Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients

Aims: Improved local control and survival in the treatment of rectal cancer have been reported after total mesorectal excision and after extended lymphadenectomy, Comparison of published results is difficult because of differences in patient populations and definitions. We compared three series of patients who underwent standardized surgery [i.e. total mesorectal excision (TME) or D3 lymphadenectomy] with patients who underwent conventional surgery, using actual patient data and uniform definitions. Methods: TME was performed at Memorial Sloan-Kettering Cancer Center, New York, USA (n = 254) and the North Hampshire Hospital, Basingstoke, UK(n = 204). D3 lymphadenectomy was performed at the National Cancer Center, Tokyo (rr = 233). Conventional surgery was used in hospitals in Norway (n = 366) and in hospitals of the Comprehensive Cancer Center West,;The Netherlands (n = 354). Only patients with a curatively resected primary TNM Stage II or Stage III rectal cancer within 12 cm from the anal verge were included. Results: Five-year overall survival and canter-specific survival were 62-75% and 75-80%,respectively, in the standardized surgery groups and 42-44% and 52%, respectively, in the conventional surgery groups. Local recurrence rates ranged from 4 to 9% in the standardized surgery groups and 32-35% in the conventional surgery groups. Conclusions: A 30% survival difference and 25% local recurrence difference is not likely to be caused by the shortcomings which are inherent in a non-randomized study: selection bias, assessment variability or stage migration. This study suggests that standardized surgery gives superior survival and local control when compared to conventional surgery.