Locally recurrent rectal cancer: role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence

Laparoscopic versus open lateral pelvic lymph node dissection in locally advanced rectal cancer: multicentre retrospective cohort study

BACKGROUND

Lateral pelvic lymph node dissection (LPLND) is an option in the treatment of rectal cancer and may reduce local recurrence/improve disease-free survival. Advancements in minimally invasive technology have improved the ability to identify anatomy and neurovascular structures that may help in LPLND. The aim of this retrospective study was to evaluate the technical feasibility and oncological safety of laparoscopic LPLND compared with the open LPLND.

METHOD

Between July 2010 and July 2019, patients from three tertiary referral hospitals who underwent LPLND with total mesorectal excision for primary rectal cancer were included. Baseline patient characteristics, perioperative outcomes, pathologic results, recurrence, and survival were compared between the laparoscopic and open groups.

RESULTS

There were 126 and 70 patients in the laparoscopic and open groups respectively. The laparoscopic group had less estimated blood loss (100 ml versus 300 ml, P < 0.001) and lower transfusion rate (0.8 per cent versus 10.0 per cent; P = 0.003) but longer operating times (318 min versus 270 min, P = 0.004). The laparoscopic group had fewer wound infections (1.6 per cent versus 10.0 per cent, P = 0.011) and neuropathy (0 per cent versus 4.3 per cent, P = 0.044). Lateral pelvic recurrence rate was 7.6 per cent in the laparoscopic group and 19.6 per cent in the open group (P = 0.053). Recurrence-free survival (72.2 per cent versus 63.5 per cent; P = 0.190) and overall survival (93.3 per cent versus 85.0 per cent; P = 0.118) were not significantly different.

CONCLUSION

Laparoscopic LPLND was associated with improved perioperative outcomes and non-inferior oncological outcomes.

Long-Term Outcome in a Phase II Study of Regional Hyperthermia Added to Preoperative Radiochemotherapy in Locally Advanced and Recurrent Rectal Adenocarcinomas

Hyperthermia was added to standard preoperative chemoradiation for rectal adenocarcinomas in a phase II study. Patients with T3-4 N0-2 M0 rectal cancer or local recurrences were included. Radiation dose was 54 Gy combined with capecitabine 825 mg/m2 × 2 daily and once weekly oxaliplatin 55 mg/m2. Regional hyperthermia aimed at 41.5–42.5 °C for 60 min combined with oxaliplatin infusion. Radical surgery with total or extended TME technique, was scheduled at 6–8 weeks after radiation. From April 2003 to April 2008, a total of 49 eligible patients were recruited. Median number of hyperthermia sessions were 5.4. A total of 47 out of 49 patients (96%) had the scheduled surgery, which was clinically radical in 44 patients. Complete tumour regression occurred in 29.8% of the patients who also exhibited statistically significantly better RFS and CSS. Rate of local recurrence alone at 10 years was 9.1%, distant metastases alone occurred in 25.6%, including local recurrences 40.4%. RFS for all patients was 54.8% after 5 years and CSS was 73.5%. Patients with T50 temperatures in tumours above median 39.9 °C had better RFS, 66.7% vs. 31.3%, p = 0.047, indicating a role of hyperthermia. Toxicity was acceptable.

Work: saviour or struggle? A qualitative study examining employment and finances in colorectal cancer survivors living with advanced cancer

PURPOSE

Continuing employment or returning to work (RTW) as a cancer survivor can be meaningful and financially necessary, yet challenging. However, there is a lack of qualitative research on RTW experiences and financial wellbeing of people with advanced colorectal cancer (CRC-A). This study aimed to fill this gap.

METHODS

Adults treated for CRC-A were recruited 0.5-2 years post-surgery (or post-diagnosis of CRC-A for palliative chemotherapy participants). Semi-structured telephone interviews, exploring RTW and finances, were subjected to framework analysis. Demographic, clinical, and quality of life data (FACT-C, Distress Thermometer, COST measure) were collected to characterise the sample and inform the framework analysis.

RESULTS

Analysis of 38 interviews revealed five overarching themes: work as a struggle, work as my identity, work as my saviour, work as a financial necessity, and employer and colleague response. Many survivors with CRC-A desired to, and had the capacity to, continue work or RTW, yet faced unique challenges from compounded stigma of both cancer and toileting issues. Inability to RTW negatively impacted financial and psychosocial wellbeing. Workplace support was an important facilitator of RTW.

