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Journal Information
Vol. 93. Issue 3.
Pages 207-208 (March 2015)
Vol. 93. Issue 3.
Pages 207-208 (March 2015)
Letter to the Editor
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“The Paradigm of Surgical Treatment of Distal Rectal Cancer: What to Remove vs What to Leave Behind”
Paradigma del tratamiento quirúrgico del cáncer de recto del tercio distal. «Qué extirpamos vs. qué dejamos»
Javier A. Cienfuegos
Corresponding author

Corresponding author.
, Jorge Baixauli, Fernando Rotellar, José Luis Hernández Lizoáin
Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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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 editorial3 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 IIIII) 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

S. Biondo, L. Trenti, E. Kreisler.
Distal third rectal cancer: intersphincteric anterior resection with manual anastomosis using the techniques of Parks Or Turnbull-Cutait.
Cir Esp, 92 (2014), pp. S13-S20
B. Flor-Lorente, M. Frasson, E. Montilla.
Extralevator abdominoperineal resection in the prone position.
Cir Esp, 92 (2014), pp. S30-S39
E. García-Granero, M. Frasson, M. Trallero.
Extended resection and pelvic exenteration in distal third rectal cancer.
Cir Esp, 92 (2014), pp. S40-S47
A. Reshef, I. Lavery, R.P. Kiran.
Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only.
Dis Colon Rectum, 55 (2012), pp. 51-58
M. Den Dulk, C.A. Marijnen, H. Putter, H.J. Rutten, G.L. Beets, T. Wiggers, et al.
Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial.
S. Stelzner, C. Koehler, J. Stelzer, A. Sims, H. Witzigmann.
Extended abdominoperineal excision vs standard abdominoperineal excision in rectal cancer – a systematic overview.
Int J Colorectal Dis, 26 (2011), pp. 1227-1240
T. Holm.
Controversies in abdominoperineal excision.
Surg Oncol Clin N Am, 23 (2014), pp. 93-111
J.G. Guillem, D.B. Chessin, A.M. Cohen, J. Shia, M. Mazumdar, W. Enker, et al.
Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer.
Ann Surg, 241 (2005), pp. 829-836
P. Ding, D. Liska, P. Tang, J. Shia, L. Saltz, K. Goodman, et al.
Pulmonary recurrence predominates after combined modality therapy for rectal cancer: an original retrospective study.
Ann Surg, 256 (2012), pp. 111-116
J. Arredondo, J. Baixauli, C. Beorlegui, L. Arbea, J. Rodríguez, J.J. Sola, et al.
Prognosis factors for recurrence in patients with locally advanced rectal cancer preoperatively treated with chemoradiotherapy and adjuvant chemotherapy.
Dis Colon Rectum, 56 (2013), pp. 416-421
C. Fernández-Martos, C. Pericay, J. Aparicio, A. Salud, M. Safont, B. Massuti, et al.
Phase II, randomized study of concomitant chemoradiotherapy followed by surgery and adjuvant capecitabine plus oxaliplatin (CAPOX) compared with induction CAPOX followed by concomitant chemoradiotherapy and surgery in magnetic resonance imaging-defined, locally advanced rectal cancer: Grupo cancer de recto 3 study.
J Clin Oncol, 28 (2010), pp. 859-865
I. Chau, G. Brown, D. Cunningham, D. Tait, A. Wotherspoon, A.R. Norman, et al.
Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer.
J Clin Oncol, 24 (2006), pp. 668-674
D. Schrag, M.R. Weiser, K.A. Goodman, M. Gonen, E. Hollywood, A. Cercek, et al.
Neoadjuvant chemotherapy without routine use of radiation therapy for patients with locally advanced rectal cancer: a pilot trial.
J Clin Oncol, 32 (2014), pp. 513-518
N.N. Rahbari, M. Aigner, K. Thorlund, N. Mollberg, E. Motschall, K. Jensen, et al.
Meta-analysis shows that detection of circulating tumor cells indicates poor prognosis in patients with colorectal surgery.
Gastroenterology, 138 (2010), pp. 1714-1726
M. Balic, A. Williams, H. Lin, R. Datar, R.J. Cote.
Circulating tumor cells: from bench to bedside.
C. Alix-Panabieres, H. Schwarzenbach, K. Pantel.
Circulating tumor cells and circulating tumor DNA.
Annu Rev Med, 63 (2012), pp. 199-215

Please cite this article as: Cienfuegos JA, Baixauli J, Rotellar F, Hernández Lizoáin JL. Paradigma del tratamiento quirúrgico del cáncer de recto del tercio distal. «Qué extirpamos vs. qué dejamos». Cir Esp. 2015;93:207–208.

Copyright © 2014. AEC
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