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Journal of Clinical Oncology, Vol 23, No 22 (August 1), 2005: pp. 4905-4912 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.10.041 Distal cT2N0 Rectal Cancer: Is There an Alternative to Abdominoperineal Resection?From the Department of Radiation Oncology, the Colorectal Service, Department of Surgery, and the Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY Address reprint requests to Bruce D. Minsky, MD, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; e-mail: minskyb{at}mskcc.org
PURPOSE: Patients with cT2N0 distal rectal cancer do not require adjuvant therapy. However, when a patient refuses an abdominoperineal resection (APR), is there an alternative? The purpose of this trial is to determine whether preoperative external-beam radiation therapy can increase the rate of sphincter preservation for patients with distal cT2N0 adenocarcinoma of the rectum. PATIENTS AND METHODS: Between April 1988 and October 2003, 27 patients with distal rectal adenocarcinoma staged T2 by clinical and/or endorectal ultrasound who were judged by the operating surgeon to require an APR were treated with preoperative pelvic radiation alone (50.4 Gy). Surgery was performed 4 to 7 weeks later. If pathologic positive pelvic nodes were identified, postoperative adjuvant chemotherapy was recommended. The median follow-up was 55 months (range, 9 to 140 months). RESULTS: The pathologic complete response rate was 15% and 78% of patients underwent a sphincter-sparing procedure. The crude incidence of local failure for patients undergoing a sphincter sparing procedure was 10% and the 5-year actuarial incidence was 13%. The actuarial 5-year survival for patients undergoing sphincter preservation was as follows: disease-free, 77%; colostomy-free, 100%; and overall, 85%. Using the Memorial Sloan-Kettering Cancer Center sphincter function score, 54% of those undergoing a sphincter-sparing procedure had good/excellent bowel function at 12 to 24 months after surgery, and 77% had good/excellent function at 24 to 36 months after surgery. CONCLUSION: Our data suggest that for patients with cT2N0 distal rectal cancer who require an APR, preoperative pelvic radiation improves sphincter preservation without an apparent compromise in local control or survival.
In contrast with patients with cT3 and/or N+ rectal cancer, where preoperative combined radiation therapy plus chemotherapy (combined-modality therapy) is a standard therapy, the standard treatment for patients with a distal cT2 rectal adenocarcinoma who cannot undergo a low anterior resection (LAR) is abdominoperineal resection (APR). If there are pathologically positive pelvic lymph nodes, postoperative adjuvant combined-modality therapy is recommended.1 However, if a patient with distal cT2N0 rectal cancer refuses an APR is there an alternative? Randomized data now confirm that preoperative combined-modality therapy improves sphincter preservation. The German CAO/ARO/AIO 94 preoperative versus postoperative rectal trial reported that the incidence of sphincter preservation in those patients who were judged clinically by the operating surgeon to require an APR was significantly increased in the preoperative (39%) versus postoperative arm (20%, P = .004).2 Since patients enrolled in that trial had either cT3, T4, and/or N+ disease, combined-modality therapy was necessary for adjuvant therapy. In this report, we present the rates of sphincter preservation and function, toxicity, local control, and survival following preoperative pelvic radiation and selective postoperative chemotherapy in patients with distal cT2N0 rectal cancer who refused an APR.
Patient Population Between April 1988 and October 2003, 27 patients with cT2N0 primary adenocarcinoma of the distal rectum were referred to and treated in the Department of Radiation Oncology at Memorial Sloan-Kettering Cancer Center with the goal of enhancing sphincter preservation. In the operating surgeon’s office, all patients were clinically judged to require an APR if treated by initial surgery, and refused APR. The initial nine patients were enrolled on a prospective institutional review board trial (MSKCC 87-57), and informed consent was obtained. After meeting its accrual goals in December 1996, the trial was closed; the additional 18 patients were treated according to protocol specifications and are included in this report. Pretreatment evaluation included a complete history and physical examination, proctoscopy and/or colonoscopy, endorectal ultrasound (ERUS), CBC, platelet count, liver function tests, carcinoembryonic antigen (CEA), chest x-ray, and abdominal/pelvic computed tomography (CT). Patients with prior nonrectal cancer (except noninvasive cervical carcinoma and skin cancer [excluding melanoma]), or who received prior pelvic radiation were excluded. All tumors were located 2-7 cm from the anal verge as measured by digital examination. None had invasion of the anal canal. All patients had a Karnofsky performance status of 90 to 100. Of the 27 patients analyzed, 18 were male and nine were female. The median age was 56 years (range, 29 to 72 years). The median follow-up was 55 months (range, 9 to 140 months).
