Surgery for local recurrence of rectal cancer

OBJECTIVE

Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes.

METHOD

A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated.

RESULTS

Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential.

Developments in treatment of primary irresectable rectal cancer

Abstract The treatment options for primary irresectable rectal cancers are discussed. Assessment of tumour stage is the first step for an appropriate choice of treatment. Following a diagnosis of rectal cancer, a vast array of diagnostic procedures is available to determine its stage, and thereby its best treatment options. From the many (new) diagnostic options the merits and drawbacks are discussed. If a diagnosis of irresectability is made, further treatment options should include radiotherapy in most cases, some aspects of timing and application, i.e. intra-operative treatment are discussed. Chemotherapy options are manifold, the results are discussed and some new options are explored.

Can neoadjuvant radiochemotherapy improve the results of multivisceral resections in advanced rectal carcinoma (cT4a)

OBJECTIVE

To investigate the influence of neoadjuvant radiochemotherapy (nRCT) in advanced rectal carcinoma (cT4a), the prospectively collected data of all patients treated by extended multivisceral resections during the last 16 years were analysed.

METHODS

Between 1985 and 2000, 113 patients with clinical T4a rectal carcinoma (invasion of adjacent organs or structures), were treated by extended multivisceral surgery. In 1995 nRCT was introduced as a standardized treatment modality in cT4a carcinomas and applied in 32 patients. Six weeks after completion of nRCT, resection was performed. In all patients at least one additional organ was removed because of clinically evident tumour infiltration. In one third of patients (36/113) more than one organ had to be removed.

RESULTS

The rate of curative (R0) resections was 89% (101/113). It was similar in patients with and without nRCT (91 vs. 89%). In 40 (35%) patients histopathological examination could verify tumour invasion in adjacent organs (34% with vs. 36% without nRCT). The 3-year rate of locoregional recurrence after R0-resection was 12.7%. In multivariate Cox regression analysis the regional lymph node status was the most important prognostic factor (relative risk 5.8, P = 0.007). Neoadjuvant or adjuvant treatment reduced the risk by factor 0.4 (P = 0.211). The 3-year cancer-related survival rate of all patients with curative resection was 72.9%. It was 89.4% in the series treated with nRCT, while it was only 66.7% in patients with neither neoadjuvant nor adjuvant therapy. The relative risk for patients with lymph node metastases was 7.0 (P < 0.001) while it was only 0.2 in patients treated with nRCT (P = 0.049).

CONCLUSIONS

Together with curative extended multivisceral resection nRCT can improve prognosis in patients with advanced rectal carcinoma (cT4a).