Local recurrence of colorectal cancer: the problem, mechanisms, management and adjuvant therapy

Incidence and patterns of recurrence following curative resection for colorectal carcinoma

PURPOSE

This study was designed to determine incidence and patterns of recurrence after curative resection of colorectal carcinoma and to determine which variables are significant in predicting outcome.

METHOD

A retrospective review of 524 patients operated on by one surgeon from 1975 to 1992 was conducted. Variables recorded included age, gender, location, gross morphology, histology, stage of each primary and evidence of perforation and direct extension at time of original operation. Overall survival and pattern of recurrence were documented.

RESULTS

Overall recurrence rate was 27.9 percent. Anastomotic recurrence rate was 11.7 percent. Anastomotic recurrences were higher for rectal than colon lesions (20.3 vs. 6.2 percent; P = 0.001). Distant metastases developed in 14.4 percent of patients, 13.9 percent for colon carcinoma and 15.5 percent for rectal carcinoma. Average time for anastomotic recurrence was 16.2 months vs. 22.9 months for distant disease. T1,2,N0,M0 lesions had a 17.6 percent recurrence rate, T3,N0,M0 was 23.4 percent, and T1,2,3,N1,M0 was 43.7 percent (P = .001). Patients who did not undergo any intervention after diagnosis of recurrence survived an average of 28 months. Those who received palliative treatment survived an average of 39 months. Twenty-four percent of patients had reresection for cure, and 47 percent of these patients were alive at a mean of 80 months; those who died of their disease did so at an average of 53 months. Positive predictive factors for recurrence include site of lesion (rectum vs. colon), stage, invasion of contiguous organs, and presence of perforation. Age, gender, degree of differentiation, mucin secretion, and gross morphology were not found to be predictive factors in this study.

CONCLUSIONS

Recurrence after resection for rectal carcinoma is higher than after colon carcinoma. In those patients in whom reresection is possible, up to 50 percent may have long-term survival. Understanding patterns of recurrence and features that predispose to them may guide the physician in aggressive but more selective adjuvant therapy and recommendations for targeted surveillance in follow-up.

Prognostic value of negative intraoperative ultrasonography in primary colorectal cancer

The risk of developing recurrent tumour was assessed in a group of 85 patients with primary colorectal cancer who had a negative intraoperative ultrasonographic examination at the time of primary tumour resection. At a median follow-up of 40 months liver metastases had developed in 14 patients (16 per cent). Dukes classification of the primary tumours was stage A, B and C in one, three and ten patients respectively. The interval between primary tumour resection and detection of metastases varied from 6 to 24 months but all became evident within 2 years. Sixteen patients (19 per cent) presented with extrahepatic recurrence, one of whom also developed liver metastases. A negative intraoperative ultrasonographic examination did not prove to be a favourable prognostic factor which allowed exclusion from follow-up or adjuvant chemotherapy.

Preoperative detection of distal intramural spread of lower rectal carcinoma using transrectal ultrasonography

PURPOSE

Usefulness of transrectal ultrasonography (TRUS) for detecting distal intramural spread of rectal carcinoma was investigated.

METHODS

Thirty-seven patients with advanced rectal carcinoma, who had not received preoperative adjuvant therapy, underwent TRUS before surgery. Distal intramural spread was evaluated by TRUS and by pathologic examination of resected specimens.

RESULTS

Distal intramural spread was found in 7 of 37 patients (19 percent) by pathologic examination. Presence or absence of distal intramural spread was correctly diagnosed by TRUS in 86 percent of the 37 patients. Misdiagnosis by TRUS mainly occurred when distal intramural spread was 5 mm. Tumor penetration of muscularis propria, lymph node involvement, and a higher histologic grade of malignancy showed a significant relationship with the presence of distal intramural spread.

CONCLUSION

TRUS was useful for detecting distal intramural spread > 5 mm in patients with lower rectal carcinoma and may be helpful for selecting appropriate surgery.

Patterns of recurrence following pelvic exenteration and external radiotherapy for locally advanced primary rectal adenocarcinoma

BACKGROUND

Local recurrence remains the main site of failure after pelvic exenteration for locally advanced primary rectal adenocarcinoma. This is a report on the patterns of recurrence in a group of such patients treated with pelvic exenteration and radiotherapy.

