Surgery Today Jpn. J. Surg. (1992) 22:313-317
~
SURGEaYTODAY
© Springer-Verlag 1992
Low Anterior Resection Versus Abdominoperineal Excision: A Comparison of Local Recurrence After Curative Surgery for "Very Low" Rectal Cancer DOMENICO TUSCANO, MARCO CATARCI,ALESSANDRASAPUTELLI,FABIO GAJ, FRANCESCOGOSSETTI, STEFANO GUADAGNI, PAOLONEGRO, and MANLIO CARBONI The Fifth SurgicalUnit, Second SurgicalClinic, Universityof Rome "La Sapienza", 00161, Rome, Italy
Abstract: In the controversy regarding whether sphinctersaving resection (SSR) or abdominoperinea.I resection (APER) is more appropriate for the treatment of very low rectal cancer, local recurrence rates seem to play a fundamental role in patient outcome. In order to operate an effective patient selection, very low rectal cancer is defined herein as being located within 4.5 to 7.5 cm from the anal verge. This retrospective report investigates the incidence of local recurrence after curative surgery for very low rectal carcinoma in 24 consecutive patients treated by the same surgical team over a 15-year period using the above surgical procedures. In the APER group, the local recurrence rate was 45.5 %, occurring in 5 of 11 cases; and in the SSR group 46.1%, occurring in 6 of 13 cases, with no significant difference between the two groups. Recurrence was found within one year of surgical treatment in all except one case. Despite the strict follow-up program, it was only possible to perform reoperation in two recurrent cases, both previously submitted to SSR and diagnosed by means of transanal ultrasonography and macrobiopsy. The high incidence of local recurrence in this series is explained by the advanced stage of disease in the majority of cases. Thus, as the choice between APER and SSR does not seem to affect the incidence of local recurrence, which is related more to tumor size, site, stage, and grading, preservation of the sphincters and restoration of digestive continuity should be achieved whe~ever technically possible.
ing, 4 lymph nodal involvement, 5 and the degree of extraparietal infiltration, 6 can all influence the surgeon in deciding whether or not to save the sphincters with the aims of improving postoperative quality of life, obtaining satisfactory survival rates, and lowering the incidence of pelvic local recurrence. Many retrospective studies concerning the incidence of local recurrence after surgery for rectal cancer have been reported, 2'4'7'8 with variations between 3% and 39%, which seems to be related to the surgical procedure, 9 adjuvant radiotherapy, 1°'11 intraoperative lavage of the rectal stump 12'13 and, especially, to the exact location of the neoplasm. 2 The majority of these reports, however, signal the incidence of local recurrence after abdominoperineal resection ( A P E R ) or low anterior resection (SSR) without emphasis on the exact location of the neoplasm, and include lesions located between 4 and 12 cm from the anal verge. The main aim of this study was to evaluate the incidence of local recurrence in 24 consecutive patients presenting with carcinoma of the lower rectum submitted to surgical treatment.
Patients and Methods Key Words: rectum adenocarcinoma, low anterior resection, abdominoperineal resection, local recurrence, patterns of local recurrence
Introduction The choice of the surgical procedure in the treatment of low rectal cancer is still a matter of much controversy. C a n c e r location, 1'2 dimensions, 3 histopathologic grad-
Reprint requests to: M. Catarci (Received for publication on Oct. 18, 1990; accepted on May 1, 1992)
From 1975 to 1989, 109 consecutive patients with rectal cancer were surgically treated by the same surgical team at the Surgical Department of the University of L'Aquila from 1975 to 1986 and at the Fifth Surgical Unit of the University " L a Sapienza" or R o m e from 1986 to 1989. From this series, we conducted a retrospective evaluation of 34 patients with "very low" rectal cancer operated on from 1983 to 1989. The lower rectum was defined as being 4.5 to 7.5 cm (_+0.5 cm) from the anal verge and neither tumors of the anal canal nor any tumor located from 0 to 4.5 cm from the anal verge were included in this study. Effectively, in each patient
314
D. Tuscano et al.: Local Recurrence in Rectal Cancer
Table 1. Characteristics of the Group A (APER) patients Patient no.
Sex
Age
Stage
Grade
1 2 3 4 5 6 7 8 9 10 11
F M M F M F M M M M M
65 54 72 60 53 59 63 57 61 64 56
B C B C A B B C C C C
G1 G2 G2 G2 G2 G2 G3 G2 G2 G2 G3
APER, abdominoperineal resection
Table 2. Characteristics of the Group B (SSR) patients Patient no.
