Selective Approach to Sphincter-Saving Procedure after Chemoradiation in Low Rectal Cancer

ABSTRACT

PURPOSE: The conventional surgical treatment for patients with potentially curable low rectal cancer is abdominoperineal resection. Recently there has been increasing interest in the use of preoperative radiation therapy and sphincter-saving procedure as primary therapy for selected low rectal cancers. We report our institutional experience with this approach. METHODS: From 1995 to 1997, Twelve patients with resectable distal rectal cancer were offered sphincter-saving procedure, excluding the patients whose pretreatment tumor presentation demonstrated fixation to anal sphincter or puborectalis muscle. The distance from the anal verge to the distal tumor margin at initial diagnosis ranged from 1 to 5 cm. Patients received a median 50.4 Gy and chemotherapy Surgery was carried out 4 to 8 weeks after radiation. RESULTS: No patient had toxic reaction that required interruption of chemoradiation. Four patients (33%) had complete pathologic response, but one patient with complete clinical response had residual cancer. Seven patients underwent hand-sewn coloanal anastomosis and five patients transanal excision en bloc. All patients were able to successfully undergo a sphincter-saving procedure. With a mean follow-up of 23 months (range, 6~32), the authors noted no recurrence or complication. Sphincter function was good in 92%. Daily bowel movements was two (range, 1~10). CONCLUSION: Preoperative chemoradiation appears promising in terms of better patient compliance, lesser toxicity, and downstaging tumor, making the sphincter-saving procedure feasible in carefully selected cases. Surgical resection remains essential to confirm and to achieve complete clinical remission. The results of preoperative chemoradiation and sphinctersaving procedure are encouraging, but more experience is needed to determine whether this approach ultimately has similar local control and survival rate compared to standard surgery.