CRS Journal Reading

Reporter R1 : Chiang Kuan Yu

Rectal cancer guideline

Rectal cancer guideline

Abdomino-Perineal resection

Low anterior resection

Total Mesorectal Excision

However

Low recurrence rate with stage I rectal cancer in the range of 4~16% within 5 years.

Local excision remains controversial for T2 tumors

The primary aim To determine:

MATERIALS AND METHODS Retrospective study

Patients with: (175 patients) T1/2 N0 rectal adenocarcinoma LAR, APR, or Transanal local excision Without neoadjuvant or adjuvant CRT Apparent metastases on preoperative CT or PET were excluded.

Between 2000 -2008

At the Brigham and Women’s Hospital or Massachusetts General Hospital

Result

Local Recurrence

Overall Survival

Local Recurrence Time to local recurrence (TTLR)

as a surrogate for absolute risk of local recurrence (LR)

23 (16.8%) patients had a local recurrence. The median time was 1.1 years (0.1–7.8).

Local Recurrence Associated with an increase risk of LR

male sex (HR 2.9, p = 0.02) current alcohol use (HR 2.4, p = 0.04) lymphovascular invasion (HR 2.6, p = 0.05) tumor ulceration (HR 2.9, p = 0.01)

clinical data, race, smoking status, family history, and clinical presentation were not associated with local recurrence.

Tumor size, CRM, histological grade, preoperative CEA, peri-neural invasion, and large-vessel invasion were not related to local failure, although no patient had a positive CRM.

Overall Survival Among these patients, the median overall survival was 12

years.

Associated with decreased survival Age (at diagnosis) > 65 y/o (HR 2.3, p = 0.015), T2 pathologic stage (HR 2.9, p = 0.002), Tumor size >4.5 cm (HR 2.5, p = 0.04).

Within the clinical data, race, smoking status, family history, and clinical presentation were not associated with overall survival.

Degree of circumferential involvement, preoperative CEA, PNI, and large-vessel invasion were unrelated to mortality.

Approach relationship

No significant difference in risk of LR & OS between patients undergoing radical resection or local excision for T1 or T2 tumors.

Interestingly, there was a trend toward a significantly greater risk of LR for patients with pT2 tumors treated with LAR alone

Discussion Male lateral margin

More difficult to obtain in the male pelvis Significantly smaller CRM in men than in women

Male vs female patients A similar proportion of local excisions, LAR, and APR as well

as extent of lymph node dissection. Male patients had a significantly higher proportion of alcohol

users

Discussion Increase in risk of local recurrence in patients with

ulcerated tumors, both after radical surgery and local excision.

Not an independent risk factor for recurrence or mortality, but rather was associated with histological characteristics.

Discussion Alcohol use is a significant prognostic factor for patients

with rectal cancer after resection

Stronger with rectal tumors in comparison with colon tumors (previous study)

Ethanol metabolism genes-encoding dehydrogenases Genotoxic effect

Discussion T2 pathologic stage was an independent prognostic factor

for reduced survival in our patients.

We cannot exclude the possibility of micrometastasis within perirectal or pelvic lymph nodes that were not sampled.

May require radical surgery (ie, APR or LAR) and/or adjuvant therapies to maximize the likelihood of local control and survival

CONCLUSIONS Identification of prognostic factors Promoting individualized treatment