Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population-based study in the west Netherlands

doi:10.1016/S0748-7983(98)93500-4

European Journal of Surgical Oncology (EJSO)

Volume 24, Issue 6, December 1998, Pages 528-535

https://doi.org/10.1016/S0748-7983(98)93500-4 Get rights and content

Aims.

We carried out a population-based study of local recurrence rates in curatively resected patients with rectal cancer, diagnosed between 1988 and 1992. The first objective was to make an inventory of the overall local recurrence rate after non-standardized conventional surgery, inter-institutional recurrence rate variability, and correlations between patient- and tumour-related factors and recurrence rate. A second objective was to investigate the compliance to guidelines for post-operative radiotherapy.

Methods.

Data were obtained from the Comprehensive Cancer Centre West. The study comprised 1105 patients from 12 hospitals. Of these patients, 437 were ineligible because of missing medical records, no carcinoma, incorrect registration, no laparotomy, non-curative resection, or loss to follow-up.

Results.

The overall local recurrence rate was 22.5% with a range of 9–36% between the hospitals. These differences were not significant. Dukes' Astler-Coller stage, tumour location, and residual tumour were significant independent prognostic factors for the risk of local recurrence. Indications for post-operative radiotherapy were Dukes' Astler-Coller B2 and C tumours, positive surgical margins, and tumour spill. Compliance to the guidelines for radiotherapy was only 50%. However, no significant difference in recurrence rate was found between patients treated according to the guidelines and those not treated according to the guidelines.

Conclusion.

This study shows a large variability in local recurrence rate between the participating hospitals and confirms that the risk of recurrence in primary rectal cancer is dependent on Dukes' Astler-Coller stage, tumour location and residual tumour. Furthermore, this study contributes to the discussion about the feasibility of guidelines for post-operative radiotherapy.

References (47)

MacFarlaneJK et al.
Mesorectal excision for rectal cancer
Lancet
(1993)
QuirkeP et al.
Local recurrence of rectal adenocarcinoma due to inadequate surgical resection
Histopathological study of lateral tumour spread and surgical excision
Lancet
(1986)
MinskyBD et al.
Lymphatic vessel invasion is an independent prognostic factor for survival in colorectal cancer
Int J Radiat Oncol Biol Phys
(1989)
Rinnert GongoraS et al.
Multivariate analysis of recurrence after anterior resection for colorectal carcinoma
Am J Surg
(1989)
MollenRMHG et al.
Local recurrence and survival in patients with rectal cancer, diagnosed 1981–86: a community hospital-based study in the south-east Netherlands
Eur J Surg Oncol
(1997)
RanbargerKR et al.
Prognostic significance of surgical perforation of the rectum during abdominoperineal resection for rectal carcinoma
Am J Surg
(1982)
FieldingLP et al.
Surgeon-related variables and the clinical trial
Lancet
(1978)
SteeleRJ
The influence of surgeon case volume on outcome in site-specific cancer surgery
Eur J Surg Oncol
(1996)
HermanekP et al.
The importance of volume in colorectal cancer surgery
Eur J Surg Oncol
(1996)
VisserO et al.
Incidence of Cancer in The Netherlands, 1992
(1995)

WiggersT et al.

Surgery for local recurrence of rectal carcinoma

Dis Colon Rectum

(1996)

HarnsbergerJR et al.

Radical abdominopelvic lymphadenectomy: historic perspective and current role in the surgical management of rectal cancer

Dis Colon Rectum

(1994)

McArdleCS et al.

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival

Br Med J

(1991)

EnkerWE

Potency, cure, and local control in the operative treatment of rectal cancer

Arch Surg

(1992)

HealdRJ et al.

Results of radical surgery for rectal cancer

World J Surg

(1992)

MoriyaY et al.

Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection

Dis Colon Rectum

(1989)

PhillipsRK et al.

Local recurrence following ‘curative’ surgery for large bowel cancer: I. The overall picture

Br J Surg

(1984)

PilipshenSJ et al.

Patterns of pelvic recurrence following definitive resections of rectal cancer

Cancer

(1984)

MichelassiF et al.

