Surgical treatment of recurrent colorectal cancer. Five-year follow-up

Follow-up recommendations for colon cancer

Recent evidence suggests that intensive follow-up after curative resection of colorectal cancer is associated with a small but significant improvement in survival. Regimens that employ cross-sectional imaging and carcinoembryonic antigen determination appear to have the greatest benefit. A risk-adapted approach to follow-up, intensively following patients at highest risk of recurrence, increases efficacy and cost-effectiveness. Ongoing improvements in risk stratification, disease detection, and treatment will increase the benefits of postoperative surveillance. Large randomized controlled trials are needed to determine the optimal surveillance regimen and must include an analysis of survival, quality of life, and cost-effectiveness to assess efficacy properly.

Combined modality therapy including intraoperative electron irradiation for locally recurrent colorectal cancer

PURPOSE

To evaluate survival, relapse patterns, and prognostic factors in patients with colorectal cancer relapse treated with curative-intent therapy, including intraoperative electron radiation therapy (IOERT).

METHODS AND MATERIALS

From April 1981 through January 2008, 607 patients with recurrent colorectal cancer received IOERT as a component of treatment. IOERT was preceded or followed by external radiation (median dose, 45.5 Gy) in 583 patients (96%). Resection was classified as R0 in 227 (37%), R1 in 224 (37%), and R2 in 156 (26%). The median IOERT dose was 15 Gy (range, 7.5-30 Gy).

RESULTS

Median overall survival was 36 months. Five- and 10-year survival rates were 30% and 16%, respectively. Survival estimates at 5 years were 46%, 27%, and 16% for R0, R1, and R2 resection, respectively. Multivariate analysis revealed that R0 resection, no prior chemotherapy, and more recent treatment (in the second half of the series) were associated with improved survival. The 3-year cumulative incidence of central, local, and distant relapse was 12%, 23%, and 49%, respectively. Central and local relapse were more common in previously irradiated patients and in those with subtotal resection. Toxicity Grade 3 or higher partially attributable to IOERT was observed in 66 patients (11%). Neuropathy was observed in 94 patients (15%) and was more common with IOERT doses exceeding 12.5 Gy.

CONCLUSIONS

Long-term survival and disease control was achievable in patients with locally recurrent colorectal cancer. Continued evaluation of curative-intent, combined-modality therapy that includes IOERT is warranted in this high-risk population.

Presentation and prognosis of local recurrence after total mesorectal excision

OBJECTIVE

The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma.

METHOD

Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively.

RESULTS

Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3-60 months. Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months. Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7-58), all patients were alive.

CONCLUSION

Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 itérative resection.

Surgical adjuvant therapy for colorectal cancer: current approaches and future directions

Colon cancer is the fourth most common cancer worldwide. The role of systemic adjuvant chemotherapy in colorectal cancer patients with lymph node involvement has been established in a large number of clinical trials. However, its role in stage II colorectal cancer is less well established. 5-Fluorouracil has been the mainstay of therapy for the last four decades. With the development of novel chemotherapy and biological agents, we have entered into a new era for the treatment of colorectal cancer. The combination of adjuvant 5-fluorouracil, leucovorin, and oxaliplatin has been shown to significantly improve disease-free survival and is now considered the standard of care for completely resected colon cancer in healthy patients. For rectal cancer patients with locally advanced tumors, neoadjuvant chemoradiation followed by adjuvant chemotherapy after surgery is the mainstay of treatment. The availability of oral chemotherapy agents has helped with the ease of administration and avoidance of indwelling catheters. A number of national clinical trials are under way to determine the role of targeted agents in combination with chemotherapy. The goal is to develop a regimen that would improve survival without excessive toxicity while maintaining quality of life. Patients should be encouraged to participate in clinical trials whenever feasible. Despite the advances, many patients will develop recurrent disease. It is of utmost importance to develop molecular markers that could predict which patients are at high risk for disease recurrence. Clinical trials are under way to address this issue. Thus, it will be advantageous to be able to tailor therapy individually, according to the risk of recurrence.

