Originally published as JCO Early Release 10.1200/JCO.2007.15.6646 on June 9 2008

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Extended Perineal Resection of Distal Rectal Cancers: Surgical Advance, Increased Utilization of Neoadjuvant Therapies, Proper Patient Selection or All of the Above?

José G. Guillem

Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY

Bruce D. Minsky

Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL

With the introduction of improved surgical techniques such as total mesorectal excision¹ and autonomic nerve preservation² during the last two decades, a corresponding decrease in local recurrence rates and increase in overall survival of patients with rectal cancer has been observed.^3,4 Despite the broad implementation of these techniques, local recurrence and survival after an abdominoperineal resection (APR) have not improved to the same degree as that seen after an anterior resection.^5,6 This difference has been attributed, in part, to relative smaller tissue volumes around the tumor and higher rates of cancer at circumferential resection margins (CRM) after an APR compared with an anterior resection.^5-7 Because of this, a number of investigators have called for a change in the technical approach of the APR.

Since the late 1990s, surgeons at the Karolinska University Hospital have used an extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor in patients with extensive primary or locally recurrent rectal cancer infiltrating the pelvic floor or with coccygeal or sacral involvement.⁸ In the retrospective review by West et al⁹ in this issue of Journal of Clinical Oncology, standard APR specimens are compared with those obtained with a cylindrical approach. Specifically, they compare the amount of tissue removed around potentially curable primary rectal adenocarcinomas as well as rates of CRM and intraoperative perforations. In addition, an effort is made to document the impact of such a change in surgical approach on a single surgeon's practice.

The authors must be commended for their long-standing efforts and contributions addressing the importance of surgical technique and pathologic assessment of adequacy of the resected specimen. In this article, the authors report the superiority of the cylindrical relative to the standard APR approach in terms of CRM and perforation rates. We agree with their final concluding sentence: "Use of this operation in combination with new preoperative neoadjuvant therapies should further improve results without the risk of increasing perforation rates." However, we would add that the incorporation of a more extensive APR approach to the surgical armamentarium will necessitate further emphasis on the need for improved patient selection,¹⁰ given that it is not clear whether all distal rectal adenocarcinomas requiring an APR will benefit from a cylindrical approach as much as from preoperative neoadjuvant therapies.

Though the authors demonstrate an apparent superiority of the cylindrical APR approach, their analysis should be interpreted with caution. It is retrospective and based on a small sample size, especially for the cylindrical group, with just 27 combined reported experiences between the two institutions. Therefore, due to the small sample size, statistically significant differences cannot be detected among patients undergoing a standard and a cylindrical APR, but it appears that there is a trend toward more preoperative therapy utilization (97% v 67%) and less stage III disease (30% v 43%) in the cylindrical group compared with the standard APR group. Would the results, therefore, have been the same if the rate of preoperative therapy had been similar between both surgical approaches?

Similarly, although the authors demonstrate that a highly experienced, senior surgeon can learn and adopt the cylindrical APR approach, the data do not fully support their conclusion "that adoption of the cylindrical technique can lead to an immediate improvement in CRM positivity and perforation rates for an individual surgeon." First, this conclusion is based on a single surgeon's experience with only eight patients who were treated with the cylindrical approach. Second, it is unclear how many of these patients received preoperative chemoradiotherapy. Was the rate of preoperative chemoradiotherapy use similar between the standard APR and cylindrical APR groups? The data from Table 1 in West et al suggest that preoperative therapy was used much more frequently in the cylindrical than in the standard APR group.

Furthermore, given that the Leeds group⁹ adopted the Karolinska approach in 2005, is it possible that—in addition to performing a cylindrical APR—they also began to use preoperative chemoradiotherapy more liberally? The Karolinska standard practice has been to use neoadjuvant radiation or chemoradiotherapy for "all patients with low rectal cancer requiring an APR." In fact, in the published Karolinska experience, nearly 70% of patients received neoadjuvant 50 Gy of radiation.⁸ Therefore, are the reported improvements in CRM and perforation rates solely due to a more extended APR, to increased use of neoadjuvant therapies, or a combination of both?

In our published experience with preoperative chemoradiotherapy (mostly continuous fluorouracil-based chemotherapy and median 50.4 Gy) in locally advanced rectal cancer, a complete pathologic response was observed in 16% of patients.¹¹ In patients in whom residual disease was present, the median CRM, as identified with standardized whole-mount sections as described by Quirke et al,¹² was 10 mm. This was similar in patients undergoing either a low anterior resection or APR performed in the standard combined abdominal perineal fashion in the lithotomy position. Though there were no positive CRMs, 2% of patients had a CRM of less than 1 mm. These results differ from those reported by West et al, where positive CRM rates of 15% and 41% where identified in the cylindrical and standard APR groups, respectively. Although possible differences in tumor stage and patient populations may explain the striking differences in rates of CRM, it is likely that differences in rates of preoperative chemoradiotherapy use (100% v 27%) are an important contributing factor. In fact, West et al demonstrated that patients treated with preoperative radiotherapy or radiochemotherapy "showed the lowest rate of CRM positivity."

The authors clearly demonstrate that the cylindrical approach removes more tissue in the distal rectum, as reflected in greater distances between the muscularis propria or internal sphincters, and anterior, posterior, and lateral resection margins. However, the implementation of this approach by one surgeon reduced the CRM rate from 36% to 13%, not zero, suggesting that despite procuring more tissue, the cylindrical approach was unable to remove all disease, presumably because of tumor bulk. This is supported by their observation that in males, despite more tissue procured with the cylindrical approach than in females, CRM and perforation rates were not significantly lower; this is perhaps related to the challenges of a narrow male pelvis. It is precisely in these patients with bulky tumors and difficult anatomy that preoperative therapies would be expected to enhance procurement of negative margins. Similarly, given that the cylindrical approach had the least benefit on the anterior resection margin distance and anteriorly based lesions are more likely to be associated with perforations and positive CRMs, neoadjuvant therapies would likely have substantial value in these patients.

Clearly, proper patient selection for the type of surgery, as well as for neoadjuvant therapies compared with surgery alone, is essential. It is likely that these decisions will be based on a variety of clinical, anatomic, and pathologic variables yet to be fully defined, but which may include digital rectal examination, endoscopic evaluation, and imaging (such as computed tomography/positron emission tomography, magnetic resonance imaging, or endorectal ultrasound) for determination of pelvic bony dimensions, tumor bulk, degree of tetherdness or invasion into surrounding structures, status of CRM, mesorectal lymph node involvement, and overall extent of disease. The impact of these confounding variables needs to be better understood before we recommend routine adoption of the cylindrical APR approach.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

AUTHOR CONTRIBUTIONS

Manuscript writing: José G. Guillem, Bruce D. Minsky

Final approval of manuscript: José G. Guillem, Bruce D. Minsky

NOTES

published online ahead of print at www.jco.org on June 9, 2008.

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