Preoperative Staging
Radiation Therapy Technical Details Whole pelvic field. The lateral borders were 2.0 cm lateral to the widest bony margin of the true pelvic side walls. The distal border was at the base of the obturator foramen or 1 cm below the anus, whichever was lower. The superior border was at the L5/S1 junction. The posterior field margin was a minimum of 1 cm behind the anterior bony sacral margin, and blocks were used to spare the posterior muscle and soft tissues. The external iliac nodes were not included in the lateral radiation fields. The anterior margin was at the most posterior aspect of the symphysis pubis. The anus was considered part of the target volume; therefore, it was included in the whole pelvic field. The whole pelvis plus the primary nodal groups at risk received 46.8 Gy. This was followed by a 3.6-Gy boost to the primary tumor bed. Boost field. The intent of the boost was to treat the primary tumor with a 3-cm margin and not to include the nodal groups. Therefore, the exact size was determined by the size and location of the primary tumor. In general, field sizes measured 10 x 10 or 12 x 12 cm, and corner blocks were used if possible. Opposed lateral fields were used. The boost dose was 3.6 Gy; therefore, the total dose (pelvis + boost) was 50.4 Gy.
Chemotherapy
Toxicity Assessment During Radiation Therapy
Surgical Procedure
Toxicity Assessment Following Surgery Sphincter function was assessed using a questionnaire administered by a physician and scored according to the previously published Memorial Sloan-Kettering sphincter function scale (Table 1).8 Sphincter function at the various time points after surgery were tabulated and grouped into 12-month intervals after surgery to assess the change in function with time (Fig 3). For this analysis, when a temporary ileostomy was performed, the ileostomy takedown date was used as the date of surgery.
Soilage was defined as minimal leakage of mucus or liquid stool that occurred occasionally (one to two episodes per week = mild soilage) or more frequently (two episodes per week = moderate soilage). These episodes were easily managed by wearing a pad. Difficulty with evacuation was defined as the need, having left the toilet, to return for a second or multiple evacuations. Six patients were excluded from sphincter function analysis because they underwent an abdominoperineal resection. Therefore, 21 were eligible for the analysis of sphincter function.
Determination of Patterns of Failure
Statistical Analysis
Patient Characteristics Patient characteristics are presented in Table 2. The median follow-up for all patients was 55 months (range, 9 to 140 months) for patients undergoing LAR was 37 months (range, 9 to 140 months), 49 months for surviving patients (range, 9 to 140 months), and for those undergoing APR, 101 months (range, 51 to 134 months), with all alive at last follow-up. The median distance from the anal verge was 5 cm for all patients and those undergoing LAR (range, 2 to 7 cm), and 3 cm for those undergoing APR (range, 2 to 4 cm). The median tumor diameter was 3 cm for all patients and those undergoing LAR (range, 1 to 5 cm). The median tumor diameter was 4 cm for those undergoing APR (range, 1 to 5 cm).
Surgical Assessment of Tumor Response to Therapy Twenty-one (78%) of 27 patients were able to undergo a low anterior resection with coloanal anastomosis. The remaining six patients underwent an abdominoperineal resection. Four (15%) of 27 patients had a pathologic complete response (pT0) at the primary site to therapy, with an additional five (19%) of patients being staged as pT1 after preoperative radiation therapy. Two patients were noted to have transmural involvement of tumor (pT3) at the time of surgery. Five patients were noted to have nodal involvement (pN1) at the time of surgery. Four of the five received postoperative chemotherapy. Chemotherapy was deferred in one patient due to medical contraindications. One patient was noted to have isolated liver metastases, in addition to nodal metastases, at the time of surgery, and therefore received postoperative chemotherapy. The superior and inferior margins of resection were negative in all cases. The lateral or radial margin was not routinely assessed.