Follow-up of patients with colorectal cancer: the evidence is in favour but we are still in need of a protocol

The prevalence of colorectal cancer is high in the western world and follow-up after treatment of the primary tumour is claimed to consume resources that could be used in improving screening and early diagnosis. Although some patients with recurrent disease can be treated successfully there has been a debate on whether an overall improvement in survival is achieved by follow-up. There is no agreement on a follow-up protocol of investigations. A review via a Medline search of all published studies and reports on the issue of follow-up of colorectal cancer dated from 1975-2006. We examined retrospective and prospective studies, randomised controlled trials, and meta-analyses attempting to identify the optimum follow-up protocol. There is widespread diversity of follow-up policies for colorectal cancer. Follow-up of colorectal cancer does not have a negative impact on Quality of life. There is no evidence that annual colonoscopy provides any survival advantage. It has been shown that intensive follow-up with frequent carcinoembryonic antigen measurement has a survival advantage and is cost-efficient. Similar evidence seems to be gathering about liver imaging with CT scan although it is less conclusive.

Preservation of bowel and urinary continence in the management of locally recurrent rectal cancer

BACKGROUND

The management of locally recurrent rectal cancer should achieve local tumor control and potentially improving disease-free and overall survival. Radical pelvic resection has traditionally been associated with permanent fecal and urinary diversion. However, as advanced techniques have evolved to allow restoration of intestinal and urinary continence, we reviewed the use of these techniques in patients with recurrent rectal cancer.

METHODS

Patients with recurrent rectal cancer who underwent a resection at Norris Comprehensive Cancer Center between 1993 and 1999 were retrospectively reviewed. Data collected included demographic data, surgical and oncological history, patterns of recurrence, treatment modalities, and outcome. Follow-up data was obtained from the last clinic visit and/or tumor registry.

RESULTS

Sixty-seven patients with locally recurrent rectal cancer (male/female 45/22, age 32-81 years) were included in the analysis. Continence was re-established in 22 (33%) patients, urinary continence was restored in 12 patients, and intestinal continuity in 14 patients (both in 4 patients). A temporary diverting ostomy was necessary in 5 out of 14 (36%) patients. Mortality was zero and morbidity was low and included two urinary leaks and one fecal leak all of which could be managed non-operatively. At a median follow-up of 16 months (range 5-55), 11 (50%) patients were still alive, 7 (31%) without evidence of disease. Comparison of the groups of patients either with or without continence preservation showed no statistically significant difference in disease-free survival and overall survival rates. High quality of life was achieved with restoration of continuity, no patient with restored continuity expressed a desire for a diversion.

CONCLUSION

If an oncologically adequate resection of the recurrent rectal cancer can be performed without impairment of the pelvic floor integrity, continence preservation is feasible and results in good functional and oncological outcome.

Operative salvage for locoregional recurrent colon cancer after curative resection: an analysis of 100 cases

PURPOSE

Locoregional recurrence after resection of colon carcinoma is an uncommon and difficult clinical problem. Outcome data to guide surgical management are limited. This investigation was undertaken to review our experience with surgical resection for patients with locoregional recurrence colon cancer, determine predictors of respectability, and define prognostic factors associated with survival.

PATIENTS AND METHODS

A prospective database was queried for patients who had recurrent colon cancer between January 1991 and October 2002. Patients were selected for analysis if they had either isolated resectable locoregional recurrence or concomitant resectable distant disease. Disease-specific survival analysis was performed with the Kaplan-Meier actuarial method, and factors associated with outcome were determined by the log-rank test and Cox regression.

RESULTS

During this period of time, 744 patients with recurrent colon cancer were identified and 100 (13.4 percent) underwent exploration with curative intent for potentially resectable locoregional recurrence: 75 with isolated locoregional recurrence, and 25 with locoregional recurrence and resectable distant disease. The median follow-up for survivors was 27 months. Locoregional recurrence was classified into four categories: anastomotic; mesenteric/nodal; retroperitoneal; and peritoneal. Median survival for all patients was 30 months. Fifty-six patients had an R0 resection (including distant sites). Factors associated with prolonged disease-specific survival included R0 resection (P < 0.001); age <60 years (P < 0.01); early stage of primary disease (P = 0.05); and no associated distant disease (P = 0.03). Poor prognostic factors included more than one site of recurrence (P = 0.05) and involvement of the mesentery/nodal basin (P = 0.03). The ability to obtain an R0 resection was the strongest predictor of outcome, and these patients had a median survival of 66 months.

