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Rectal Cancer Treatment

Approximately 37,000 new cases of rectal cancer are diagnosed each year in the United States.[1] The overall survival rate for individuals with rectal cancer is approximately 50 percent.[2] Tumors of the distal rectum have classically been treated by abdominoperineal resection, which is associated with significant morbidity and mortality and leaves patients with a permanent colostomy. To overcome these shortcomings, methods of local treatment of rectal cancer have been developed as alternatives to abdominoperineal resection in selected patients.

The rationale for local treatment is based on several factors. Theoretically, a tumor confined to the bowel wall can be effectively managed if it is completely destroyed by either local or radical excision. Abdominoperineal resection is performed to remove cancer from the rectal wall as well as the draining lymph nodes. If no lymphatic spread is present, a radical procedure does not improve the chance for cure. Conversely, local treatment is inadequate for cancers with lymph node spread.

The clinical dilemma is how to identify suitable candidates for local treatment. Newer diagnostic modalities such as endorectal ultrasonography have improved the accuracy and reliability of preoperative staging of rectal cancer. With a knowledge of the tumor grade, depth of penetration and probability of lymph node spread, surgeons can discuss the option of local treatment with patients. However, preoperative staging is still difficult, and only 5 to 10 percent of patients with low rectal cancers are candidates for curative local treatment.

Preoperative Staging of Rectal Cancer

Accurate preoperative staging is essential for successful local treatment of rectal cancer. The staging of rectal cancers is based on the depth of bowel wall penetration and the presence of lymph node or distant spread.

When local treatment is being considered, the TNM classification system is particularly useful because it categorizes four levels of penetration of the rectal wall (Table 1).[3] In the TNM system, an invasive lesion that breaks through the muscularis mucosa and invades the submucosa is classified as T1, while a lesion that enters but does not completely traverse the muscularis propria is classified as T2. A T3 lesion completely penetrates the muscularis propria and extends into the perirectal fat, and a T4 lesion invades adjacent structures, such as the prostate gland or the vagina. The probability of lymph node spread correlates with the depth of penetration. Candidates for local treatment should have no evidence of regional lymph node involvement (N0) and no distant metastasis (M0).

TABLE 1

TNM Staging System for Tumors of the Colon and Rectum

Tumor

T1      Tumor invasion into the submucosa
T2      Tumor invasion into the muscularis propria
T3      Tumor invasion into the subserosa, nonperitonealized
          pericolic/perirectal tissues
T4      Tumor invasion into the visceral peritoneum, other
          organs or structures

Lymph nodes

N0      No metastatic lymph nodes
N1      Up to three pericolic/perirectal lymph nodes
N2      More than three pericolic/perirectal lymph nodes
N3      Nodes on named vascular trunk

Metastases

M0      No distant metastases
M1      Distant metastases

Selection criteria have been developed to predict which patients have the lowest risk of lymph node metastasis and thus are the best candidates for curative local treatment. The decision to proceed with local treatment is occasionally difficult, especially in younger patients in whom the risk of leaving positive nodes behind may be unacceptable. Local treatment becomes a more acceptable option in elderly patients or in patients with significant comorbid conditions that would pose a high risk of mortality following abdominoperineal resection.

Unlike local treatment for cure, local treatment for palliation is not restricted by strict selection criteria. Palliative local treatment is often the best option to avoid radical resection and permanent colostomy in patients with metastatic disease.

Options for Local Treatment

The three most common methods of local treatment of low rectal cancers are local excision, electrocoagulation and endocavitary contact radiation (Table 3). No prospective randomized trials have compared these modalities with abdominoperineal resection. A better perspective can be gained by considering the data on patients who have undergone abdominoperineal resection for cancers confined to the rectal wall (T1 or T2). The morbidity rate for abdominoperineal resection in these patients has been approximately 50 percent in several series.[2,30] In addition, patients who have undergone this procedure are faced with the psychosocial stresses and other disadvantages of living with a permanent colostomy.

TABLE 3
Options for Local Treatment of Rectal Cancer

Method of treatment      Advantages     Disadvantages

Local excision           Specimen available for histologic
                           review
                         Lymph nodes frequently obtained
                           in the specimen, and samples can
                           be sent for pathologic review

Electrocoagulation       Technically easier to obtain more
                            proximal and deeper margins

Endocavitary contact     No surgery
  radiation              Well tolerated, even by frail patients
                         Outpatient treatment

Method of treatment      Disadvantages

Local excision           Difficult to excise proximal tumors
                         Usually requires hospital stay

Electrocoagulation       No specimen for histologic review
                         Multiple sessions frequently required
                         Surgeon must be familiar with technique
                         Usually requires hospital stay

Endocavitary contact     Requires specialized equipment and is
  radiation                performed in only a few centers in the
                           United States

Complications are rare in patients who receive endocavitary contact radiation, and no deaths have been reported.[42] The five-year survival rate is between 74 and 78 percent, and local recurrence rates range from 5 to 38 percent.[41-43]

The addition of external-beam radiation to contact radiotherapy produced encouraging results in a select group of patients.[42,44] With this combined treatment, the tumor recurrence rate was approximately 7 percent.[44] Patients with local tumor recurrence may be treated for cure by resectional surgery.

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MARK J. PIDALA, M.D. is in private practice in Kent, Ohio. He received his medical degree from the University of Cincinnati College of Medicine and completed a five-year general surgery residency at Akron (Ohio) City Hospital/Summa Health System. Dr. Pidala also completed a fellowship in colon and rectal surgery at the University of Medicine and Dentistry of New Jersey (UMDNJ)-Robert Wood Johnson School of Medicine Affiliated Hospitals, Plainfield.

GREGORY C. OLIVER, M.D. is associate clinical professor of surgery at the UMDNJ-Robert Wood Johnson School of Medicine. Dr. Oliver received his medical degree from George Washington University School of Medicine, Washington, D.C., where he also completed a residency in general surgery. He completed a fellowship in colorectal surgery at the UMDNJ-Robert Wood Johnson School of Medicine.

Address correspondence to Mark J. Pidala, M.D., The Western Reserve Medical Center, 1930 State Route 59, Kent, OH 44240.

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