Tech Coloproctol (2004) 8:S132–S134 DOI 10.1007/s10151-004-0134-9
E. Christoforidis • I. Kanellos • T. Tsachalis • K. Blouhos • I. Lamprou • D. Betsis
Locally recurrent rectal cancer after curative resection
Abstract Background To determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME). Patients and methods During the last ten years, 120 patients underwent curative resection for rectal cancer. As a rule, except for the cases that underwent high anterior resection, TME was applied. In terms of local relapse, routine TME, preoperative radiotherapy, tumour’s stage, differentiation grade and number of positive nodes were taken into account. Results Eight patients (6.7%) presented with local relapse. At 5 years, 91.9% of patients were free of local recurrence and the actuarial disease-free sur-
vival was 81%. A significant association between routine TME, tumour’s stage, differentiation grade, lymph node invasion and local recurrence was observed. Conversely, preoperative radiotherapy appeared to play no protective role. Conclusions The curative resection of rectal cancer, with the application of TME, has led to a very low incidence of local relapse during the last few years. Key words Rectal cancer • Resection • Recurrence
Introduction The local recurrence rate after surgical treatment for rectal cancer varies between 4 and 50% [1]. The importance of surgical technique and of preoperative radiotherapy in producing a low recurrence rate has been emphasised. In addition, other factors related to tumour biology are known to affect local recurrence such as the pathological stage of the disease [2, 3]. The aim of our study is to determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME).
Patients and methods E. Christoforidis • I. Kanellos • T. Tsachalis • K. Blouhos I. Lamprou • D. Betsis 4th Surgical Department Aristotle University, Thessaloniki, Greece E. Christoforidis () Kiriakidou 16-20 Kalamaria 55132, Thessaloniki, Greece E-mail:
[email protected]
A retrospective review of 158 patients, with an operable carcinoma within 12 cm of dental line, who were referred to our institute during the last ten years, was performed. Thirty-eight patients who underwent palliative operation or local excision, who had primary therapy elsewhere, who underwent defunctioning colostomy or diagnostic laparotomy only, or who had a follow-up period shorter than three months, were excluded from the analysis. Preoperative assessment was done using clinical evaluation, blood analyses and radiological examinations. All patients were prepared with standard mechanical bowel preparation preopera-
E. Christoforidis et al.: Locally recurrent rectal cancer after resection tively, having been given antibiotics perioperatively. To all patients, except those who underwent high anterior resection, TME was applied. There were 82 anterior resections, 34 abdominoperineal resections and 4 Hartmann’s procedures. Curative resection was defined as negative margins pathologically and absence of residual metastatic disease. A computerised retrospective database was used to retrieve the characteristics of the patients. Astler–Coller staging defined that 4 patients had cancer in situ, 12 had stage A disease, 25 had stage BI disease, 43 had stage BII disease, 6 had stage CI disease, 25 had stage CII disease and 5 had stage D disease. Eighty-five patients underwent neoadjuvant or adjuvant therapy. Local recurrence was defined as the presence of tumour in the pelvis, perineum or at the anastomosis as diagnosed by clinical, radiologic or histologic examination. The overall survival and disease-free survival was estimated with the actuarial life table analysis and it was presented with the Kaplan–Meier plot. Predictors of time to local recurrence were evaluated with Cox proportional hazards model, after ascertaining that proportionality of hazards was not violated. First, the univariate models were estimated and then the final multivariate model was built using backward elimination of variables according to likelihood ratio criteria. Statistical analyses were conducted in SPSS 11.0 (SPSS, Inc., Chicago, Illinois). All p-values are two-tailed with a significance level of 0.05.
Results Eight patients (6.7%) developed local recurrence. Demographics of these patients as well as the type of preor postoperative adjuvant therapy are shown in Table 1. A total of 22 patients received preoperative radiotherapy, and only 1 patient with neoadjuvant radiation presented with local recurrence. According to life table analysis, 91.9% of patients were free of local recurrence at 5 years (Fig. 1). For the same study period, 84.6% of patients were free of Table 1 Demographics of patients with local recurrence Median age, years
65
S133
Fig. 1 Time to local recurrence
distant metastasis and 81% were free from local recurrence or metastatic disease. Overall survival at 60 months was 72.2%. In Table 2 it can been seen that the risk for local recurrence increased 3.65-fold for every worse grade of differentiation (p=0.025), 4.61-fold for every higher level of TNM stage (p
