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[Surgery and radiotherapy in rectal cancer: indications for anal sphincter conservation]
C Coco1, V Valentini, S Cogliandolo
1Ist. Patologia Chirurgica, Università Cattolica S. Cuore Roma.
Purpose:
Aim of this study is to evaluate the possible increase of sphincter preservation rate in locally advanced extraperitoneal rectal cancer after neoadjuvant treatment.
Methods:
123 patients with a T3 or N+ cancer of middle or lower rectum have been included in this study. Accurate measurement of pre-treatment tumor distance from the anal canal and an individual judgment of the surgeon about the technical feasibility of a sphincter saving resection have been recorded. Two different protocols of concomitant preoperative chemoradiation have been adopted. Radiotherapy ranged from 37.8 to 50.4 Gy. Chemotherapy regimens included mitomycin-C 10 mg/m2; 5FU 1000 mg/m2 and c-DDP 60 mg/m2. All patients underwent surgery 4-8 weeks after the end of chemoradiation.
Results:
16 out of a total 121 resected patients (13%) had a complete histologically response at surgical specimen examination (pT0). The post-treatment variation of tumor distance from the anal canal was 1 cm. in 50% of cases, 2 cm. in 20% of cases and > 3 cm. in 10% of cases. 80% of patients (97/121) could benefit of a sphincter saving procedure compared to a pre-treatment expected rate of 55%. 69% of 70 patients with a tumor of the distal rectum maintained their sphincter function; in particular, a sphincter saving procedure was made possible in 16 of 37 patients (43%) with a tumor located in the distal 3 cm. of the rectum. No significant difference in sphincter saving rate was observed between the two different protocols of neoadjuvant treatment.
Discussion:
Decrease of tumor size, post-treatment variation of tumor distance from the anal canal, histological downstaging and decrease of tumor fixity to adjacent structures are the main effects of neoadjuvant treatment which are responsible for an increase of sphincter saving rate.
Conclusion:
According to the presented data, neoadjuvant protocols of concomitant chemoradiation therapy are effective in increasing the rate of sphincter saving procedures in locally advanced cancer of distal rectum.