Local recurrence is no longer the main problem in rectal cancer with optimal multidisciplinary
management
W Truin1, JG Bloemen1, SME Engelen1, RG Jansen2, G Lammering4, RGH Beets-Tan3, GL Beets1
1Department
of Surgery, 2Department of Internal Medicine, 3Department of Radiology, Maastricht
University Medical Centre, Maastricht, 4Maastro Clinic, Maastricht, The Netherlands
The last decade major changes have been made in the treatment of rectal cancer, with the main focus
on improvement of local control. Since the introduction of neoadjuvant treatment consisting of shortterm radiotherapy or chemoradiotherapy together with total mesorectal excision surgery, the local
recurrence (LR) rate has reduced significantly. Routine preoperative magnetic resonance imaging
(MRI) and multidisciplinary management can lead to further optimization of surgical outcome. Since
2001 this multimodal treatment has become standard practice in our hospital. The aim of this study
was to investigate the effect of this multidisciplinary approach upon local recurrence rate. All patients
with a primary resectable adenocarcinoma of the rectum operated on in our hospital between January
1998 and December 2005 were reviewed. To obtain a group of patients that can be compared to the
population seen by a general hospital, only patients from within our own catchment area were
included. Data about preoperative imaging, neoadjuvant and surgical treatment and local recurrences
were collected. Two groups were defined; group I served as historical control and these patients were
operated on between 1998-2000; group II included patients operated on between 2001-2005.
Differences were tested statistically using a Chi square test. In total 271 patients (159 men, 112
women), with a median age of 68 (35-96) years were included. Group I (n=102) and group II (n=169)
did not differ significantly with respect to tumor stage. The local recurrence rate in group I was 12,7%
and in group II 2,4%. According to the Cox proportional hazard analysis patients in group II developed
significantly less local recurrences as compared to group I (HR 0.275, CI 0,096-0,782, p=0,016). The
interval between surgery and LR was 764 (171-2180) days. Use of preoperative MRI increased from
46,1% to 82,2% in group I and II, respectively (p<0.001). In group I 5,9% received neoadjuvant
treatment compared to 63,9% in group II (p<0.001). In conclusion, the incidence of local recurrences
in patients with rectal cancer operated in our center has decreased dramatically since the introduction
of a multidisciplinary approach. Optimal local control is most likely achieved through a combination of
preoperative MRI, neoadjuvant treatment and optimal surgical technique. The focus of rectal cancer
treatment should now be directed towards early detection and treatment of distant metastases.