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Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer
European Journal of Surqical Oncoloyy 1995; 21: 640-643
Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer
Ji~rg T s c h m e l i t s c h ,
Peter Kronberger, Rupert Prommegger,
Gilbert Reibenegger,
Karl Glaser and Ernst Bodner
Second Department o./'Surgel 3" Unirersitr o/hmshruck, Austria
The aim o f this retrospective stud)' is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in 136 patients. Local recurrence rates and 5-year survival probabilities were estimated for the AR and APE group. Further comparisons were carried out between hand-sewn and stapled anastomoses after AR, and between patients after AR and APE for tumours 2 to 6 cm from the dentate line. Local recurrence after AR occurred in 14% and after APE in 10% of these cases. Five-year survival probabilities and local recurrence frequencies showed no statistically significant difference (P > 0.05). Local recurrence rates were 13.5% after hand-sewn anastomoses and 15% after the stapled procedure. No statistically significant difference was observed in the 5-year survival and recurrence rate (P > 0.05). Seventy-four of 136 patients had tumours located 2 to 6 cm from the dentata line. Local recurrence occurred in 21% after AR and 5% after APE, showing a statistically significant difference in frequency (P < 0.05). No significant difference was found in cumulative 5-year survival probabilities. APE for advanced IQw rectal cancer showed a significant reduction in local recurrences compared to AR. Key wm'ds: rectal cancer; surgery; survival; anterior resection; abdominoperineal excision.
Introduction
Material and methods
One of the most serious problems following "curative surgery" for reclal cancer is local recurrence. The incidence of local failure varies from 0% to 67% depending upon stage, ~~ about 8 5 % - 9 0 % of the recurrences occur within 2 years after surgery. Although local recurrence rates in patients having either A R or APE are similar in some studies, ~ other authors ='~ zt report that A R in cancer of the middle and lower third of the rectum causes a higher incidence of local failure. Moreover, the widespread use of the 'stapler" for low ARs which leave a shorter margin of distal clearance, may result in increased local recurrences, t~3 In previous publications no differences between handsewn and stapled anastomoses are reportedJ 4'~5 In the treatment of rectal cancer, surgeons should evaluate carefully the therapeutic possibilities of improving the quality of life for patients, however, sphincter-saving procedures must not jeopardize survival rates. This study was undertaken to compare the outcorne of A R and APE for rectal cancer in terms of local recurrence and 5-year survival. A further comparison has been carried out for hand-sewn and stapled anastomoses in the A R group and for patients with tumours 2 to 6 cm from the dentate line.
This study comprises 136 patients (77 male, 59 female: aged between 42 years and 91 years, mean: 62 years) with adenocarcinoma of the rectum, treated by radical surgery in our department between 1982 and 1989. Follow-up duration was 5 years. Neoplasms of the anal canal were not considered in the present study. The lower edge of the lesion was located not higher than 15.5 cm from the anal verge measured at rigid rectoscopy. Fifty-two patients were treated by APE. and 84 patients underwent AR. Of the latter group, 44 patients had handsewn anastomoses, and 40 anastomoses were stapled (EEA, Auto~'uture. USSC. Norwalk, Connecticut, USA). All specimens were examined histologically and classified according to Dukes" classification (Dukes" A carcinoma limited to the bowel wail: Dukes' B carcinoma infiltrating perirectal tissues without lymph-node involvement: Dukes' C carcinoma with lymph-node metastases). Tumour grading was classified as well, moderate and poor (.Table I). All patients underwent mechanical bowel preparation and short-term antibiotic prophylaxis before surgery. Neither pre-operative nor post-operative radiation therapy was performed on any patient. The operations were performed by senior staff surgeons. Resectability was assessed after laparotomy. After division of the inferior ruesenteric vessels and mobilization of the sigmoid colon and rectum, the lateral ligaments were divided and ligated to allow clearance of the mesorectum. In case of restorative
Correspondence to: J. Tschmelitsch, Memorial Sloan Kettering Cancer Center, Colorectal Service, C 968, 1275 York Avenue, New York, NY 10021, USA. 0748-7983/95/060640+04 SI2.00/0
~" 1995W.B. Saunders Company Limited
Recurrence o./"rectal cancer Table 1. Clinical data from 136 patients with rectal cancer