Cumulative Patterns of Failure and Survival
Radiation Toxicity Acute. The toxicities that were experienced during preoperative radiation therapy were primarily gastrointestinal, skin, and genitourinary toxicity (Table 4). No patients required hospitalization for management of acute toxicity of therapy.
(1) Nonhematologic. The majority of patients experienced grade 1 and grade 2 diarrhea and frequent bowel movements (70% and 70%, respectively), which were managed effectively with diphenoxylate/atropine. A significant number of patients also experienced grade 1 or 2 tenesmus (77%), for which there was no effective intervention. (2) Hematologic. The median nadir complete blood indices were: granulocytes, 4.2 (x 1,000 cells/µL; range, 2.3 to 8.9), hemoglobin, 13.6 g/dL (range, 8.7 to 16.7 g/dL), and platelets, 186 (x1,000 cells/µL; range, 109 to 260).
Chronic
Sphincter Function
Our data suggest that for patients with distal cT2 rectal cancers who were judged clinically to require an APR, preoperative pelvic radiation therapy improved the chance of sphincter preservation. Overall, 78% were able to undergo an LAR/coloanal anastomosis. In our study, 5-year overall survival for patients undergoing sphincter preservation was 86%, with 5-year disease-free survival (DFS) being 77%. The 5-year DFS for all patients was 65%. Sphincter preservation did not negatively impact DFS in our study. Our actuarial 5-year local failure rate after sphincter preservation was 13%. Willet et al reported a local failure rate of 11% and 5-year recurrence-free survival of 85% for patients with T2 rectal carcinoma undergoing APR.10 Our data suggest that sphincter preservation for patients with distal T2 rectal cancer utilizing this approach can be accomplished without compromising local control or survival. There are potential disadvantages with this treatment strategy. First, there is a chance of undertreatment, since approximately 50% of patients are downstaged from pN+ to pN0 after preoperative radiation and therefore will not receive adjuvant chemotherapy.11 Although pretreatment magnetic resonance imaging (MRI) can help predict patients who may have positive circumferential margins,12-14 neither MRI nor any other imaging modality or clinicopathologic factor can accurately identify patients with N+ disease. Second, there is the additional toxicity of pelvic radiation, which can adversely affect bowel, bladder, and sexual function.15-19 Additionally, data from the INT 0114 trial of postoperative combined-modality therapy reveal that there is a continued decrease in local control and survival after 5 years.1 Since the median follow-up in our series is only 55 months for all patients with 37 months for those undergoing sphincter preservation (49 months for surviving patients), further follow-up is needed to determine the ultimate local control and survival rates. The primary advantage of this approach is sphincter preservation. Most patients seek alternatives to an APR. In one series, patients who underwent an LAR had a better quality of life than those patients who undergo an APR.20 Patients undergoing an LAR had a significantly better body image, decreased sexual problems, decreased genitourinary complaints, and increased physical functioning at 4 years than those who had an APR. Sphincter preservation without good function, however, is of questionable benefit. For example, in a series of 73 patients who underwent surgery, Grumann et al reported that the 23 patients who underwent an APR had a more favorable quality of life compared with the 50 who underwent a low anterior resection.21 We examined sphincter function using our previously published MSKCC sphincter function scale and found that 77% of patients had good/excellent bowel function 24 to 36 months and all patients had good/excellent bowel function at 36 months and beyond after sphincter preserving therapy in our series. These data reveal a gradual improvement in sphincter function over time. This probably reflects patient adaptation to the changes in bowel function and continued physiologic maturation of the pouch.22 Although our sphincter function scale is simplistic, other investigators have used this scale.23-25 There is no consensus as to the ideal sphincter function scale. Functional results vary according to the scale used, median follow-up, the survey methodology, and the individual assessing function. Furthermore, our scale