Pelvic recurrence after surgical treatment of rectal and sigmoid cancer: A prospective clinical trial on 274 patients

The aim of this collaborative prospective study was to verify the incidence of pelvic recurrence (PR) after radical surgery for cancer of the rectum and sigmoid. Very low anterior resection (VLAR) was usually performed, with the aim of preserving anal function and obtaining the maximum of radicality by means of en bloc excision of the mesorectum. Between 1984 and 1987, 274 patients underwent curative surgery for rectal and sigmoid cancer, 230 (84%) of whom underwent anterior resection (AR) and 44 (16%) abdominoperineal resection (APR). Post-operative mortality was 2.5%. Follow-up ranged from 24 to 72 months (mean 37 m); 248 cases (90.5%) were included in the final prospective study. PR occurred in 41/248 cases (16%), within 24 months in 80% of cases. PR occurred in 15.8% (33/208) after AR and in 20% (8/40) after APR, p=NS. Nevertheless in middle and low rectal tumours at stage C the incidence of PR in patients who had VLAR was 34.5% (10/29) and 12% (3/25) in those who had APR (p<0.05). PR rates in VLAR patients was 40% for stage C low rectal tumours and 54.5% for low rectal tumours at Astler Coller stage C2. The PR incidence for stage C1 tumours of the low rectum was zero after VLAR and APR, allowing the assumption that lymphnode metastases in non-penetrating tumours do not compromise the results when the mesorectum is completely excised. We can assume that the choice of VLAR as a substitute for APR whenever possible limits the comparison of their results. However before performing a VLAR for an advanced tumour of the middle or low rectum it is necessary to consider the high risk of PR, which, after conservative AR, causes greater distress to the patient and is less effectively treated with radiotherapy.