New Hope for Sphincter Preservation in the Cure for Cancer of the Distal Rectum

Gerald J. Marks MD, Mohammed Mohiuddin MD, Arieh Eitan MD, Luigi Masoni MD, Marco Basile MD
Division of Colorectal Surgery, Department of Surgery, Division of Radiation Oncology, Department of Radiology and the Comprehensive Rectal Cancer Center

The overriding concerns of rectal cancer management have been the high incidence of local recurrence and its very disagreeable consequences as well as the too frequent need for permanent colostomy. This report describes a program of rectal cancer management that has reduced the frequency of local recurrence, preserved normal rectal function where conventional surgical wisdom would deem it impossible, and, at the same time, has dramatically improved survival.

At a time when the medical world was convinced that radiation had no significant effect upon the cancers of the colon and rectum, Dr. Simon Kramer of Jefferson proved in the late 50's and early 60's that, in high doses, radiation could kill rectal cancer cells. It was also in that period of time that I developed a surgical technique for treating cancers in the very low rectum which spared the sphincter mechanism and alleviated the need for permanent colostomy.

In 1976, following the discovery that low-lying rectal cancer had completely disappeared after high dose radiation therapy, we initiated a treatment program that combined the use of high dose preoperative radiation therapy and special sphincter preserving techniques. Nearly 200 patients with low-lying rectal or otherwise unfavorable cancers have been treated using this combined method. This is the largest study in which sphincter-preserving surgery followed high dose radiation, and it is the only planned study of sphincter-preserving surgery for cancer of the lower rectum.

A recent review of the data collected on this large group of rectal cancer patients showed that the incidence of local recurrence has been reduced considerably over published data, while normal sphincter function was maintained. A totally unexpected finding was that of an increased survival rate. The 5-year actuarial survival among those with certain favorable cancers was 100%, and the 5-year actuarial survival for the entire group was 80%, which when compared to other published reports represents a range of improvement from 25% to 100%.

The effect of high dose preoperative radiation upon the cancer and the extrarectal lymphatics provides the opportunity to employ a new spectrum of surgical options with the goal being the preservation of normal rectal function without sacrificing cure. Realizing that all cancers are not the same, the key is patient selection and knowing which treatment can be successfully used for specific cancers. We think we have learned which cancers respond to which technique, and have developed specific guidelines for the selection of patients. For example, in a select group of patients with cancer in the lowest 1 1/4 inch of rectum operated on with a special technique of my design, there was a 91% 5-year actuarial survival rate. When one considers that conventional surgical judgment mandates permanent colostomy for cancers at this level, the benefits of a highly refined patient selection process using preoperative radiation can be appreciated.

This study is unique in that it is the largest single-institution experience with high dose preoperative radiation and sphincter-preserving surgery, and the only planned study of sphincter preservation surgery in the distal one third of the rectum. Because the study proved that, in the treatment of low-level cancers of the rectum, reconstruction can be accomplished and normal function maintained following high dose radiation therapy while reducing local recurrence and improving survival, we believe it has shaken the tree of tradition and provides new hope for patients with cancer of the distal rectum.