METHODS

Between 1980 and 1992, we treated 49 patients. Thirty-one received preoperative radiotherapy (pre-RT), 4,500 cGy. Six weeks later, we performed posterior pelvic exenteration (PPE) in 21 patients, and total pelvic exenteration (TPE) in 10. Nine patients received postoperative radiotherapy (post-RT), 5,000 cGy after a PPE. Nine patients had surgery only, PPE (n = 7) and TPE (n = 2).

RESULTS

Surgical mortality occurred in 16% of those patients who received pre-RT. The median follow-up was 52 months. Recurrences occurred in 23% of those patients who received pre-RT (local, one; local/distant, one; distant, four); in 88% of those patients treated with surgery only (local/distant, four; distant, four); and in 11% of those treated with post-RT (distant, one). The 5-year survival for patients who received radiotherapy was 66 versus 44% for those treated with surgery only.

CONCLUSION

Local control of locally advanced primary rectal adenocarcinoma requiring a pelvic exenteration is improved by the addition of radiotherapy. When recurrences do occur they are predominantly at extrapelvic sites.

Stapling instruments for intestinal anastomosis in colorectal surgery

The circular stapling instrument has had a major impact in the practice of colorectal surgery. Stapling technology was pioneered in the early part of this century and subsequently modified. Russian initiatives led to development of the original circular stapling instrument and further progress has resulted in instruments that are widely available, reliable and totally disposable. Mechanical failure is now rare and malfunction is generally due to operator error. Complications related to the stapling technique are uncommon, although anastomotic stricture may be more frequent than when handsewn anastomosis is performed. A stapling instrument facilitates and may expedite a surgical procedure but it is an adjunct to, and not a substitute for, meticulous surgical technique.

A three-dimensional approach for re-irradiation of recurrent colorectal adenocarcinoma

A large number of patients with resected rectal cancer will develop a symptomatic pelvic recurrence despite previous adjuvant radiation therapy. Re-irradiation after previous high dose radiation therapy carries an increased risk of complications in the normal tissues of the pelvis. However, other treatment modalities are not likely to provide a palliative benefit. Previous studies have shown that re-irradiation may be feasible and may palliate the patient. As minimal data is available on the toxicity of additional radiation therapy, this approach would be considered only when there is no other alternative for effective therapy and in the face of progressive and severe symptoms. With the use of three dimensional (3-D) treatment planning, portals can be designed to limit dose to previously irradiated critical structures while minimizing the risk of treatment related complications.

Substantial variation in therapy for colorectal cancer across Europe: EUROCARE analysis of cancer registry data for 1987

To provide a quantitative description of the treatments applied to malignant colorectal cancer across Europe, we analysed all cases (11,333) of colorectal cancer registered in 1987 by 15 Cancer Registries in eight European countries. In a third of cancer registries, therapy was known for all cases, in the others 1-15% of registrations lacked treatment information. Eighty per cent of all patients received surgical resection, ranging from 58% (Estonia) to 92% (Tarn). The proportion of resections decreased with advancing age (85-73% for colon cancer; 85-70% for rectal cancer for < 65 years to > 74 years, respectively). Only 4% of colon cancer patients received adjuvant or palliative chemotherapy, range 1-12%. Sixteen per cent of rectal cancer patients received radiotherapy with great inter-registry variability (1-43%). Since the proportion of surgically resected patients correlated positively with the 5-year relative survival probability reported by the recently published EUROCARE study, this may be part of the explanation for the major differences in survival for these cancers among different European populations. The most likely determinant of this correlation is stage at diagnosis, but, quality of, and access to surgery, as well as access to endoscopy, may differ among countries and registry areas, and these may also contribute to inter-country survival differences.

Manual dissection of adenocarcinoma of the lower third of the rectum specimens for detection of lymph node metastases smaller than 5 mm

BACKGROUND

The question of whether manual dissection when searching for metastatic lymph nodes from rectal cancer (less than 5 mm) is a reliable method remains controversial.