Local recurrence after curative resection of colorectal adenocarcinoma

Surgery

(1990)

QuirkeP et al.

The prediction of local recurrence in rectal adenocarcinoma by histopathological examination

Int J Colorectal Dis

(1988)

SteinbergSM et al.

Importance of tumor pathology and morphology in patients with surgically resected colon cancer

Findings from the Gastrointestinal Tumor Study Group

Cancer

(1986)

BonfantiG et al.

Results of extended surgery for cancer of the rectum and sigmoid

Br J Surg

(1982)

DurdeyP et al.

The effect of malignant and inflammatory fixation of rectal carcinoma on prognosis after rectal excision

Br J Surg

(1984)

Cited by (170)

Complete pathological response in rectal cancer utilising novel treatment strategies for neo-adjuvant therapy: A systematic review
2021, European Journal of Surgical Oncology
Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates.
A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded.
Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%.
A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.
The technical aspects of rectal cancer surgery
2019, Seminars in Colon and Rectal Surgery
Despite recent advances in perioperative chemoradiation for the treatment of rectal cancer, surgery remains the only curative therapy for most patients. Surgeries for rectal cancer are considered some of the most technically challenging operations for colorectal surgeons due to the anatomy of the pelvis, proximity to critical structures, and the widespread use of preoperative chemoradiation. This review will focus on the technical aspects of surgery for rectal cancer and appraise the current literature on select controversial topics.
Early local recurrence and one-year mortality of rectal cancer after restricting the neoadjuvant therapy regime
2019, European Journal of Surgical Oncology
To reduce the risk of local recurrence after rectal cancer surgery, neoadjuvant radiotherapy (RT) can be applied. However, as this causes morbidity and increases mortality, new Dutch guidelines withhold RT in low-risk patients. The aim of this study is to investigate if early local recurrence and one-year mortality in rectal cancer patients has changed since this more restricting indication for neoadjuvant RT was introduced in 2014.
This retrospective study included all consecutive patients treated with a mesorectal excision for primary rectal cancer in the Amphia Hospital, the Netherlands, between January 2011 and July 2016. Data were extracted from the electronic patient records. Survival data were collected from the Municipal Personal Records Database.
Between 2011 and July 2016, 407 resections of primary rectal cancer without synchronic metastases were performed, 225 under the old guidelines and 182 under the new guidelines. Significantly fewer patients received neoadjuvant treatment under the new guidelines (89% vs 41%, p < 0.001). Both clinical tumour stage (p = 0.001) and clinical lymph node stage (p < 0.001) were lower in the new group, but no difference in pathologic TN-stage was found. There was no difference in one-year local recurrence (2.2% in both groups, p = 0.987), nor in one-year mortality (5.3% vs 3.8%, p = 0.479).
Introducing a new guideline and thereby restricting the indication for neoadjuvant RT in rectal cancer patients did not increase the early local recurrence rate or decreased one-year mortality in our hospital.
Radiotherapy of rectal cancer in elderly patients: Real-world data assessment in a decade
2018, Digestive and Liver Disease
There is paucity of data on the efficacy and toxicity of radiotherapy in rectal cancer (RC) elderly patients. The objective was to identify management strategies and resulting outcomes in RC patients ≥70 years undergoing radiotherapy.
A retrospective study included consecutive RC patients ≥70 years undergoing rectal radiotherapy.
From 2004–2015, 340 RC patients underwent pre-operative (n = 238; 70%), post-operative (n = 41, 12%), or exclusive (n = 61, 18%) radiotherapy, with a median age of 78.5 years old (range: 70–96). Radiotherapy protocols were tailored, with 54 different radiotherapy programs (alteration of the total dose, and/or fractionation, and/or volume). Median follow-up was 27.1 months. Acute and late grade 3–4 radio-induced toxicities were reported in 3.5% and 0.9% of patients. Metastatic setting (OR = 6.60, CI95% 1.47–46.03, p = 0.02), exclusive radiotherapy (OR = 5.08, CI95% 1.48–18.21, p = 0.009), and intensity-modulated radiotherapy (OR = 6.42, CI95% 1.31–24.73, p = 0.01) were associated with grade ≥3 acute toxicities in univariate analysis. Exclusive radiotherapy (OR = 9.79, CI95% 2.49–43.18, p = 0.001) and intensity-modulated radiotherapy (OR = 12.62, CI95% 2.05–71.26, p = 0.003) were independent predictive factors of grade ≥3 acute toxicities in multivariate analysis. A complete pathological response was achieved in 12 out of 221 pre-operative patients (5.4%). Age, tumor stage, and surgery were independent predictive factors of survival in multivariate analysis. At end of follow-up, 7.1% of patients experienced local relapse.
Radiotherapy for RC in elderly patients appeared safe and manageable, perhaps due to the tailoring of radiotherapy protocols. Tailored management resulted in acceptable rate of local tumor control.
Carbon-Ion Radiation Therapy for Pelvic Recurrence of Rectal Cancer
2016, International Journal of Radiation Oncology Biology Physics
