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Operative Versus Nonoperative Treatment for Stage 0 Distal Rectal Cancer Following Chemoradiation Therapy: Long-term Results

Habr-Gama, Angelita MD*; Perez, Rodrigo Oliva MD*; Nadalin, Wladimir MD†; Sabbaga, Jorge MD†; Ribeiro, Ulysses Jr MD‡; Silva e Sousa, Afonso Henrique Jr MD*; Campos, Fábio Guilherme MD*; Kiss, Desidério Roberto MD*; Gama-Rodrigues, Joaquim MD‡

Original Articles and Discussions

Objective: Report overall long-term results of stage 0 rectal cancer following neoadjuvant chemoradiation and compare long-term results between operative and nonoperative treatment.

Methods: Two-hundred sixty-five patients with distal rectal adenocarcinoma considered resectable were treated by neoadjuvant chemoradiation (CRT) with 5-FU, Leucovorin and 5040 cGy. Patients with incomplete clinical response were referred to radical surgical resection. Patients with incomplete clinical response treated by surgery resulting in stage p0 were compared to patients with complete clinical response treated by nonoperative treatment. Statistical analysis was performed using χ2, Student t test and Kaplan-Meier curves.

Results: Overall and disease-free 10-year survival rates were 97.7% and 84%. In 71 patients (26.8%) complete clinical response was observed following CRT (Observation group). Twenty-two patients (8.3%) showed incomplete clinical response and pT0N0M0 resected specimens (Resection group). There were no differences between patient's demographics and tumor's characteristics between groups. In the Resection group, 9 definitive colostomies and 7 diverting temporary ileostomies were performed. Mean follow-up was 57.3 months in Observation Group and 48 months in Resection Group. There were 3 systemic recurrences in each group and 2 endorectal recurrences in Observation Group. Two patients in the Resection group died of the disease. Five-year overall and disease-free survival rates were 88% and 83%, respectively, in Resection Group and 100% and 92% in Observation Group.

Conclusions: Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.

Neoadjuvant chemoradiation therapy for distal rectal cancer may lead to complete clinical response or complete pathologic response in about 30% of patients. Seventy-one patients with complete clinical response followed by observation alone were compared with 22 patients with complete pathologic response following radical surgery. Radical surgery patients experienced high rates of stoma creation and unnecessary operative morbidity and mortality, without 5-year overall or disease-free survival advantage.

From the *Colorectal Surgery Division, Department of Gastroenterology, †Radiotherapy Division, Department of Radiology, and ‡Surgery of Alimentary Tract Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Reprints: Angelita Habr-Gama, Professor Rua Manoel da Nóbrega, 1564 Zip 04001-005 São Paulo, SP-Brazil. E-mail: gamange@uol.com.br.

© 2004 Lippincott Williams & Wilkins, Inc.