Purpose:
To compare local control, disease-free survival and overall survival after postoperative radiochemotherapy with or without total mesorectal excision (TME) in a retrospective analysis.
Patients and Methods:
Between 1993 and 2002, 103 patients with UICC stage II and III rectal cancer were treated by surgery and postoperative chemoradiation. Group B (n = 50; 1993–1998) were operated before TME era without using TME and group A (n = 53; 1998–2002) with TME; both groups received identical radiochemotherapy to a total dose of 50.4 Gy (median) and two courses of continuous 5-fluorouracil infusion.
Results:
Patients in group A (TME) showed a significant improvement in 5-year disease-free survival (71.1%; 46.8%) and freedom from distant metastases (76.3%; 46.9%) and a marked improvement of local control (85.2%; 62.5%). Acute and late toxicity were significantly less frequent in group A.
Conclusion:
Radiochemotherapy cannot compensate an insufficient surgical procedure. These data confirm that TME is the standard. High outcome quality can be achieved in daily practice compared to results of randomized studies without patient selection.
Ziel:
In einer retrospektiven Analyse werden die lokale Kontrollrate, das krankheitsfreie Überleben und das Gesamtüberleben nach postoperativer simultaner Radiochemotherapie mit oder ohne totale mesorektale Exzision (TME) verglichen.
Patienten und Methodik:
Im Zeitraum von 1993 bis 2002 wurden 103 Patienten mit Rektumkarzinom im Stadium UICC II und III einer Operation mit anschließender Radiochemotherapie unterzogen. Gruppe B (n = 50; 1993–1998) wurde vor der TME-Ära operiert, Gruppe A (n = 53; 1998–2002) mit TME; beide Patientengruppen erhielten eine identische postoperative Radiochemotherapie mit Bestrahlung der Sakralhöhle bis zu einer Gesamtreferenzdosis von 50,4 Gy (Median) und zwei Kursen einer Chemotherapie mit 5-Fluorouracil als Dauerinfusion.
Ergebnisse:
Die Patienten der Gruppe A (TME) zeigten eine signifikante Verbesserung des krankheitsfreien 5-Jahres-Überlebens (71,1%; 46,8%) und des metastasenfreien Überlebens (76,3%; 46,9%) sowie einen Trend zu einer verbesserten lokalen Kontrollrate (85,2%; 62,5%). Akut- und Spätnebenwirkungen traten in Gruppe A signifikant seltener auf als in Gruppe B.
Schlussfolgerung:
Die Radiochemotherapie kann eine insuffiziente Operationstechnik nicht kompensieren. Standard ist die TME. Im Vergleich zu Ergebnissen randomisierter Studien lässt sich eine hohe Behandlungsqualität auch in der klinischen Routine ohne studientypische Patientenselektion erreichen.
Similar content being viewed by others
References
Arbman G, Nilsson E, Hallböök O, et al. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 1996;83:375–9.
Bolognese A, Cardi M, Angelo IM, et al. Total mesorectal excision for surgical treatment of rectal cancer. J Surg Oncol 2000;74:21–3.
Carlsen E, Schlichting E, Guldvog I, et al. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg 1998;85:526–9.
Dahlberg M, Glimelius B, Pahlman L. Changing strategy for rectal cancer is associated with improved outcome. Br J Surg 1999;86:379–84.
Douglass HO, Moertel CG, Mayer RJ, et al. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315:1294–9.
Fielding LP, Arsenault PA, Chapuis PH, et al. Clinicopathological staging for colorectal cancer: an international documentation system (IDS) and an international comprehensive anatomical terminology (ICAT). J Gastroenterol Hepatol 1991;6:325–44.
Fisher B, Wolmark N, Rockette H, et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: Results from NSABP protocol R-01. J Natl Cancer Inst 1988;80:21–9.
Frykholm GJ, Glimelius B, Pahlman L. Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects. Dis Colon Rectum 1993;36:564–72.
Goldberg SM, Klas JV. Total mesorectal excision in the treatment of rectal cancer: a view from the USA. Semin Surg Oncol 1998;15:87–90.
