Skip to main content

Advertisement

Log in

Effect of total mesorectal excision on the outcome of rectal cancer after standardized postoperative radiochemotherapy

Do randomized studies translate into clinical routine?

Effekt der totalen mesorektalen Exzision auf die Therapieergebnisse beim Rektumkarzinom nach standardisierter postoperativer Radiochemotherapie. Können die Ergebnisse randomisierter Studien im klinischen Alltag reproduziert werden?

  • Original Article
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Arbman G, Nilsson E, Hallböök O, et al. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 1996;83:375–9.

    Article  PubMed  CAS  Google Scholar 

  2. Bolognese A, Cardi M, Angelo IM, et al. Total mesorectal excision for surgical treatment of rectal cancer. J Surg Oncol 2000;74:21–3.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  4. Dahlberg M, Glimelius B, Pahlman L. Changing strategy for rectal cancer is associated with improved outcome. Br J Surg 1999;86:379–84.

    Article  PubMed  CAS  Google Scholar 

  5. Douglass HO, Moertel CG, Mayer RJ, et al. Survival after postoperative combination treatment of rectal cancer. N Engl J Med 1986;315:1294–9.

    PubMed  Google Scholar 

  6. 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.

    Article  PubMed  CAS  Google Scholar 

  7. 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.

    Article  PubMed  CAS  Google Scholar 

  8. 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.

    Article  PubMed  CAS  Google Scholar 

  9. 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.

    Article  PubMed  CAS  Google Scholar 

  10. 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.

    Article  PubMed  Google Scholar 

  11. 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.

    Article  PubMed  Google Scholar 

  12. 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.

    Article  Google Scholar 

  13. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery — the clue to pelvic recurrence? Br J Surg 1982;69:613–6.

    Article  PubMed  CAS  Google Scholar 

  14. Hermanek P, Klimpfinger M. Sphinktererhaltende radikale Resektion des Rektumkarzinoms aus der Sicht des Pathologen. Acta Chir Austriaca 1994;26:125–30.

    Article  Google Scholar 

  15. Hohenberger W, Schick CH, Göhl J. Mesorectal lymph node dissection: is it beneficial? Langenbecks Arch Surg 1998;383:402–8.

    Article  PubMed  CAS  Google Scholar 

  16. 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.

    Google Scholar 

  17. Konhäuser C, Altendorf-Hofmann A, Stolte M. Operation technique determines frequency of recurrence of colorectal carcinoma. Chirurg 1999;70:1042–9.

    Article  PubMed  Google Scholar 

  18. 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.

    PubMed  CAS  Google Scholar 

  19. 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.

    Article  PubMed  Google Scholar 

  20. 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.

    Article  PubMed  CAS  Google Scholar 

  21. 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.

    Google Scholar 

  22. Rödel C, Sauer R. Integration of novel agents into combined-modality treatment for rectal cancer. Strahlenther Onkol 2007;183:227–35.

    Article  PubMed  Google Scholar 

  23. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731–40.

    Article  PubMed  CAS  Google Scholar 

  24. 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.

    Article  PubMed  CAS  Google Scholar 

  25. Schmiegel S, Kühlbacher T, Pox C, et al. S3-Leitlinienkonferenz “Kolorektales Karzinom” 2004. Dtsch Med Wochenschr 2005;130 (Suppl 1):S5–53.

    Article  PubMed  Google Scholar 

  26. 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.

    Google Scholar 

  27. 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.

    Article  PubMed  CAS  Google Scholar 

  28. 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.

    Article  PubMed  CAS  Google Scholar 

  29. 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.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ludwig Keilholz.

Rights and permissions

Reprints 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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00066-009-1940-9

Key Words:

Schlüsselwörter:

Navigation