Retrospective Study
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World J Gastroenterol. Jul 21, 2014; 20(27): 9138-9145
Published online Jul 21, 2014. doi: 10.3748/wjg.v20.i27.9138
Abdominoperineal excision following preoperative radiotherapy for rectal cancer: Unfavorable prognosis even with negative circumferential resection margin
Lin Wang, Guo-Li Gu, Zhong-Wu Li, Yi-Fan Peng, Jin Gu
Lin Wang, Yi-Fan Peng, Jin Gu, Department of Colorectal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
Zhong-Wu Li, Department of Pathology, Department of Gastroenterology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
Guo-Li Gu, Department of General Surgery, Air Force General Hospital, Beijing 100142, China
Author contributions: Wang L, Gu GL, Li ZW and Peng YF contributed equally to this study; Wang L contributed to collecting data, designing research and writing article; Gu GL contributed to drafting and revising the article; Li ZW contributed to pathological quality control and assessment; Peng YF contributed to references management; Gu J contributed to the final approval of this article.
Supported by Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (code ZY201410)
Correspondence to: Jin Gu, MD, FACS, Department of Colorectal Surgery, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, 52 Fuchenglu Road, Beijing 100142, China. zlgujin@126.com
Telephone: +86-10-88196085 Fax: +86-10-88196085
Received: January 26, 2014
Revised: March 10, 2014
Accepted: April 15, 2014
Published online: July 21, 2014
Abstract

AIM: To evaluate whether an abdominoperineal excision (APE) is associated with increased local recurrence (LR) and shortened disease-free survival (DFS) in mid-low rectal cancer with a negative circumferential resection margin (CRM).

METHODS: 283 consecutive cases of mid-low rectal cancer underwent preoperative 30 Gy/10 F radiotherapy and surgery in Peking University Cancer Hospital between August 2003 and August 2009. Patients with positive CRM and intraoperative distant metastasis were precluded according to exclusion criteria. Survival analyses were performed in patients with APE or non-APE procedures.

RESULTS: 256 of the 283 (90.5%) cases were enrolled in the analysis, including 78 (30.5%) and 178 (69.5%) cases who received APE and non-APE procedures. Fewer female patients (P = 0.016), lower level of tumor (P = 0.000) and higher body mass index (P = 0.006) were found in the APE group. On univariate analysis, the APE group had a higher LR rate (5.1% vs 1.1%, P = 0.036) and decreased DFS (73.1% vs 83.4%, P = 0.021). On multivariate analysis, APE procedure was also an independent risk factor for LR (HR = 5.960, 1.085-32.728, P = 0.040) and decreased DFS (HR = 2.304, 1.298-4.092, P = 0.004). In stratified analysis for lower rectal cancer, APE procedure was still an independent risk factor for higher LR rate (5.6% vs 0%, P = 0.024) and shortened DFS (91.5% vs 73.6%, P = 0.002).

CONCLUSION: Following preoperative 30 Gy/10 F radiotherapy, APE procedure was still a predictor for LR and decreased DFS even with negative CRM. More intensive preoperative treatment should be planned for the candidates who are scheduled to receive APE with optimal imaging assessment.

Keywords: Abdominoperineal excision, Preoperative radiotherapy, Circumferential resection margin, Survival

Core tip: The present study focused on survival differences between rectal cancer treated with abdominoperineal excision or non-abdominoperineal excision (APE) following preoperative radiotherapy, with the adjustments of the circumferential resection margin (CRM) to preclude the influence of surgical radicality. The results revealed the more aggressive oncological behavior of low-lying or fixed tumors, which were unavailable for the sphincter preservation procedure even with negative CRM. We also emphasized the importance of preoperative staging and decision-making before APE procedure, and reviewed the related hypotheses for the unfavorable local control of APE in the discussion.