METHODS

We examined 50 consecutive cases of primary adenocarcinoma of the rectum treated with a sphincter-sparing total rectum resection, total mesorectum excision, and coloanal anastomosis. We used a manual method for the detection of lymph nodes.

RESULTS

One thousand seven hundred ninety-three lymph nodes were found (mean, 36 per patient). One hundred seventy-four contained metastases. Seventy-nine (45.4%) of the affected lymph nodes were less than 5 mm in greatest dimension. The percentage of metastases to small lymph nodes was similar to the percentage reported by Kotanagi (50%), but lower than the report of Herrera (78%), who used a clearing technique to search for regional lymph nodes.

CONCLUSIONS

A median 17 months follow-up in these patients demonstrated that metastases in small lymph nodes are important in the accurate staging of rectal tumors and that a manual method of searching for small lymph nodes is reliable.

Outcome of restorative perineal graciloplasty with simultaneous excision of the anus and rectum for cancer. A ten-year experience with 81 patients

PURPOSE

To review the complications, survival, and long-term functional outcome of patients with anorectal cancer who had restorative perineal graciloplasty (RPG) simultaneously with abdominoperineal resection (APR).

METHODS

Between 1985 and 1994, 81 patients underwent APR plus RPG. Gracilis muscles were then conditioned by electrostimulation, either intermittently or chronically. Thirtyseven surviving patients were followed for a mean of 78.6 months and were analyzed for long-term functional outcome of RPG.

RESULTS

Postoperative complications occurred in 30 patients (37 percent). Crude five-year survival rate was 58 percent, and five-year estimated cumulative probability of survival was 65 percent. There was no statistically significant difference for probability of survival and for probability of disease-free interval between uncomplicated and complicated patients. Fecal continence was obtained in 90 percent of patients.

CONCLUSION

RPG does not reduce the effectiveness of APR in the cure of cancer. Postoperative complications, though frequent, were not serious and resolved without sequelae. There was no statistically significant impact on the probability of survival and of disease-free interval by graciloplasty. Continence was achieved by most patients (90 percent) who underwent RPG simultaneously with APR.

Recurrences of rectal cancers: results of a multimodal approach with intraoperative radiation therapy. French Group of IORT. Intraoperative Radiation Therapy

PURPOSE

Prognosis of recurrent rectal cancer remains poor, mainly because of the difficulties of achieving a satisfactory local control. Intraoperative radiation therapy (IORT) allows for the delivery of a complementary single dose to the tumor residues or to the tumor bed and could be useful jn a multimodal treatment. In an attempt to evaluate this interest, a retrospective analysis of patients treated with IORT in six French hospitals has been performed.

METHODS AND MATERIALS

Data have been collected in 73 patients (41 men), with a mean age of 62 years, treated with IORT. Initial rectal tumors were large (mean diameter: 45 mm), partially or totally fixed to the contiguous structures in 39%, and with nodal involvement in 50% of the cases. Initial surgery had been a sphincter-sparing surgery in 67%; external radiation therapy had been delivered in 52%, and a chemotherapy had been given in 10% of the patients. Recurrences were isolated (without metastases) in 86%, and were posterior or posterolateral in 55% of the cases. Surgery allowed for a complete macroscopical resection in 57%, a partial resection with gross residual disease in 29%, and no resection in 14% of the recurrences. Intraoperative radiation therapy was delivered in a dose of 10 to 25 Gy (mean 18.5) through localizators of a mean diameter of 75 mm (60 to 110). External radiation therapy, either preoperative or postoperatively was given to 30 patients without prior radiation therapy. Ten patients received additional chemotherapy with 5-fluorouracil.

RESULTS

Four postoperative deaths occurred. Postoperative morbidity occurred in 16 patients and some complications were probably related to the IORT procedure. Four long-term complications were observed. Overall actuarial survival occurred in 72.4% of the patients at 1 year, in 44.6% at 2 years, and in 30.6% at 3 years. Twenty-one local failures have been observed. Actuarial local control occurred in 71.3% of the patients at 1 year, 47.7% at 2 years, and 31.3% at 3 years.