CONCLUSION

Salvage surgery for locoregional recurrence colon cancer is appropriate for select patients. Complete resection is critical to long-term survival and is associated with a single site of recurrence, perianastomotic disease, low presalvage carcinembryonic antigen level, and absence of distant disease.

Cost-effectiveness of two follow-up strategies for curative resection of colorectal cancer: comparative study using a Markov model

The follow-up of patients with curative resection of colorectal cancer is still controversial. The means mobilized for postoperative monitoring come at a high cost. However, the modalities are neither formalized nor validated with regard to an improved 5-year survival rate. To compare the cost-effectiveness of both strategies for patient follow-up during the 7 years following curative resection of colorectal cancer, we performed a costeffectiveness analysis adjusted for quality of life. Using data from the literature and a population study, a simulation of follow-up on patients who had undergone curative resection of colorectal cancer was carried out over a 7-year period using a Markov model. Two Markov processes were modeled to compare the cost-effectiveness ratio adjusted for quality of life in patients with a follow-up in accordance with the recommendations of the 1998 French Consensus Conference (standard follow-up) with the carcinoembryonic antigen (CEA) assay and a simplified follow-up. The influence of standard follow-up on the quality-adjusted life expectancy of patients who had Duke's stage A and B colorectal cancer appears to be modest, with increases of 2.5 months and 1.3 months, respectively; it is more acceptable for patients who had had Duke's stage C, with an increase of 11 months. The high variability of cost-effectiveness ratios (> 7 years) of +/- 44,830 and 180,195 Euro per quality-adjusted life-years (QALY), respectively) did not favor the standard follow-up. The cost-effectiveness ratio (> 7 years) of patients having had Duke's stage C colorectal cancer was 1,058 (sd: 2746) Euro per QALY and could favor the standard follow-up. This study showed that standard follow-up with CEA assay tended to preferentially improve the survival of Duke's stage C patients. The type of examination needed and the frequency with which it has to be carried out should take account of the stage, treatment for the initial illness, and the patient's age.

Cost and effectiveness of follow-up examinations in patients with colorectal cancer resected for cure in a French population-based study

The cost of follow-up examinations for patients having undergone potentially curative surgery for colorectal cancer is considerable. The aim of this study was to provide a thorough assessment of the cost and effectiveness of the follow-up tests used during the 5 years after surgical resection for colorectal cancer and its recurrences. We studied medical and economic data from the records of 256 patients registered in the Herault Tumor Registry who underwent potentially curative surgical resection in 1992. Recurrence, curative recurrence, survival, and the cost of follow-up tests were assessed respectively for at least 5 years. We analyzed the cost and effectiveness of follow-up tests in patients who received either follow-up with carcinoembryonic antigen (CEA) monitoring as advocated by the 1998 French consensus conference recommendations (standard follow-up) or a more minimal follow-up schedule. Nine patients died in the postoperative period. The 5-year survival rates in the standard and minimal follow-up groups were 85% and 79%, respectively (p=0.25). Cost-effectiveness ratios were 2123 in Dukes' stage A patients, 4306 in Dukes' stage B patients, and 9600 in Dukes' stage C patients. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the standard follow-up group were 1238 and 2261.5, respectively. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the minimal follow-up group were 1478 and 573, respectively. There were no survivors 5 years after a recurrence when the recurrence was detected by physical examination, chest X-ray, and colonoscopy in either follow-up group. Dukes' classification is a poor indicator of patient selection. The follow-up tests should only include CEA monitoring and abdominal ultrasonography for the diagnosis of recurrence.

A novel indicator for surveillance colonoscopy following colorectal cancer resection

INTRODUCTION

Current surveillance for recurrent intraluminal or metachronous colorectal cancer following resection is largely undertaken by colonoscopic examination of the remaining colon. The burden on colonoscopic services is high and the procedure is expensive. Immunological faecal occult blood testing (FOBT) is a sensitive and specific test for detecting colorectal cancer, and may fine tune the need for timely surveillance colonoscopy.

METHODS

Consecutive patients due for surveillance colonoscopy following colonic resection for cancer were prospectively studied. Each patient had a single faecal sample obtained at per rectal examination on a gloved examining finger. This was subjected to immunological FOBT in the clinic, and patients were categorized as FOBT positive or negative, according to the result. Colonoscopy as well as ultrasound or CT of the liver were performed within eight weeks of FOBT.