Stage
A B
Grade
C Well Moderate Poor
Hand-sewn Stapled REC
APE (. = 52)
AR (n = 84)
n
%
n
%
12 22 18 13 24 15 0 0 5
23 42 35 25 46 29
21 38 25 20 43 21 44 40 12
25 45 30 24 51 25
10
641
differences of cumulative survival probabilities were determined by the M a n t e l - C o x test. Recurrence frequencies were c o m p a r e d by the Fisher exact test. Results
Patients undergoing A R were c o m p a r a b l e as f!tr as age and sex were concerned to patients in the A P E group. There was no significant difference regarding tunaour stage and grading between the two groups. Histological examination of the resected specimen showed tumour-free resection margins in all cases. Post-operative mortality (mortality during the first 30 days after surgery) was 4 % (two patients) following A P E and 4.5'% (four patients) after AR. A n a s t o m o t i c leakage occurred in the A R group in nine cases (11%), four times after stapled anastomosis and five times after hand-sewn anastomosis (difference not statistically significant). The 5-year disease-free survival probability, estimated by the K a p l a n - M e i e r technique, was 72% (SE = 9.2%) for the A R group and 75% (SE = 7.4% ) for the A P E group. No statistically significant difference was found between the two groups (P > 0.05). In c o m p a r i n g hand-sewn vs stapled technique within the A R group, no statistically significant difference could be found either: the 5-year survival probability after hand-sewn anastomosis was 72% (SE = 11%), and 74% (SE = 12%) after stapled anastomosis ( P > 0.05). Local recurrence developed after A R in 12 cases (14"/o), and after A P E in five patients (10%). This shows a trend for recurrence following A R but the difference did not reach a level of statistical significance ( P > 0.05). Within the A R group recurrences developed after the hand-sewn procedure in six patients (13.5%) and in six patients (15%) after the stapled procedure (not significant). A further comparison was carried out for the subgroup of patients with tumou,'s 2 to 6 cm from the dentate line. O f 74 patients with tumours in that location, 33 underwent AR, and in 41 cases an A P E was performed. The two groups were c o m p a r a b l e regarding age, sex, Dukes' stage and grading (Table 2). Distal margins in the 33 cases after A R ranged from I. 1 to 3.5 cm (median 2.6 cm). Recurrence occurred in the A R group in seven cases (21%), and in the A P E group in two cases (5%), showing a statistically significant difference ( P < 0.05).
14
APE = Abdominoperineal excision; AR = Anterior resection: REC = Local recurrence: n =nurnber of cases.
procedures a m i n i m u m distal margin of clearance (distance from lower b o r d e r of t u m o u r to distal resection margin as measured on the fresh operative specimen) of 2 cm was the aim. During histological examination the distal resection margin was free of turnouts in all cases~ No rectal wash-outs with cytostatic agents were performed. In cases of APE, the perineal procedure ';vas performed simultaneously by a second team. Follow-up e x a m i n a t i o n s comprised clinical examination. including rectal/vaginal digital examination, laboratory findings (CEA, CA 19-9), a b d o m i n a l ultrasound and rigid rectoscopy every 3 m o n t h s for the first 2 years, at 6 m o n t h intervals fi-orn years 3 to 5 and at yearly intervals thereafter. I,a addition chest X-rays every 6 months, pancolonoscopy and c o m p u t e d t o m o g r a p h y (CT) each year were performed. 1,1 1990 we also introduced e n d o s o n o g r a p h y to our followup programme. Local recurrence rates and 5-year survival probabilities were estin'tated for the A R and A P E group. Further c o m p a r i s o n s were carried out between hand-sewn and stapled anastomoses after AR, and between patients after A R and A P E for tumours 2 to 6 cm from the dentate line.
Statistical anaIjwis The cumulative surviwtl probabilities were c o m p u t e d by the product lirnit a p p r o a c h ( K a p l a n - M e i e r technique). This method also yields estimates for the 5-year survival probabilities and their associated s t a n d a r d errors. Statistical
Table 2. Local recurrences after rectal cancer 2 to 6 cm from tile dentata line related to
primary operation, stage and tumour differentiation APE (11 = 41) n Stage
A B
Grade
C Well Moderate Poor
10 19 12 I1 20 10
f
REC (n = 2)
AR (n = 33)
REC(n = 7)
%
n
%
it
%
n
%
24 46 30 27 49 24
0
0
I
5
I 0 I I
8 0 5 10
8 12 13 7 18 8
24 36 40 21 55 24
0 3 4 1 4 2
0 25 31 14 22 25
APE = Abdominoperineal excision: AR = Anterior resection: REC = Local recurrence; number of cases.
n =
642
J. T s c h m e l i t s c h et al.
1°°i 9o
/ ....