does not assess the impact of pelvic radiation on other functional outcomes such as bladder function, sexual function, and overall quality of life. There is limited experience with the use of preoperative radiation therapy for patients with distal cT2 rectal cancer. Rouanet and associates reported the results of 43 patients with T27 or T336 distal rectal cancers who were treated with preoperative radiotherapy.26 Patients received 40 Gy plus an additional 20 Gy boost depending on tumor response followed by surgery. Overall, 70% of patients were able to undergo a sphincter-sparing procedure. With a median follow-up of 82.4 months, the crude local failure rate was 13%. Thirty percent of patients had complete continence of stool and 20% of patients had serious incontinence. These data are comparable to the results presented in our study with the exception that none of the patients in our series experienced serious incontinence of stool. The most accurate method by which to determine if preoperative therapy increases sphincter preservation is to perform a prospective clinical assessment. In this setting, the operating surgeon examines the patient before the start of preoperative therapy and declares the type of operation thought to be required. It should be noted that this assessment is based on an office examination and may not accurately reflect the assessment when the patient is relaxed under general anesthesia. The only method by which to account for this potential bias is to perform a randomized trial of preoperative versus postoperative therapy. The German CAO/ARO/AIO 94 trial was stratified by surgeon and reported that this assessment is accurate in 80% of patients.2 One critical factor in this analysis is the selection criteria for offering patients sphincter preservation. In our study, each patient was examined by the colorectal surgeon and declared to need an APR before referral for preoperative radiation therapy. It is not possible to know whether some of these patients may have been able to undergo an LAR without the need for preoperative radiation therapy. There are data from randomized and nonrandomized trials for patients with clinically resectable (cT2-4) distal rectal cancer in whom a prospective clinical assessment was performed by their surgeon before the start of preoperative therapy. In the seven nonrandomized trials, three used radiation therapy alone26-28 and four used combined-modality therapy.29-32 The incidence of sphincter preservation was 44% in the Lyon series28; however, in the remaining series, it was approximately 70%. In the four of seven preoperative series discussed above reporting functional outcome, the majority of cases (approximately 76%) had good to excellent sphincter function. The two randomized trials of preoperative versus postoperative combined-modality therapy for clinically resectable T3-4 rectal cancer used conventional doses and techniques of radiation therapy and concurrent FU-based chemotherapy. The sphincter preservation rate in the National Surgical Adjuvant Breast and Bowel Project R-03 trial was 44% in patients randomized to the preoperative versus 34% in the postoperative arm.33 The German CAO/ARO/AIO 94 trial reported a significant increase in sphincter preservation in the preoperative versus postoperative arm (39% v 20%; P = .004).2 The concept of which patient requires an APR has evolved over the past several years, with more patients undergoing LAR who were previously felt to require an APR. In general, the distance from anal verge is used as a marker to judge the need for APR. However, there are several other factors that are known to impact this decision including tumor bulk, the patient’s pelvic anatomy (narrow v broad pelvis), tumor location (anterior v posterior), the body mass of the patient, and distance from the anorectal ring (due to variations in length of anal canal).34 In our study, there was clear documentation of the rationale for preoperative radiotherapy in each patient. In the case of those with tumors further from the anal verge, factors such as unfavorable tumor location (bulky, anterior) or an unusually long anal canal (tumor in close proximity to anorectal ring) were the rationale for preoperative radiotherapy.
