if absolutely necessary to save the rectum.(2) Surgeons also appreciate the importance of radial margins - the distant out, away from the tumor. In 1975, surgical stapling devices were introduced which could staple
together two ends of intestine in this technically difficult procedure.
In 1974, Sterns from Memorial Sloan-Kettering Hospital compared low anterior resection to abdominoperineal resection for patients with mid
rectal cancers. He reported no differences in local recurrence and survival rates between the two forms of treatment.(3) These results have been confirmed by many surgeons, including results from a randomized, prospective trail.
Well into the 1970's surgeons believed that they had to preserve the terminal 3 to 7 cm of the rectum to maintain continence. But, surgeons have observed that sphincter competence can remain after the colon was
sewn to the lower 1 to 2 cm of the rectum.(4) Surgeons became able to treat both larger tumors and lower tumors with sphincter-saving procedures. Preoperative radiation therapy (5,000 cGy) and excision of the entire rectum were performed on patients with tumors, which averaged 4 cm in diameter. Memorial Sloan-Kettering and Jefferson University have reported excellent results.(5) Chemotherapy has been added before or after surgery.
In 1992, surgeons from M.D. Anderson Hospital reported their experience with ten patients with large tumors of the lower (sigmoid) colon and rectum.(6) The patients required extensive operations including removal of the bladder to remove the tumors. No one required a permanent colostomy and all survivors had normal bowel function. Their local recurrence and survival results were comparable to those following more extensive surgery.
For most of this century local excision has been used to treat small, superficial lesions. George Binkley of Memorial Hospital, New York used radium needles or excision to treat early cancers in the 1920's. Electrocoagulation or fulguration was first described as primary treatment is 1935. Low energy radiation therapy was used in the 1930's and 1940's to treat small tumors of the rectum, but the complications
usually exceeded the benefit.
The modern experience with local excision can be traced to the work of Jackson and Culp.(7) In 1973, they reported local recurrence in only four of 25 patients treated with local excision. Surgeons at St. Mark's Hospital in London increased their experience with local excision from 1% to 9% of cases between 1948 and 1972. They recommended this treatment
for patients with tumors of a favorable grade. They performed an excision of the full thickness of the rectal wall, and insisted on margins that were free of tumor cells.
Between 1954 and 1982, surgeons at Memorial Sloan-Kettering Hospital treated 57 patients with local excision.(8) This represented only about 4% of all their patients with invasive rectal cancer. Twenty-seven patients had no adverse prognostic factors, and none of them died of rectal cancer. Thirty patients had adverse prognostic factors. Nine of these patients were treated with APR for recurrent disease and three died of rectal cancer. Twenty-one had no further surgery, and three (14%) died of rectal cancer.
Jena Papillon of the Centre Leon Bernard in Lyon, France was one of the first to use intracavitary radiation therapy as the primary treatment of
rectal cancer beginning in 1951.(9) His treatment was limited to very early tumors. Intracavitary radiation is used in the United States primarily to reduce local recurrence following local excision or in patients with incurably advanced disease. By 1985, surgeons at the Mayo Clinic were recommending local excision for patient with grade 1 tumors less than 3 cm in diameter.(10) Experience from several institutions
suggests that local excision and postoperative radiation therapy for selected T1 and T2 lesions produce local recurrence and survival results that are equivalent to those of more aggressive surgery.(11)
In 1990, Graham et al. reviewed sixteen series of patients treated with local excision alone.(12) The overall local recurrence rate was 19%, and
42% of these patients were salvaged with additional surgery. Patients with favorable disease had recurrence rates that varied from 6% to 11%.
Favorable criteria included stage A disease, well or
moderately-differentiated tumor, and clear margins of excision.
