Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades

BMC Cancer

Ingo Klein³  Christoph-Thomas Germer¹  Joachim Reibetanz³  Nicolas Schlegel³  Michael Flentje⁵  Uwe Maeder¹  Alexander Kerscher¹  Sabine Ackermann³  Volker Kunzmann²  Ulrich A Dietz³  Christoph Isbert³  Armin Wiegering⁴ 

[1]Comprehensive Cancer Centre Mainfranken, University Hospital, University of Wuerzburg, Josef-Schneiderstr. 6, 97080 Wuerzburg, Germany

[2]Department of Internal Medicine II, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080 Wuerzburg, Germany

[3]Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 2, 97080 Wuerzburg, Germany

[4]Department of Biochemistry and Molecular Biology, University of Wuerzburg, Am Hubland, 97074 Wuerzburg, Germany

[5]Department of Radiation Oncology, University Hospital, University of Wuerzburg, Josef-Schneiderstr. 11, 97080 Wuerzburg, Germany

关键词: TME;    Improved survival;    Rectal cancer;   

Others  :  1120229
DOI  :  10.1186/1471-2407-14-816

 received in 2014-06-24, accepted in 2014-10-27,  发布年份 2014

【 摘 要 】

Background

The management of rectal cancer (RC) has substantially changed over the last decades with the implementation of neoadjuvant chemoradiotherapy, adjuvant therapy and improved surgery such as total mesorectal excision (TME). It remains unclear in which way these approaches overall influenced the rate of local recurrence and overall survival.

Methods

Clinical, histological and survival data of 658 out of 662 consecutive patients with RC were analyzed for treatment and prognostic factors from a prospectively expanded single-institutional database. Findings were then stratified according to time of diagnosis in patient groups treated between 1993 and 2001 and 2002 and 2010.

Results

The study population included 658 consecutive patients with rectal cancer between 1993 and 2010. Follow up data was available for 99.6% of all 662 treated patients. During the time period between 2002 and 2010 significantly more patients underwent neoadjuvant chemoradiotherapy (17.6% vs. 60%) and adjuvant chemotherapy (37.9% vs. 58.4%). Also, the rate of reported TME during surgery increased. The rate of local or distant metastasis decreased over time, and tumor related 5-year survival increased significantly with from 60% to 79%.

Conclusion

In our study population, the implementation of treatment changes over the last decade improved the patient’s outcome significantly. Improvements were most evident for UICC stage III rectal cancer.