RESULTS

Six hundred and eleven patients had both FOBT and colonoscopy. Fifty-nine (13.6%) were categorized as FOBT-positive. Of these, nine had biopsy-proven recurrent or metachronous cancer, 12 patients had one, or more adenomatous polyps, one patient had radiation proctitis and two patients had pan-colonic mucositis following chemotherapy. In the remaining 552 FOBT-negative patients, no cancers were found. Thirty-eight patients had polyps that were removed. The sensitivity and specificity for detecting cancer by immunological FOBT was 100% sensitivity for detecting adenomatous polyps was 24% but specificity was 93%.

CONCLUSION

The immunological faecal occult blood test provides sensitive detection of metachronous and recurrent cancer in postoperative surveillance. Routine application may be used to reduce the frequency of colonoscopic surveillance, as a negative FOBT may be taken as a sign that colonoscopy may be deferred safely.

Follow-up of patients with colorectal cancer: numbers needed to test and treat

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.

[Curative treatment of local and regional rectal cancer recurrences]

How to select patients likely to benefit from reoperation? When a neoadjuvant treatment is still feasible, is it useful to perform preoperative radiation or chemoradiation? What can be expected after resection of local recurrences in terms of survival and quality of life? Does surveillance of patients operated for rectal carcinoma influence resectability of local recurrences and results? These are the main questions concerning the management of local recurrences after resection of a rectal carcinoma.

Surgical resection of locally recurrent colorectal adenocarcinoma

BACKGROUND

Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence.

METHODS

This retrospective review analyzed a series of 120 patients who underwent resection of colonic (56) or rectal (64) locoregional recurrence. Sixty-nine resections were considered as curative. Sixty-one recurrences required extended resection. There were nine synchronous hepatic resections.

RESULTS

The hospital mortality rate was 7 per cent and the morbidity rate was 40 per cent. The overall 5-year survival rate was 27 per cent. Survival was significantly higher: (1) after curative resection (44 versus 0 per cent after palliative resection, P < 0.0001); (2) in women (44 versus 11 per cent for men, P = 0.0036); and (3) after resection for intramural recurrence (45 versus 19 per cent for extramural recurrence, P = 0.0024). Multifactorial analysis showed that curability of the resection was the most important prognostic parameter.

CONCLUSION

The results in this highly selected group seem to justify an attempt at reresection whenever possible. Long-term results may be improved by using adjuvant treatment.

Use of brachytherapy in management of locally recurrent rectal cancer

PURPOSE

Locally recurrent rectal cancer is associated with poor quality of life and has justified aggressive surgical and adjuvant approaches to control the disease. This study was designed to evaluate if the use of brachytherapy in association with wide surgical excision (debulking operation) can offer reasonable palliation for patients with locally recurrent rectal cancer.

MATERIALS AND METHODS

Patients with biopsy-proven locally recurrent rectal cancer who were not candidates for intraoperative radiation therapy and who were previously considered as having unresectable tumors were included in the study and were followed-up from May 1981 to November 1990. All of them had undergone laparotomy and had either radical or debulking surgical resection performed. At the same time, brachytherapy was used with temporary or permanent implant of seeds of iridium-192 or iodine-125.

RESULTS

Thirty patients were included. Patients ranged in age from 28 to 74 years, and 16 patients were female. No mortality was observed, and morbidity was low (small-bowel obstruction (1 patient), intestinal fistula (1 patient), and urinary fistula (1 patient). Histologic examination of the specimen showed gross residual disease in 67 percent of patients and microscopic disease in 25 percent of patients. Long-term follow-up was possible in 28 patients. Mean follow-up and local control were, respectively, 26.5 months and 37.5 percent for gross residual disease and 34 months and 66 percent for microscopic residual disease. Eighteen patients (64 percent) had locally recurrent rectal cancer under control at the time of the last follow-up, with seven patients (25 percent) having no evidence of local or distant recurrence.

CONCLUSION

This is the first report of brachytherapy for locally recurrent rectal cancer. This appears to offer a therapeutic alternative to patients who are not candidates for intraoperative radiation therapy. Surgical morbidity and mortality are acceptable. Local control in 18 patients (64 percent) is comparable with intraoperative radiation therapy or more morbid surgical alternatives. Cancer-related deaths are most often related to disseminated disease, which suggests the need for systemic therapy in addition to brachytherapy.

