The oncological outcomes of postoperative radiotherapy in patients with stage II and III upper rectal cancer

Abstract

Objective: We assessed the oncological outcomes of postoperative radiotherapy and chemotherapy in patients with stage II or III upper rectal cancer who had undergone curative surgery.

Patients and Methods: We retrospectively investigated 133 patients who underwent primary curative resection of stage II or III upper rectal cancer. The median age was 62 years (range 30–82 years). Among these patients, 48% were stage II and 52% stage III. All received postoperative radiotherapy, and most received adjuvant 5-fluorouracil-based chemotherapy for 6 months after radiotherapy ceased. Survival curves were plotted using the Kaplan–Meier method, and survival was compared using the log-rank test.

Results: The median follow-up was 71.4 months. The 5-year local recurrence-free survival, cancer specific survival, and overall survival (OS) rates were 91.6%, 80.6%, and 75.4%, respectively. Nodal stage 2 (p = 0.02, p = 0.05) was a significant predictor of poor local recurrence-free survival and cancer specific survival rates. In the multivariate analysis, older age (p = 0.01) and a higher N stage (p = 0.01) were independent risk factors for poor OS.

Conclusion: The nodal state was predictive of all endpoints in patients with upper rectal stage II or III cancer.

Keywords

• Upper rectal cancer
• Postoperative radiotherapy
• Outcomes

References

1. [1] Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016; 66:7-30. doi: 10.3322/caac.21332. Epub 2016 Jan 7.
2. [2] Cedermark B, Dahlberg M, Glimelius B, Påhlman L, Rutqvist LE, Wilking N. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997;336: 980-7. doi: 10.1056/NEJM199.704.033361402.
3. [3] Kapiteijn E, Marijnen CA, Nagtegaal ID, et al; Dutch Colorectal Cancer Group: Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345: 638-46. doi: 10.1056/NEJMoa010580.
4. [4] Zaborowski A, Stakelum A, Winter DC. Systematic review of outcomes after total neoadjuvant therapy for locally advanced rectal cancer. Br J Surg 2019;106: 979-87. doi: 10.1002/ bjs.11171.
5. [5] Yamamoto S, Watanabe M, Hasegawa H, Kitajima M. Prospective evaluation of laparoscopic surgery for rectosigmoidal and rectal carcinoma. Dis Colon Rectum 2002; 45:1648e54. doi: 10.1097/01.DCR.000.003.4514. 34747.80.
6. [6] Ponz de Leon M, Marino M, Benatti P , et al. Trend of incidence, subsite distribution and staging of colorectal neoplasms in the 15-year experience of a specialised cancer registry. Ann Oncol 2004; 15:940e6. doi: 10.1093/annonc/mdh224.
7. [7] Kaser SA, Froelicher J, Li Q, et al. Adenocarcinomas of the upper third of the rectum and the rectosigmoid junction seem to have similar prognosis as colon cancers even without radiotherapy, SAKK 40/87. Langenbeck’s Arch Surg 2015;400:675e82. doi:10.1007/s00423.014.1243-1.
8. [8] Suttie SA, Shaikh I, Mullen R, Amin AI, Daniel T, Yalamarthi S. Outcome of right – and left-sided colonic and rectal cancer following surgical resection. Colorectal Dis 2011; 13:884-9. doi:10.1111/j.1463-1318.2010. 02356.x.

9. [9] Guan X, Jiang Z, Ma T, et al. Radiotherapy dose led to a substantial prolongation of survival in patients with locally advanced rectosigmoid junction cancer: a large population based study. Oncotarget 2016; 7:28408e19. doi: 10.18632/ oncotarget.8630.
10. [10] Burton S, Brown G, Daniels I, et al. MRI identified prognostic features of tumors in distal sigmoid, rectosigmoid, and upper rectum: treatment with radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 2006;65: 445e51. doi: 10.1016/j. ijrobp.2005.12.027.
11. [11] Bussotti C, Burattini MF, Ricci E, Giuliani N, Bufalari A, Servoli A, et al. Rectosigmoid junction neoplasms: our experience. Geka Chiryo 2003; 24:409e12.
12. [12] Moutinho-Ribeiro M, de Sousa JP. 81 cancers of the rectosigmoid junction. Colonic or rectal neoplasms? Acta Med Port 1993; 6:443e7.
13. [13] Greene FL. AJCC cancer staging manual. 7th ed. New York: Springer-Verlag; 2010.
14. [14] Song C, Song S, Kim JS, et al. Impact of postoperative chemoradiotherapy versus chemotherapy alone on recurrence and survival in patients with stage II and III upper rectal cancer: A propensity score-matched analysis. PLoS One 2015;22;10: e0123657. doi: 10.1371/journal.pone.0123657.
15. [15] Kang BM, Baek JH, Park SJ, et al. Impact of adjuvant therapy type on survival in stage II/III rectal cancer without preoperative chemoradiation: A Korean multicenter retrospective study. Ann Coloproctol 2018; 34: 144-51. doi:10.3393/ac.2017.09.26.1.
16. [16] Pilipshen SJ, Heilweil M, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer 1984; 53: 1354- 62. doi: 10.1002/1097-0142(19840315)53:6<1354::aidcncr282.053.0623> 3.0.co;2-j.
17. [17] Polk HC, Spratt JS. Recurrent colorectal carcinoma: Detection, treatment, and other considerations. Surgery 1971; 69:9-23.
18. [18] Welch JP, Donaldson GA. The clinical correlation of an autopsy study of recurrent colorectal cancer. Ann Surg 1979; 189:496-502. doi: 10.1097/00000.658.197904000-00027.
19. [19] Vassilopoulos PP, Yoon JM, Ledesma EJ, Mittelman A. Treatment of recurrence of adenocarcinoma of the colon and rectum at the anastomotic site. Surg Gynecol Obstet 1981; I52:777-80.
20. [20] Mittelman AM, Knowlton AH, Weiland L. Phase Ill study of adjuvant therapy of surgically operable rectal carcinoma, Stages B2 and C. Proceedings Gastrointestinal Tumor Study Group, National Cancer Institute, 1975.
21. [21] Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351: 1731-40. doi: 10.1056/NEJMoa040694
22. [22] Valentini V, van Stiphout RG, Lammering G, MC, et al. 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; 29:3163-72. doi: 10.1200/ JCO.2010.33.1595
23. [23] Gunderson LL, Sargent DJ, Tepper JE, et al. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol 2004; 22:1785-96. doi: 10.1200/JCO.2004.08.173. Epub 2004 Apr 5.
24. [24] Quirke P, Steele R, Monson J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 2009; 373:821-8. doi: 10.1016/S0140-6736(09)60485-2.
25. [25] Hu S, Li S, Teng D, et al. Analysis of risk factors and prognosis of 253 lymph node metastasis in colorectal cancer patients. BMC Surg . 2021;21:280. doi: 10.1186/s12893.021.01276-2.
26. [26] Vigliotti A, Rich TA, Romsdahl MM, Withers HR, Oswald MJ. Postoperative adjuvant radiotherapy for adenocarcinoma of the rectum and rectosigmoid. Int J Radiat Oncol Biol Phys 1987;13:999-1006. doi: 10.1016/0360-3016(87)90037-x.
27. [27] Tabchouri N, Eid Y, Manceau G, et al. Neoadjuvant treatment in upper rectal cancer does not improve oncologic outcomes but increases postoperative morbidity. Anticancer Res 2020 ;40:3579-87. doi:10.21873/anticanres.14348.