Surgeons at Memorial Hospital believe that local excision is less suitable for patients with large lesions. Among patients with tumors larger than 3 cm, the recurrence rate was 33%. Among the four patients
whose lesions penetrated through the bowel wall, the local recurrence rate was 50%. Many of these patients can have sphincter-preserving surgery using resection techniques described above.(13)
Following abdominoperineal resection (APR) local recurrence is associated with markedly decreased survival, usually leading to death within fifteen to eighteen months.(14) Surgeons from the Free Hospital in Amsterdam reported their experience with cryosurgery to treat patients with recurrent rectal cancer.(15) They began their paper,"Locally recurrent rectal cancer is, in most cases, unresectable and incurable." This is true for two reasons. One, tumors with characteristics which favor local recurrence are also most likely to spread. Risky tumors are large, high grade, mucin-producing, etc. Once these aggressive tumors are removed, there is little that can be done to
hinder their deadly course. The outcome in these patients is not influenced by the scope of the original surgery. Two, if patients are not closely followed with regular proctoscopic examination, recurrent tumors will grow to a large size. Sometimes the large recurrent tumors will become the cause of distant metastases. The problem here is not the original conservative surgery, but the failure to discover local recurrence in a timely fashion.
Local recurrence following conservative surgery (local persistence) has a markedly different prognosis. Surgeons at the Royal Melbourne Hospital in Australia treated 28 patients with local excision.(16) Six of these patients developed local recurrence and required additional surgery. All six were followed for an average of fifty months after their second operation. All six patients were free of all local and disseminated disease.
Surgeons from Roswell Park Cancer Institute studied 50 patients who developed local recurrence following resection of cancer in the colon or rectum -- 40 cases occurred in the rectum or sigmoid colon. These local
recurrences developed at the site where the two segments of intestine were sewn together. Forty-five of these patients developed cancer elsewhere and survived an additional 16 months. All five patients with cancer isolated to the site of surgery were alive with no evidence of cancer an average of 37 months following the recurrence. Three patients were still alive more than five years following the second operation.(17)
Surgeons from the Lahey Clinic in Boston treated 40 patients with cancer of the rectum using local excision (7 patients) or electrocoagulation (33 patients).(18) Overall, 30 patients (75%) survived five years free of disease or were free of disease when they died of other causes. Thirteen patients had recurrent cancer isolated to the rectum. Eight of the 13 patients (62%) were free of disease an average of 5.6 years following additional treatment.
In 1986, the NSABP reported the results of its study comparing abdominoperineal resection to low anterior resection in patients with lesions in the middle and upper rectum.(19) Both operations were equally
effective. Patients treated by abdominoperineal resection lived as long as those treated with low anterior resection. About one-fourth of the
patients were treated with a lower margin of less than 2 cm. Twenty-two percent of these patients developed local recurrence. Patients treated with a margin of greater than 3 cm experienced a 12% local recurrence rate. Thus, a narrow margin of excision almost doubled the local recurrence rate (22% vs. 12%). This did not reduce survival. The authors concluded,"There are unmistakable parallels between the evolution of the operative strategy of carcinoma of the rectum and that of breast cancer." Promptly-treated local recurrence does not reduce survival. Techniques of this sort allow surgeons to remove tumors, which are within 5 cm of the anus.
In 1994 surgeons at Memorial Sloan-Kettering Hospital published their experience treating 130 patients with low anterior resection and coloanal anastamosis.(20) Five patients (4%) developed isolated local recurrence. From their data it appears that two of these patients were alive and well, 2 were living with disease, and one was dead of disease.
The death occurred in a patient with a T3 tumor and mesenteric implants. These results are remarkably good and suggest that promptly treated local recurrence is not risk to survival for patients with this disease.
1. Glass RE, Ritchie JK, Thompson HR, Mann CV. The results of surgical treatment of cancer of the rectum by radical resection and extended abdomino-iliac lymphadenectomy. Br J Surg 1985; 72:599-601.
2. Welch JP, Welch CE. Cancer of the rectum. Where are we? Where are we going? Arch Surg 1993; 128:687-702.
3. Stearns MW. The choice among anterior resection, the pull-through and abdominoperineal resection of the rectum. Cancer 1974; 34:969.