The need for a multidisciplinary approach in the treatment of advanced colorectal cancer: a critical review from a medical oncologist and surgeon

Over the last 10 years important advances have been made in the treatment of patients with advanced colorectal cancer, particularly with surgery either alone or in combination with radiotherapy. Furthermore, despite early scepticism, several chemotherapy studies have now reported significant clinical benefits with 5-FU-based regimens and promising results have also been reported with newer agents such as raltitrexed and irinotecan. Taken together these advances now enable a significant proportion of patients to undergo treatment which will improve their quality of life, prolong survival and even result in cure in certain cases. Patients with advanced colorectal cancer can only benefit from these important advances, however, if a truly multidisciplinary approach to patient care is adopted which requires integration of the roles of the surgeon, medical oncologist and radiotherapist.

Salvage therapy for pelvic recurrence following curative rectal cancer resection

INTRODUCTION

Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients.

PURPOSE

In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection.

METHODS

A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy.

RESULTS

For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P = 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI group vs. the MSKCC group (34/51 vs. 9/25; P < 0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients.

CONCLUSIONS

Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.

Current perspectives on repeat hepatic resection for colorectal carcinoma: a review

BACKGROUND

Recurrence occurs in 65% to 85% of patients after initial hepatectomy for metastases from colorectal cancer. Approximately one half of these have liver metastases, and in 20% to 30% only the liver is involved. Opportunity for resection is frequently limited because of diffuse liver disease or extrahepatic extension, and only 10% to 25% of these patients have conditions amenable to resection. This current review is focused on the rationale, indications, and results of resection of hepatic metastases from colorectal cancer.

METHODS

The major series of liver resection were reviewed, and the cases of repeat resections were culled out. In addition to standard clinical parameters, the indications and timing after initial resection and the survival and subsequent recurrence after repeat resection were recorded.

RESULTS

A comprehensive review of the 28 series showed that the mean interval between the first and second liver varied from 9 to 33 months and was about 17.5 months in the two largest series. The median survival in series reporting 10 or more patients was 19 months (mean, 24 months), which is comparable to data in single resection series. In the large French Association series containing 1626 patients with single resections and 144 patients with two resections, the 5-year survival was 25% and 16%, respectively. The recurrence rate after repeat resection is high (greater than 60%), and one half are in the liver. The prognostic factors favoring repeat resection are variable, but they include absence of extrahepatic extension of tumor and a complete resection of the liver metastases.

CONCLUSIONS

Repeat hepatic liver resection for metastatic colorectal cancer in carefully selected patients appears warranted in view of reasonable survival expectations, which approach that of single liver resection. Risk of recurrence is high, however, suggesting the need for rigorous preoperative and intraoperative assessment and postoperative adjuvant therapy

Preoperative infusional chemoradiation, selective intraoperative radiation, and resection for locally advanced pelvic recurrence of colorectal adenocarcinoma

OBJECTIVE

The results of preoperative infusional chemoradiation, resection, and selective intraoperative radiation (IORT) boost in 43 previously nonirradiated patients with locally advanced pelvic recurrence of colorectal adenocarcinoma are described.

SUMMARY BACKGROUND DATA

After surgery alone 10% to 30% of patients with carcinoma of the distal colon and rectum will develop isolated pelvic recurrence. In most cases, the disease is locally advanced and not amenable to curative resection. Preoperative infusional chemoradiation has been shown to increase resectability and decrease local recurrence in primary locally advanced colorectal cancer. Based on this experience, we initiated a multimodality treatment protocol to treat patients with pelvic recurrence of colorectal adenocarcinoma.

METHODS

Forty-three consecutive patients with histologically proven pelvic recurrence of colorectal adenocarcinoma were enrolled on a multimodality treatment protocol. The treatment plan consisted of 5 weeks of concurrent pelvic external beam radiotherapy (45 Gy) with continuous intravenous infusion of 5-fluorouracil and/or cisplatin. This was followed by surgery that included IORT boost (10-20 Gy) for 21 patients and brachytherapy for 4 patients.

RESULTS

Forty patients (93%) underwent operation and 33 (77%) underwent resection with curative intent. There were 29 (88%) margin-negative resections. Fifteen patients (48%) underwent sphincter-preserving operations. There were no treatment-related deaths. Twenty-two patients experience perioperative complications. Median follow-up for the 43 patients was 26 months. The local recurrence rate was 36%. Median survival for the patients who underwent resection was 34 months, and actuarial 5-year disease-free and overall survival were 37% and 58%, respectively.