CONCLUSION

Intraoperative radiation therapy is a complementary treatment for recurrences of rectal cancer. It provides encouraging results, particularly in some selected situations, when patients have not previously been treated with external radiation therapy. Further studies of multimodal treatments are necessary.

Preoperative and postoperative radiotherapy in rectal carcinoma

Surgery is the initial treatment of choice for most patients with rectal neoplasms. The objectives are to remove of tumor and drain the primary nodes. In stage I disease the surgical approach is though to be sufficiently effective. However, at least in the case of abdominoperineal resection, this causes considerable morbidity. Therefore, at the present time, there are efforts to reduce the extent of the resection by applying other treatment modalities in stage I disease. After curative resection in stage II/III disease a considerable number of patients suffer from local recurrence or distant metastases. In these patients adjuvant therapy is currently recommended. In locally advanced disease, primary resection is not feasible. Different treatment settings which apply combinations of all treatment modalities are possible. The article reviews the literature and shows future directions.

p53 nuclear overexpression may not be an independent prognostic marker in early colorectal cancer

PURPOSE

This study was designed to determine if p53 nuclear overexpression, as detected by immunohistochemistry, is a marker of prognostic significance in early (Stage I) colorectal cancer (CRC).

METHODS

Tissue sections obtained from archival blocks of 66 patients with surgically treated Stage 1 CRC were stained immunohistochemically for p53 using a monoclonal antibody (PAB 1801-Ab2). Differences in survival between p53 positive (p53+) and p53 negative (p53-) groups were compared using Kaplan-Meier survival curves and the log-rank test.

RESULTS

Thirty-four patients (51.5 percent) were p53+ and 32 (48.5 percent) were p53-. There were significantly more p53+ tumors in females (23 of 34) compared with males (11 of 34) (P = 0.01). Follow-up ranged from 1 to 128.5 (mean, 44.7; median, 38.2) months. Thirteen patients (19.7 percent) developed recurrence, of whom five died of disease. Univariate analysis of clinical and pathologic variables did not reveal my statistically significant differences between p53+ and p53- tumors. Mean actuarial survival was longer (48.2 months) in the p53- group compared with the p53+ group (41.5 months). However, comparison of survival curves using the log-rank test did not show a statistically significant difference in survival (log-rank chi-squared = 0.2; P = 0.6).

CONCLUSION

p53 nuclear overexpression does not appear to be an independent marker of prognostic significance in surgically treated early CRC. Females were more likely to have p53+ tumors. The biologic significance of this findings is unknown.

Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence

PURPOSE

Since the early 1980s to relieve functional disturbances after rectal excision, we have been performing nerve-sparing surgery for rectal cancer. The aim of this study was to analyze patterns of recurrences, especially concerning causes of local ones. Furthermore, we would like to address the criteria we used in patient selection to effect successful nerve-sparing surgery.

METHODS

From 1982 to 1991, 306 patients underwent nerve-sparing operations, which may be categorized into three types: 1) total autonomic nerve preservation (125 cases), 2) complete pelvic nerve preservation (105 cases), and 3) partial pelvic nerve preservation with removal of parasympathetic nerve (79 cases). Single and multivariant regression analyses were conducted to investigate patterns of recurrence, especially causes of local ones.

RESULTS

Sixty-five patients (21 percent) developed recurrent tumors, 19 of which (6.2 percent) were local. Using Dukes terms, there were five patients with Dukes A 13 with Dukes B, and 47 (35 percent) with Dukes C stages. Rate of local recurrences was 13 percent in patients with Dukes C tumor. According to single-variant analysis of Dukes C patients, the following factors are thought to influence local recurrences: number of lymph nodes metastases, level of primary growth, and direction of lymphatic spread. Multivariate regression analysis suggested that lymph node metastasis was the most important and influencing factor on local regrowth (P < 0.002).

CONCLUSIONS

Compared with local recurrences is so-called extended surgery appeared to be lower. Our current policy is aggressive application of nerve-sparing surgery, even to patients with node-positive rectal cancer, taking into consideration the exact extent of cancer spread. From the viewpoint of neuroanatomy related to mesorectum, we discussed patient determination for our nerve-sparing surgery.

