Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an internationalanalysis of 1411 patients

Aims: Improved local control and survival in the treatment of rectal cancer have been reported after total mesorectal excision and after extended lymp hadenectomy, Comparison of published results is difficult because of differ ences in patient populations and definitions. We compared three series of p atients who underwent standardized surgery [i.e. total mesorectal excision (TME) or D3 lymphadenectomy] with patients who underwent conventional surge ry, using actual patient data and uniform definitions. Methods: TME was performed at Memorial Sloan-Kettering Cancer Center, New Y ork, USA (n = 254) and the North Hampshire Hospital, Basingstoke, UK(n = 20 4). D3 lymphadenectomy was performed at the National Cancer Center, Tokyo ( rr = 233). Conventional surgery was used in hospitals in Norway (n = 366) a nd in hospitals of the Comprehensive Cancer Center West,;The Netherlands (n = 354). Only patients with a curatively resected primary TNM Stage II or S tage III rectal cancer within 12 cm from the anal verge were included. Results: Five-year overall survival and canter-specific survival were 62-75 % and 75-80%,respectively, in the standardized surgery groups and 42-44% an d 52%, respectively, in the conventional surgery groups. Local recurrence r ates ranged from 4 to 9% in the standardized surgery groups and 32-35% in t he conventional surgery groups. Conclusions: A 30% survival difference and 25% local recurrence difference is not likely to be caused by the shortcomings which are inherent in a non- randomized study: selection bias, assessment variability or stage migration . This study suggests that standardized surgery gives superior survival and local control when compared to conventional surgery.