Sex
Age
Stage
Grade
1
M
66
C
2 3 4 5 6 7 8 9 10 11 12 13
F F M M M F M F M M F M
59 73 47 73 51 54 62 60 58 64 57 61
C A B B A C B C B C C C
G2 G2 G1 G3 G2 G2 G2 G1 G2 G2 G2 G2 G2
SSR, sphincter-saving resection
the t u m o r involved a segment of rectum from the puborectal muscle extending proximally 3 cm. Preoperative evaluation included rigid proctosigmoidoscopy in the jack-knife position to precisely assess the distance from the lower edge of the neoplasm to the anal verge. Ten patients presenting with invasion of the pelvic floor were excluded from the study. The remaining 24 patients without invasion of the puborectal muscle or of the pelvic floor underwent one of two different surgical procedures. G r o u p A, comprised of 11 patients treated during the period 1983-1986, was submitted to A P E R procedure (Table 1), while G r o u p B, comprised of 13 patients treated during the period 1986-]989, was submitted to a "very low" anterior resection, namely the SSR procedure (Table 2). Both groups were h o m o g e n e o u s concerning the patients' age and sex, t u m o r dimensions, stage and histopathologic grading, this one being intended as r e c o m m e n d e d by the T N M joint committee. 4 The m e a n follow-up was 57.8 months with a range of 3 6 - 7 8 months and 23.9 months with a range of 1 0 - 3 4 months for Groups A and B, respectively.
Fig. 1. Transanal ultrasonographic evaluation of local submucosal recurrence after SSR The other steps of the surgical procedure were identical in both groups, including the division of the inferior mesenteric artery at its origin, complete excision of the mesorectum and manual or mechanic colo-anal anastomosis, either ILS or E E A , with a diameter of 31 or 33 m m with lavage of the rectal stump in the SSR cases or terminal colostomy in the A P E R cases. N o n e of the patients underwent any pre- or postoperative adjuvant therapy. All patients underwent a clinical examination, seric carcinoembryonic antigen ( C E A ) evaluation, hepatic ultrasonography (US), and c o m p u t e d t o m o g r a p h y (CT) scanning at the time of discharge and then every six months. Furthermore, from 1987, in all SSR cases a endorectal ultrasonographic evaluation was performed every three months (Fig. 1). W h e n e v e r necessary, other diagnostic procedures such as cystoscopy or I V urography were also performed. A transanal macrobiopsy was obtained under general anaesthesia from all SSR cases presenting with a high suspicion of recurrence, whereas a CT or US guided fine-needle aspiration biopsy was obtained from similar A P E R cases. During the follow-up, the mean length of which was 25 months with a range of 5 - 3 6 months, the incidence of local recurrence and its patterns were evaluated.
D. Tuscano et al.: Local Recurrence in Rectal Cancer
315
Table 3. Cases of Local Recurrence in the Two Groups. T, death GROUP A (APER) Patient no. Sex Stage
Grading
Time a
Outcome
1
M
C
G2
5
T
2 3 4 5
M M M M
B C C C
G3 G2 G2 G2
9 6 7 12
T T T T
Stage
Grading
Time a
Outcome
GROUP 13 (SSR) Patient no. Sex 1
M
C
G2
9
T
2 3 4 5 6
F F M M M
C C C B C
G2 G2 G2 G2 G2
10 12 8 6 14
T b T c T
~Time interval from the operation (months) b Reoperated and survived 18 months with death from systemicdisease CReoperated and survived 26 months, now alive with hepatic metastases
Results
As shown in Table 3, the local recurrence rate in G r o u p A was 45.5% (five cases), with a mean time interval from the operation of 9 months. Four of these patients had a Dukes' C grade G2 t u m o r and one a Dukes' B grade G3 tumor. G r o u p B presented a local recurrence rate of 46.1% (six cases), with a mean time interval from the operation of 9.8 months. Five of these patients had a Dukes' C and one a Dukes' B tumor (6 grade G2). The difference of 0.6% between the two local recurrence rates, with a 95% confidence interval ranging from - 3 8 . 8 % to 40.2% was clearly not significant. In both groups, the clinical presentation of local recurrence was based on the elevation of seric C E A levels. In G r o u p A, the main symptoms were perineal pain and tenderness resistent to any kind of medical therapy, and two patients presented with associated hematuria due to urinary bladder involvement. Conversely, in G r o u p B, it was tenesmus, vague abdominal distension and pain, difficult defecation due to stenosis and retraction of the colo-anal anastomosis. All the patients of both groups presenting with clinical signs of local recurrence had advanced disease which was impossible to manage surgically. The mean survival time after the detection of local recurrence in these patients was 5 months with a range of 3 - 9 months. In two of the G r o u p B patients who had been diagnosed by CT and ultrasonography, it was possible to perform a re-operation in the form of an A P E R . One of these patients died of systemic recurrence 18 months after the re-operation and the other is
now alive with hepatic metastases 26 months after the re-operation.