A valid concern of surgeons is that in order to perform sphincter preservation in those patients who would otherwise require an APR, the distal resection margin may be suboptimal ( Do higher doses of preoperative radiation improve sphincter preservation? The Lyon R96-02 trial examined the impact of dose escalation on sphincter preservation rates in patients with T2 or T3 rectal cancer.23 Patients with T2-3 rectal cancer received preoperative pelvic radiation with 39Gy in 13 fractions and were then randomized to total mesorectal excision (TME) versus an additional contact boost to a mean dose of 85 Gy followed by TME. Approximately one third of the patients in each arm had T2 rectal cancers. Although the sphincter preservation rate was increased in the 85 Gy versus the 39 Gy arm (76% v 44%; P = .04; there was no difference in 2-year local recurrence-free survival (92% v 88%). A subgroup analysis of patients with T2 disease was not reported. When the goal of preoperative therapy is sphincter preservation, we recommend conventional doses and techniques of radiation. These include multiple-field techniques to a total dose of 45 to 50.4 Gy at 1.8 Gy per fraction. Surgery should be performed 4 to 7 weeks following the completion of radiation. This allows for recovery from the acute side effects of radiation and adequate time for tumor down staging. Data from the Lyon R90-01 trial of preoperative radiation suggest that an interval > 2 weeks following the completion of radiation increases the chance of down staging.28 Are there any patients for whom this is not a suitable approach? In our practice, if the anorectal ring is invaded by tumor, these patients are not felt to be appropriate candidates for sphincter preservation. It is felt that these patients are unlikely to become amenable to an LAR. Additionally, at our institution, we offer select patients who have small (1 to 2 cm), mobile, exophytic tumors that are well placed (posteriorly), surgery alone without preoperative radiotherapy. Is there any role for concurrent chemotherapy in this setting? From an oncologic standpoint, it is unlikely that the addition of concurrent chemotherapy for these patients would improve outcome providing that the nodes are negative. Even in patients with more advanced pT3N0 rectal cancers, there is controversy regarding the benefit of adjuvant therapy, with patients having excellent outcomes with surgery alone.36,37 However, would the addition of concurrent chemotherapy enhance the rate of sphincter preservation over preoperative radiotherapy alone? Gerard et al randomized patients with 685 patients with distal T3/T4 rectal cancers to preoperative radiotherapy alone versus preoperative chemoradiotherapy using a FU-based regimen. They found that although combined-modality therapy significantly increased tumor sterilization, it also significantly increased grade 3 to 4 toxicity, and most importantly, did not improve the rate of sphincter preservation.38 Given these data, outside of a clinical trial, it is difficult to justify the routine use of preoperative chemoradiotherapy for distal T2 rectal cancers.
We advocate an LAR/coloanal anastomosis following preoperative radiation alone. An alternative approach, if technically possible, is local excision either before or following pelvic radiation. The results with local excision followed by postoperative therapy are not satisfactory. In those series with a median follow-up of In conclusion, the standard treatment for patients with distal cT2N0 rectal cancer who cannot undergo a LAR is APR. Our retrospective data suggest that for those patients who refuse APR, preoperative pelvic radiation followed by LAR/coloanal anastomosis and the selective use of postoperative chemotherapy is reasonable. This approach does offer the majority of patients the possibility of sphincter preservation with good to excellent function without an apparent compromise of local control or survival. Although randomized data are needed to confirm these findings, it remains a viable alternative to APR.
The authors indicated no potential conflicts of interest.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
1. Tepper JE, O'Connell MJ, Niedzwiecki D, et al: Adjuvant therapy in rectal cancer: Analysis of stage, sex, and local control—Final report of Intergroup 0114. J Clin Oncol 20: 1744-1750, 2002