,
60
~J
50 40 30 '20 10
......... I........... I........... I........... I........... I........... 12 24 36 48 60 72 Months Fig. l. Cumulative survival probabilities after anterior resection (AR. --) and abdominoperineal excision (APE, - - ) for rectal carcinoma 2 to 6 cm from the dentata line showing no statistically significant difference. Five-year survival probability after APE: 84% (95% CI = 68-99%), after AR: 65% (95% CI = 36-96%).
No correlation between distal margin and recurrence could be found. Distal margins in the seven cases with recurrent tumour after A R were 1.4 to 2.8 cm (median 2.4 cm). The median distal margin in the 26 patients who did not develop local recurrence was 2.6 cm. T u m o u r stage and differentiation in the cases with recurrence after low rectal cancer are shown in Table 2. The 5-year survival probabilities showed no significant difference. 5-year survival probability was 84% (SE = 7.3%; 95% CI = 68-99%) after APE, and 65% (SE = 15.5%; 95% CI = 36-96%) after A R (for survival curves see Fig. I). N o n e of the recurrences in this subgroup developed after primary Dukes' A carcinoma (8 AR, 10 APE).
Discussion During the last few years an increase in the number of sphincter-saving operations for low and especially mid-rectal carcinomas has developedJ 6 This is due to the fact that a distal resection margin of 2 cm is obviously sufficient in terms of oncological principles, tT--'°Distal intramural spread occurs in only 10% of tumours and is, moreover, a poor prognostic sign often associated with extensive lymphatic involvement and disseminated disease. Indeed, patients may not be salvaged by wider resection margins. Furthermore, the introduction of stapling devices has clearly improved the technical feasibility of anastomoses after low resections. The safety and reliability ofcircular stapling instruments are now generally acknowledged. According to some authors, -''9-~
A R for mid- and low rectal cancer shows a higher recurrence rate than does APE. Other authors deny an increased risk for recurrence after restorative procedures. 5 s To adequately resolve this controversy prospective studies are needed and these, to our knowledge, are not yet available. This study was a retrospective one, however, the two groups of patients undergoing A R or APE showed no difference as far as age, sex, stage and grading were concerned. Overall survival probabilities in our study were similar in the A R and APE group. There appears to be a slight trend towards more local recurrences after AR, however we could not show that this trend reached the level of statistical significance. Regarding tile comparison of hand-sewn and stapled anastomosis, our results did not show an increased risk for either procedure. Basically, there is little controversy about the treatment of upper rectal tumours. In these cases an A R is the operation of choice. On the other hand, for tumours 0 to 2 cm from the dentata line an APE is performed by most surgeons because of oncological and also technical reasons. The crucial point concerns the adequate treatment of very low rectal carcinomas where restorative procedures with a distal margin of clearance of at least 2 cm are technically feasible, but might result in a higher rate of local recurrence. In our study significantly higher recurrence rates were found after A R compared to APE for tumours 2 to 6 cm from the dentata line. All recurrences developed after Dukes" B and C tumours. No recurrent turnouts developed following a Dukes" A carcinoma. Distal margins of clearance in patients with recurrent tumours did not differ from patients without recurrences. It is argued that a 2 cm distal margin might not be acceptable for poorly differentiated tumours and the conventional 5 cm margin is still necessary in patients with these turnouts. In our study two of eight patients (25%) developed local recurrence after A R for poorly differentiated low rectal cancer, compared with five of 25 patients (20%) with well or moderately differentiated tumours. However our numbers are too small to draw conclusions regarding the sufficiency of a 2 cm distal margin in poorly differentiated rectal cancer. From our data we were not able to distinguish between pelvic and so-called