4. Marks G, Mohiuddin M, Masoni L, Montori A. High-dose preoperative radiation therapy as the key to extending sphincter-preservation surgery
for cancer of the distal rectum. Surg Oncol Clin North Am 1991; 1:71-86.
5. Enker WE, Paty PB, Minsky BD, Cohen AM. Restorative or preservative operations in the treatment of rectal cancer. Surg Oncol Clin North Am 1992; 1:57-69.
6. Fuhrman GM, Talamonti MS, Curley SA. Sphincter-preserving extended resection for locally advanced rectosigmoid carcinoma involving the urinary bladder. J Surg Oncol 1992; 50:77-80.
7. Culp CE, Jackson RJ,. Reappraisal of conservative management of certain selected cancer of the rectum. In: Najarian, Delaney (eds.) Surgery of the Gastrointestinal Tract. New York: Stratton, 1974:511-519.
8. DeCosse JJ, Wong RJ, Quan SHQ, et al. Conservative treatment of distal rectal cancer by local excision. Cancer 1989; 63;219-23.
9. Papillon J. Intracavitary irradiation of early rectal cancer for cure. Cancer 1975; 36:696-701.
10. Beart Jr RW, Biggers O. Local excision of rectal cancer. Prob in Gen Surg 1985; 2:240-3.
11. Minsky BD. Clinical experience with local excision and postoperative radiation therapy for rectal cancer. Dis Colon Rectum. 1993; 36:405-9.
12. Graham RA, Garney L, Jessup JM. Local excision of rectal carcinoma. Am J Surg 1990; 160:306-311.
13. Minsky BD, Cohen AM, Enker WE, and Mies C. Sphincter preservation in rectal cancer by local excision and postoperative radiation therapy. Cancer 1991; 67:908-14.
14. 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.
15. Meijer S, de Rooij PD, Derksen EJ, Boutkan H, Cuesta MA. Cryosurgery for locally recurrent rectal cancer. Eur J Surg Oncol 1992; 18:255-7.
16. Cuthbertson AM, Simpson RL. Curative local excision of rectal adenocarcinoma. Aust NZ J Surg 1986; 56:229-231.
17. Stulc JP, Davidson B, Herrera L, Petrelli NJ. The prognostic significance of anastomotic recurrence from colorectal adenocarcinoma. Read before the forty-Third Annual Meeting of the Society of Surgical Oncology, Washington, D.C. , May 21, 1990.
18. Stahl TJ, Murray JJ, Coller JA, et al. Sphincter-saving alternatives in the management of adenocarcinoma involving the distal rectum. Arch Surg 1993; 128:545-50.
19. Wolmark N, Fisher B. An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes' B and C rectal carcinoma. Ann Surg 1986; 204:480-487.
20. Paty PB, Enker WE, Cohen AM, and Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg
1994; 219:365-373.
Medical Research since 1995
Sphincter-sparing surgery is now widely practiced in U.S. Medical centers. Since 1995 dozens of articles have been written on this subject - most all of them favorable. Most patients with rectal cancer should have no trouble finding a surgeon who practices conservative surgery. This progress can be attributed, in part, to the surgical subspeciality of colon and rectal surgery. These surgeons had an incentive to distinguish themselves from their more conservative colleagues, the general surgeons.
In 1997, A. K. Ng and associates from Harvard Medical School reviewed the world wide experience with sphincter-sparing treatment for rectal cancer.(1) They found 4 studies dealing with nonsurgical therapy, e.g., cryosurgery, electrocoagulation, and endocavitary radiation. There were 14 studies dealing with local excision alone - without radiation of chemotherapy. There were 11 studies dealing with local excision and radiation - with or without chemotherapy.
Ng and associates found that local recurrence rates varied among the different studies. About 50% of patients were successfully salvaged with additional surgery. This resulted in overall local control rates and survival rates similar to that for abdominoperineal resection.