2. Sauer R, Becker H, Hohenberger P, et al: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351: 1731-1740, 2004 3. Minsky BD: Pelvic radiation therapy in rectal cancer: Technical considerations. Semin Radiat Oncol 3: 42-47, 1993[Medline] 4. Minsky BD, Cohen AM, Enker WE, et al: Pre-operative 5-FU, low dose leucovorin, and concurrent radiation therapy for rectal cancer. Cancer 73: 273-278, 1994[CrossRef][Medline] 5. Minsky BD, Kemeny N, Cohen AM, et al: Preoperative high-dose leucovorin/5-fluorouracil and radiation therapy for unresectable rectal cancer. Cancer 67: 2859-2866, 1991[CrossRef][Medline] 6. Parks AG: Perianal anastomosis. World J Surg 6: 531-538, 1982[Medline] 7. Pollett WG, Nicholls RJ: The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 198: 159-163, 1984 8. Minsky BD, Cohen AM, Enker WE, et al: Sphincter preservation with preoperative radiation therapy and coloanal anastomosis. Int J Radiat Oncol Biol Phys 31: 553-559, 1995[CrossRef][Medline] 9. Kaplan EL, Meier P: Nonparametric estimation for incomplete observation. J Am Stat Assoc 53: 457-481, 1958[CrossRef] 10. Willett CG, Compton CC, Shellito PC, et al: Selection factors for local excision or abdominoperineal resection of early stage rectal cancer. Cancer 73: 2716-2720, 1994[CrossRef][Medline] 11. Mendenhall WM, Million RR, Bland KI, et al: Preoperative radiation therapy for clinically resectable adenocarcinoma of the rectum. Ann Surg 202: 215-222, 1985[Medline] 12. Beets-Tan RGH, Beets GL: Rectal cancer: How accurate can imaging predict the T stage and the circumferential resection margin? Int J Colorec Dis 18: 385-391, 2003 13. Beets-Tan RGH, Beets GL, Vliegen RFA, et al: Accuracy of magnetic resonance imaging in prediction of tumor-free resection margin in rectal cancer surgery. Lancet 357: 497-504, 2001[CrossRef][Medline] 14. Branagan G, Chave H, Fuller C, et al: Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? Dis Colon Rectum 47: 1317-1322, 2004[Medline] 15. Bonnel C, Pare YR, Pocard M, et al: Effects of preoperative radiotherapy for primary resectable adenocarcinoma on male sexual and urinary function. Dis Colon Rectum 45: 934-939, 2002[CrossRef][Medline] 16. Dehni N, McNamara DA, Schlegel RD, et al: Clinical effects of preoperative radiation therapy on anorectal function after proctectomy and colonic J-pouch-anal anastomosis. Dis Colon Rectum 45: 1635-1640, 2002[CrossRef][Medline] 17. Temple LKF, Wong WD, Minsky B: The impact of radiation on functional outcomes in patients with rectal cancer and sphincter preservation. Semin Radiat Oncol 13: 469-477, 2003[CrossRef][Medline] 18. Nathanson DR, Espat NJ, Nash GM, et al: Evaluation of preoperative and postoperative radiotherapy on long-term functional results of straight coloanal anastomosis. Dis Colon Rectum 46: 888-894, 2003[CrossRef][Medline] 19. Havenga K, Enker WE, McDermott K, et al: Male and female sexual amd urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182: 495-502, 1996[Medline] 20. Engel J, Kerr J, Schlesinger-Raab A, et al: Quality of life in rectal cancer patients: A four-year prospective study. Ann Surg 238: 203-213, 2003[CrossRef][Medline] 21. Grumann MM, Noack EM, Hoffman IA, et al: Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 233: 149-156, 2001[CrossRef][Medline] 22. Selvaggi F, Guiliani A, Gallo C, et al: Randomized, controlled trial to compare the J-pouch and W-pouch configurations for ulcerative colitis in the maturation period. Dis Colon Rectum 43: 615-620, 2000[Medline]
23. Gerard JP, Chapet O, Nemoz C, et al: Improved sphincter preservation in low rectal cancer with high dose preoperative radiotherapy: The Lyon R96-02 randomized trial. J Clin Oncol 22: 2404-2409, 2004 24. Weber DC, Nouet P, Kurtz JM, et al: Assessment of target dose delivery in anal cancer using in vivo thermoluminescent dosimetry. Radiother Oncol 59: 39-43, 2001[Medline]
25. Feliu J, Calvillo J, Escribano A, et al: Neoadjuvant therapy of rectal carcinoma with UFT-leucovorin plus radiotherapy. Ann Oncol 13: 730-736, 2002 26. Rouanet P, Saint Aubert B, Lemanski C, et al: Restorative and non-restorative surgery for low rectal cancer after high dose radiation: Long-term oncologic and functional results. Dis Colon Rectum 45: 305-315, 2002[Medline] 27. Wagman R, Minsky BD, Cohen AM, et al: Sphincter preservation with preoperative radiation therapy and coloanal anastomosis: Long term follow-up. Int J Radiat Oncol Biol Phys 42: 51-57, 1998[CrossRef][Medline]