Abdominoperineal resection and anterior resection in the treatment of rectal cancer: results in relation to adjuvant preoperative radiotherapy

The outcome of patients with rectal cancer treated by abdominoperineal or anterior resection, with or without preoperative radiotherapy, was assessed to detect any differences attributable to the operative method and interactions between radiotherapy and type of surgery. The study was based on 1292 patients included in two consecutive controlled randomized trials of preoperative radiotherapy in operable rectal carcinoma. The outcome was not related to surgical method. Radiotherapy increased postoperative mortality and complications and reduced local and distant recurrence, but had no effect on overall survival. Effects of radiotherapy were similar irrespective of the type of surgery, except that the increase in postoperative mortality in irradiated patients was greater in those treated with abdominoperineal resection. Sphincter-saving procedures appear to have no adverse effects on outcome of rectal cancer, but the optimum use of radiotherapy is still to be defined.

Five-year prospective study of DNA tumor ploidy and colorectal cancer survival

BACKGROUND

Retrospective studies have suggested that DNA tumor content (ploidy) has a significant effect on survival. This group has reported, prospectively, that among patients who had colorectal resections for carcinoma, the 2-year tumor recurrence rate was significantly greater for patients with aneuploid tumor than for those with diploid tumors. This paper reports the 5-year survival rates of this cohort of patients.

METHODS

Three hundred sixty-three patients who had colorectal resections for cancer between November, 1982, and March, 1988, were studied prospectively. The DNA tumor ploidy was measured from fresh and paraffin embedded tissues. These patients were followed regularly in a dedicated colorectal clinic for a minimum of 5 years or until death. Of the 363 patients studied, 2 were lost to follow-up.

RESULTS

Forty percent of the tumors were diploid, the remainder aneuploid. The 5-year survival for patients who had curative resections was 76% for those with diploid tumors compared with 64% for aneuploid tumors (P = 0.05; Mantel-Cox, 3.7). On further analysis, the survival benefit conferred by a diploid tumor appeared to be confined to those with Stage B tumors. There was no relation between ploidy and sex, age of patient, stage, histologic grade, or site of tumor.

CONCLUSIONS

Ploidy is a useful objective measurement of the aggressiveness of Stage B tumors. Patients with aneuploid Stage B tumors have a poor prognosis; this group may benefit from adjuvant therapy.

Definition of local recurrence after surgery for rectal carcinoma

Local recurrence rates of rectal carcinoma have been analysed among 284 patients in a prospective randomized multicentre trial of adjuvant preoperative radiotherapy for locally advanced rectal carcinoma. Wide variations in local recurrence rates are demonstrated depending on the definition of local recurrence employed and the subgroup studied. Thus after surgical operation alone, rates as high as 43.3 per cent or as low as 12.7 per cent can be calculated. After both adjuvant preoperative radiotherapy and operation the overall local recurrence rate is 12.8 per cent, although the local recurrence rate inside the radiotherapy field (true recurrence) may be as low as 2.3 per cent. It is recommended that local recurrence after operation for rectal carcinoma be defined as any detectable local disease at follow-up, occurring either alone or in conjunction with generalized recurrence, in patients who have undergone resection. A rate should be given both for all patients and for those operated on for cure, but not for the latter group alone as this could introduce bias.

Adjuvant intraoperative photodynamic therapy in experimental colorectal cancer

A reliable animal model for quantitative assessment of local recurrence of colorectal cancer was developed using colo26 tumour in BALB/c mice. The effect of adjuvant intraoperative photodynamic therapy to potentially curative surgery on local recurrence was examined in four study and four control groups. Study groups received 15 mg kg-1 Photofrin (a photosensitizing drug) 24 h before surgery. After 'curative' tumour excision, the tumour beds were illuminated with either 630 nm or 510 nm laser light each at 40 and 70 J/cm-2. Controls received surgery only, surgery and Photofrin only or surgery and either 630 nm or 510 nm light. The local recurrence rates at 70 days were 17-33 per cent in the study groups compared with 83-100 per cent in the control groups (P < 0.001; log rank test). Photodynamic therapy is capable of reducing local recurrence following potentially curative excision of tumour in this model.