Discussion
Until 10 years ago, mid and low rectal cancers were systematically treated with the A P E R procedure. However, more recently, the possibility of saving the sphincters through a low anterior resection with equivalent oncologic disease control and survival rates has been suggested. 14 In fact, some authors suggest that SSR should be performed every time the anatomic situation allows it, 15"t6 although other authors prefer the A P E R procedure for achieving better long-term results. 17,18 We have been able to report results related to both these procedures for tumors located from 4.5 to 7.5 cm from the anal verge, from our experience. Until 1986, we had always performed a A P E R procedure, after which we began to routinely perform the SSR operation, reserving the A P E R for lesions infiltrating the pelvic floor because in such cases the SSR is technically and oncologically unfeasible. Considering that the safe margin of resection from the lower edge of the tumor is presently evaluated around 2 c m , 19'20 w e believe that all tumors located in the lower rectum can be successfully treated with SSR in the absence of pelvic floor invasion. Even lesions located at the lower edge of the rectum can be treated with SSR because, as demonstrated by Goligher, 21 an adequate circumferential dissection of the rectum at the level of the ano-rectal ring enables one to obtain a free margin of up to 4 c m distally. In our series of SSR operations, it was always possible to recuperate at least 2 c m of tumor-free rectal tissue with this procedure, thus achieving the desiderated oncologic radicality. The only contraindication of the SSR procedure is represented by the functional impairment of the sphincteric complex which can be responsible for postoperative incontinence. However, this condition can now be easily diagnosed preoperatively by means of rectal m a n o m e t r y and pelvic floor electromyography. 22 The local recurrence rates vary remarkably in the literature (Table 4), however, our data show no significant differences between the two procedures according to this study. Moreover, in SSR, the recurrence rate did not vary in relation to mechanical or manual colo-anal anastomosis. Based on a recent multivariate analysis of recurrence after rectal cancer surgery, 3° D u k e s ' stage appears to be the most significant prognostic factor related to local recurrence. In another series, 2 it has been shown that the location of the tumor also has a strong influence on local recurrence. Even though the incidence of local recur-
316
D. Tuscano et al.: Local Recurrence in Rectal Cancer Table 4. Review of the Local Recurrence Rates after Surgery for Cancer of the Rectum
Reference
Year
Hurst 23 1982 Anderberg 24 1983 Luke 25 1983 Lasson26
1984
Reid 27 Adloff1 Vlasak 2~
1984 1985 1988 1989
Sweeney29 Warneke 2
1989 1989
Ziv 4
s.s.,
Procedure SSR SSR SSR APER SSR APER SSR APER SSR SSR APER SSR SSR
Follow-up Recurrences (months) Patients (n) (n) (%) 3-22 1-17 24 24 3-57 3-57 24-72 60 18- 78 1-86 1-86 60
34 38 44 36 53 49 29 113 53 38 61 84 31
11 9 10 8 9 7 8 36 17 10 9 14 7
32.3 23.6 22.7 22.2 16.9 14.2 27.5 31.8 32.1 26.3 14.7 16.6 22.6
s.s.
n.s. ll.S.
I1.S.
