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Do Patients Requiring a Multivisceral Resection for Rectal Cancer Have Worse Oncologic Outcomes Than Patients Undergoing Only Abdominoperineal Resection?
Eslam M. Dosokey*1, Justin Brady1, Ruel Neupane1, Murad A. Jabir1, Sharon L. Stein1, Harry L. Reynolds1, Conor P. Delaney2, Scott R. Steele1
1Surgery, University Hospitals Case Medical Center/Case Western Reserve University, Cleveland, OH; 2Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH
Purpose
Abdominoperineal Resection (APR) remains an important option for curative resection of rectal cancer. For locally advanced rectal cancer, patients may require multivisceral resection (MVR) in addition to an APR. To date, short and long-term outcome comparison between patients undergoing APR and MVR is limited. We hypothesized that oncological outcomes would be worse with MVR.
Methods
A retrospective chart review was performed of 118 patients who underwent curative (R0) APRs for rectal cancer from 2006 - 2015 at a single tertiary academic medical center. The patients were classified according to APR alone or APR as part of a MVR. MVR included prostatectomy, cystectomy, hysterectomy, vaginectomy, coccygectomy, or small bowel resection. Preoperative, intra-operative and postoperative metrics were evaluated including disease-free (DFS) and overall survival (OS).
Results
There were 82 patients who underwent APR and 36 patients who underwent MVR. Patients were demographically similar including age, body mass index and co-morbidities (p > 0.05). Similarly, surgical approach, pre-operative imaging, use of ureteral stents, rate of intraoperative perforation were not significantly different (p > 0.05). Operating time (p = 0.004) and blood loss (p = 0.006) were significantly higher in MVR group. Post-operatively, the rate of abdominal and perineal wound complications, hospital complications, length of stay, urinary dysfunction and ostomy dysfunction were not significantly different. Rates of pre-operative chemoradiation, margin distance and post-operative chemotherapy were not significantly different. MVR patients had higher rates of post-operative radiation therapy (p = 0.02).
Mean follow-up was 36 months (range 2-120 months) for APR- patients and 33 months (range 2-123) for MVR patients. Overall, there were ten total recurrences: in the APR group, there were 4 distant recurrences and 1 local recurrence; in the MVR group, there were 4 distant recurrences and 1 local recurrence. DFS at 5-years by Kaplan-Meier analysis was 87% for APR versus 79% for MVR (log-rank p=0.11). Cox regression analysis showed patients undergoing MVR had a shorter DFS, but it was not statistically significant (HR 2.6, 95% CI 0.8 - 9.2). The 5-year Kaplan-Meier analysis showed OS rates were 87% and 67 % for APR and MVR patients, respectively (log-rank test p = 0.10). Cox regression analysis showed patients undergoing MVR had a non-statistically significant shorter OS (HR 2.5, 95% CI 0.8 - 7.8).
Conclusion
MVR with APR can be performed safely with low morbidity and comparable oncologic outcomes. Patients who undergo MVR tend to have higher rate of post-operative radiation therapy but do not have significantly reduced overall survival or adverse oncologic outcomes compared to patients who undergo APR.
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