CONCLUSION

For survivors with CRC-A, continuing or RTW is fraught with challenges, including physical functioning challenges, financial anxiety, and unsupportive workplace environments. Survivors require psychosocial, financial, and employer support to manage these difficulties. This paper recommends a multiprong approach, including education programmes (facilitated through workers' union groups, human resource institutions, and/or large consumer CRC groups) and policies, to support workers and for employers to understand the unique challenges of employees with CRC-A.

High-intensity focused ultrasound ablation in the treatment of recurrent ovary cancer and metastatic pelvic tumors: a feasibility study

OBJECTIVE

To explore the feasibility of high-intensity focused ultrasound (HIFU) ablation for treating metastatic pelvic tumors and recurrent ovary cancer.

MATERIALS AND METHODS

Eight patients with metastatic pelvic tumors or recurrent ovary cancer were enrolled in this study. Among them, 5 patients had ovarian cancer, 1 had cervical cancer, 1 had endometrial cancer, and 1 had rectal cancer. Six of them received abdominal surgical operation for their primary cancer, no one received radiotherapy. HIFU treatment was performed under conscious sedation. Vital signs were monitored during the procedure, and adverse effects were recorded. Postoperative follow-up was performed to observe pain relief and the improvement of the patient's quality of life.

RESULTS

The median age of the patients was 54 (range: 33-76) years, with a total of 12 lesions. The average volume of the lesions was 238.0 cm³. Six patients completed 12 months follow-up. Postoperative pain relief rate was 60% (3/5), and the quality of life improved in the short term. The main adverse effect of HIFU was pain in the treated area, with the pain score lower than 4, and all of which was self-relieved within 1 day after HIFU treatment. No serious complications such as skin burn, intestinal perforation, and nerve injury occurred.

CONCLUSION

HIFU is feasible for the treatment of metastatic pelvic tumors or recurrent ovary cancer without serious complications. Therefore, HIFU seems a promising treatment for recurrent ovary cancer, metastatic pelvic tumors from cervical cancer, endometrial cancer, and rectal cancer.

The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction

INTRODUCTION

Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT.

METHODS

A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps.

RESULTS

Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy.

CONCLUSIONS

Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.

The affect of personality traits and decision-making style on postoperative quality of life and distress in patients undergoing pelvic exenteration

AIM

Our aim was to identify whether personality traits and decision-making styles affect quality of life (QoL) outcomes and levels of psychological distress following pelvic exenteration (PE).

METHOD

Patients undergoing PE between 2008 and 2015 were identified from a prospectively maintained database at a single quaternary referral centre. Patients were invited to complete two validated questionnaires, with the Big Five inventory being used to assess personality traits and the Melbourne Decision Making Questionnaire to determine decision-making style. Data on QoL outcomes and distress from the prospectively established database were utilized. QoL with respect to both physical and mental health components was measured using Short Form 36 version 2 (SF-36v2) and the Functional Assessment of Cancer Therapy - Colorectal (FACT-C). Distress was measured using the Distress Thermometer. Postoperative pain scores were also measured using SF-36v2.

RESULTS

Of the 93 patients eligible for participation, 42 returned the study questionnaire. On multivariate analysis, neuroticism was the most significant predictor of poorer QoL and increased levels of distress, consistent across all of the measures utilized and at the different time points used. Other personality traits showed an isolated statistically significant impact upon QoL. There were no significant findings with respect to decision-making style. Apart from neuroticism, the most significant predictor of QoL was the number of major complications for the patient.

CONCLUSION

Patients demonstrating neurotic personality traits show poorer QoL outcomes and higher levels of distress following PE. Identification of these patients would allow targeted pre- and postoperative intervention to improve outcomes following PE.

The efficacy and dosimetry analysis of CT-guided 125I seed implantation assisted with 3D-printing non-co-planar template in locally recurrent rectal cancer

Background

Locally recurrent rectal cancer (LRRC) after surgery or external beam radiotherapy (EBRT) is a serious challenge for which no standard treatment is defined. In the present study, we investigated the feasibility of computed tomography (CT)-guided radioactive ¹²⁵I seed (RIS) implantation assisted with three-dimensional printing non-coplanar template (3D-PNCT) in LRRC patients who previously received surgery or EBRT.