Investigation of the treatment potential of carbon-ion radiation therapy in pelvic recurrence of rectal cancer.
A phase 1/2 dose escalation study was performed. One hundred eighty patients (186 lesions) with locally recurrent rectal cancer were treated with carbon-ion radiation therapy (CIRT) (phase 1/2: 37 and 143 patients, respectively). The relapse locations were 71 in the presacral region, 82 in the pelvic sidewalls, 28 in the perineum, and 5 near the colorectal anastomosis. A 16-fraction in 4 weeks dose regimen was used, with total dose ranging from 67.2 to 73.6 Gy(RBE); RBE-weighted absorbed dose: 4.2 to 4.6 Gy(RBE)/fraction.
During phase 1, the highest total dose, 73.6 Gy(RBE), resulted in no grade >3 acute reactions in the 13 patients treated at that dose. Dose escalation was halted at this level, and this dose was used for phase 2, with no other grade >3 acute reactions observed. At 5 years, the local control and survival rates at 73.6 Gy(RBE) were 88% (95% confidence interval [CI], 80%-93%) and 59% (95% CI, 50%-68%), respectively.
Carbon-ion radiation therapy may be a safe and effective treatment option for locally recurrent rectal cancer and may serve as an alternative to surgery.
Preoperative chemoradiotherapy for rectal cancer: Experience from one centre
2015, Cancer/Radiotherapie
Au cours des dernières décennies, la prise en charge des cancers du rectum a été nettement améliorée par l’optimisation du traitement chirurgical avec l’implémentation de l’excision totale du mésorectum et le développement des stratégies néoadjuvantes de radiothérapie avec ou sans chimiothérapie. Dans cette étude, nous avons évalué l’impact de l’évolution des pratiques sur l’efficacité du traitement au cours d’une période de 15 ans dans un centre expert.
Cette étude rétrospective a été conduite chez des patients qui ont reçu une chimioradiothérapie pour un adénocarcinome rectal localement évolué (de stade T3–4 ayant ou non colonisé les ganglions) entre 1993 et 2008 au centre hospitalier universitaire (CHU) Jean-Minjoz de Besançon. Nous avons étudié les taux de conservation sphinctérienne, de réponse complète histologique (ypT0), de contrôle et de survie, ainsi que la toxicité selon la chimiothérapie concomitante utilisée et la période de prise en charge.
Au total, 179 patients ont été ainsi pris en charge. Une dose moyenne de 45 Gy a été délivrée en 25 fractions de 1,8 Gy avec une chimiothérapie concomitante par 5-fluoro-uracile et leucovorine, capécitabine, et capécitabine et oxaliplatine pour respectivement 56,4, 28,5 et 15,1 % des patients. La probabilité de survie sans récidive à 5 ans était de 74,3 % et celle de survie globale de 68,8 %. Les taux de récidive locale et à distance étaient de 6,1 et 23,6 %. En analyse bifactorielle, la chimiothérapie concomitante par capécitabine et oxaliplatine a montré un taux de réponse complète histologique supérieur (22,2 % contre 6 % avec la capécitabine et 10, 3 % avec le 5-fluoro-uracile et la leucovorine) mais non significativement (p = 0,12), avec des taux de toxicité et d’interruption de traitement plus importants. Le taux de conservation sphinctérienne ne s’est pas amélioré significativement durant la période de prise en charge (1993–2004 contre 2005–2008), mais la probabilité de survie sans récidive a augmenté de 72,2 à 87,5 % (p = 0,03).
Nos résultats sont concordants avec ceux de la littérature. La chimiothérapie concomitante par 5-fluoro-uacile ou capécitabine reste le schéma standard. L’évaluation de la chimiothérapie néoadjuvante, avant la chimioradiothérapie, doit être poursuivie au regard de la prédominance des récidives à distance.
In recent decades, the management of rectal cancer has been significantly improved by optimizing the surgical treatment with the total mesorectal excision and the development of neoadjuvant radiotherapy with or without chemotherapy. In this study, we investigated the impact of changes in practice over a period of 15 years in an expert centre.
A monocentric study was conducted retrospectively on cT3-resectable T4 patients who received chemoradiotherapy for a locally advanced rectal adenocarcinoma between 1993 and 2008. We studied sphincter preservation, pathological complete response (ypT0), survival, and toxicities by different concomitant chemotherapy and treatment period.
Among the 179 patients who had a chemoradiotherapy, 56.4% were received concomitant 5-fluoro-uracil-leucovorin, 28.5% with concomitant capecitabine, and 15.1% with concomitant oxaliplatin and capecitabine. The average dose of radiotherapy was 45 Gy (25 × 1.8 Gy). Five-year disease-free survival was 74.3% and overall survival 68.8%. The rate of local recurrence and distant metastases were 6.1 and 23.6%. In multivariate analysis, concomitant chemotherapy oxaliplatin and capecitabine improved the pathological complete response rate (ypT0; capecitabine: 6%, 5-fluoro-uracil-leucovorin: 10.3%, capecitabine-oxaliplatin: 22.2%), but not significantly (P = 0.12) and with more toxicities, and treatment interruptions. Sphincter preservation rate was not improved significantly during the study period (1993–2004 vs. 2005–2008), but disease-free survival improved from 72.2% up to 87.5% (P = 0.03).
Our results are consistent with those published in the literature. Concomitant chemotherapy with 5-fluoro-uracil or capecitabine remains the standard scheme. Upfront chemotherapy, before chemoradiotherapy, should be investigated with regard to the predominance of metastasis.

