Local Excision of T2 and T3 Rectal Cancers After Downstaging Chemoradiation

Colorectal cancer is the third most common site for cancer in men and women in the United States. It is estimated that there will be 36,400 new diagnoses of rectal cancer and 8,600 deaths from rectal cancer in the year 2000. 1 The current standard treatment for distal rectal cancer is abdominoperineal resection (APR), low anterior resection, or resection with coloanal anastomosis. These operations are associated with significant rates of death and complications, and local or distant recurrences occur in 10% to 65% of patients. 2 The complications associated with radical rectal surgical procedures include urinary dysfunction in 10% to 70%, sexual dysfunction in 13% to 70%, and anastomotic leaks in 5% to 17%, with death rates of 2% to 6%. 3–10 Compared with a radical resection for distal rectal cancer, local excision avoids a laparotomy, permanent colostomy, and the complications associated with pelvic dissection. The incidence of local recurrence even after radical surgery ranges from 10% to 29%. 11–14 A recent review of published series reported an 18.5% overall local recurrence rate after APR. The incidence of local recurrence increased with advancing stage: 8.5%, 16.3%, and 28.6% for Dukes A, B, and C, respectively. 11 Extrapelvic and distant recurrences occur in approximately 30% of patients. These patients likely present with occult metastatic disease and would not be expected to benefit from the more radical operations. The 5-year disease-free survival rate of patients with node-positive rectal cancers is 30% to 40%. 2 Therefore, most patients with advanced rectal cancers are not cured by radical resection of the tumor. For these reasons, treatment alternatives for distal rectal cancers are of interest. Historically, local excision for distal rectal cancers has been approached with caution because of the high rates of local recurrence. Local therapy alone for rectal cancer has been used for patients with significant comorbid conditions that make a more radical surgery prohibitive. With newer techniques in adjuvant radiation therapy and advancements in chemotherapy, it has been possible to explore the option of multimodality treatment schemas to improve local control rates and allow better functional outcomes in a select group of patients with distal rectal cancer. In the United States, initial studies of preoperative radiation treatment for rectal cancer were influenced by the lack of efficacy of low-dose (2,000–3,000 cGy) radiation. However, data from Europe suggest that preoperative radiation alone reduces local recurrence rates and improves overall survival compared with surgery alone 15 and was more effective than postoperative radiotherapy. 16 Combination therapy using moderate-dose (4,000–4,500 cGy) and high-dose (>5,000 cGy) chemoradiation has allowed downstaging of tumors in 59% to 76% of patients, with complete pathologic response rates of 20% to 44%. 17–20 These studies have encouraged the use of preoperative chemoradiation and expanded the realm of surgical options to include sphincter preservation. We report on a highly select group of patients with advanced distal rectal cancers who had good responses to preoperative chemoradiation therapy and were treated with transanal local excisions.