statistical significance of the difference between SSR and APER; n . s . , not significant
rence in our series is very high, it should be stressed that approximately 90% of these tumors were in an advanced stage with 2 to 5 involved nodes in the mesorectum, and that in all cases the tumor was located within 7.5 cm from the anal verge. Actually, the "gold standard" for preventing local recurrence following the surgical treatment of rectal cancer is complete excision of the mesorectum.13 The overall incidence of local recurrence after surgery for rectal cancer with complete excision of the mesorectum in our experience of 87 evaluable cases was 17.2% (15/87), with 12.5% (3/24) and 3.4% (1/29) for the midand upper rectum, respectively. A n o t h e r important step of the prevention of local recurrence, especially anastomotic recurrence, is represented by intraoperative lavage of the rectal stump either with cytotoxic solutions such as mercury perchlorhydrate or with saline solution, t~ We routinely perform intraoperative lavage of the rectal stump with saline solution, as we believe it to be less aggressive and equally effective to clear exfoliative neoplastic cells. In our SSR group, we had only one anastomotic line recurrence. Conversely, we do not believe that lymphadenectomy extending to the lateral lymph nodes 31 should be routinely performed because involvement of these nodes indicates far advanced disease with a very poor outcome. 12,13 The clinical presentation of local recurrence is easily detectable, but the presence of clinical signs strongly suggest far advanced disease unsuitable for surgical management. The two cases in our series submitted to re-operation were both asymptomatic with suspicion of local recurrence having been suggested by seric C E A level elevation, CT and ultrasonographic findings, and the final diagnosis was confirmed with a transanal biopsy. Moreover, the interval between surgery and the onset of local recurrence seems to be influenced by
tumor location. In our series, related to very low cancers, it was very short. Finally, the choice between A P E R and SSR in the treatment of lower rectal cancer does not seem to affect the incidence of local recurrence, which is more related to tumor size, site, stage and histopathologic grading. The surgical procedure should therefore be oncologically correct, involving complete excision of the mesorectum, rectal stump lavage, and division of the inferior mesenteric artery at its origin. Thus, preservation of the sphincters and restoration of digestive continuity should be achieved whenever possible, being contraindicated in the presence of pelvic floor invasion or sphincteric complex functional impairment. Furthermore, SSR can assure without any doubt a better postoperative quality of life with equal oncologic control of the disease. A postoperative program of follow-up can allow for earlier detection of local recurrence, although at present the diagnostic tools employed still present some interpretative problems. 32 However, a lower incidence of local recurrence could possibly be achieved with the routine adoption of pre- and/or postoperative radiotherapy. 33
References
1. AdloffM, Arnaud JP, ScholoegelM, Thibaud D (1985) Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 28:413-415 2. WarneckeJ, Petrelli NJ, Herrera L (1989) Local recurrence after sphincter-saving resection for rectal adenocarcinoma. Am J Surg 158:3-5 3. Elias D, Henry-AmourM, Lasser P, Gareer W, BognelC (1985) Cancer du rectum: Facteurs predictif de la survenue des recidives locoregionales. Etude multifactorielle. Gastroenterol Clin Biol 9:776-781 4. Ziv Y, Baruch DB, Waizer A, Flex D, Wolloch Y (1988) Local recurrence after low anterior resection using the EEA stapling device. Dis Colon Rectum 31:945-947
D. T u s c a n o et al.: Local R e c u r r e n c e in R e c t a l C a n c e r 5. Perim ME, Nicholls RJ (1984) Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann Surg 200:729-733 6. Williams NS, Johnston D (1984) Survival and recurrence after sphincter-saving resection and abdominoperineal resection for carcinoma of the middle third of the rectum. Br J Surg 71:278-282 7. Ciatoo S, Pacini P (1982) Radiation therapy in recurrences of carcinoma of the rectum and sigmoid after surgery. Acta Radiol [Oncol] 21:105-109 8. Dozois RR, Perim RE, Gunderson LL (1986) Carcinoma of the rectum: Current management. Surg Clin North Am 66: 821-832 9. Keighley MRB, Hall C (1987) Anastomotic recurrence of colorectal cancer - - a biological phenomenon or an avoidable calamity? Gut 28:786-791 10. Kodner I J, Shemesh EI, Fry RD, Walz B J, Myerson R, Fleshman JW, Schechtman KB (1989) Preoperative irradiation for rectal cancer. Ann Surg 209:194-199 11. Friedman P, Garb JL, Park WC (1985) Survival following moderate dose preoperative radiation therapy for carcinoma of the rectum. Cancer 55:967-973 12. Jeckel J (1986) Curative resection of primary colorectal cancer. Br J Surg 73:687-688 13. Heald R J, Ryall RDM (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 28:1479-1482 14. Yeatman TJ, Bland KI (1989) Sphincter-saving procedures for distal carcinoma of the rectum. Ann Surg 209:1-18 15. Goligher JC (1988) Sphincter-saving resections. Scand J Gastroenterol [Suppl] 149:110-116 16. Shafik A (1986) A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Am J Surg 151:278-284 17. Pheils MT, Chapuis PH, Colguzzoun NK (1983) Local recurrence following curative resection for carcinoma of the rectum. Dis Colon Rectum 26:98-102 18. Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fieling LP (1984) Local recurrence following "curative" surgery for large bowel cancer: II. The rectum and rectosigmoid. Br J Surg 71:17-20 19. Williams NS (1984) The rationale for preservation of the anal sphincter in patients with rectal cancer. Br J Surg 71:575-581
317 20. Kirwan WO, Drumm J, Hogan JM, Kehoane C (1988) Determining safe margin of resection in low anterior resection for rectal cancer. Br J Surg 75:720 21. Goligher JC (1984) Surgery of the anus, rectum, and colon, 5th edn. Bailliere-Tindall, London 22. Pescatori M, Ravo B (1988) Diagnostic anorectal functional studies: Manometry, sphincter electromyography, and defecography. Surg Clin North Am 68(6):1231-1248 23. Hurst PA, Prout WG, Kelly JM, Bannister JJ, Walker RT. Local recurrence after low anterior resection using the staple gun. Br J Surg 1982; 69:275-276. 24. Andenberg B, Enblad P, Sjodhal R, Wetterfors J. Recurrent rectal carcinoma after anterior resection and rectal stapling. Br J Surg 1983; 70:1-4. 25. Luke M, Kirkegaard P, Lendorf A, Christiansen J. Pelvic recurrence rate after abdominoperineal resection and low anterior resection for rectal cancer before and after the introduction of the stapling technique. World J Surg 1983; 7:616-619. 26. Lasson AL, Ekelund GR, Lindstrom CG. Recurrence risk after stapled anastomosis for rectal carcinoma. Acta Chir Scand 1984; 150:85-89. 27. Reid JDS, Edward Robins R, Atkinson KG. Pelvic recurrence after anterior resection and E E A stapling anastomosis for potentially curable carcinoma of the rectum. Am J Surg 1984; 147:629632. 28. Vlasak JW, Wagner D, Passaro E, Wilson SE. Local recurrence after curative resection of rectal cancer: A comparison of low anterior resection and abdominoperineal resection. J Surg Oncol 1989; 41:236-239. 29. Sweeney JL, Ritchie JK, Hawley PR. Resection and sutured peranal anastomosis for carcinoma of the rectum. Dis Colon Rectum 1989; 32:103-106. 30. Rinnert Gongora S, Tartter PI (1989) Multivariate analysis of recurrence after anterior resection for colorectal carcinoma. Am J Surg 157:573-576 31. Moriya Y, Hojo K, Sawada T, Koyama Y (1989) Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection. Dis Colon Rectum 32:307-315 32. Roediger WEW, Tucker WG (1989) Thickening of pelvic fascia in carcinoma of the rectum. Dis Colon Rectum 29:117-119 33. Gunderson LL (1986) Perineal irradiation for rectal cancer? Int J Radiat Oncol Biol Phys 12:283-284
~
SURGEaYTODAY
© Springer-Verlag 1992
Low Anterior Resection Versus Abdominoperineal Excision: A Comparison of Local Recurrence After Curative Surgery for "Very Low" Rectal Cancer DOMENICO TUSCANO, MARCO CATARCI,ALESSANDRASAPUTELLI,FABIO GAJ, FRANCESCOGOSSETTI, STEFANO GUADAGNI, PAOLONEGRO, and MANLIO CARBONI The Fifth SurgicalUnit, Second SurgicalClinic, Universityof Rome "La Sapienza", 00161, Rome, Italy
Abstract: In the controversy regarding whether sphinctersaving resection (SSR) or abdominoperinea.I resection (APER) is more appropriate for the treatment of very low rectal cancer, local recurrence rates seem to play a fundamental role in patient outcome. In order to operate an effective patient selection, very low rectal cancer is defined herein as being located within 4.5 to 7.5 cm from the anal verge. This retrospective report investigates the incidence of local recurrence after curative surgery for very low rectal carcinoma in 24 consecutive patients treated by the same surgical team over a 15-year period using the above surgical procedures. In the APER group, the local recurrence rate was 45.5 %, occurring in 5 of 11 cases; and in the SSR group 46.1%, occurring in 6 of 13 cases, with no significant difference between the two groups. Recurrence was found within one year of surgical treatment in all except one case. Despite the strict follow-up program, it was only possible to perform reoperation in two recurrent cases, both previously submitted to SSR and diagnosed by means of transanal ultrasonography and macrobiopsy. The high incidence of local recurrence in this series is explained by the advanced stage of disease in the majority of cases. Thus, as the choice between APER and SSR does not seem to affect the incidence of local recurrence, which is related more to tumor size, site, stage, and grading, preservation of the sphincters and restoration of digestive continuity should be achieved whe~ever technically possible.