anastomotic recurrences. However, according to several studies 2~-23 suture line recurrences seem to b~ rare and are related to secondary invasion of the adjacent bowel from a pelvic recurrence rather than to actual growth of turnout cells on the anastomotic line. Although the excised specimen showed clear margins in all patients, the importance of the lateral resection margin might have been underestimated in the histological examination. Quirke e t al. "-4 have suggested that local recurrence is predominantly a factor of incomplete circumferential clearance when the tumour extends beyond the muscularis propria. Further studies should be carried out because controversy still exists in this area. The possible increased risk for restorative procedures for advanced low rectal tumours has to be attributed to tile operative technique rather than to tumour biology. Trying to approach the bowel below the tumour, surgeons tend to take less surrounding perirectal tissue, possibly leaving
Recurrence o f rectal cancer viable t u m o u r cells b e h i n d , b e c a u s e the d i s s e c t i o n b e c o m e s m o r e difficult in the d e p t h s o f the pelvis.-' t3 In a n A P E this p r o b l e m d o e s n o t o c c u r b e c a u s e all the tissue c a n be excised w i t h o u t t h e necessity o f a p p r o a c h i n g the bowel wall. O u r r e c u r r e n c e rate a f t e r A R for locally a d v a n c e d low rectal t u m o u r s c o r r e s p o n d s to t h e results o f several a u t h o r s .,.~..,5 .,s b u t lower r e c u r r e n c e f r e q u e n c i e s are r e p o r t e d by o t h e r s . ~''''-9 ~-' C o m p a r i s o n s are difficult b e c a u s e o f t h e varied l o c a t i o n o f t h e t u m o u r s in e a c h series a n d the a d d i t i o n o f a d j u v a n t i r r a d i a t i o n a n d c h e m o t h e r a p y in s o m e s t u d i e s . T h e r e is a wide r a n g e o f results. T h i s is d u e to several variables: dist r i b u t i o n o f t u m o u r l o c a t i o n , t u m o u r s t a g e a n d histological grade. O u r r e s u l t s s h o w a significantly r e d u c e d local r e c u r r e n c e rate a f t e r A P E c o m p a r e d to A R for a d v a n c e d low rectal c a n c e r s . H o w e v e r , this c o n c l u s i o n n e e d s to be c o n f i r m e d in p r o s p e c t i v e trials.
12.
13.
14.
15.
16. 17.
18.
19. References I. Ohrnau U. Colorcctal carcinoma: a survey of 1345 cases 19501984. Acta Chh" Stand 1985: 151: 675-9. 2. Neville R. Fielding LP, Amendola C. Local tumor recurrence after curative resection for rectal cancer: a ten hospital review. Dis Colon Rectum 1987; 30: 12-7. 3. Tyvin R, Gunderson LL, Lew R, Galdibini ,l,i, Cohen AM, Donaldson G. Patterns of recurrence of rectal cancer after potentially curative surgery. Cancer 1983: 52:1317-29. 4. Hojo K, Sawada T, Moriya Y. An analysis of survival and voiding, sexu~,l function after wide iliopelvic lymphadenectomy in patients with carcinoma of the rectum, compared with conventional lymphadenectomy. Dis Colon Rectum 1989: 32: 12833. 5. Amato A, Pescatori M, Butti A. Local recurrence following abdominoperineal excision and anterior resection for rectal carcinoma. Dis Colon Rectum 1991; 34:317-22. 6. Williams NS, Johnston D. Survival and recurrence after sphincter saving resection and abdominoperine:d resection for carcinoma of the middle third of the rectum. Br J Surg 1984: 71: 278-82. 7. Nicholls R J, Ritchie ,lK, Wadsworth ,i, Parks AG. Total excision or restorative resection for carcinoma of the middle third of the rectum. Br J Sur9 1979: 66: 625-27. 8. Oudu MW, O'Conell TX. Changes in the treatment of rectal carcinoma and effects on local recurrence. Arch Sur9 1986; 121: 1114-6. 9. Wolmark N, Fisher B. An analysis of survival and treatment failure following abdominoperineal and sphincter saving resection in Dukes" B and C rectal carcinoma. ,'lm~ Surg 1986; 204: 480-7. 10. Terranova O, Celi D, Martella B, Battocchio F. Local recurrence of rectal cancer: anterior resection versus abdomino-perineal resection, h~t Surg 1988; 73:111-3. I1. Phillips RK. Hittinger R, Blesovski L, Fry .IS, Fielding LP. Local recurrence following curative surgery for large bowel
20.
21. 22. 23. 24.
25.
26.
27.
28. 29. 30.
31.
32.
