Complete resection key to preventing recurrence in T4 rectal disease

Achieving clear surgical margins is essential to the successful treatment of multivisceral resections in rectal cancer, a study confirms.

"The ability to obtain negative margins and perform sphincter-preserving surgery were the factors most strongly associated with favourable survival," say Philip Paty (Memorial Sloan-Kettering Cancer Center, New York, USA) and colleagues.

In the retrospective study, 4.6 times as many patients with R1 resection status, defined as a need for re-excision due to an involved margin, had local disease recurrence within 5 years compared with patients with no microscopic margin disease, or R0 status (69 vs 15%).

Patients without metastases were 2.2 times more likely to die within 5 years if their tumor was incompletely resected compared with those whose tumors were completely resected (25 vs 64%).

The study included 124 rectal cancer patients with en bloc resection of an adjacent organ or part of an adjacent organ. The 5-year overall survival rate for all patients was 53.3% and the 5-year local recurrence rate was 18.8%. The authors noted that in comparison to previous studies of standard rectal resection, there was a high prevalence of women in their sample (72.6%) and a low rate of sphincter preservation (37.9%).

Reporting in the British Journal of Surgery, they found that the only factor associated with local recurrence was the completeness of resection.

Meanwhile, in addition to tumor resection status, factors associated with improved 5-year survival were sphincter-preserving surgery, lower overall pathologic stage, lower pathologic tumor category, absence of nodal disease, absence of metastatic disease, and absence of lymphovascular invasion.

Only 47 patients underwent sphincter-preserving surgery, which the authors suggest is due to the size of the tumors involved. Of patients who did not have sphincter-preserving surgery, 56% died within five years. However, patients in whom sphincter-preserving surgery was successfully performed had a 53% decreased risk for death within 5 years in comparison.

The authors also say that their study highlights a potential survival advantage for patients who respond well to neoadjuvant therapy. They found that, in the 100 patients who received neoadjuvant therapy, those with a tumor categorized T3-4 were at a 2.5 times greater risk for death within 5 years than those with tumor categorized as T0-2; however, this did not reach statistical significance.

This supports similar findings in standard rectal resection, although the authors stress that their small, retrospective study limits interpretation.

However, they conclude: "The data support the use of neoadjuvant treatment to downstage these large, locally advanced primary tumours and facilitate R0 resection."

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