ing, 4 lymph nodal involvement, 5 and the degree of extraparietal infiltration, 6 can all influence the surgeon in deciding whether or not to save the sphincters with the aims of improving postoperative quality of life, obtaining satisfactory survival rates, and lowering the incidence of pelvic local recurrence. Many retrospective studies concerning the incidence of local recurrence after surgery for rectal cancer have been reported, 2'4'7'8 with variations between 3% and 39%, which seems to be related to the surgical procedure, 9 adjuvant radiotherapy, 1°'11 intraoperative lavage of the rectal stump 12'13 and, especially, to the exact location of the neoplasm. 2 The majority of these reports, however, signal the incidence of local recurrence after abdominoperineal resection ( A P E R ) or low anterior resection (SSR) without emphasis on the exact location of the neoplasm, and include lesions located between 4 and 12 cm from the anal verge. The main aim of this study was to evaluate the incidence of local recurrence in 24 consecutive patients presenting with carcinoma of the lower rectum submitted to surgical treatment.
Patients and Methods Key Words: rectum adenocarcinoma, low anterior resection, abdominoperineal resection, local recurrence, patterns of local recurrence
Introduction The choice of the surgical procedure in the treatment of low rectal cancer is still a matter of much controversy. C a n c e r location, 1'2 dimensions, 3 histopathologic grad-
Reprint requests to: M. Catarci (Received for publication on Oct. 18, 1990; accepted on May 1, 1992)
From 1975 to 1989, 109 consecutive patients with rectal cancer were surgically treated by the same surgical team at the Surgical Department of the University of L'Aquila from 1975 to 1986 and at the Fifth Surgical Unit of the University " L a Sapienza" or R o m e from 1986 to 1989. From this series, we conducted a retrospective evaluation of 34 patients with "very low" rectal cancer operated on from 1983 to 1989. The lower rectum was defined as being 4.5 to 7.5 cm (_+0.5 cm) from the anal verge and neither tumors of the anal canal nor any tumor located from 0 to 4.5 cm from the anal verge were included in this study. Effectively, in each patient
314
D. Tuscano et al.: Local Recurrence in Rectal Cancer
Table 1. Characteristics of the Group A (APER) patients Patient no.
Sex
Age
Stage
Grade
1 2 3 4 5 6 7 8 9 10 11
F M M F M F M M M M M
65 54 72 60 53 59 63 57 61 64 56
B C B C A B B C C C C
G1 G2 G2 G2 G2 G2 G3 G2 G2 G2 G3
APER, abdominoperineal resection
Table 2. Characteristics of the Group B (SSR) patients Patient no.
Sex
Age
Stage
Grade
1
M
66
C
2 3 4 5 6 7 8 9 10 11 12 13
F F M M M F M F M M F M
59 73 47 73 51 54 62 60 58 64 57 61
C A B B A C B C B C C C
G2 G2 G1 G3 G2 G2 G2 G1 G2 G2 G2 G2 G2
SSR, sphincter-saving resection
the t u m o r involved a segment of rectum from the puborectal muscle extending proximally 3 cm. Preoperative evaluation included rigid proctosigmoidoscopy in the jack-knife position to precisely assess the distance from the lower edge of the neoplasm to the anal verge. Ten patients presenting with invasion of the pelvic floor were excluded from the study. The remaining 24 patients without invasion of the puborectal muscle or of the pelvic floor underwent one of two different surgical procedures. G r o u p A, comprised of 11 patients treated during the period 1983-1986, was submitted to A P E R procedure (Table 1), while G r o u p B, comprised of 13 patients treated during the period 1986-]989, was submitted to a "very low" anterior resection, namely the SSR procedure (Table 2). Both groups were h o m o g e n e o u s concerning the patients' age and sex, t u m o r dimensions, stage and histopathologic grading, this one being intended as r e c o m m e n d e d by the T N M joint committee. 4 The m e a n follow-up was 57.8 months with a range of 3 6 - 7 8 months and 23.9 months with a range of 1 0 - 3 4 months for Groups A and B, respectively.