Methods

Sixty-six patients with LRRC treated by CT-guided RIS implantation in our institute from December 2015 to May 2019 were included. The treatment procedure included: preoperative CT localization, planning design, the printing of 3D individualized template, CT-guided RIS implantation assisted with 3D-PNCT, and postoperative dose evaluation. Therapeutic outcomes including local control (LC) and overall survival (OS) were retrospectively evaluated, as well as side effects.

Results

All the patients had previously received surgery or EBRT. The median follow-up time was 12.2 (range, 2.5–35.9) months. The median radioactive activity of a single RIS was 0.6 (range, 0.43–0.72) mCi. The median number of RIS was 60, ranging from 10 to 175. The dosimetric parameters included D90 (140.7 ± 33.1) Gy, D100 (90.3 ± 138.6) Gy, and V100 (91.0 ± 13.3) %. Pain relief was achieved in 85.1% (40/47) of patients. Besides, 9.1% (6/66) of patients had severe side effects (≥grade 3), including perianal skin ulcer in 1 case, fistula, radiation proctitis, and intestinal obstruction each in two cases. Median OS time was 14.7 (95% confidence interval (CI): 13.0–16.3) months, and median LC time was 12.2 (95% CI: 9.1–15.2) months. Univariate analysis revealed that when D90 > 130 Gy or D100 > 55 Gy or V100 > 90%, the LC time was remarkably prolonged. However, none of the parameters significantly affected OS.

Conclusions

CT-guided RIS implantation assisted with 3D-PNCT is an effective and safe salvage treatment strategy for patients with LRRC after EBRT or surgery. D90, D100, and V100 can be used as prognostic predictors.

Trial registration

NCT03890926.

125I implantation under computed tomography guidance to treat patients with recurrent pelvic tumors: Retrospective analysis of clinical results

Objective

The objective of the study was to evaluate computed tomography (CT)-guided ¹²⁵I implantation for the treatment of recurrent and malignant pelvic tumors.

Materials and Methods

Fifteen cases of pelvic malignant tumors were studied. Tumor length/diameter was 4-10 cm (average: 6.8 ± 2.3 cm). In patients with pelvic recurrence or metastasis of malignant tumors, comprehensive treatment, including surgery, chemotherapy, or radiotherapy, was performed alongside CT-guided ¹²⁵I implantation. The follow-up clinical benefit rate, rate of pain relief, quality of life score, and status of any complications were analyzed.

Results

The patients were followed up for 6 months after the operation, and evaluation of lesions revealed complete response (CR) in 3/15 cases, partial response (PR) in 8/15 cases, stable disease in 3/15 cases, and progressive disease in 1/15 cases. The total effective rate (CR + PR) was 73.3% (11/15), and the pain relief rate was 86.6% (13/15). No bleeding, pelvic abscesses, intestinal fistulas, intestinal perforations, or other complications were reported.

Conclusions

When using CT-guided ¹²⁵I implantation, patients with malignant abdominal tumors undergo a convenient operation, sustain little trauma, and have an improved quality of life.

Intra-abdominal recurrence from colorectal carcinoma: Differences and similarities between local and peritoneal recurrence

BACKGROUND

Peritoneal recurrences from colo-rectal cancer can be isolated (PR) or associated with local recurrences (LR). The purpose of this study was to analyze patterns and outcomes of LR and PR.

METHODS

Analyze from a prospective database of 108 patients treated with CCS plus HIPEC at two cancer centers between 2008 and 2015.

RESULTS

The population was divided into an LPR group (presence of LR with or without PR, n = 56) and a PR group (isolated PR, n = 52). The patients characteristics (age, sex, Charlson score, PCI) or perioperative treatments were comparable between the groups. The median number of resected organs for tumor involvement (respectively, 2 vs 1; p < 0.001), the percentage of patients with metastatic lymph nodes (LN+) from the resected specimen (respectively, 25% vs 7%; p = 0.016) and the mortality rate (respectively, 9% vs 0%; p = 0.023) were significantly higher in the LPR group. After a median follow-up of 32 (1-108) months, median overall survival was comparable between the two groups (respectively, 46 vs 42 months; p = 0.262).