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cancer 11. The rectum and rectosigmoid. Br J Sur9 1984; 71t 17 20. Hojo K. Anastomotic recurrence after sphincter saving resection for rectal cancer: length of distal clearance of the bowel. Dis Colon Rectum 1986; 29:11-4. Anderberg B, Enbald P, Sjodahl R, Wetterfors J. Recurrent rectal carcinoma after anterior resection and rectal stapling. Br J Sur9 1984; 71: 98-100. Moran BJ, Blenkinsop -l, Finnis D. Local recurrence after anterior resection for rectal cancer using a double stapling technique. Br J Sur9 1992; 79: 836-8. Left El. Shaver ,lO, Hoexter B. Anastomosis recurrence after low anterior resection: stapled versus hand-sewn. Dis Colon Rectum 1985; 28: 164-7. Cohen AM, Enker WE, Minsky BD. Proctectomy and coloanal reconstruction for rectal cancer. Dis Col Rect 1990; 33: 40. McDerrnott FT, Hughes ES, Phil E, Johnson WR, Price AB. Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Sur9 1985: 72: 34-7. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5centimeter rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients survival. Br J Surq 1983; 70: 150-4. Cawthorn S,l, Parums DV, Gibbs NM. A'Hearn RP, Caffarey SM, Broughton CIM, Marks CG. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer. Lam'et 1990; 335: 1055-9. Heald R,l, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence? Br J Sur!l 1982: 69: 613-7. Umpleby HC, Williamson RCN. Anastomotic recurrence in large bowel cancer. Br J Surq 1987; 74: 873-8. Morson BC, Vaughan EG, Bussey H JR. Pelvic recurrence after excision of rectum for carcinoma. Br M e d J 1963: 2: 13-9. Sannella NA. Abdominoperineal resection following anterior resection. Cancer 1976; 38: 378-81. Quirke P. Durdey P, Dixon MF, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumor spread and surgical excision. Lancet 1986; 1: 996-9. Hurst PA, Prout WG, Kelly ,lM, Bannister J.I, Walker RT. Local recurrences after low anterior resection using the staple gun. Br J Sur9 1982: 69: 99-103. Lasson AL, Ekelund GR, Lindstr6m CG. Recurrence risk after stapled anastomosis for rectal carcinoma. Acta ClairScand 1984; 150: 85-9. Garlock H,l, Ginzburg L. An appraisal of the operation of anterior resection for carcinoma of the rectum and rectosigmoid. Sur9 Gyneeol Obstet 1950; 90: 525-34. Floyd CE, Corley RG. Cohn I Jr. Local recurrence ofcarcinoma of the colon and rectum. Am J Sur9 1965; 109: 153-9. Heald R J, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986; 2: 1479-82. Deddish MR, Stearns MW. Anterior resection for carcinoma of the rectum and rectosigmoid area. Ann Surg 1961: 154: 9616. Heald R,l. Rectal cancer: anterior resection and local recurrence--a personal view. Perspect Colon Rectal Sur9 1988; I: 126. Enker WE. Potency, Cure and local control in the operative treatment of rectal cancer. Arch Surg 1992: 127: 1396--402.
Accepted for publication 10 August 1995
Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer
Ji~rg T s c h m e l i t s c h ,
Peter Kronberger, Rupert Prommegger,
Gilbert Reibenegger,
Karl Glaser and Ernst Bodner
Second Department o./'Surgel 3" Unirersitr o/hmshruck, Austria
The aim o f this retrospective stud)' is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in 136 patients. Local recurrence rates and 5-year survival probabilities were estimated for the AR and APE group. Further comparisons were carried out between hand-sewn and stapled anastomoses after AR, and between patients after AR and APE for tumours 2 to 6 cm from the dentate line. Local recurrence after AR occurred in 14% and after APE in 10% of these cases. Five-year survival probabilities and local recurrence frequencies showed no statistically significant difference (P > 0.05). Local recurrence rates were 13.5% after hand-sewn anastomoses and 15% after the stapled procedure. No statistically significant difference was observed in the 5-year survival and recurrence rate (P > 0.05). Seventy-four of 136 patients had tumours located 2 to 6 cm from the dentata line. Local recurrence occurred in 21% after AR and 5% after APE, showing a statistically significant difference in frequency (P < 0.05). No significant difference was found in cumulative 5-year survival probabilities. APE for advanced IQw rectal cancer showed a significant reduction in local recurrences compared to AR. Key wm'ds: rectal cancer; surgery; survival; anterior resection; abdominoperineal excision.