Fig. 1. Transanal ultrasonographic evaluation of local submucosal recurrence after SSR The other steps of the surgical procedure were identical in both groups, including the division of the inferior mesenteric artery at its origin, complete excision of the mesorectum and manual or mechanic colo-anal anastomosis, either ILS or E E A , with a diameter of 31 or 33 m m with lavage of the rectal stump in the SSR cases or terminal colostomy in the A P E R cases. N o n e of the patients underwent any pre- or postoperative adjuvant therapy. All patients underwent a clinical examination, seric carcinoembryonic antigen ( C E A ) evaluation, hepatic ultrasonography (US), and c o m p u t e d t o m o g r a p h y (CT) scanning at the time of discharge and then every six months. Furthermore, from 1987, in all SSR cases a endorectal ultrasonographic evaluation was performed every three months (Fig. 1). W h e n e v e r necessary, other diagnostic procedures such as cystoscopy or I V urography were also performed. A transanal macrobiopsy was obtained under general anaesthesia from all SSR cases presenting with a high suspicion of recurrence, whereas a CT or US guided fine-needle aspiration biopsy was obtained from similar A P E R cases. During the follow-up, the mean length of which was 25 months with a range of 5 - 3 6 months, the incidence of local recurrence and its patterns were evaluated.
D. Tuscano et al.: Local Recurrence in Rectal Cancer
315
Table 3. Cases of Local Recurrence in the Two Groups. T, death GROUP A (APER) Patient no. Sex Stage
Grading
Time a
Outcome
1
M
C
G2
5
T
2 3 4 5
M M M M
B C C C
G3 G2 G2 G2
9 6 7 12
T T T T
Stage
Grading
Time a
Outcome
GROUP 13 (SSR) Patient no. Sex 1
M
C
G2
9
T
2 3 4 5 6
F F M M M
C C C B C
G2 G2 G2 G2 G2
10 12 8 6 14
T b T c T
~Time interval from the operation (months) b Reoperated and survived 18 months with death from systemicdisease CReoperated and survived 26 months, now alive with hepatic metastases
Results
As shown in Table 3, the local recurrence rate in G r o u p A was 45.5% (five cases), with a mean time interval from the operation of 9 months. Four of these patients had a Dukes' C grade G2 t u m o r and one a Dukes' B grade G3 tumor. G r o u p B presented a local recurrence rate of 46.1% (six cases), with a mean time interval from the operation of 9.8 months. Five of these patients had a Dukes' C and one a Dukes' B tumor (6 grade G2). The difference of 0.6% between the two local recurrence rates, with a 95% confidence interval ranging from - 3 8 . 8 % to 40.2% was clearly not significant. In both groups, the clinical presentation of local recurrence was based on the elevation of seric C E A levels. In G r o u p A, the main symptoms were perineal pain and tenderness resistent to any kind of medical therapy, and two patients presented with associated hematuria due to urinary bladder involvement. Conversely, in G r o u p B, it was tenesmus, vague abdominal distension and pain, difficult defecation due to stenosis and retraction of the colo-anal anastomosis. All the patients of both groups presenting with clinical signs of local recurrence had advanced disease which was impossible to manage surgically. The mean survival time after the detection of local recurrence in these patients was 5 months with a range of 3 - 9 months. In two of the G r o u p B patients who had been diagnosed by CT and ultrasonography, it was possible to perform a re-operation in the form of an A P E R . One of these patients died of systemic recurrence 18 months after the re-operation and the other is
now alive with hepatic metastases 26 months after the re-operation.
