Anatomical prognostic factors after abdominal perineal resection

Abstract The natural history of 153 patients with rectosigmoid adenocarcinoms treated by abdominal perineal resection was retrospectively studied with emphasis on survival, clinical signs and symptoms of recurrence distantly and in the pelvis. We analyzed diagnostic factors that might predict tumor stage preoperatively and anatomical factors of the tumor itself that might predict behaviour of the lesion. Age, sex, tumor size, and distance from the anal verge were not useful in predicting stage. Constriction of the lesion tended to occur with high stage, but was not a reliable predictor. The grade or differentiation of the biopsy (when noted) did not correlate with either the grade of the resected specimen or the stage. The highest grade of the resected specimen was quite predictive of subsequent outcome. Seventy-three percent of the poorly differentiated tumors were Stage C or D, though a lower grade specimen did not rule out high stage. The Astler-Coller stage was reliable in predicting the likelihood of survival, pelvic recurrence, and distant metastases. In Stage C patients, the number of positive lymph node metastases strongly affected prognosis: if only one node was positive, survival was intermediate between Stages B and C; if more than seven modes were positive, no patient survived. Of the evaluable cases, 48% survived clinically free of disease five or more years; 43% failed (died of the rectosigmoid tumor); 22% developed pelvic recurrence (6% pelvis only, 16% pelvis plus distant metastases). Fifty-two percent of the patients falling had tumor in the pelvis. Seven of the 56 failures (13%) occurred at or after fire years; six of these seven failed locally, usually with metastases. Patients under age 40 or over age 80 had the same results as the group in general. Sixteen percent of the entire group had major complications 52% minor. There were eight postoperative deaths (5%); 18 patients (12%) required reoperation. This series documents the need for adjuvant therapy without, however, resolving which adjuvant therapy is optimal. The data indicate that distant metastases may sometimes result from local failure. We feel that adjuvant therapy, particularly pelvic irradiation, will not only decrease pelvic failure, but may also decrease the rate of distant metastases and substantially increase disease-free survival.