Preoperative Radiation Therapy and Sphincter Preservation by the Combined Abdominotranssacral Technique for Selected Rectal Cancers GERALD MARKS, M.D.,* MOHAMMED MOHIUDDIN, M.D.,t BETTED. BORENSTEIN, PH.D.+ + Marks G, Mohiuddin M, Borenstein BD. Preoperative radiation ther- apy and sphincter preservation by the combined abdominotranssacral technique for selected rectal cancers. Dis Colon Rectum 1985;28:565- 571. In an attempt to reduce the incidence of local recurrence and maintain normal sphincteric function in selected patients treated for rectal cancer, a clinical experience using full dose preoperative radiation therapy and a combined abdominotranssacral technique was begun in 1976. The first 24 of 55 patients treated have now been followed for 20 to 84 months, the median follow-up period being 39 months; sufficient data related to their clinical courses are available for analysis. Cancers were selected on the basis of unfavorability and location in the rectum (3- and 7-cm levels). Clinical staging of the disease was accurate and allowed selection and treatment of only those cancers considered unfavorable (stages B2 and C), thereby avoiding unnecessary radiation of more favorable tumors. One anastomotic disruption required recon- struction, but perioperative complications were otherwise unremark- able. Local recurrence in this group of highly unfavorable cancers has not been observed. Normal anal sphincteric function has been pre- served in each instance. Preliminary results indicate that full dose preoperative radiation therapy for selected unfavorable and low level cancers permits safe and effective sphincter preservation surgery by the combined abdominotranssacral technique. When proper precaution- ary measures are observed, surgery can be conducted with the expecta- tion of normal continence and significant reduction in local recurrence. [Key words: Cancer; CATS; Combined abdominotranssacrai tech- nique; Preoperative radiation; Radiation therapy; Rectal cancer, Sphincter preservation] THE QUALITY OF RECTAL CANCER MANAGEMENT is measured by the safety, appropriateness, and effectiveness of the treatment. The effectiveness is primarily measured by the ability to control local recurrence, with the impor- tant but secondary consideration being the maintenance Supported in part by The Colorectal Surgical Foundation and The Kapnek Charitable Trust. *Professor of Surgery, Director, Division of Colorectal Surgery. tProfessor and Chief, Clinical Division, Department of Radiation Therapy and Nuclear Medicine. SResearch Associate, Center for Research in Medical Education and Health Care. Received for publication December 17, 1984. Address reprint requests to Dr. Marks: 111 South 11th Street, Suite 8254, Philadelphia, Pennsylvania 19107. From the Division of Colorectal Surgery, the Department o] Radiation Therapy and Nuclear Medicine, and the Center for Research in Medical Education and Health Care, Je/lerson Medical College, Thomas Jellerson University, Philadelphia, Pennsylvania of normal functions and sphincter preservation. Address- ing these two considerations in terms of safety and appropriateness, a clinical experiment began in 1976. Selected cancers of the rectum were treated with pre- operative full dose radiation therapy and a combined abdominotranssacral surgical technique to prevent local recurrence and to permit expanded use of sphincter preser- vation. 1 The operative method includes an abdominal proctosigmoidectomy with anastomosis created trans- sacrally at the 1- to 2-cm level. Using this muhimodal approach, a permanent colostomy can now be avoided in all patients except those with cancers originating below the 3-cm level (as measured from the pectinate line). Of 55 patients so treated, 24 have been observed for a sufficient period of time to permit analysis (median follow-up period, 37 months; minimum, 20; maximum 84). The use of radiation therapy in the treatment of rectal cancer began at the Thomas Jefferson University Hospi- hal in the late 1950s, when Dr. Simon Kramer successfully initiated cobalt therapy for perineal recurrence. 1 Subse- quently, selected patients with highly unfavorable ano- rectal cancers were treated with observed benefit by full dose preoperative radiation therapy in conjunction with a Miles' resection. In 1975, a 47-year-old woman presented with an unfavorable, deeply ulcerated cancer at the 3-cm level of the anterior rectal wall. The cancer involved the rectovaginal septum and was treated preoperatively with radiation therapy. The cancer disappeared grossly and microscopically but, despite this, we fionetheless felt obliged to proceed with a combined abdominoperineal proctosigmoidectomy and permanent colostomy. The total absence of cancer cells in the surgical specimen of 565