Discussion
Until 10 years ago, mid and low rectal cancers were systematically treated with the A P E R procedure. However, more recently, the possibility of saving the sphincters through a low anterior resection with equivalent oncologic disease control and survival rates has been suggested. 14 In fact, some authors suggest that SSR should be performed every time the anatomic situation allows it, 15"t6 although other authors prefer the A P E R procedure for achieving better long-term results. 17,18 We have been able to report results related to both these procedures for tumors located from 4.5 to 7.5 cm from the anal verge, from our experience. Until 1986, we had always performed a A P E R procedure, after which we began to routinely perform the SSR operation, reserving the A P E R for lesions infiltrating the pelvic floor because in such cases the SSR is technically and oncologically unfeasible. Considering that the safe margin of resection from the lower edge of the tumor is presently evaluated around 2 c m , 19'20 w e believe that all tumors located in the lower rectum can be successfully treated with SSR in the absence of pelvic floor invasion. Even lesions located at the lower edge of the rectum can be treated with SSR because, as demonstrated by Goligher, 21 an adequate circumferential dissection of the rectum at the level of the ano-rectal ring enables one to obtain a free margin of up to 4 c m distally. In our series of SSR operations, it was always possible to recuperate at least 2 c m of tumor-free rectal tissue with this procedure, thus achieving the desiderated oncologic radicality. The only contraindication of the SSR procedure is represented by the functional impairment of the sphincteric complex which can be responsible for postoperative incontinence. However, this condition can now be easily diagnosed preoperatively by means of rectal m a n o m e t r y and pelvic floor electromyography. 22 The local recurrence rates vary remarkably in the literature (Table 4), however, our data show no significant differences between the two procedures according to this study. Moreover, in SSR, the recurrence rate did not vary in relation to mechanical or manual colo-anal anastomosis. Based on a recent multivariate analysis of recurrence after rectal cancer surgery, 3° D u k e s ' stage appears to be the most significant prognostic factor related to local recurrence. In another series, 2 it has been shown that the location of the tumor also has a strong influence on local recurrence. Even though the incidence of local recur-
316
D. Tuscano et al.: Local Recurrence in Rectal Cancer Table 4. Review of the Local Recurrence Rates after Surgery for Cancer of the Rectum
Reference
Year
Hurst 23 1982 Anderberg 24 1983 Luke 25 1983 Lasson26
1984
Reid 27 Adloff1 Vlasak 2~
1984 1985 1988 1989
Sweeney29 Warneke 2
1989 1989
Ziv 4
s.s.,
Procedure SSR SSR SSR APER SSR APER SSR APER SSR SSR APER SSR SSR
Follow-up Recurrences (months) Patients (n) (n) (%) 3-22 1-17 24 24 3-57 3-57 24-72 60 18- 78 1-86 1-86 60
34 38 44 36 53 49 29 113 53 38 61 84 31
11 9 10 8 9 7 8 36 17 10 9 14 7
32.3 23.6 22.7 22.2 16.9 14.2 27.5 31.8 32.1 26.3 14.7 16.6 22.6
s.s.
n.s. ll.S.
I1.S.
statistical significance of the difference between SSR and APER; n . s . , not significant
rence in our series is very high, it should be stressed that approximately 90% of these tumors were in an advanced stage with 2 to 5 involved nodes in the mesorectum, and that in all cases the tumor was located within 7.5 cm from the anal verge. Actually, the "gold standard" for preventing local recurrence following the surgical treatment of rectal cancer is complete excision of the mesorectum.13 The overall incidence of local recurrence after surgery for rectal cancer with complete excision of the mesorectum in our experience of 87 evaluable cases was 17.2% (15/87), with 12.5% (3/24) and 3.4% (1/29) for the midand upper rectum, respectively. A n o t h e r important step of the prevention of local recurrence, especially anastomotic recurrence, is represented by intraoperative lavage of the rectal stump either with cytotoxic solutions such as mercury perchlorhydrate or with saline solution, t~ We routinely perform intraoperative lavage of the rectal stump with saline solution, as we believe it to be less aggressive and equally effective to clear exfoliative neoplastic cells. In our SSR group, we had only one anastomotic line recurrence. Conversely, we do not believe that lymphadenectomy extending to the lateral lymph nodes 31 should be routinely performed because involvement of these nodes indicates far advanced disease with a very poor outcome. 12,13 The clinical presentation of local recurrence is easily detectable, but the presence of clinical signs strongly suggest far advanced disease unsuitable for surgical management. The two cases in our series submitted to re-operation were both asymptomatic with suspicion of local recurrence having been suggested by seric C E A level elevation, CT and ultrasonographic findings, and the final diagnosis was confirmed with a transanal biopsy. Moreover, the interval between surgery and the onset of local recurrence seems to be influenced by
tumor location. In our series, related to very low cancers, it was very short. Finally, the choice between A P E R and SSR in the treatment of lower rectal cancer does not seem to affect the incidence of local recurrence, which is more related to tumor size, site, stage and histopathologic grading. The surgical procedure should therefore be oncologically correct, involving complete excision of the mesorectum, rectal stump lavage, and division of the inferior mesenteric artery at its origin. Thus, preservation of the sphincters and restoration of digestive continuity should be achieved whenever possible, being contraindicated in the presence of pelvic floor invasion or sphincteric complex functional impairment. Furthermore, SSR can assure without any doubt a better postoperative quality of life with equal oncologic control of the disease. A postoperative program of follow-up can allow for earlier detection of local recurrence, although at present the diagnostic tools employed still present some interpretative problems. 32 However, a lower incidence of local recurrence could possibly be achieved with the routine adoption of pre- and/or postoperative radiotherapy. 33
References
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