Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?
intersphincteric resection
neoadjuvant radiotherapy
sphincter saving surgery
ultra low rectal carcinoma
Journal
Journal of surgical oncology
ISSN: 1096-9098
Titre abrégé: J Surg Oncol
Pays: United States
ID NLM: 0222643
Informations de publication
Date de publication:
Jan 2021
Jan 2021
Historique:
received:
01
09
2020
accepted:
19
09
2020
pubmed:
25
10
2020
medline:
12
1
2021
entrez:
24
10
2020
Statut:
ppublish
Résumé
Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR). ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection. Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%). GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.
Sections du résumé
BACKGROUND
BACKGROUND
Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR).
METHODS
METHODS
ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection.
RESULTS
RESULTS
Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%).
CONCLUSION
CONCLUSIONS
GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.
Types de publication
Clinical Trial, Phase III
Journal Article
Multicenter Study
Randomized Controlled Trial
Langues
eng
Sous-ensembles de citation
IM
Pagination
299-310Informations de copyright
© 2020 Wiley Periodicals LLC.
Références
Goligher JC. Bradshaw lecture, 1978. Recent trends in the practice of sphincter-saving excision for rectal cancer. Ann R Coll Surg Engl. 1979;61(3):169-176.
Rouanet P, Fabre JM, Dubois JB, et al. Conservative surgery for low rectal carcinoma after high dose radiation. Functional and oncological results. Ann Surg. 1995;221:67-73.
Rouanet P, Saint-Aubert B, Lemanski C, et al. Restorative and nonrestorative surgery for low rectal cancer after high-dose radiation: long-term oncologic and functional results. Dis Colon Rectum. 2002;45:305-313.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;2:996-999.
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44:77-80.
Rullier E, Zerbib F, Marrel A, Amouretti M, Lehur PA. Validation of the French fecal incontinence quality of life scale. Gastroenterol Clin Biol. 2004;28:562-568.
Maas M, Beets-Tan RGH, Lambregts DMJ, et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol. 2011;29:4633-4640.
Habr-Gama A, Sabbaga J, Gama-Rodrigues J, et al. Watch and wait approach following extended neoadjuvant chemoradiation for distal rectal cancer: are we getting closer to anal cancer management? Dis Colon Rectum. 2013;56(10):1109-1117.
Stijns RCH, de Graaf EJR, Punt CJA, et al. Long-term oncological and functional outcomes of chemoradiotherapy followed by organ-sparing transanal endoscopic microsurgery for distal rectal cancer: the CARTS study. JAMA Surg. 2019;154(1):47-54.
Rullier E, Rouanet P, Tuech JJ, et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet. 2017;390(10093):469-479.
Rouanet P, Aubert BS, Fabre JM, et al. Conservative treatment for low rectal carcinoma by local excision with or without radiotherapy. Br J Surg. 1993;80:1452-1456.
Tilney HS, Heriot AG, Purkayastha S, et al. A national perspective on the decline of abdominoperineal resection for rectal cancer. Ann Surg. 2008;247:77-84.
National bowel cancer audit (NBOCA): annual report 2019: https://www.nboca.org.uk/content/uploads/2020/01/NBOCA-2019-V2.0.pdf. Accessed May 8, 2020.
Keller DS, Reif de Paula T, Kiran RP. Ready for the National Accreditation Programs for rectal cancer? Auditing rectal cancer outcomes in the United States. Colorectal Dis. 2019;21:1213-1215.
Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Who performs proctectomy for rectal cancer in the United States? Dis Colon Rectum. 2011;54(10):1210-1215.
Roxburgh CSD, Strombom P, Lynn P, et al. Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes. Colorectal Dis. 2019;21(10):1140-1150.
Warschkow R, Ebinger SM, Brunner W, Schmied BM, Marti L. Survival after abdominoperineal and sphincter-preserving resection in nonmetastatic rectal cancer: a population-based time-trend and propensity score-matched SEER analysis. Gastroenterol Res Pract. 2017;2017:605-907.
Ghadban T, Reeh M, Bockhorn M, et al. Minimally invasive surgery for colorectal cancer remains underutilized in Germany despite its nationwide application over the last decade. Sci Rep. 2018;8(1):15146.
Park JS, Park SY, Kim HJ, Cho SH, Kwak SG, Choi GS. Long-term oncologic outcomes after neoadjuvant chemoradiation followed by intersphincteric resection with coloanal anastomosis for locally advanced low rectal cancer. Dis Colon Rectum. 2019;62(4):408-416.
Marwan K, Staples MP, Thursfield V, Bell SW. The rate of abdominoperineal resections for rectal cancer in the state of Victoria, Australia: a population-based study. Dis Colon Rectum. 2010;53(12):1645-1651.
Ogura A, Konishi T, Cunningham C, et al. Neoadjuvant (chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: results of the multicenter lateral node study of patients with low cT3/4 rectal cancer consortium. J Clin Oncol. 2019;37(1):33-43.
Conroy T, Lamfichekh N, Etienne PL, et al. Total neoadjuvant therapy with mFOLFIRINOX versus preoperative chemoradiation in patients with locally advanced rectal cancer: final results of PRODIGE 23 phase III trial, a UNICANCER GI trial. JCO. 2020;38:4007. 38.15_suppl.4007.