【 授权许可】

   
2014 Wiegering et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D: Global cancer statistics. CA Cancer J Clin 2011, 61:69-90.
• [2]American Cancer societyhttp://www.cancer.org webcite
• [3]Gesellschaft der epidemiologischen Krebsregister in Deutschland/Robert - Koch Institut: Krebs in Deutschland 2007–2008, Häufigkeiten und Trends. Darm 2012, 8:36-39.
• [4]Heald RJ, Ryall RD: Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986, 1:1479-1482.
• [5]Weitz J, Koch M, Debus J, Höhler T, Galle PR, Büchler MW: Colorectal cancer. Lancet 2005, 365:153-165.
• [6]Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ, Dutch Colorectal Cancer Group: Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001, 345:638-646.
• [7]Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004, 351:1731-1740.
• [8]Heald RJ, Husband EM, Ryall RD: The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg 1982, 69:613-616.
• [9]MacFarlane JK, Ryall RD, Heald RJ: Mesorectal excision for rectal cancer. Lancet 1993, 341:457-460.
• [10]Kockerling F, Reymond MA, Altendorf-Hofmann A, Dworak O, Hohenberger W: Influence of surgery on metachronous distant metastases and survival in rectal cancer. J Clin Oncol 1998, 16:324-329.
• [11]Havenga K, Enker WE, Norstein J, Moriya Y, Heald RJ, van Houwelingen HC, van de Velde CJ: Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients. Eur J Surg Oncol 1999, 25:368-374.
• [12]O’Connell MJ: Current status of adjuvant therapy for colorectal cancer. Oncology (Williston Park) 2004, 18:751-755. discussion 755–8
• [13]Petersen SH, Harling H, Kirkeby LT, Wille-Jørgensen P, Mocellin S: Postoperative adjuvant chemotherapy in rectal cancer operated for cure. Cochrane Database Syst Rev 2012, 3:CD004078.
• [14]Nordlinger B, Van Cutsem E, Gruenberger T, Glimelius B, Poston G, Rougier P, Sobrero A, Ychou M, European Colorectal Metastases Treatment Group: Combination of surgery and chemotherapy and the role of targeted agents in the treatment of patients with colorectal liver metastases: recommendations from an expert panel. Ann Oncol 2009, 20:985-992.
• [15]Glimelius B, Pahlman L, Cervantes A, ESMO Guidelines Working Group: Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010, 21(Suppl 5):v82-v86.
• [16]Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, Nordlinger B, van de Velde CJ, Balmana J, Regula J, Nagtegaal ID, Beets-Tan RG, Arnold D, Ciardiello F, Hoff P, Kerr D, Köhne CH, Labianca R, Price T, Scheithauer W, Sobrero A, Tabernero J, Aderka D, Barroso S, Bodoky G, Douillard JY, El Ghazaly H, Gallardo J, Garin A, Glynne-Jones R, et al.: ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making. Ann Oncol 2012, 23:2479-2516.
• [17]van de Velde CJ, Boelens PG, Borras JM, Coebergh JW, Cervantes A, Blomqvist L, Beets-Tan RG, van den Broek CB, Brown G, Van Cutsem E, Espin E, Haustermans K, Glimelius B, Iversen LH, van Krieken JH, Marijnen CA, Henning G, Gore-Booth J, Meldolesi E, Mroczkowski P, Nagtegaal I, Naredi P, Ortiz H, Påhlman L, Quirke P, Rödel C, Roth A, Rutten H, Schmoll HJ, Smith JJ, et al.: EURECCA colorectal: multidisciplinary management: European consensus conference colon & rectum. Eur J Cancer 2014, 50:1. e1-1 e34
• [18]Cox DR: Regression models and life tables (with discussion). J R Stat Soc Series B 1972, 34:931-940.
• [19]Hosmer D: Applied Survival Analysis Regression Modelling of Time to Event Data. New York: Wiley; 1990.
• [20]Dietz UA, Debus ES: Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery. World J Surg 2005, 29:396-401.
• [21]Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J: Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a meta-analysis. Radiology 2004, 232:773-783.
• [22]Matsuoka H, Nakamura A, Sugiyama M, Hachiya J, Atomi Y, Masaki T: MRI diagnosis of mesorectal lymph node metastasis in patients with rectal carcinoma. what is the optimal criterion? Anticancer Res 2004, 24:4097-4101.
• [23]Feinstein AR, Sosin DM, Wells CK: The Will Rogers phenomenon, Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Engl J Med 1985, 312:1604-1608.
• [24]De Caluwe L, Van Nieuwenhove Y, Ceelen WP: Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer. Cochrane Database Syst Rev 2013, 2:CD006041.
• [25]Kapiteijn E, Putter H, van de Velde CJ, Cooperative investigators of the Dutch ColoRectal Cancer Group: Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002, 89:1142-1149.
• [26]Wong RK, Tandan V, De Silva S, Figueredo A: Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev 2007. Issue 2. Art. No.: CD002102.
• [27]Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, Rutten H, Pahlman L, Glimelius B, Leer JW, van de Velde CJ, Dutch Colorectal Cancer Group: The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg 2007, 246:693-701.
• [28]Bosset JF, Calais G, Daban A, Berger C, Radosevic-Jelic L, Maingon P, Bardet E, Pierart M, Briffaux A, EORTC Radiotherapy Group: Preoperative chemoradiotherapy versus preoperative radiotherapy in rectal cancer patients: assessment of acute toxicity and treatment compliance. Report of the 22921 randomised trial conducted by the EORTC Radiotherapy Group. Eur J Cancer 2004, 40:219-224.
• [29]Gastrointestinal Tumor Study Group: Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med 1985, 312:1465-1472.
• [30]Krook JE, Moertel CG, Gunderson LL, Wieand HS, Collins RT, Beart RW, Kubista TP, Poon MA, Meyers WC, Mailliard JA, Twito DI, Morton RF, Veeder MH, Witzig TE, Cha S, Vidyarthi SC, M : Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991, 324:709-715.
• [31]West NP, Anderin C, Smith KJ, Holm T, Quirke P, European Extralevator Abdominoperineal Excision Study Group: Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 2010, 97:588-599.
• [32]Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J: Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 2007, 94:232-238.
• [33]Fong Y, Cohen AM, Fortner JG, Enker WE, Turnbull AD, Coit DG, Marrero AM, Prasad M, Blumgart LH, Brennan MF: Liver resection for colorectal metastases. J Clin Oncol 1997, 15:938-946.
• [34]Nordlinger B, Guiguet M, Vaillant JC, Balladur P, Boudjema K, Bachellier P, Jaeck D: Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Francaise de Chirurgie. Cancer 1996, 77:1254-1262.
• [35]Scheele J, Altendorf-Hofmann A, Grube T, Hohenberger W, Stangl R, Schmidt K: Resection of colorectal liver metastases. What prognostic factors determine patient selection? Chirurg 2001, 72:547-560.
• [36]Kato T, Yasui K, Hirai T, Kanemitsu Y, Mori T, Sugihara K, Mochizuki H, Yamamoto J: Therapeutic results for hepatic metastasis of colorectal cancer with special reference to effectiveness of hepatectomy: analysis of prognostic factors for 763 cases recorded at 18 institutions. Dis Colon Rectum 2003, 46:S22-S31.
• [37]Kopetz S, Chang GJ, Overman MJ, Eng C, Sargent DJ, Larson DW, Grothey A, Vauthey JN, Nagorney DM, McWilliams RR: Improved survival in metastatic colorectal cancer is associated with adoption of hepatic resection and improved chemotherapy. J Clin Oncol 2009, 27:3677-3683.
• [38]Valentini V, van Stiphout RG, Lammering G, Gambacorta MA, Barba MC, Bebenek M, Bonnetain F, Bosset JF, Bujko K, Cionini L, Gerard JP, Rödel C, Sainato A, Sauer R, Minsky BD, Collette L, Lambin P: Nomograms for predicting local recurrence, distant metastases, and overall survival for patients with locally advanced rectal cancer on the basis of European randomized clinical trials. J Clin Oncol 2011, 29:3163-3172.
• [39]Heald RJ, Karanjia ND: Results of radical surgery for rectal cancer. World J Surg 1992, 16:848-857.
• [40]Enker WE: Total mesorectal excision–the new golden standard of surgery for rectal cancer. Ann Med 1997, 29:127-133.
• [41]Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D: Surgical treatment of adenocarcinoma of the rectum. Ann Surg 1998, 227:800-811.
• [42]Leong AF: Selective total mesorectal excision for rectal cancer. Dis Colon Rectum 2000, 43:1237-1240.
• [43]Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G: Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 1999, 86:1164-1170.
• [44]Brenner H, Bouvier AM, Foschi R, Hackl M, Larsen IK, Lemmens V, Mangone L, Francisci S, EUROCARE Working Group: Progress in colorectal cancer survival in Europe from the late 1980s to the early 21st century: the EUROCARE study. Int J Cancer 2012, 131:1649-1658.