Patterns of recurrence following high-dose preoperative radiation and sphincter-preserving surgery for cancer of the rectum

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Abstract
High-dose preoperative radiation with new sphincter-preserving surgical options for the management of distal and unfavorable cancers of the rectum is gaining recognition as an alternative to abdominoperineal resection and permanent colostomy. From 1976 to 1989, 161 patients with cancer of the rectum were entered into a program of high-dose preoperative radiation and radical sphincter-preserving surgery. Selection was based on prospective clinical staging of unfavorability or tumor location at a low level in the rectum. All patients received a minimum dose of 4,000 to 4,500 cGy over 4 1/2 weeks in fractional doses of 180 to 250 cGy. Patients with tumor fixation were given an additional boost of 1,000 to 1,500 cGy for a total of 5,500 to 6,000 cGy using a coned-down field. Surgery was carried out four to eight weeks following completion of radiation. Fourteen patients, found at surgery to have liver metastasis, were treated by palliative resection. One hundred forty-seven patients underwent radical curative surgery with sphincter preservation. The surgical procedures performed were combined abdominotranssacral resection (63), transanal-abdominal-transanal resection (53), and anterior resection (31). Follow-up ranged from a minimum of two years to 15 years, with a median of five years. There was no perioperative mortality. Anastomotic failure occurred in three patients, two of whom were reconstituted. Late diversion was required in 10 other patients, primarily for recurrent disease. One hundred thirty-four of the 147 patients (91 percent) maintained long-term normal sphincter function. Pelvic-perineal recurrence was observed in 18 patients (12.4 percent), 12 of whom had fixed tumors located below the 6-cm level of the distal rectum. Median time to local recurrence was 24 months. Distant metastasis with or without local recurrence occurred in 35 patients, 22 of whom had fixed tumors below the 6-cm level of the rectum. Median time to distant metastasis was 17 months. Forty-three patients have died, 32 of disease. The overall five-year Kaplan-Meier actuarial survival for the total group of patients is 79 percent, with a disease-free survival of 73 percent. The findings of this study indicate that high-dose preoperative radiation used in combination with radical sphincter-preserving surgical techniques results in excellent local control of disease, improved survival, and enhanced quality of life with retention of normal anal sphincter function.