CONCLUSIONS

Tumor cytoreduction by preoperative chemoradiation can increase resectability and enable sphincter-preserving surgery in patients with locally advanced pelvic recurrence of colorectal cancer.

Palliative endoscopic therapy of rectal carcinoma

Curative surgery is not feasible in a considerable proportion of patients with rectal cancer because of extensive local spread or metastatic disease. However, most of these patients require palliative treatment to improve the symptoms of the disease, e.g. obstruction, pain and haemorrhage. Palliative surgery may be associated with a morbidity of 20-40% and a mortality of more than 10%. Endoscopic procedures can provide effective palliation with less complications. Before the development of lasers, endoscopic electrocoagulation and cryosurgery were used with some success. Currently, endoscopic Nd:YAG photocoagulation must be considered the treatment of choice in non-resectable rectal cancer. Laser therapy allows effective palliation in 85-95% of the patients, and generally, treatment-related complications occur in less than 10% of the patients and mortality is negligible. Transanal endoscopic resection may be effective in selected patients. New approaches to endoscopic palliation include photodynamic therapy (PDT) and implantation of self-expanding metal stents.

Resection of hepatic metastases from colorectal carcinoma. The registry data

When liver metastases from colorectal carcinoma are detected, the surgeon must decide whether or not the patient is a candidate for resection. Even though long-term survival after resection is far from optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. Better understanding of liver anatomy and improvement in resection techniques have decreased the morbidity and mortality. The RHM and the GITSG reports have better defined the prognostic factors for resections of colorectal liver metastases and allowed for a better understanding of the indications for resection. During the last decades, liver resection has been extended to older patients, patients with multiple liver lesions, and patients with larger solitary metastases. At the same time, anatomic rather than wedge resections are more common, and it is preferable to perform the colon and liver resection at different stages. The end result has been a marked increase in the number of hepatic resections performed for colorectal liver metastases during the last two decades.

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

Local recurrence of colorectal cancer after 'curative' surgery is a major clinical problem. Typically, 50-70 per cent of patients presenting to a surgical clinic will undergo apparently curative surgery for disease and of these about 10-25 per cent will develop local recurrence, in either the tumour bed or bowel wall. The wide differences in local recurrence rate both between and within institutions is probably caused by variation in surgical technique. The main causes of local recurrence are inadequate excision of the primary tumour or the draining lymph nodes, and intraoperative tumour cell implantation. The most significant single factor prognostic of local recurrence is Dukes' tumour stage. Other important factors include tumour grade and fixity, level of the tumour in the rectum, blood and lymphatic vessel invasion, inadvertent perforation of the tumour during resection, and the surgeon's experience. The prognosis of patients with local recurrence is poor. Prevention of recurrence by adequate surgery and adjuvant therapy as well as its early detection offer the best prospect of improving results.

Is follow-up of colorectal cancer patients worthwhile?

Between 1978 and 1989, 1,045 of 1,399 patients (580 male and 474 female) underwent curative surgery for colorectal carcinoma. Of these patients, 350 (33 percent) had recurrences, another 16 (1.5 percent) developed a metachronous colorectal cancer, and 23 (2 percent) had cancers of other organs. An isolated locoregional recurrence was found in 75/350 (21 percent). The remaining 275/350 patients (79 percent) showed systemic dissemination of the carcinoma. Reoperations with curative intent were performed on 56/350 patients (16 percent). Only 21 of the 56 resected patients (38 percent), i.e., 21/350 (6 percent), were without recurrence at the end of the follow-up period on December 31, 1990. Despite a curative reoperation, 62 percent of the patients again developed recurrent growths. There is an imbalance between the efforts invested in tumor follow-up and the benefits gained. Further follow-up programs should be investigated in a controlled, prospective fashion.