Introduction
Material and methods
One of the most serious problems following "curative surgery" for reclal cancer is local recurrence. The incidence of local failure varies from 0% to 67% depending upon stage, ~~ about 8 5 % - 9 0 % of the recurrences occur within 2 years after surgery. Although local recurrence rates in patients having either A R or APE are similar in some studies, ~ other authors ='~ zt report that A R in cancer of the middle and lower third of the rectum causes a higher incidence of local failure. Moreover, the widespread use of the 'stapler" for low ARs which leave a shorter margin of distal clearance, may result in increased local recurrences, t~3 In previous publications no differences between handsewn and stapled anastomoses are reportedJ 4'~5 In the treatment of rectal cancer, surgeons should evaluate carefully the therapeutic possibilities of improving the quality of life for patients, however, sphincter-saving procedures must not jeopardize survival rates. This study was undertaken to compare the outcorne of A R and APE for rectal cancer in terms of local recurrence and 5-year survival. A further comparison has been carried out for hand-sewn and stapled anastomoses in the A R group and for patients with tumours 2 to 6 cm from the dentate line.
This study comprises 136 patients (77 male, 59 female: aged between 42 years and 91 years, mean: 62 years) with adenocarcinoma of the rectum, treated by radical surgery in our department between 1982 and 1989. Follow-up duration was 5 years. Neoplasms of the anal canal were not considered in the present study. The lower edge of the lesion was located not higher than 15.5 cm from the anal verge measured at rigid rectoscopy. Fifty-two patients were treated by APE. and 84 patients underwent AR. Of the latter group, 44 patients had handsewn anastomoses, and 40 anastomoses were stapled (EEA, Auto~'uture. USSC. Norwalk, Connecticut, USA). All specimens were examined histologically and classified according to Dukes" classification (Dukes" A carcinoma limited to the bowel wail: Dukes' B carcinoma infiltrating perirectal tissues without lymph-node involvement: Dukes' C carcinoma with lymph-node metastases). Tumour grading was classified as well, moderate and poor (.Table I). All patients underwent mechanical bowel preparation and short-term antibiotic prophylaxis before surgery. Neither pre-operative nor post-operative radiation therapy was performed on any patient. The operations were performed by senior staff surgeons. Resectability was assessed after laparotomy. After division of the inferior ruesenteric vessels and mobilization of the sigmoid colon and rectum, the lateral ligaments were divided and ligated to allow clearance of the mesorectum. In case of restorative
Correspondence to: J. Tschmelitsch, Memorial Sloan Kettering Cancer Center, Colorectal Service, C 968, 1275 York Avenue, New York, NY 10021, USA. 0748-7983/95/060640+04 SI2.00/0
~" 1995W.B. Saunders Company Limited
Recurrence o./"rectal cancer Table 1. Clinical data from 136 patients with rectal cancer
Stage
A B
Grade
C Well Moderate Poor
Hand-sewn Stapled REC
APE (. = 52)
AR (n = 84)
n
%
n
%
12 22 18 13 24 15 0 0 5
23 42 35 25 46 29
21 38 25 20 43 21 44 40 12
25 45 30 24 51 25
10
641
differences of cumulative survival probabilities were determined by the M a n t e l - C o x test. Recurrence frequencies were c o m p a r e d by the Fisher exact test. Results
Patients undergoing A R were c o m p a r a b l e as f!tr as age and sex were concerned to patients in the A P E group. There was no significant difference regarding tunaour stage and grading between the two groups. Histological examination of the resected specimen showed tumour-free resection margins in all cases. Post-operative mortality (mortality during the first 30 days after surgery) was 4 % (two patients) following A P E and 4.5'% (four patients) after AR. A n a s t o m o t i c leakage occurred in the A R group in nine cases (11%), four times after stapled anastomosis and five times after hand-sewn anastomosis (difference not statistically significant). The 5-year disease-free survival probability, estimated by the K a p l a n - M e i e r technique, was 72% (SE = 9.2%) for the A R group and 75% (SE = 7.4% ) for the A P E group. No statistically significant difference was found between the two groups (P > 0.05). In c o m p a r i n g hand-sewn vs stapled technique within the A R group, no statistically significant difference could be found either: the 5-year survival probability after hand-sewn anastomosis was 72% (SE = 11%), and 74% (SE = 12%) after stapled anastomosis ( P > 0.05). Local recurrence developed after A R in 12 cases (14"/o), and after A P E in five patients (10%). This shows a trend for recurrence following A R but the difference did not reach a level of statistical significance ( P > 0.05). Within the A R group recurrences developed after the hand-sewn procedure in six patients (13.5%) and in six patients (15%) after the stapled procedure (not significant). A further comparison was carried out for the subgroup of patients with tumou,'s 2 to 6 cm from the dentate line. O f 74 patients with tumours in that location, 33 underwent AR, and in 41 cases an A P E was performed. The two groups were c o m p a r a b l e regarding age, sex, Dukes' stage and grading (Table 2). Distal margins in the 33 cases after A R ranged from I. 1 to 3.5 cm (median 2.6 cm). Recurrence occurred in the A R group in seven cases (21%), and in the A P E group in two cases (5%), showing a statistically significant difference ( P < 0.05).