CONCLUSIONS

LR is associated with a higher incidence of organ invasion, LN involvement (25%) and postoperative mortality. Optimal surgical resection of LR with systematic lymphadenectomy of invaded organs seems mandatory.

Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer

INTRODUCTION

Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist.

OBJECTIVE

This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration.

DESIGN

A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period.

SETTINGS

This study was conducted at a tertiary level exenteration unit.

MAIN OUTCOME MEASURES

Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality.

RESULTS

Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6-15) hours, and median blood loss was 2971 (range, 300-8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4-12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common.

LIMITATIONS

This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample.

CONCLUSION

Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.

Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration

BACKGROUND

Malignant infiltration of the pubic bone traditionally is considered inoperable. Consequently, there is little published on surgical approaches to resection of the anterior pelvic bone. En bloc partial or complete pubic bone excision can be performed depending on the degree of involvement.

OBJECTIVE

This article describes our surgical approach of pelvic exenteration with en bloc composite pubic bone excision.

DESIGN

The surgical technique describes 2 distinct aspects of the surgery, first, a perineal as opposed to abdominal transection of the urethra, and, second, varying extents of en bloc pubic bone excision.

SETTINGS

This study was conducted at a tertiary care hospital.

MAIN OUTCOME MEASURES

Pelvic tumors infiltrating the pubic bone require radical en bloc composite bone resection to achieve an R0 margin that should translate to longer-term survival versus nonoperative treatments.

RESULTS

Results of our study are currently under review.

CONCLUSIONS

As the magnitude of pelvic exenteration surgery continues to evolve for all compartments of the pelvis, malignant infiltration of the anterior pelvic bone should not be considered a contraindication to surgery.

Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy

BACKGROUND

Pelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient-reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration.

METHODS

Consecutive patients referred for consideration of pelvic exenteration completed clinical and patient-reported outcome assessments at baseline, hospital discharge (exenteration patients only), and 1, 3, 6, 9 and 12 months. Outcomes included cancer-specific quality of life (Functional Assessment of Cancer Therapy - Colorectal; FACT-C), physical and mental health status (Short Form 36 version 2), psychological distress (Distress Thermometer), and pain (study-specific composite) scores. Linear mixed modelling compared trajectories between exenteration and no-exenteration groups.

RESULTS

Among 182 patients, 148 (81.3 per cent) proceeded to exenteration. There were no baseline differences between the two groups. Among patients who had exenteration, the mean FACT-C score at baseline of 93.0 had reduced by 14·4 points at hospital discharge, but increased to 86·7 at 1 month after surgery and continued to improve, returning to baseline by 9 months. For patients in the no-exenteration group, FACT-C scores decreased between baseline and 1 month, increased slowly to 6 months and then began to decline at 9 months. There were few statistically or clinically significant differences in any patient-reported outcomes between the groups.

CONCLUSION

Quality of life and related patient-reported outcomes improve rapidly after pelvic exenteration surgery. For 9 months after surgery, these outcomes are comparable with those of similar do patients who do not have surgery; thereafter, there is a decline in patients who do not have exenteration. Pelvic exenteration can be performed with acceptable quality of life and patient-reported outcomes.

Pelvic exenteration for advanced rectal cancer

SUMMARY Advanced rectal cancer is defined by local tumor invasion into adjacent structures and organs in the pelvis. A curative multimodal therapy approach for patients with advanced rectal cancer includes neoadjuvant treatment with subsequent pelvic exenteration. Pelvic exenteration is associated with high perioperative morbidity as this surgical procedure includes an extensive resection of pelvic anatomical planes with en bloc removal of the tumor and surrounding organs and structures. Safe reconstruction of the large pelvic floor defect is very important. Quality of life and oncological outcome after pelvic exenteration for advanced rectal cancer are good. In this article, we highlight important clinical and surgical aspects of pelvic exenteration for advanced rectal cancer and review the recent literature.

Accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy for locally recurrent and irresectable rectal cancer

OBJECTIVES

To evaluate the efficacy and treatment-related toxicity of accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy for locally recurrent and irresectable rectal cancer (LRIRC).

