Current Trends in the Rate of Rectal Cancer Restorative Operations in the Era of Neoadjuvant Chemoradiation
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Purpose of Review
The following review addresses the relationship between neoadjuvant chemoradiotherapy and the rate of restorative operations in patients with rectal cancer.
The rate of restorative operations performed for rectal cancer has improved over the past several decades. The relationship between this increase and the addition of neoadjuvant chemoradiotherapy to the treatment regimen for locally advanced rectal cancer is still being defined. Improved rates of sphincter-sparing procedures between patients who receive preoperative chemoradiation compared to those who receive treatment postoperatively have not been supported in the literature. The patients who seem to benefit from neoadjuvant therapy in terms of sphincter preservation are those with distal tumors. Better tumor response to neoadjuvant chemotherapy and longer interval to surgical intervention appear to have little if any benefit to preserving the sphincter.
Increased rates of restorative operations for rectal cancer seem to be most significant among distal tumors. The reasons for the increase are likely multifactorial and include improvements in patient selection, surgical technique, imaging modalities, and patient care. The role of neoadjuvant chemoradiotherapy in this setting remains equivocal.
KeywordsRectal cancer Rectal adenocarcinoma Neoadjuvant chemoradiotherapy Restorative operations Sphincter-sparing operations Sphincter preservation
Low anterior resection
Total mesorectal excision
Locally advanced rectal cancer
Clinical complete response
Pathologic complete response
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 6.Cancer NGVPMR. Rectal Cancer. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). 2016. p. 1–136. https://www.tri-kobe.org/nccn/guideline/colorectal/english/rectal.pdf
- 7.Grosek J, Velenik V, Edhemovic I, Omejc M. The influence of the distal resection margin length on local recurrence and long-term survival in patients with rectal cancer after chemoradiotherapy and sphincter-preserving rectal resection. Radiol Oncol. 2017;51(2):169–77. https://doi.org/10.1515/raon-2016-0030.CrossRefPubMedGoogle Scholar
- 8.Sineshaw HM, Jemal A, Thomas CR Jr, Mitin T. Changes in treatment patterns for patients with locally advanced rectal cancer in the United States over the past decade: an analysis from the National Cancer Data Base. Cancer. 2016;122(13):1996–2003. https://doi.org/10.1002/cncr.29993.CrossRefPubMedGoogle Scholar
- 10.Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, et al. Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys. 1999;44(5):1027–38. https://doi.org/10.1016/S0360-3016(99)00099-1.CrossRefPubMedGoogle Scholar
- 11.Hiotis SP, Weber SM, Cohen AM, Minsky BD, Paty PB, Guillem JG, et al. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg. 2002;194(2):131–5; discussion 135–136. https://doi.org/10.1016/S1072-7515(01)01159-0.CrossRefPubMedGoogle Scholar
- 12.Maas M, Nelemans PJ, Valentini V, Das P, Rodel C, Kuo LJ, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 2010;11(9):835–44. https://doi.org/10.1016/S1470-2045(10)70172-8.CrossRefPubMedGoogle Scholar
- 13.Pucciarelli S, Toppan P, Friso ML, Russo V, Pasetto L, Urso E, et al. Complete pathologic response following preoperative chemoradiation therapy for middle to lower rectal cancer is not a prognostic factor for a better outcome. Dis Colon Rectum. 2004;47(11):1798–807. https://doi.org/10.1007/s10350-004-0681-1.CrossRefPubMedGoogle Scholar
- 14.Gerard A, Buyse M, Nordlinger B, Loygue J, Pene F, Kempf P, et al. Preoperative radiotherapy as adjuvant treatment in rectal cancer. Final results of a randomized study of the European Organization for Research and Treatment of Cancer (EORTC). Ann Surg. 1988;208(5):606–14. https://doi.org/10.1097/00000658-198811000-00011.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Aschele C, Pinto C, Cordio S, Rosati G, Tagliagambe A, Artale S, et al. Preoperative fluorouracil (FU)-based chemoradiation with and without weekly oxaliplatin in locally advanced rectal cancer: pathologic response analysis of the Studio Ter-apia Adjuvante Retto (STAR)-01 randomized phase III trial. J Clin Oncol. 2009;27(18S):CRA4008. https://doi.org/10.1200/jco.2009.27.18s.cra4008.CrossRefGoogle Scholar
- 16.Crane CH, Skibber JM, Feig BW, Vauthey JN, Thames HD, Curley SA, et al. Response to preoperative chemoradiation increases the use of sphincter-preserving surgery in patients with locally advanced low rectal carcinoma. Cancer. 2003;97(2):517–24. https://doi.org/10.1002/cncr.11075.CrossRefPubMedGoogle Scholar
