Radical and local excisional methods of sphincter-sparing surgery after high-dose radiation for cancer of the distal 3 cm of the rectum

Background: Despite conventional attitudes that interdict sphincter-preservation surgery (SPS) for cancers arising in the terminal 3 cm of rectum, we have selectively employed high-dose preoperative external radiation (HDPER) and either radical or local excisional SPS techniques for rectal cancer arising between the 0.5 and 3 cm levels above the anorectal ring. We have reported a preliminary experience with HDPER and full-thickness local excision (FTLE) and three different methods of radical SPS. We now describe our experience with a single method of radical excision, transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) and FTLE in conjunction with HDPER for cancers of the distal 3 cm of rectum based on specific guidelines. Methods: Since 1984, 109 patients with cancers at or below the 3 cm level have been treated with HDPER in doses of 4,500-7,000 cGy and a sphincter-preserving radical or local excision method in a prospective rectal cancer management program. Sixty-five patients (group A) underwent transanal abdominal transanal radical proctosigmoidectomy with coloanal anastomosis (TATA) and 44 patients (group B) underwent FTLE. Results: There was one death (1%). Mean follow-up was 40 months. Local recurrence rates for groups A and B were 9 and 14%, respectively. Kaplan-Meier 5-year actuarial survival was 85 and 90% for groups A and B, respectively, and 87% collectively. Conclusion: Experience with 109 patients with cancers of the distal 3 cm of rectum indicates that SPS can be accomplished by either radical or local excisional methods with acceptable local control and survival if HDPER and strict selection guidelines are employed.