METHODS

72 patients with LRIRC who underwent the treatment were studied. Three-dimensional conformal accelerated hyperfractionation radiotherapy (3D-CAHRT) was performed and the dose was delivered with a schedule of 1.2 Gy twice daily, with an interval of at least 6 h between fractions, 5 days a week. Concurrent capecitabine chemotherapy was administered twice daily. After 36 Gy in 30 fractions over 3 weeks, patients were evaluated to define the resectability of the disease. If resection was not feasible irradiation was resumed until the total dose administered to the tumour reached 51.6-56.4 Gy.

RESULTS

Two patients temporarily interrupted concurrent chemoradiation because of Grade IV diarrhoea. The remaining 70 patients completed the planned concurrent chemoradiation. In all patients, the complete response rate was 8.3% and the partial response rate was 51.4%. The overall response rate was 59.7% and clinical benefit rate was 93.1%. Symptomatic responses proved to be obvious and tumour resection was performed in 18 patients. The overall median survival time and median progression-free survival time were 32 and 17 months, respectively. 3 year overall survival and progression-free survival were 45.12% and 31.19%, respectively. Severely acute toxicities included Grade III-IV diarrhoea and granulocytopenia with 9.7% and 8.3% incidence respectively. Small bowel obstruction was severely late toxicity, and the incidence was 1.4%.

CONCLUSION

Three-dimensional conformal accelerated hyperfractionation field-involved re-irradiation combined with concurrent capecitabine chemotherapy might be an effective and well-tolerated regimen for patients with LRIRC.

Quality of life of survivors after pelvic exenteration for rectal cancer

INTRODUCTION

There is little information about the impact of pelvic exenteration on patients' quality of life. This study aimed to measure quality of life for longer-term disease-free survivors after pelvic exenteration.

METHODS

A retrospective review to identify patients who underwent pelvic exenteration for locally advanced primary or recurrent rectal cancer was performed. Telephone interviews to assess quality of life were performed using the Short Form 36 version 2 and Functional Assessment of Cancer Therapy-Colorectal instruments. Responses were compared with normative data from the general Australian population and patients with rectal cancer who underwent low anterior resection or abdominoperineal excision.

RESULTS

Of 75 patients with rectal cancer, 44 were alive and 37 (84%) completed the quality-of-life assessment a median 47 months after pelvic exenteration. Functional Assessment of Cancer Therapy scores in the survivors were good (107) and comparable to those for patients who had a low anterior resection or abdominoperineal excision a median of 3 months previously (106). Although the physical component summary scale of the Short Form 36 was lower in pelvic exenteration patients (44.7) than for the Australian population, the mental component summary scale was high (53.5) and comparable.

CONCLUSION

Despite the small sample, long-term quality of life in survivors of pelvic exenteration for rectal cancer is comparable to early results following primary rectal cancer resection and to mental but not physical norm-based population scores.

Management of locally advanced primary and recurrent rectal cancer

Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.

Risk factors for local recurrence of middle and lower rectal carcinoma after curative resection

AIM: To explore the risk factors for local recurrence of middle and lower rectal carcinoma after curative resection.

METHODS: Specimens of middle and lower rectal carcinoma from 56 patients who received curative resection at the Department of General Surgery of Guangdong Provincial People’s Hospital were studied. A large slice technique was used to detect mesorectal metastasis and evaluate circumferential resection margin status. The relations between clinicopathologic characteristics, mesorectal metastasis and circumferential resection margin status were identified in patients with local recurrence of middle and lower rectal carcinoma.

RESULTS: Local recurrence of middle and lower rectal carcinoma after curative resection occurred in 7 of the 56 patients (12.5%), and was significantly associated with family history (χ² = 3.929, P = 0.047), high CEA level (χ² = 4.964, P = 0.026), cancerous perforation (χ² = 8.503, P = 0.004), tumor differentiation (χ² = 9.315, P = 0.009) and vessel cancerous emboli (χ² = 11.879, P = 0.001). In contrast, no significant correlation was found between local recurrence of rectal carcinoma and other variables such as age (χ² = 0.506, P = 0.477), gender (χ² = 0.102, χ² = 0.749), tumor diameter (χ² = 0.421, P = 0.516), tumor infiltration (χ² = 5.052, P = 0.168), depth of tumor invasion (χ² = 4.588, P = 0.101), lymph node metastases (χ² = 3.688, P = 0.055) and TNM staging system (χ² = 3.765, P = 0.152). The local recurrence rate of middle and lower rectal carcinoma was 33.3% (4/12) in patients with positive circumferential resection margin and 6.8% (3/44) in those with negative circumferential resection margin. There was a significant difference between the two groups (χ² = 6.061, P = 0.014). Local recurrence of rectal carcinoma occurred in 6 of 36 patients (16.7%) with mesorectal metastasis, and in 1 of 20 patients (5.0%) without mesorectal metastasis. However, there was no significant difference between the two groups (χ² = 1.600, P = 0.206).