Van der Valk MJM, Marijnen CAM, Van Etten B, et al. Compliance and tolerability of short-course radiotherapy followed by preoperative chemotherapy and surgery for high-risk rectal cancer-results of the international randomized RAPIDO-trial. Radiother Oncol. 2020;147:75-83.
Kim CH, Yeom SS, Kwak HD, et al. Clinical outcomes of patients with locally advanced rectal cancer with persistent circumferential resection margin invasion after preoperative chemoradiotherapy. Ann Coloproctol. 2019;35(2):72-82.
Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum. 2004;47(1):48-58.
Wang XT, Li DG, Li L, Kong FB, Pang LM, Mai W. Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer. Pathol Oncol Res. 2015;21(1):19-27.
Guren MG, Eriksen MT, Wiig JN, et al. Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer. Eur J Surg Oncol. 2005;31(7):735-742.
Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ. Patients with low rectal cancer treated by abdominoperineal excision have worse tumors and higher involved margin rates compared with patients treated by anterior resection. Dis Colon Rectum. 2010;53:53-56.
West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26:3517-3522.
Prytz M, Angenete E, Bock D, Haglind E. Extralevator abdominoperineal excision for low rectal cancer--extensive surgery to be used with discretion based on 3-year local recurrence results: a registry-based, observational national cohort study. Ann Surg. 2016;263(3):516-521.
Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg. 2012;204(3):274-282.
Lehtonen T, Räsänen M, Carpelan-Holmström M, Lepistö A. Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit. Colorectal Dis. 2019;21:183-190.
den Dulk M, Putter H, Collette L, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer. 2009;45(7):1175-1183.
van Leersum N, Martijnse I, den Dulk M, et al. Differences in circumferential resection margin involvement after abdominoperineal excision and low anterior resection no longer significant. Ann Surg. 2014;259(6):1150-1155.
Lyttle JA, Parks AG. Intersphincteric excision of the rectum. Br J Surg. 1977;64:413-416.
Marks G, Mohiuddin M, Masoni L. The reality of radical sphincter preservation surgery for cancer of the distal 3 cm of rectum following high-dose radiation. Int J Radiat Oncol Biol Phys. 1993;27:779-783.
Kusunoki M, Shoji Y, Yanagi H, et al. Modified anoabdominal rectal resection and colonic J-pouch anal anastomosis for lower rectal carcinoma: preliminary report. Surgery. 1992;112:876-883.
Schiessel R, Novi G, Holzer B, et al. Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum. 2005;48:1858-1865.
Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg. 2005;241:465-469.
Saito N, Moriya Y, Shirouzu K, et al. Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience. Dis Colon Rectum. 2006;49:S13-S22.
Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg. 2012;99:603-612.
Collard M, Lefevre J. Ultimate functional preservation with intersphincteric resection for rectal cancer. Front Oncol. 2020;10:297.
Krishnamurty DM, Wise PE. Importance of surgical margins in rectal cancer. J Surg Oncol. 2016;113(3):323-332.
Mezhir JJ, Shia J, Riedel E, et al. Whole-mount pathologic analysis of rectal cancer following neoadjuvant therapy: implications of margin status on long-term oncologic outcome. Ann Surg. 2012;256(2):274-279.
Kuvshinoff B, Maghfoor I, Miedema B, et al. Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are < or = 1 cm distal margins sufficient? Ann Surg Oncol. 2001;8(2):163-169.
Rutkowski A, Bujko K, Nowacki MP, Chmielik E, Nasierowska-Guttmejer A, Wojnar A. Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? Ann Surg Oncol. 2008;15(11):3124-3131.
Rutkowski A, Nowacki MP, Chwalinski M, et al. Acceptance of a 5-mm distal bowel resection margin for rectal cancer: is it safe? Colorectal Dis. 2012;14(1):71-78.
Weiser MR, Quah HM, Shia J, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236-242.
Yeom SS, Park IJ, Jung SW, et al. Outcomes of patients with abdominoperineal resection (APR) and low anterior resection (LAR) who had very low rectal cancer. Medicine. 2017;96:e8249.
Park J, Yoon SM, Yu CS, Kim JH, Kim TW, Kim JC. Randomized phase 3 trial comparing preoperative and postoperative chemoradiotherapy with capecitabine for locally advanced rectal cancer. Cancer. 2011;117(16):3703-3712.
Sauer R, Liersch T, Merkel S, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926-1933.
Han YB, Oh SN, Choi MH, et al. Clinical impact of tumor volume reduction in rectal cancer following preoperative chemoradiation. Diagn Interv Imaging. 2016;97(9):843-850.
Memon S, Lynch AC, Bressel M, Wise AG, Heriot AG. Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy. Colorectal Dis. 2015;17(9):748-761.
Kanso F, Maggiori L, Debove C, Chau A, Ferron M, Panis Y. Perineal or abdominal approach first during intersphincteric resection for low rectal cancer: which is the best strategy? Dis Colon Rectum. 2015;58(7):637-644.