Outcome of patients with rectal adenocarcinoma and localized pelvic non-nodal metastatic foci

PURPOSE: The aim of this study was to evaluate the outcome of patients with primary rectal adenocarcinoma and soft tissue metastatic foci restricted t o the pelvis and to determine whether this entity, which is considered N1 d isease in the American Joint Committee on Cancer staging system, behaves li ke completely replaced nodal disease or the first sign of M1 disease. The c linical course for patients with this finding is not well-described in the literature. METHODS: The authors retrospectively reviewed the medical recor ds of 395 patients with rectal adenocarcinoma who received radiation treatm ent. Eighteen patients had pelvic soft tissue metastatic foci. Exclusions f rom this study included 1) cases without metastatic pelvic foci; 2) cases o f recurrent cancer; 3) cases with known distant metastatic disease as defin ed by American Joint Committee on Cancer criteria; and 4) cases with extrap elvic metastatic foci. All patients received adjuvant radiotherapy. Thirtee n cases received preoperative radiotherapy. Four cases received postoperati ve radiotherapy. One case received both preoperative and postoperative radi otherapy. Eight cases received chemotherapy. RESULTS: All eighteen patients had T3 or T4 lesions. Thirteen patients had lymph nodes that contained met astatic disease and would therefore have been scored N1 or N2 even without the pelvic tumor implants. Sixteen of 18 (89 percent) patients died of dise ase after a survival time of 12 to 37 (mean, 25) months. Only 1 of 18 (6 pe rcent) patients was disease free at five years. The other remaining survivo r was undergoing palliative therapy for metastatic disease to the lung. Thi s is significantly worse than our institution's experience with T3,4N+ dise ase after: preoperative radiation (5-year survival, 11 vs. 56 percent; P = 0.0002, Generalized Wilcoxon of Breslow). There was a high incidence of loc al (9/18) and distant (14/18) failure. No other factor, including radiation dose, margin status, chemotherapy, T stage, and number of involved nodes o r soft tissue implants, correlated independently with outcome. CONCLUSIONS: Pelvic metastatic foci confer a significantly worse prognosis than other T 3,4N+ disease. Such cases should be excluded from prospective trials for lo calized disease. Although this entity probably represents M1 disease for mo st patients, survival can be long, and aggressive locoregional and systemic treatment is warranted.