Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum

Objective To evaluate the complications and oncologic and functional result s of preoperative radiochemotherapy and sphincter-saving resection for T3 c ancers of the lower third of the rectum. Summary Background Data Carcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdomi noperineal resection, especially for T3 lesions. Few data are available eva luating concomitant chemotherapy with preoperative radiotherapy for increas ing sphincter-saving resection in low rectal cancer. Methods Between 1995 and 1999, 43 patients underwent preoperative radiochem otherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors, Patients re ceived preoperative radiotherapy with a mean dose of 50 Gy (range 40-54) an d concomitant chemotherapy with 5-FU in continuous infusion (n = 36) or bol us (n = 7). Sphincter-saving resection was performed 6 weeks after treatmen t, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patie nts had a protecting stoma. Results There were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patient s but one had closure of the stoma. Distal and radial surgical margins were respectively 23 +/- 8 mm (range 10-40) and 8 +/- 4 mm (range 1-20) and wer e negative in 98% of the patients. Downstaging (pT0-2N0) was observed in 42 % of the patients (18/43) and was associated with a greater radial margin ( 10 vs. 6 mm; P = .02). After a median follow-up of 30 months, the rate of l ocal recurrence was 2% (1/43), and four patients had distal metastases. Ove rall and disease-free survival rates were both 85% at 3 years. Functional r esults were good (Kirwan continence I, II) in 79% of the available patients (n = 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a coloni c pouch (74 vs. 16%; P = .01). Conclusions These results suggest that preoperative radiochemotherapy allow ed sphincter-saving resection to be performed with good local control and g ood functional results in patients with T3 low rectal cancers that would ha ve required abdominoperineal resection in most instances.