Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results.

OBJECTIVE: Using a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after high-dose radiation. SUMMARY BACKGROUND DATA: Colo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship. METHODS: Since June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3). RESULTS: Mortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients. CONCLUSIONS: These first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.

[Proctectomy and colo-anal anastomosis after high-dose irradiation of cancers of the lower third of the rectum. Functional and oncological results]. / Proctectomie et anastomose colo-anale après irradiation à hautes doses des cancers du tiers inférieur du rectum. Résultats fonctionnels et carcinologiques.

This prospective study was designed to evaluate morbidity and functional and oncological outcomes in patients with carcinoma of the distal third of the rectum treated by high-dose radiation therapy followed by conservative surgery. Twenty-two patients with adenocarcinoma of the distal third of the rectum treated after June 1990 were included in the study. Mean distances separating the tumor from the upper edge of the levator ani muscle and from the anal verge were 17 mm and 47 mm, respectively. None of the tumors were fixed; preoperative stage, established by endoscopic ultrasound, was T2 in 12 patients and T3 in 10. Patients received induction radiation therapy in two series delivered three weeks apart (40 Gy on the pelvis, then 20 Gy on the tumor only) followed by surgical resection (proctectomy with colo-anal anastomosis in 17 cases and amputation in five). After radiation, two tumors were negative for malignant cells, 12 were Astler-Coller B1, two were B2, and six were C2. Mean safety margin after colo-anal anastomosis was 16.8 mm; all the resection margins were negative. Mortality and morbidity were not increased by the high-dose radiation protocol. Conservation of the sphincter was possible in 80% of patients. All the patients were continent. Functional outcome was rated good in 77% of cases, fair in 9% and poor in 4%. During the mean follow-up of 24 months, there were three disease-related deaths, including one due to a strictly regional recurrence; metastatic dissemination to the lungs occurred in two patients and the remaining 17 patients (80%) were disease-free. These data suggest that high-dose radiation therapy followed by conservative surgery ensures satisfactory functional outcomes in patients with carcinomas of the distal rectum. Evaluation of oncological outcomes will require a longer follow-up.

Conservative treatment for low rectal carcinoma by local excision with or without radiotherapy.

Thirty-seven patients with low rectal carcinoma were treated by transanal resection between January 1979 and December 1988. Adjuvant radiotherapy was used in eight patients before operation, in 13 after operation and six patients had both preoperative and postoperative radiotherapy. The selection criteria for transanal resection were low, superficial tumours treated conservatively with curative intent (group 1, 18 patients) or patients medically unfit for (12) or refusing (seven) abdominoperineal resection (APR) (group 2, 19 patients). In group 1, the local recurrence rate was 11 per cent with an overall 5-year survival rate of 100 per cent. In group 2, the local recurrence rate was 53 per cent with an overall 5-year survival rate of 35 per cent. There was no postoperative mortality and minimal morbidity. Salvage of local failure was by APR in six patients. The survival rate after local recurrence was 70 per cent at 1 year and 30 per cent at 5 years. Transanal resection can be proposed as a curative procedure for selected low, small, minimally infiltrating and well differentiated adenocarcinomas. Local control might be improved by postoperative radiotherapy for Astler-Coller stage B1 tumours or those above 3 cm in diameter. Further trials should examine the results of high-dose (60 Gy) preoperative radiotherapy so that transanal resection might be employed for favourable post-irradiation stage (0 or A) lesions. This new strategy will benefit from a better evaluation of tumour response after primary radiotherapy and an improved assessment of histological excision margins.

Montpellier Cancer Institute strategy and experience in surgical treatment of multi-bilateral hepatic metastases from digestive tract cancers.

Montpellier Cancer Institute strategy and experience in surgical treatment of multi-bilateral hepatic metastases from digestive tract cancers is presented based on retrospective case by case analysis of survival time of 38 patients. The mean age was 46.2 years and the primaries were colorectal (22 patients) and endocrine (16 patients). Liver surgery was synchronous to the resection of primary lesions in 8 patients and metachronous in 22 patients. Two-step liver surgery was performed in 8 patients. Overall thirty-days postoperative mortality was 7.8% and morbidity 15.7% (wound sepsis, subphrenic abscess, transitory jaundice, biliary fistula). The analysis of survival time evidenced that with reasonable risk-benefit ratio the aggressive surgical approach can be justified especially in patients with endocrine primaries.

Endometrial carcinoma: a comparative analysis of the therapeutic results and causes of failure after treatment by radiation combined with surgery or radiation therapy alone.

At the present time endometrial carcinoma is considered to be among the most frequent of gynecological tumors and its incidence is now reaching that of cervix carcinoma. In this paper, we present the results of two series of treatment for endometrial carcinoma, one using the combination of surgery and radiation, the second one using radiation treatment alone. Indeed, due to our recruitment criteria between 1968 and 1978 at the Montpellier Cancer Institute, the proportion of patients treated exclusively by physical agents was more or less equal to those receiving combined treatment. In many cases, either because of the poor condition of the patient, or due to local involvement, irradiation alone was used. The report of the results explain the therapeutic failures and show by means of two sequential series how techniques have been developed. Previously treated patients were excluded (44 cases).