Analysis of local recurrence rates after surgery alone for rectal cancer

Local recurrence (LR) continues to be a major problem following surgical treatment for rectal cancer, and proposed ways of reducing this remain controversial. The aim of this study was to review results from published surgical series in which adjuvant therapies were not used. A Medline search identified series published between January 1982 and December 1992 with follow-up on at least 50 patients with rectal cancer treated surgically for cure, without adjuvant therapy. Fifty one papers reported follow-up on 10,465 patients with a median LR rate of 18.5%. LR was 8.5%, 16.3% and 28.6% in Dukes' A, B and C patients respectively, 16.2% following anterior resection and 19.3% following abdominoperineal resection. Nine papers (1,176 patients) reported LR rates of 10% or less. LR was 7.1% in 1,033 patients having total mesorectal excision and 12.4% in 476 patients having extended pelvic lymphadenectomy. Routine cytocidal stump washout in 1,364 patients was associated with 12.2% LR, however a higher proportion (41%) also underwent total mesorectal excision. In 52% of cases, LR was reported to have occurred with no evidence of disseminated disease. Surgical technique is an important determinant of LR risk. LR rates of 10% or less can be achieved with surgery alone in expert hands.

Role of extended lymph node dissection in the treatment of gastrointestinal tumours: a review of the literature

Over recent decades the long-term survival of patients operated on for gastrointestinal cancer has shown little if any improvement, despite sometimes aggressive surgical procedures and a significant fall in postoperative mortality.

BACKGROUND

We went through the literature to see if there were any eventual effects of extended lymph node dissection or survival.

METHODOLOGY

We reviewed recent literature on the different types of gastrointestinal cancer.

RESULTS

Japanese centres report excellent results when wide local excision is combined ith systematic extended lymph node dissection, especially in gastric and oseophageal cancer. The overall 5-year survival of over 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of the extended lymphadenectomy. All oriental studies are uncontrolled, as are most reports from Western countries. The role of extended lymphadenectomy is therefore far from certain. The results from two randomized studies (British Medical Research Council and Dutch Gastric Cancer Trial) are awaited. It is evident from these prospective studies that the procedure adds a considerable operative risk. From non-randomized studies there is evidence that extended lymph node dissection in the treatment of pancreatic cancer might be of benefit to patients with small stage I and II tumours. In the treatment of proximal bile duct cancer the main goal of surgery is optimal relief of biliary obstruction. Whether there will ever be a role for extensive lymphadenectomy is doubtful. The extent of the surgical procedure in the treatment of gallbladder cancer is related to the depth of tumour infiltration. Extended resections are only recommended for patients with stage II to IV tumours. Extended lateral pelvic node dissection in the treatment of rectal cancer is demonstrated in Japanese retrospective studies to induce considerable urogenital problems, whereas the risk for local recurrence is still present.

CONCLUSIONS

No firm conclusions can be drawn based on data as available from the studied literature. Trial results will have to be awaited. Specific subgroups such as gastric and rectal cancer might benefit from these more extensive procedures.

Role of circumferential margin involvement in the local recurrence of rectal cancer

Local recurrence after resection for rectal cancer remains common despite growing acceptance that inadequate local excision may be implicated. In a prospective study of 190 patients with rectal cancer, we examined the circumferential margin of excision of resected specimens for tumour presence, to examine its frequency and its relation to subsequent local recurrence. Tumour involvement of the circumferential margin was seen in 25% (35/141) of specimens for which the surgeon thought the resection was potentially curative, and in 36% (69/190) of all cases. After a median 5 years' follow-up (range 3.0-7.7 years), the frequency of local recurrence after potentially curative resection was 25% (95% CI 18-33%). The frequency of local recurrence was significantly higher for patients who had had tumour involvement of the circumferential margin than for those without such involvement (78 [95% CI 62-94] vs 10 [4-16]%). By Cox's regression analysis tumour involvement of the circumferential margin independently influenced both local recurrence (hazard ratio = 12.2 [4.4-34.6]) and survival (3.2 [1.6-6.53]). These results show the importance of wide local excision during resection for rectal cancer, and the need for routine assessment of the circumferential margin to assess prognosis.