Neoadjuvant Chemoradiotherapy and Total Mesorectal Excision in the Management of Locally Advanced Rectal Carcinoma - The PGH CRPoCan Study Group Experience 2008-2009

Henri S. Co,1 Marie Dione P. Sacdalan,2 Marc J. Lopez,2 Irisyl O. Real,3 Mark C. Ang,4
Edilberto V. Fragante,1 Manuel T. Roxas,2 Dennis L. Sacdalan3  and Andrew D. Dimacali4

1Section of Radiation Oncology, Department of Radiology, College of Medicine and
Philippine General Hospital, University of the Philippines Manila
2Division of Colorectal Surgery, Department of Surgery, College of Medicine and
Philippine General Hospital, University of the Philippines Manila
3Section of Medical Oncology, Department of Medicine, College of Medicine and
Philippine General Hospital, University of the Philippines Manila
4Department of Laboratories, Philippine General Hospital, Manila

Introduction. The use of neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) has shown promising result in the management of locally advanced rectal carcinoma, and is associated with improvement n local control, disease free survival (DFS) and overall survival (OS). However, these clinical endpoints cannot be properly assessed due to poor follow up among many patients. Other endpoints such as negative circumferential resection margins (CRM), pathologic complete response (pCR) and sphincter-preserving surgery (SPS) may serve as indirect means of assessing successful treatment. This study reports the experience of the Philippine General Hospital (PGH) Colorectal Polyp and Cancer (CRPoCan) Study Group in using neoadjuvant CRT and TME in the management of locally advanced rectal carcinoma, towards quality care.

Methods. The Integrated Surgical Information System (ISIS) database of the Department of Surgery, PGH was queried for rectal cancer patients with pretreatment clinical stage II and III disease that underwent neo-adjuvant CRT followed by TME between January 2008 and December 2009. The final surgical pathology reports of the subjects were reviewed for treatment response. Response was categorized as: (1) positive or negative CRM; and (2) with or without pCR. The study assessed whether SPS was done.

Results. Of 140 potential neoadjuvant CRT patients followed by TME, 82 patients completed the treatment. Thirty two of the patients who completed treatment (39%) were eligible since the other 50 patients (61%) had no post-operative histopahology results. Among those eligible, 10 patients (31%) had pCR. Only 1 patient had a positive CRM. Of the 14 patients whose tumor distance was <= 5cm from the anal verge, only 1 patient underwent SPS. The small sample size was mainly attributed to low resources for treatment. Non-availability of post-operative histopathology results was due to poor record keeping.

Conclusion. The PGH CRPoCan Study Group's use of neoadjuvant CRT followed by TME for locally advanced rectal carcinoma has resulted in acceptable numbers of pCR and clear CRM but has not translated into an increased number of SPS. Despite the limitations of the study, the institutionalization of the multidisciplinary team in the PGH CRPoCan Study Group and the implementation of the ISIS database program are considered the first steps towards quality health care.

Key Words: neoadjuvant chemoraditherapy, total mesorectal excision, rectal carcinoma, quality care