View all citing articles on Scopus

View full text

Original articleLocal recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population-based study in the west Netherlands

Aims.

Methods.

Results.

Conclusion.

Lancet

Lancet

Int J Radiat Oncol Biol Phys

Am J Surg

Eur J Surg Oncol

Am J Surg

Lancet

Eur J Surg Oncol

Eur J Surg Oncol

Incidence of Cancer in The Netherlands, 1992

Surgery for local recurrence of rectal carcinoma

Dis Colon Rectum

Radical abdominopelvic lymphadenectomy: historic perspective and current role in the surgical management of rectal cancer

Dis Colon Rectum

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival

Br Med J

Potency, cure, and local control in the operative treatment of rectal cancer

Arch Surg

Results of radical surgery for rectal cancer

World J Surg

Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection

Dis Colon Rectum

Local recurrence following ‘curative’ surgery for large bowel cancer: I. The overall picture

Br J Surg

Patterns of pelvic recurrence following definitive resections of rectal cancer

Cancer

Local recurrence after curative resection of colorectal adenocarcinoma

Surgery

The prediction of local recurrence in rectal adenocarcinoma by histopathological examination

Int J Colorectal Dis

Importance of tumor pathology and morphology in patients with surgically resected colon cancer

Findings from the Gastrointestinal Tumor Study Group

Cancer

Results of extended surgery for cancer of the rectum and sigmoid

Br J Surg

The effect of malignant and inflammatory fixation of rectal carcinoma on prognosis after rectal excision

Br J Surg

Original article
Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population-based study in the west Netherlands