A new technique of total three-stage esophagectomy for carcinoma with a combined right cervical and thoracic approach.

Total esophagectomy with a combined right cervicothoracic approach can be considered to be an extension of the classic right abdominothoracic method. The inclusion of a wide operating field composed of the neck and thorax, as well as the upper right limb, makes the method applicable to both provisional and obligatory operations. The nonobligatory cervical phase constitutes a useful safety approach when frozen section biopsy of the residual esophagus yields positive specimens, if a conventional Lewis-Santy right abdominothoracic procedure has been chosen.

Multivariate analysis of prognostic factors for curative resectable rectal cancer.

Several reports have shown that prognostic factors of rectal cancer are pathological parameters such as lymph node metastases, tumour infiltration, perineural and venous infiltration, and clinical parameters such as tumour level, mobility of the tumour and number of quadrants involved. From 1979 to 1983, 208 patients were treated curatively for rectal cancer in Montpellier Cancer Institute. A multivariate analysis was done to evaluate prognostic factors of our population. Prognosis was influenced by lymph node metastases, preoperative radiotherapy, tumour infiltration and histological type. The role of preoperative radiotherapy in local control and in survival appeared highly significant. Our results confirm the importance of external beam irradiation in local recurrence and in survival as shown randomly in the EORTC prospective trial. The growing trend in sphincter-saving surgery should be associated with preoperative radiotherapy.

[Cancer of the rectum: treatment by a radiosurgical combination of 328 patients. Mono- and multivariate analysis of prognostic factors]. / Cancer du rectum: traitement par association radio-chirurgicale de 328 malades. Etude mono- et multifactorielle des facteurs de pronostic.

From 1973 to 1983, 328 patients have been treated for rectal carcinoma in the Centre Paul Lamarque by preoperative radiotherapy (40 Grays) followed by surgical excision. The average age was 64 years and the sex ratio was 2:1. Abdominoperineal resection was performed in 219 patients anterior resection in 99 patients and transanal resection in 10 patients. Overall 3 years survival was 82 p. 100 and 5 year survival was 73 p. 100. The five year local recurrence rate was 9.4 p. 100 with 3.5 p. 100 of patients having liver metastases. Monovariate analysis revealed that the local recurrence rate was influenced by tumor circumference (p = 0.005), tumor reduction after radiotherapy (p less than 0.001), histological type (p = 0.049), lymph node metastases and tumor infiltration (p = 0.001). Survival was influenced by lymph node metastases, tumor infiltration (p = 0.001) and histological type (p = 0.01). The multivariate analysis revealed that prognosis was influenced by lymph node metastases and tumor infiltration. The "down staging" induced by the radiotherapy did not modify the predictive value of these 2 prognostic parameters when compared to groups treated by surgery only.

Colorectal carcinoma in patients younger than 40 years of age. Montpellier Cancer Institute experience with 78 patients.

During an 18-year period, 2600 patients were treated for colorectal carcinoma in the Montpellier Cancer Institute. Of the 93 patients younger than 40 years of age (3.6%), 78 records were retrospectively studied. The overall 5-year survival rate was 30%. Their survival was not significantly affected by the site of the primary tumor, the degree of tumor differentiation, or sex. The only significant parameter was Dukes' staging at presentation (P less than 0.0001). An analysis of sites of recurrence revealed the frequency of liver metastasis, ovarian metastasis in women, and local recurrence of rectal cancer. Although the high failure rate in these areas clearly justifies aggressive combined therapy, the high frequency of inaugural Stage D patients (27%) and their short mean survival time (5 months), underline the crucial importance of early detection. However, it is unfortunate that colorectal cancer screening in young patients is difficult because of the low rates of precancerous states (4%).

Endometrial cancer: a comparative analysis of the therapeutic results and causes of failure after treatment by radiation combined with surgery or radiation therapy alone.

The present study involved 215 endometrial carcinoma patients. Ninety-nine were treated by combined irradiation and surgery (preoperative external irradiation and intracavitary insertion followed by total hysterectomy and lymphadenectomy). Radiotherapy alone was used with 116 patients i.e. whole pelvis external irradiation and Heyman radium packing (40 patients) or afterloading techniques with Fletcher-Suit-Delclos applicators and cesium (76-patients). The 5-year NED survival rate was 78.7% in the combined therapy group and 44% in the exclusive radiotherapy group. The locoregional recurrence rates were 10% in the combined group and 28% in the exclusive radiotherapy group. These results are discussed in relation to data in the literature and to biases introduced due to patient selection in this nonrandomized study. Five-year survival rates, locoregional recurrence rates and sites of failures are analyzed according to the different treatments. Modifications of the external irradiation and intracavitary techniques allowed us to obtain better results and fewer complications.