14
APE = Abdominoperineal excision; AR = Anterior resection: REC = Local recurrence: n =nurnber of cases.
procedures a m i n i m u m distal margin of clearance (distance from lower b o r d e r of t u m o u r to distal resection margin as measured on the fresh operative specimen) of 2 cm was the aim. During histological examination the distal resection margin was free of turnouts in all cases~ No rectal wash-outs with cytostatic agents were performed. In cases of APE, the perineal procedure ';vas performed simultaneously by a second team. Follow-up e x a m i n a t i o n s comprised clinical examination. including rectal/vaginal digital examination, laboratory findings (CEA, CA 19-9), a b d o m i n a l ultrasound and rigid rectoscopy every 3 m o n t h s for the first 2 years, at 6 m o n t h intervals fi-orn years 3 to 5 and at yearly intervals thereafter. I,a addition chest X-rays every 6 months, pancolonoscopy and c o m p u t e d t o m o g r a p h y (CT) each year were performed. 1,1 1990 we also introduced e n d o s o n o g r a p h y to our followup programme. Local recurrence rates and 5-year survival probabilities were estin'tated for the A R and A P E group. Further c o m p a r i s o n s were carried out between hand-sewn and stapled anastomoses after AR, and between patients after A R and A P E for tumours 2 to 6 cm from the dentate line.
Statistical anaIjwis The cumulative surviwtl probabilities were c o m p u t e d by the product lirnit a p p r o a c h ( K a p l a n - M e i e r technique). This method also yields estimates for the 5-year survival probabilities and their associated s t a n d a r d errors. Statistical
Table 2. Local recurrences after rectal cancer 2 to 6 cm from tile dentata line related to
primary operation, stage and tumour differentiation APE (11 = 41) n Stage
A B
Grade
C Well Moderate Poor
10 19 12 I1 20 10
f
REC (n = 2)
AR (n = 33)
REC(n = 7)
%
n
%
it
%
n
%
24 46 30 27 49 24
0
0
I
5
I 0 I I
8 0 5 10
8 12 13 7 18 8
24 36 40 21 55 24
0 3 4 1 4 2
0 25 31 14 22 25
APE = Abdominoperineal excision: AR = Anterior resection: REC = Local recurrence; number of cases.
n =
642
J. T s c h m e l i t s c h et al.
1°°i 9o
/ ....
,
60
~J
50 40 30 '20 10
......... I........... I........... I........... I........... I........... 12 24 36 48 60 72 Months Fig. l. Cumulative survival probabilities after anterior resection (AR. --) and abdominoperineal excision (APE, - - ) for rectal carcinoma 2 to 6 cm from the dentata line showing no statistically significant difference. Five-year survival probability after APE: 84% (95% CI = 68-99%), after AR: 65% (95% CI = 36-96%).
No correlation between distal margin and recurrence could be found. Distal margins in the seven cases with recurrent tumour after A R were 1.4 to 2.8 cm (median 2.4 cm). The median distal margin in the 26 patients who did not develop local recurrence was 2.6 cm. T u m o u r stage and differentiation in the cases with recurrence after low rectal cancer are shown in Table 2. The 5-year survival probabilities showed no significant difference. 5-year survival probability was 84% (SE = 7.3%; 95% CI = 68-99%) after APE, and 65% (SE = 15.5%; 95% CI = 36-96%) after A R (for survival curves see Fig. I). N o n e of the recurrences in this subgroup developed after primary Dukes' A carcinoma (8 AR, 10 APE).