- 17.Roh MS, Colangelo LH, O’Connell MJ, Yothers G, Deutsch M, Allegra CJ, et al. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol. 2009;27(31):5124–30. https://doi.org/10.1200/JCO.2009.22.0467.CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Bujko K, Kepka L, Michalski W, Nowacki MP. Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials. Radiother Oncol. 2006;80(1):4–12. https://doi.org/10.1016/j.radonc.2006.04.012.CrossRefPubMedGoogle Scholar
- 19.Gerard JP, Rostom Y, Gal J, Benchimol D, Ortholan C, Aschele C, et al. Can we increase the chance of sphincter saving surgery in rectal cancer with neoadjuvant treatments: lessons from a systematic review of recent randomized trials. Crit Rev Oncol Hematol. 2012;81(1):21–8. https://doi.org/10.1016/j.critrevonc.2011.02.001.CrossRefPubMedGoogle Scholar
- 20.•• Song JH, Jeong JU, Lee JH, Kim SH, Cho HM, Um JW, et al. Preoperative chemoradiotherapy versus postoperative chemoradiotherapy for stage II-III resectable rectal cancer: a meta-analysis of randomized controlled trials. Radiat Oncol J. 2017;35(3):198–207. https://doi.org/10.3857/roj.2017.00059. This is a meta-analysis of randomized trials which found no difference in restorative operation rates between postoperative and NCRT; however, in subgroup analysis, conversion from planned APR to a sphincter-sparing procedure was seen in those patients with distal rectal tumors. CrossRefPubMedPubMedCentralGoogle Scholar
- 21.• MAS K, Ang CW, Hakeem AR, Scott N, Saunders RN, Botterill I. The impact of tumour distance from the anal verge on clinical management and outcomes in patients having a curative resection for rectal cancer. J Gastrointest Surg. 2017;21(12):2056–65. https://doi.org/10.1007/s11605-017-3581-0. This study characterizes the outcomes in distal tumors and finds that tumor distance results in higher rates of NCRT but also higher rates of non-restorative operations.CrossRefGoogle Scholar
- 22.Habr-Gama A, Perez RO, Nadalin W, Nahas SC, Ribeiro U Jr, Silva ESAH Jr, et al. Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg. 2005;9(1):90–9; discussion 99–101. https://doi.org/10.1016/j.gassur.2004.10.010.CrossRefPubMedGoogle Scholar
- 23.Gerard JP, Chapet O, Nemoz C, Hartweig J, Romestaing P, Coquard R, et al. Improved sphincter preservation in low rectal cancer with high-dose preoperative radiotherapy: the lyon R96-02 randomized trial. J Clin Oncol. 2004;22(12):2404–9. https://doi.org/10.1200/JCO.2004.08.170.CrossRefPubMedGoogle Scholar
- 24.Ihn MH, Kim YH, Kim DW, Oh HK, Lee SY, Park JT, et al. Effects of preoperative chemoradiotherapy on the likelihood of sphincter preservation surgery in locally advanced distal rectal cancer: a longitudinal study based on pelvic magnetic resonance imaging. Ann Surg Oncol. 2015;22(7):2159–67. https://doi.org/10.1245/s10434-014-4286-1.CrossRefPubMedGoogle Scholar
- 26.Francois Y, Nemoz CJ, Baulieux J, Vignal J, Grandjean JP, Partensky C, et al. Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J Clin Oncol. 1999;17(8):2396. https://doi.org/10.1200/JCO.19184.108.40.2066.CrossRefPubMedGoogle Scholar
- 27.• Du D, Su Z, Wang D, Liu W, Wei Z. Optimal interval to surgery after neoadjuvant chemoradiotherapy in rectal cancer: a systematic review and meta-analysis. Clin Colorectal Cancer. 2017; https://doi.org/10.1016/j.clcc.2017.10.012. This article reviews the relevant literature for the optimal wait period to surgery after NCRT and found that while the rates of pCR were higher, this had no impact on rates of sphincter preservation.
- 29.Krouse RS, Herrinton LJ, Grant M, Wendel CS, Green SB, Mohler MJ, et al. Health-related quality of life among long-term rectal cancer survivors with an ostomy: manifestations by sex. J Clin Oncol. 2009;27(28):4664–70. https://doi.org/10.1200/JCO.2008.20.9502.CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Ozgen Z, Ozden S, Atasoy BM, Ozyurt H, Gencosmanoglu R, Imeryuz N. Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis. Radiat Oncol. 2015;10(1):168. https://doi.org/10.1186/s13014-015-0479-4.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Battersby NJ, Juul T, Christensen P, Janjua AZ, Branagan G, Emmertsen KJ, et al. Predicting the risk of bowel-related quality-of-life impairment after restorative resection for rectal cancer: a multicenter cross-sectional study. Dis Colon Rectum. 2016;59(4):270–80. https://doi.org/10.1097/DCR.0000000000000552.CrossRefPubMedGoogle Scholar