Surgical management of nonhepatic intra-abdominal recurrence of carcinoma of the colon

The role of surgery in the management of intra-abdominal recurrence of colon cancer has not been clearly determined. We reviewed the charts of 28 patients operated upon at our institution for nonhepatic intra-abdominal recurrence of carcinoma of the colon and followed for a median of 10.5 months after reoperation. Total resection of gross disease was possible in 15 patients, who had a median overall actuarial survival of 25.5 months and a disease-free survival of 13 months. Within this group, disease-free survival was significantly prolonged when time to first recurrence was greater than 16 months and when patients had not had a prior operation for recurrent disease (P < 0.05). Six patients having a partial resection and seven patients having only a bypass or ostomy had significantly shorter survivals than those in the totally resected group, with median survivals of 8 and 3.5 months, respectively (P < 0.05). Operative management of recurrent colon cancer may prolong survival when disease can be eradicated, and palliative operations appear more successful when tumor is resected rather than bypassed.

Preoperative chemotherapy and radiation therapy for locally advanced primary and recurrent rectal carcinoma. A report of surgical morbidity

BACKGROUND

Complete surgical resection of locally advanced primary and recurrent rectal cancer is often incomplete. Improved tumor downstaging may improve resection rates and local control if postoperative morbidity is not increased.

METHODS

The clinical and pathologic records of 119 patients with locally advanced primary and recurrent rectal carcinoma were reviewed to determine the effect of preoperative chemoradiation on postoperative morbidity compared with a control group treated with external beam radiation therapy alone. Group I (56 patients) was treated with 45 Gy of external beam radiation therapy. Group II (63 patients) received 45 Gy of external beam radiation therapy with continuous-infusion cisplatin, 5-fluorouracil, or both.

RESULTS

Forty-one patients (73.2%) in Group I and 48 in Group II (76.1%) underwent surgical resection. Anal-sparing procedures were performed more frequently in Group II (25%) than in Group I (5.3%, P < 0.05). The overall complication rate for Group I was 51% versus 44% for Group II (P < 0.05) or 1.17 complications per patient in Group I and 0.58 complications per patient in Group II. One patient in each group died of treatment-related septic complications.

CONCLUSIONS

It was concluded that the addition of chemotherapy to radiation to treat rectal carcinoma does not result in an increased operative morbidity and may contribute to a higher proportion of patients being treated with anal-rectal-conserving surgical procedures.

Management of recurrent and metastatic colorectal carcinoma

When metastatic or recurrent disease from colorectal carcinoma is detected, the surgeon must decide whether a patient is a candidate for resection. Although long-term survival after resection is not optimal, the relegation of patients to nonresective treatment means denying them the only chance for cure currently available. When isolated disease involving the liver, lung, or region of the primary carcinoma is documented, curative resection must be considered. Symptomatic patients may also obtain maximal palliation from resection, diversion, or a bypass procedure. Chemotherapy for the treatment of recurrent disease is palliative and probably should be considered only within clinical trials. Future alternative methods of treatment or new chemotherapeutic regimens need to be studied to improve survival and quality of life.

Early results of follow-up after radical resection for colorectal cancer. Preliminary results of a prospective randomized trial

One-hundred and six consecutive patients were included in a prospective study of intensive monitoring after radical resection for colorectal cancer, 54 being randomized into a conventional follow-up group (Group I) and 52 into an intensified follow-up group (Group II). After a median follow-up of 2 years the overall rate of detection recurrence in Group I was 24% (13/54) and in Group II 25% (13/52). The recurrence rates among those followed up for at least 2 years were 36% (10/28) and 30% (9/30), respectively. Of the recurrences in Group I, one was local, five regional and six distant, and the corresponding figures in Group II were three, four and five. One radical extirpation of a local perineal recurrence has been performed in Group I, whereas two intestinal reresections for local anastomotic recurrences and two hepatic resections for solitary hepatic metastases have been performed in Group II. Mortality to date is 13% (7/54) in Group I and 8% (4/52) in Group II. Two adenomatous polyps have been removed from the colon in Group I during endoscopic surveillance and seven in Group II. These preliminary results encourage us to continue the trial up to 5 years after primary surgery.

Prevention and management of recurrent rectal cancer

Increased attention to surgical indications and technique can minimize the risks of recurrent rectal cancer. In addition, the use of adjuvant chemoradiation therapy has been shown to further decrease the risks of recurrent rectal cancer. In the event a recurrence develops, surgical therapy, combined with radiation therapy, can result in local control in as many as 75% of patients and long term survival in 25% to 40% of patients.