Discussion During the last few years an increase in the number of sphincter-saving operations for low and especially mid-rectal carcinomas has developedJ 6 This is due to the fact that a distal resection margin of 2 cm is obviously sufficient in terms of oncological principles, tT--'°Distal intramural spread occurs in only 10% of tumours and is, moreover, a poor prognostic sign often associated with extensive lymphatic involvement and disseminated disease. Indeed, patients may not be salvaged by wider resection margins. Furthermore, the introduction of stapling devices has clearly improved the technical feasibility of anastomoses after low resections. The safety and reliability ofcircular stapling instruments are now generally acknowledged. According to some authors, -''9-~
A R for mid- and low rectal cancer shows a higher recurrence rate than does APE. Other authors deny an increased risk for recurrence after restorative procedures. 5 s To adequately resolve this controversy prospective studies are needed and these, to our knowledge, are not yet available. This study was a retrospective one, however, the two groups of patients undergoing A R or APE showed no difference as far as age, sex, stage and grading were concerned. Overall survival probabilities in our study were similar in the A R and APE group. There appears to be a slight trend towards more local recurrences after AR, however we could not show that this trend reached the level of statistical significance. Regarding tile comparison of hand-sewn and stapled anastomosis, our results did not show an increased risk for either procedure. Basically, there is little controversy about the treatment of upper rectal tumours. In these cases an A R is the operation of choice. On the other hand, for tumours 0 to 2 cm from the dentata line an APE is performed by most surgeons because of oncological and also technical reasons. The crucial point concerns the adequate treatment of very low rectal carcinomas where restorative procedures with a distal margin of clearance of at least 2 cm are technically feasible, but might result in a higher rate of local recurrence. In our study significantly higher recurrence rates were found after A R compared to APE for tumours 2 to 6 cm from the dentata line. All recurrences developed after Dukes" B and C tumours. No recurrent turnouts developed following a Dukes" A carcinoma. Distal margins of clearance in patients with recurrent tumours did not differ from patients without recurrences. It is argued that a 2 cm distal margin might not be acceptable for poorly differentiated tumours and the conventional 5 cm margin is still necessary in patients with these turnouts. In our study two of eight patients (25%) developed local recurrence after A R for poorly differentiated low rectal cancer, compared with five of 25 patients (20%) with well or moderately differentiated tumours. However our numbers are too small to draw conclusions regarding the sufficiency of a 2 cm distal margin in poorly differentiated rectal cancer. From our data we were not able to distinguish between pelvic and so-called anastomotic recurrences. However, according to several studies 2~-23 suture line recurrences seem to b~ rare and are related to secondary invasion of the adjacent bowel from a pelvic recurrence rather than to actual growth of turnout cells on the anastomotic line. Although the excised specimen showed clear margins in all patients, the importance of the lateral resection margin might have been underestimated in the histological examination. Quirke e t al. "-4 have suggested that local recurrence is predominantly a factor of incomplete circumferential clearance when the tumour extends beyond the muscularis propria. Further studies should be carried out because controversy still exists in this area. The possible increased risk for restorative procedures for advanced low rectal tumours has to be attributed to tile operative technique rather than to tumour biology. Trying to approach the bowel below the tumour, surgeons tend to take less surrounding perirectal tissue, possibly leaving
Recurrence o f rectal cancer viable t u m o u r cells b e h i n d , b e c a u s e the d i s s e c t i o n b e c o m e s m o r e difficult in the d e p t h s o f the pelvis.-' t3 In a n A P E this p r o b l e m d o e s n o t o c c u r b e c a u s e all the tissue c a n be excised w i t h o u t t h e necessity o f a p p r o a c h i n g the bowel wall. O u r r e c u r r e n c e rate a f t e r A R for locally a d v a n c e d low rectal t u m o u r s c o r r e s p o n d s to t h e results o f several a u t h o r s .,.~..,5 .,s b u t lower r e c u r r e n c e f r e q u e n c i e s are r e p o r t e d by o t h e r s . ~''''-9 ~-' C o m p a r i s o n s are difficult b e c a u s e o f t h e varied l o c a t i o n o f t h e t u m o u r s in e a c h series a n d the a d d i t i o n o f a d j u v a n t i r r a d i a t i o n a n d c h e m o t h e r a p y in s o m e s t u d i e s . T h e r e is a wide r a n g e o f results. T h i s is d u e to several variables: dist r i b u t i o n o f t u m o u r l o c a t i o n , t u m o u r s t a g e a n d histological grade. O u r r e s u l t s s h o w a significantly r e d u c e d local r e c u r r e n c e rate a f t e r A P E c o m p a r e d to A R for a d v a n c e d low rectal c a n c e r s . H o w e v e r , this c o n c l u s i o n n e e d s to be c o n f i r m e d in p r o s p e c t i v e trials.
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16. 17.
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Accepted for publication 10 August 1995