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EDITORIALS |
From the Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts.
Correspondence: Address correspondence to: Richard S. Swanson, MD, Department of Surgery, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; Fax: 617-739-1728; E-mail: rswanson{at}partners.org
In 2002, there are numerous methods to palliate incurable rectal cancer. Many physicians strive to "save" an incurable patient from undergoing surgery; they use combinations of chemotherapy, radiotherapy, laser ablation, and endoscopic stents to palliate the primary rectal tumor. In this climate, investigators at Memorial Sloan-Kettering Cancer Center (MSKCC) analyzed their results with radical resection of the primary rectal cancer for patients with stage IV disease.1 With careful selection and obvious expertise, they noted excellent local control without radiotherapy (94% at 2 years); a commendable operative mortality rate (1.25%) and a remarkable 25-month median survival time.
Resection to palliate rectal cancer is not new. Certainly, it has been practiced widely for well over 100 years. Specific reports advocating this approach are older than most surgeons who currently are finishing fellowship training.2 A rather recent update was published in 1987 when investigators from Minnesota analyzed 125 patients who were considered incurable and underwent palliative procedures, including anterior resection (n = 66), abdominoperineal resection (n = 26), Hartmann’s procedure (n = 3), diverting colostomy (n = 17), and transanal excision (n = 13).3 The operative mortality rate was low (0.8%), and only one patient who had a resection required a subsequent reoperation for obstruction from local recurrence. Median survival times for patients according to procedures performed were: 6.4 months for colostomy, 14.8 months for abdominally resected cases, and 14.7 months for transanal excision. Although this report argues for surgical palliation, over the past 15 years other nonoperative palliative techniques have emerged.
Laser ablation with or without other treatment is a potential palliative modality for rectal cancer. One report suggests a lower crude relapse rate when laser ablation is combined with radiation (58% and 15% without and with radiation, respectively; P = .002).4 Those of us who use laser ablation for rectal cancer realize that it can work well for some patients, but if a patient lives long enough it can be a very unsatisfactory management strategy due to the need for repeated sessions. Endoscopic stents can palliate obstruction and bleeding. If they are too low in the rectum, tenesmus can be a disabling problem. Pain can be a problem solely related to the stent. The stents can migrate and pass per anus. Perforation can occur at the time of stent placement or over a month later.5 Finally, stent placement has a treatment related mortality that was 3% in one study.6 For a patient with a predicted short survival time and an obstructing tumor in the mid or upper rectum, a stent might be reasonable if the distal end does not sit on the levator and cause tenesmus. For a low rectal lesion, laser ablation might be better than a stent for the patient with a short time to live.
The report from MSKCC in the current issue of the Annals of Surgical Oncology is remarkable for several features that underscore the expertise at MSKCC in handling these patients. First, the operative mortality rate was exceptionally low given the advanced state of the cancers and the complexity of the surgery. Second, 94% had lesions penetrating the wall of the rectum and 74% were node positive; both pathological features are associated with a significant frequency of local failure, but in this study only 6% had local failure at 2 years. Presumably, the expertise of the colorectal surgeons at MSKCC in performing total mesorectal excisions was important in achieving local control without using adjuvant radiotherapy. Third, only 20% had colostomies.
At the same time, the MSKCC report raises several questions. Presumably not all of the patients who presented to MSKCC with stage IV rectal cancer had surgery. In the article, the investigators stated that of those 335 patients with stage IV rectal cancer who had surgery, only approximately one quarter had radical resections; 76% had other treatments. How did they select the minority (24%) for radical resection? Of those who had surgery, some did and some did not have preoperative chemotherapy; eight patients did not have any chemotherapy (and they had a relatively short median survival time of 7 months). Does this simply represent the changing philosophy over time regarding chemotherapy of some of the investigators or were particular guidelines followed? The investigators noted that only two patients had positive margins. Did all of the patients have radial, distal, and proximal margins examined? What was the minimum distal margin that they accepted to do an anastomosis and preserve the anal sphincter for a patient with a presumably short survival time? Does the group of 80 patients represent a homogeneous group of patients with incurable metastatic rectal cancer? Or were the 22 (31%) who had metastatic disease resected treated for cure while the others were simply palliated? Was the quality of life reasonable for the 20% who had colostomies, or should we offer other treatments (i.e., laser ablation) when colostomy is the only surgical choice?
Given the limitations of a retrospective review of heterogeneous patients, the MSKCC report has significant benefit for all of us who care for patients with rectal cancer. With proper selection and expertise, radical resection of the primary cancer can be done safely and with excellent results. Selection argues for offering resection to a patient who has a potentially resectable primary with a small volume of metastatic disease (i.e., <50% liver replacement, according to the MSKCC investigators) that responds to preoperative chemotherapy. Expertise argues for a multimodality team that can integrate chemotherapy and complex surgery. The investigators at MSKCC should be congratulated for a useful report that provides guidance for treatment of a difficult group of patients. We look forward to future reports that will answer some of the questions posed above and will refine our treatment of patients with stage IV rectal cancer.
Received for publication October 15, 2002. Accepted for publication October 16, 2002.
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