Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Background Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers. Methods Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. Results Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82 center dot 8 per cent (298 patients) and the local recurrence rate was 12 center dot 5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4 center dot 49, 95 per cent c.i. 1 center dot 99 to 10 center dot 14; P = 0 center dot 002) and lymphovascular invasion (HR 2 center dot 02, 1 center dot 08 to 3 center dot 77; P = 0 center dot 032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease. Conclusion This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.