The authors concluded that patients with small, favorable T1 tumors should be treated with local excision alone, if negative margins could be achieved. Patients with T2 lesions or T1 lesions with "unfavorable" clinical or pathological characteristics should receive both radiation and chemotherapy. Patients with T3 lesion should be treated with radiation and/or chemotherapy either before or after surgery. Recently, the trend has been toward preoperative treatment.
V. Valentini and colleagues from Rome treated 81 patients with T3 rectal cancer using preoperative radiation and chemotherapy.(2) In 46 patients the tumor decreased in size and 63 patients were able to have a sphincter-sparing procedure.
R. A. Graham and associates of the New England Medical Center in Boston treated five patients with T3 lesions using local excision, and postoperative radiation therapy, 5-FU and leucovorin.(3) After these patients were followed for 56 months, there had been no local or regional failures. Two patients had died of distant disease. The authors supported the use of this treatment for selected patients with T3 tumors.
M. Mohiuddin and colleagues of the University of Kentucky treated 70 patients who had tumors located in the last 2 cm of the rectum.(4) This area is difficult to treat, because it is so close to the sphincter muscles. Patients received high-dose radiation therapy before surgery. An average of 4 years later, 9 patients (13%) developed local recurrence. The statistical 5-year survival rate was 84%.
Janjan NA and associates of the M.D. Anderson Cancer Center treated 45 patients with aggressive preoperative radiation and chemotherapy.(5) The tumor decreased in size in 86% of patients and sphincter preservation was possible in 79% of patients who had surgery.
J. Garcia-Aguilar and associates of University of Minnesota issued a "word of caution."(6) They reviewed 82 patients treated with excision only. All tumors were removed with negative margins and had favorable pathologic characteristics. Ten of 55 patients with T1 tumors (18%) and 10 of 27 with T2 tumors (37%) developed local recurrence. Seventeen of the 20 underwent surgery to remove the recurrence. They warned that these recurrences rates were higher than those reported among patients treated with adjuvant therapy. After 54 months (4.5 years) of follow-up, 77% of T1 patients and 55% of T2 patients were alive and free of disease. The authors noted that these survival rates were equivalent to those of patients treated with radical surgery. This study demonstrates again that local recurrence does not adversely affect survival.
Another word of caution was reported by D. Shibata and colleagues of Memorial Sloan-Kettering Cancer Center.(7) They surveyed patients who had received sphincter-sparing treatment for locally advanced rectal cancer. The majority of patients (56%) reported unfavorable bowel function. The author suggested that some patients with advanced disease may do better with a permanent colostomy.
The Texas Cancer Center believes that all available medical evidence continues to support the increased use of sphincter-sparing surgery for cancer of the rectum.
1. Ng AK, Recht A, Busse PM. Sphincter preservation therapy for distal rectal carcinoma. Cancer 79:671-683, 1997.
2. Valentini V, Coco C, Cellini N, Picciocchi A, Genovesi D, Mantini G, Barbaro B, et al. Preoperative chemoradiation for extraperitoneal T3 rectal cancer: Acute toxicity, tumor response and sphincter preservation. Int J Radiation Oncology Biol Phys 40:1067-1075. 1998.
3. Graham RA, Hackford AW, Wazer DE. Local excision of rectal carcinoma: a safe alternative for more advanced tumors? J Surg Oncol 70:235-238, 1999.
4. Mohiuddin M, Regine WF, Marks GJ, Marks JW. High-dose preoperative radiation and the challenge of sphincter-preservation surgery for cancer of the distal 2 cm of the rectum. Int J Radiat Oncol Biol Phys 40:569-574, 1998.
5. Janjan NA, Crane CN, Feig BW and others. Prospective trial of preoperative concomitant boost radiotherapy with continuous infusion 5-fluorouracil for locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 47:713-718, 2000.
6. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg 231:345-351, 2000.
7. Shibata D, Guillem JG, Lanouette N and others. Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation. Dis Colon Rectum. 43:752-758, 2000.
(Return to Top)
The Texas Cancer Center gratefully welcomes contributions from all those 
