Local excision and postoperative radiotherapy for distal rectal cancer

Purpose: To assess the outcome following local excision and postoperative r adiotherapy (RT) for distal rectal carcinoma. Materials and Methods: Seventy-three patients received postoperative radiot herapy following local surgery for primary recta carcinoma at Princess Marg aret Hospital from 1983 to 1998. Selection factors for postoperative RT wer e patient preference, poor operative risks, and "elective" where conservati ve therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1-8 cm). There were 24 Tl, 36 T 2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tum or specimens in which margins could be adequately assessed, they were posit ive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. M edian tumor dose was SO Gy (range, 38-60 Gy), and 62 patients received 50 G y in 2.5-Gy daily fractions. The tumor volume included the primary with 3-5 cm margins. No patients received adjuvant chemotherapy. Median follow-up w as 48 months (range, 10-165 months). Results: Overall 5-year survival and disease-free survival were 67% and 55% , respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; a nd 3 relapsed distantly only. For patients with Tl, T2, and T3 lesions, 5-y ear local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-ye ar survival rates were 76%, 58%, and 33%, respectively. The 5-year local re lapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52 % vs. 89 %, p = 0.03, or where tumor fragmentation o ccurred during local excision compared to no fragmentation, 51 % vs. 76%,p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoper ineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86 % at 5 and 10 yea rs. The 5-year colostomy-free rate was 82 %. There were 2 patients who expe rienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (b owel obstruction requiring surgery). Conclusion: The local relapse rate for patients with Tl disease was high co mpared to other series of local excision and postoperative RT. Patients wit h LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative R T. (C) 2001 Elsevier Science Inc.