Cost-effective management of colon and rectal cancer

Health care costs in the United States of America continue to rise. Legislators, economists and third party payers are becoming increasingly concerned with intervention outcomes and the distribution of resources. It is the responsibility of the medical profession to assume a leading role in assessing the cost-effectiveness of health care interventions. Although many physicians perform informal cost-effectiveness analyses on a daily basis, health economists employ a variety of more complex methodologies. This article will attempt to provide physicians with an understanding of the value and limitations of the tools used in formal cost-effectiveness analyses and demonstrate how these tools may be applied to the management of colon and rectal cancer.

Second-look surgery for colorectal cancer. The second time around

Eighty-six colorectal cancer patients who entered the Radioimmunoguided Surgery (RIGS) protocol study were evaluated for 2-, 3-, 4-, and 5-year survival following second-look surgical procedures. Strict preoperative evaluation criteria eliminated patients with extra-abdominal tumor involvement. A saturated potassium iodide preparation was given before the intravenous administration of the B72.3 monoclonal antibody (1 mg) radiolabeled with 2 mCi of iodine-125 by the IODOGEN method. Precordial monitoring of the biologic clearance by the handheld, gamma-detecting probe (Neoprobe 1000 instrument) was conducted at weekly intervals until the average count was less than 20 counts in 2 seconds. Once the drug cleared from the blood, surgery was performed. The mean time interval between injection and operation was 24 days, with a range of 21 to 28 days and a median of 23 days. At surgery the abdomen was explored through the traditional methods of palpation and inspection, and the surgeon committed to a planned procedure. The abdomen was then re-explored with the handheld, gamma-detecting probe and the surgeon stated another intraoperative assessment. After using both traditional and RIGS detection methods, the surgeon stated whether his or her surgical plans changed because of the additional intraoperative information provided by the RIGS system. Fifty-three patients (62%) were deemed resectable by the traditional methods of palpation and inspection, but only 40 (47%) were specified as resectable by RIGS exploration. Two-, three-, four-, and five-year survival data could be gathered for each of the three groups: RIGS resectable (n = 40), traditional nonresectable (n = 33), and RIGS nonresectable (n = 13). At 2 years 95% of the resectable, 36% of the traditional nonresectable, and 53% of RIGS nonresectable patients survived. At 3 years 83%, 7%, and 30% of these patients survived, respectively. For the resectable patients, 74% survived at 4 years and 60% at 5 years, with no survivors from either nonresectable group. Use of the RIGS system increased accurate selection of resectable patients undergoing second-look surgery for recurrent colorectal cancer.

Follow-up of patients after primary colorectal cancer resection

Improved survival rates for patients with colorectal cancer may depend on early detection of metachronous colon lesions and early detection of distant disease. Frequent serial CEA determinations and history and physical examination are the two most useful techniques for diagnosing early recurrent disease. Colonoscopy rarely detects early recurrent disease but is useful in finding metachronous colon lesions. Other radiographic and hematologic examinations have an extremely low yield and should be used to localize and stage disease discovered by other means. Simplified follow-up can be expected to minimize early detection of recurrent and metachronous lesions yet offers minimal patient risk and expense.

Local recurrence after curative resection for colorectal cancer: frequency, risk factors and treatment

Analysis of 498 patients with colorectal carcinoma was retrospectively reviewed to evaluate the incidence, risk factors and therapy of local recurrent carcinoma following curative resection. Complete follow-up information was obtained in all but four patients (99.2%). After a median follow up of 42 months, 64 out of 469 (13.6%) patients developed local recurrence (LR). The incidence of LR was higher in rectal than in colon cancer patients (18.3% vs 8.9%) (P less than 0.005). Separate univariate and Cox analyses for rectal patients showed tumor site (P less than 0.02). Dukes stage (P less than 0.002), and adjuvant radiotherapy (P = 0.05) determined risk of LR. For colon cancer patients risk of LR was determined by histological tumor grade (P less than 0.01). Out of 64 patients, 5 (7.8%) underwent radical excision of LR. Forty percent of these survived at 5-year (P less than 0.08). Palliative treatment (radio-chemotherapy) obtained a 5-year survival of 15.3%, with no survivors in no-treatment group. These results suggest that local recurrent colorectal carcinoma remain a difficult treatment problem. More effective combinations of surgery and adjuvant therapy are therefore mandatory to reduce the incidence of local failure in high risk colorectal patients.