28. Francois Y, Nemoz CJ, Baulieux J, et al: Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: The Lyon R90-01 randomized trial. J Clin Oncol 17: 2396-2402, 1999 29. Valentini V, Coco C, Cellini N, et al: Preoperative chemoradiation for extraperitoneal T3 rectal cancer: Acute toxicity, tumor response, and sphincter preservation. Int J Radiat Oncol Biol Phys 40: 1067-1075, 1998[CrossRef][Medline] 30. Grann A, Feng C, Wong D, et al: Pre-op combined modality therapy (CMT) for uT3 rectal cancer. Proc Am Soc Clin Oncol 19: 249a, 2000 (abstr 967)
31. Kuvshinoff B, Maghfoor I, Miedema B, et al: Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: Are < 1 cm distal margins sufficient? Ann Surg Oncol 8: 163-169, 2001 32. Mehta VK, Cho C, Ford JM, et al: Phase II trial of preoperative 3D conformal radiotherapy, protracted venous infusion 5-fluorouracil, and weekly CPT-11, followed by surgery for ultrasound-staged T3 rectal cancer. Int J Radiat Oncol Biol Phys 55: 132-137, 2003[CrossRef][Medline] 33. Roh MS, Petrelli N, Weiand H, et al: Phase III randomized trial of preoperative versus postoperative multimodality therapy in patients with carcinoma of the rectum (NSABP R-03). Proc Am Soc Clin Oncol 20: 123a, 2001 (abstr 490) 34. Gonzalez QH, Heslin MJ, Shore G, et al: Results of long-term follow-up for transanal excision for rectal cancer. Am Surg 69: 675-679, 2003[Medline]
35. Moore HG, Riedel E, Minsky BD, et al: Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined modality therapy. Ann Surg Oncol 10: 80-85, 2003 36. Merchant NB, Guillem JG, Paty PB, et al: T3N0 rectal cancer: Results following sharp mesorectal excision and no adjuvant therapy. J Gastrointest Surg 3: 642-647, 1999[CrossRef][Medline] 37. Willett CG, Badizadegan K, Ancukiewicz M, et al: Prognostic factors in stage T3N0 rectal cancer: Do all patients require post-operative pelvic irradiation and chemotherapy? Dis Colon Rectum 42: 167-173, 1999[CrossRef][Medline] 38. Gerard J, Conroy T, Bonnetain F, et al: Preoperative (Preop) radiotherapy (RT) + FU(folinic acid (FA) in T3.4 rectal cancers: Prelimincary results of the FFCD 92 03 Randomized Trial. Int J Radiat Oncol Biol Phys 60: S138, 2004 39. Paty PB, Nash GM, Baron P, et al: Long-term results of local excision for rectal cancer. Ann Surg 236: 522-530, 2002[CrossRef][Medline] 40. Wagman RT, Minsky BD: Conservative management of rectal cancer with local excision and adjuvant therapy. Oncology 15: 513-524, 2001[Medline] 41. Steele GD, Herndon JE, Bleday R, et al: Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol 6: 433-441, 1999[Abstract] 42. Chakravarti A, Compton CC, Shellito PC, et al: Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg 230: 49-54, 1999[CrossRef][Medline] 43. Wagman R, Minsky BD, Cohen AM, et al: Conservative management of rectal cancer with local excision and post-op radiation ± chemotherapy. Int J Radiat Oncol Biol Phys 44: 841-846, 1999[Medline] 44. Russell AH, Harris J, Rosenberg PJ, et al: Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: Long-term results of Radiation Therapy Oncology Group protocol 89-02. Int J Radiat Oncol Biol Phys 46: 313-322, 2000[CrossRef][Medline] 45. Benson R, Wong CS, Cummings BJ, et al: Local excision and postoperative radiotherapy for distal rectal cancer. Int J Radiat Oncol Biol Phys 50: 1309-1316, 2001[Medline] 46. Schell SR, Zlotecki RA, Mendenhall WM, et al: Tansanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am Coll Surg 194: 584-591, 2002[CrossRef][Medline] 47. Ruo L, Guillem JG, Minsky BD, et al: Preoperative radiation with or without chemotherapy and full-thickness transanal excision for selected T2 and T3 distal rectal cancers. Int J Colorec Dis 17: 54-58, 2002 48. Bonnen M, Crane C, Feig BW, et al: Long term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 51: 12, 2001 Submitted January 2, 2005; accepted May 4, 2005. This article has been cited by other articles:
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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TOP
ABSTRACT
INTRODUCTION
10 MV), and multiple field techniques (three-field [PA + laterals]) were used. All fields were treated each day. Port films were obtained weekly, or more often if clinically indicated. Techniques to minimize the toxicity of pelvic radiation were used as previously described.
1 cm). Can preoperative therapy compensate for this? Retrospective data from Moore et al reveal that with preoperative combined-modality therapy, the 3-year local control rates were similar regardless of the margins being more than 2 cm, less than 2 cm, more than 1 cm, or less than 1 cm, providing they were negative.