Grosu AL, Molls M, Zimmermann FB, et al. High-precision radiation therapy with integrated biological imaging and tumor monitoring. Strahlenther Onkol 2006;182:361–8.
Guckenberger M, Meyer J, Wilbert J, et al. Precision of image-guided radiotherapy (IGRT) in six degrees of freedom and limitations in clinical practice. Strahlenther Onkol 2007;183:307–13.
Haustermans K, Roels S, Verstraete J, et al. Adaptive RT in rectal cancer: superior to 3D-CRT? A simple question, a complex answer. Strahlenther Onkol 2007;183:Special Issue 2:21–3.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery — the clue to pelvic recurrence? Br J Surg 1982;69:613–6.
Hermanek P, Klimpfinger M. Sphinktererhaltende radikale Resektion des Rektumkarzinoms aus der Sicht des Pathologen. Acta Chir Austriaca 1994;26:125–30.
Hohenberger W, Schick CH, Göhl J. Mesorectal lymph node dissection: is it beneficial? Langenbecks Arch Surg 1998;383:402–8.
Junginger T, Hossfeld DK, Sauer R. Aktualisierter Konsensus der CAO, AIO und ARO zur adjuvanten Therapie bei Kolon- und Rektumkarzinom vom 1.7.1998. Dtsch Ärztebl 1999;96:698–700.
Konhäuser C, Altendorf-Hofmann A, Stolte M. Operation technique determines frequency of recurrence of colorectal carcinoma. Chirurg 1999;70:1042–9.
Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709–15.
Milani V, Montserrat P, Issels RD, et al. Radiochemotherapy in combination with regional hyperthermia in preirradiated patients with recurrent rectal cancer. Strahlenther Onkol 2008;184:163–8.
Phillips RK, Hittinger R, Blesovsky L, et al. Local recurrence following “curative” surgery for large bowel cancer. I. The overall picture. Br J Surg 1984;71:12–6.
Pichlmaier H, Hossfeld DK, Sauer R. Konsensus der CAO, AIO, ARO zur adjuvanten Therapie bei Colon- und Rectumcarcinom vom 11.4.1994. Chirurg 1994;65:411–2.
Rödel C, Sauer R. Integration of novel agents into combined-modality treatment for rectal cancer. Strahlenther Onkol 2007;183:227–35.
Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731–40.
Sauer R, Fietkau R, Wittekind C, et al. Adjuvant versus neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94. Colorectal Dis 2003;5:406–15.
Schmiegel S, Kühlbacher T, Pox C, et al. S3-Leitlinienkonferenz “Kolorektales Karzinom” 2004. Dtsch Med Wochenschr 2005;130 (Suppl 1):S5–53.
Semrau R, Vallböhmer D, Kocher M, et al. Präoperative Radiochemo-Immun-Therapie mit Cetuximab (CET) und 5-FU bei Patienten mit fortgeschrittenen Rektumkarzinomen - erste Ergebnisse einer Phase I/II-Studie. Strahlenther Onkol 2008;184:Sondernr 1:72.
Tveit KM, Guldvog I, Hagen S, et al. Randomized controlled trial of postoperative radiotherapy and short-term time-scheduled 5-fluorouracil against surgery alone in the treatment of Dukes B and C rectal cancer. Norwegian Adjuvant Rectal Cancer Project Group. Br J Surg 1997;84:1130–5.
Wolmark N, Wieand HS, Hyams DM, et al. Randomized trial of postoperative adjuvant chemotherapy with or without radiotherapy for carcinoma of the rectum: National Surgical Adjuvant Breast and Bowel Project protocol R-02. J Natl Cancer Inst 2000;92:388–96.
Wulf J, Krämer J, van Aaken C, et al. Outcome of postoperative treatment for rectal cancer UICC stage II and III in day-to-day clinical practice. Results from a retrospective quality control analysis in six institutions in North Bavaria (Germany). Strahlenther Onkol 2004;180:5–14.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Keilholz, L., Mese, M., Henneking, K. et al. Effect of total mesorectal excision on the outcome of rectal cancer after standardized postoperative radiochemotherapy. Strahlenther Onkol 185, 364–370 (2009). https://doi.org/10.1007/s00066-009-1940-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00066-009-1940-9