The paradigm of surgical treatment of distal rectal cancer: what to remove vs. what to leave behind

To the Editor,
We have read the articles published by Biondo et al. (1) and Flor-Lorente et al. (2) about the surgical treatment of distal third rectal cancer (0–5cm). Both articles and the accompanying editorial (3) describe the surgical aspects related with the oncologic results: avoiding tumor perforation, involvement of the circumferential margin, and integrity of the mesorectum.

In spite of technical advances, there is evidence that long-term oncologic results (local recurrence and disease-free survival) are worse in tumors of the distal third of the rectum, making these patients a high-risk group. (4,5)

As discussed by the authors, it is still controversial whether extralevator abdominoperineal resection (ELAPR) is superior to conventional abdominoperineal resection (APR) for long-term survival. (6,7)

In spite of neoadjuvant chemoradiotherapy (CRTx) and the significant reduction in local recurrence rates, distant metastases are common (>25%), especially in the lungs, followed by the liver. (8) In a recent study of 593 patients (stages II/III) treated with long-course neoadjuvant CRTx and total mesorectal excision, during a mean follow-up of 44 months, 69% of the metastases were pulmonary. In addition to the distal location, other risk factors for systemic recurrence were pathological stage and perineural or lymphovascular infiltration. (9)

In an analysis at our hospital of 228 patients with locally advanced rectal cancer who had been treated with a similar neoadjuvant CRTx regime and a mean follow-up of 49 months, we observed 20.6% (47 patients) with distant recurrence and 2.6% (6 patients) with local recurrence. (10) Lung metastases were more frequently associated with the distal third than in superior portions (25% vs 9%; P=.024). In a recent update in 356 patients, lung recurrence continues to be higher in patients with distal third cancer (23.8% vs 10.9%).

Although anatomical factors have been argued (venous drainage), given the persistence of this pattern and based on results from our country and England, (10–12) phase II trials have been started. These prioritize chemotherapy and select radiotherapy in non-responsive tumors. Schrag et al. (13) have published preliminary results in 32 patients (stages II–III) treated with 6 cycles of FOLFOX-6 with bevacizumab in cycles 1–4. All patients were treated surgically, and complete pathological response was observed in 8 (25%). In the 30 patients that completed chemotherapy, local recurrence was 0%. Four patients (12.5%) developed lung metastases, and 4-year survival was 84%.

As indicated by García-Granero et al.,3 after 30 years of technical advances in the treatment of locally advanced rectal cancer, in addition to correct surgery, we should treat the systemic disease (micrometastasis, circulating tumor cells) early on in high risk cases, such as distal third rectal cancer. (13–16)

CITATION  Cir Esp. 2015 Mar;93(3):207-8. doi: 10.1016/j.ciresp.2014.10.007. Epub 2014 Nov 28