Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial

Kusters, M.; Marijnen, C.A.M.; van de Velde, C.J.H.; Rutten, H.J.T.; Lahaye, M.J.; Kim, J.H.; Beets-Tan, R.G.H.; Beets, G.L.

doi:10.1016/j.ejso.2009.11.011

« Previous Next »European Journal of Surgical Oncology
Volume 36, Issue 5 , Pages 470-476, May 2010

Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial

M. Kusters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
C.A.M. Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
C.J.H. van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Corresponding author. Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands. Tel.: +31 71 526 2309; fax: +31 71 526 6750.
H.J.T. Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
M.J. Lahaye
- Department of Radiology, University Hospital Maastricht, Maastricht, The Netherlands
J.H. Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
R.G.H. Beets-Tan
- Department of Radiology, University Hospital Maastricht, Maastricht, The Netherlands
G.L. Beets
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands

Accepted 19 November 2009.

Abstract

Aim of the study

In patients from the Dutch TME trial patterns of local recurrence (LR) in rectal cancer were studied. The purpose was to reconstruct the most likely mechanisms of LR and the effect of preoperative radiotherapy.

Methods

1417 patients were analyzed; 713 were randomized into preoperative radiotherapy and total mesorectal excision (RT + TME), 704 into TME alone. Of the 114 patients with LR, the subsites of LR were determined and related to tumor and treatment factors.

Results

Overall 5-year LR-rate was 4.6% in the RT + TME group and 11.0% in the TME group. Presacral local recurrences occurred most in both groups. Radiotherapy reduced anastomotic LR significantly, except when after low anterior resection (LAR) distal margins were less than 5 mm. Abdominoperineal resection (APR) mainly resulted in presacral LR. Even after resection with a negative circumferential resection margin, LR-rates were high. Thirty percent of the patients had advanced tumors, which resulted in 58% of all LRs. Lateral LR comprised 20% of all LR. Presacral and lateral LR resulted in a poor prognosis, in contrast to anterior or anastomotic LRs with a relatively good prognosis.

Conclusions

RT reduces LR in all subsites and is especially effective in preventing anastomotic LR after LAR. APR-surgery mainly results in presacral LR, which may be prevented by a wider resection. In the TME trial many advanced tumors were included, rather requiring chemoradiotherapy instead of RT. Currently, with good imaging techniques, better selection can take place. Especially lateral LR might be a problem in the future.

Keywords: Local recurrence, Rectal carcinoma, Abdominoperineal resection, Low anterior resection, Distal margin, Preoperative radiotherapy