Neoadjuvant Therapy in Rectal Cancer Patients Permits Conversion From Permanent Colostomy to Sphincter Preservation Surgery

Gerald J. Marks, MD; John H Marks, MD; Andreas Karachristos, MD; Mohammed Mohiuddin, MD
Lankenau Institute for Medical Research, Wynnewod, Pennsylvania

A longstanding rectal cancer management program of selective high-dose preoperative irradiation and chemoirradiation (PICI) and special surgical techniques (SST) has as a major aim to extend sphincter preservation surgery (SPS).  The purpose of this paper is to determine if those patients who were converted from an abdominal perineal resection (APR) to radical sphincter preserving surgery (RSPS) by the use of neoadjuvant therapy (NAT) and SST experienced any compromise of local control.  A retrospective analysis of 192 consecutive patients treated by NAT and RSPS identified those who by conventional standards would have had APR but were converted to RSPS by NATS according to our guidelines.  Thirty-eight patients were judged ineligible for analysis because they were suited for RSPS by conventional guidelines.  The 154 remaining patients were classified into three groups:  Group A               (n:88);Group B               (n:22); Group C            (n:44).  NAT radiation dosage ranged 4500-7000 cGy mainly 180 cGy fractions and chemotherapy with 5FU mainly by pump infusion.  All operative decisions were based on tumor reassessment 5 to 8 weeks after NAT.  Among the 154 patients, the cancers were at or below 6 cm level (           ); at or below 3 cm level (         ); at or below 1 cm level (                   ).  Fixed tumors comprised      %.  Surgery performed by transanal abdominal transanal coloanal anastomosis            ; combined abdominal transsacral              ; anterior resection               .  The local recurrence rates:  Group A:    ; Group B:         ; Group C:         ; Overall:          .  These LR rates measure favorably with historically reported rectal cancer data.  CONCLUSION:  The selective use of high-dose preoperative irradiation and chemoirradiation enables the conversion of surgery in patients with low and very low lying rectal cancers from a permanent colostomy (APR) to RSPS without compromising local cancer control.

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