CONCLUSION: Family history, high CEA level, cancerous perforation, tumor differentiation, vessel cancerous emboli and circumferential resection margin status are the significant risk factors for local recurrence of middle and lower rectal carcinoma after curative resection. Local recurrence may be more frequent in patients with mesorectal metastasis than in patients without mesorectal metastasis.

Radical resection after IORT-containing multimodality treatment is the most important determinant for outcome in patients treated for locally recurrent rectal cancer

Background

The optimal treatment for locally recurrent rectal cancer (LRRC) is still a matter of debate. This study assessed the outcome of LRRC patients treated with multimodality treatment, consisting of neoadjuvant radio (chemo-) therapy, extended resection, and intraoperative radiotherapy.

Methods

One hundred and forty-seven consecutive patients with LRRC who underwent treatment between 1994 and 2006 were studied. The prognostic values of patient-, tumor- and treatment-related characteristics were tested with uni- and multivariate analysis.

Results

Median overall survival was 28 months (range 0-146 months). Five-year overall, disease-free, and metastasis-free survival and local control (OS, DFS, MFS, and LC respectively) were 31.5%, 34.1%, 49.5% and 54.1% respectively. Radical resection (R0) was obtained in 84 patients (57.2%), microscopically irradical resection (R1) in 34 patients (23.1%), and macroscopically irradical resection (R2) in 29 patients (19.7%). For patients with a radical resection median OS was 59 months and the 5-year OS, DFS, MFS, and LC were 48.4%, 52.3%, 65.5% and 68.9%, respectively. Radical resection was significantly correlated with improved OS, DFS, and LC (P < 0.001). Patients who received re-irradiation or full-course radiotherapy survived significantly longer (P = 0.043) and longer without local recurrence (P = 0.038) or metastasis (P < 0.001) compared to patients who were not re-irradiated.

Conclusions

Radical resection is the most significant predictor of improved survival in patients with LRRC. Neoadjuvant radio (chemo-) therapy is the best option in order to realize a radical resection. Re-irradiation is feasible in patients who already received irradiation as part of the primary rectal cancer treatment.

Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection

BACKGROUND

In rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection, we evaluated the effect of clinical parameters on lateral pelvic recurrence and made an attempt to identify a risk factor for lateral pelvic recurrence.

METHODS

The study involved 366 patients who underwent preoperative CRT and curative resection between October 2001 and December 2005. Clinical parameters such as gender, age, tumor size, histologic type, cT and cN classification, ypT and ypN classification, circumferential resection margin, tumor regression grade, chemotherapeutic regimen, and lateral lymph node size were analyzed to identify risk factors associated with lateral pelvic recurrence.

RESULTS

Of the 366 patients, 29 patients (7.9%) had locoregional recurrence: 6 (20.7%) with central pelvic recurrence and 24 (82.7%) had lateral pelvic recurrence, of which 1 had simultaneous central and lateral pelvic recurrence. Multivariate analysis showed that ypN classification and lateral lymph node size were significantly associated with lateral pelvic recurrence (P < .001). Of 250 ypN0 patients, lateral pelvic recurrence developed in 1.4%, 2.9%, and 50% of patients with lateral lymph node sizes of < 5, 5-9.9, and > or = 10 mm, respectively (P < .001). Of 116 ypN+ patients, lateral pelvic recurrence developed in 4.3%, 35.7%, and 87.5% of patients with lateral lymph node sizes of < 5, 5-9.9, and > or = 10 mm, respectively (P < .001).

CONCLUSIONS

In our study, lateral pelvic recurrence was a major cause of locoregional recurrence, and ypN+ and lateral lymph node size were risk factors for lateral pelvic recurrence.