Salvage surgery for locally recurrent rectal cancer: total mesorectal excision during the primary operation does not influence the outcome

Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review

BACKGROUND

There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT).

METHODS

A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years.

RESULTS

Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%).

CONCLUSIONS

The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.

Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis

IMPORTANCE

While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer.

METHODS

Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates.

RESULTS

We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD =  - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002).

CONCLUSIONS

sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.

Outcomes and prognostic factors of multimodality treatment for locally recurrent rectal cancer with curative intent

PURPOSE

Radical management of locally recurrent rectal cancer (LRRC) can lead to prolonged survival. This study aims to assess outcomes and identify prognostic factors for patients with LRRC treated using a multimodality treatment protocol.

METHODS

An analysis of a prospectively maintained institutional database of consecutive patients who underwent radical surgical resection for LRRC was performed. Potential prognostic factors were investigated using a Cox proportional hazards model.

RESULTS

Ninety-eight patients were included in this study. A multimodality approach was taken in the majority, including preoperative chemoradiation (78%), intraoperative radiation therapy (47%) and adjuvant chemotherapy (41%). Extended resection was performed where required: bone resection (34%) and lateral pelvic sidewall dissection (31%). The rate of R0 resection was 66%. Estimated rates of 5-year overall survival (OS) and progression-free survival (PFS) were 41.8% (95% CI 32.5-53.7) and 22.5% (95% CI 15.3-33.1). On multivariate analysis, stage III disease at initial primary surgery, a positive margin at initial primary surgery, synchronous or previously resected oligometastases, a lateral or sacral invasive-type pelvic recurrence and the requirement for IORT all predicted for inferior PFS (p < 0.05). Eleven percent of patients subsequently underwent further pelvic surgery for pelvic re-recurrence and had an estimated 5-year OS rate of 54.5% (95% CI 29.0-100.0) from repeat surgery.

CONCLUSIONS

Radical multimodality management of LRRC leads to prolonged survival in approximately 40% of patients. Those with sacral or lateral invasive-type recurrence or oligometastatic disease have inferior outcomes and further research is needed to optimise treatment for these groups.

Population-based study of factors predicting treatment intention in patients with locally recurrent rectal cancer

Background

Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC.

Methods

Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed.

Results

A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44).

Conclusion

Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.

Feasibility of reirradiation in the treatment of locally recurrent rectal cancer

BACKGROUND

Many patients with locally recurrent rectal cancer receive radiotherapy for the treatment of the primary tumour. It is unclear whether reirradiation is safe and effective when a local recurrence develops. The aim of this study was to evaluate the toxicity and oncological outcome of reirradiation in patients with locally recurrent rectal carcinoma.

METHODS

From March 1994 until December 2013, data on patients with locally recurrent rectal cancer (without distant metastasis) were entered into a database. Patients were reirradiated with a reduced dose of 30 Gy and received an intraoperative electron radiotherapy boost during surgery. Morbidity associated with radiotherapy, postoperative complications and oncological outcome were evaluated.

RESULTS

Clear margins (R0) were obtained in 75 (55·6 per cent) of the 135 patients who were reirradiated. Forty-six patients developed serious postoperative complications and the 30-day mortality rate was 4·6 per cent. Multivariable analysis showed that margin status was the main factor influencing oncological outcome (hazard ratio for overall survival 2·51 for R1 and 3·19 for R2 versus R0 resection; both P < 0·001). There was no significant difference in survival between the reirradiated group and a group of 113 patients who had full-course irradiation (5-year overall survival rate 34·1 and 39·1 per cent respectively; P = 0·278). Both reirradiation and full-course irradiation were associated with better survival than no irradiation in a historical control group of 24 patients (5-year overall survival rate 23 per cent; P = 0·225 and P = 0·062).

CONCLUSION

Reirradiation (with concomitant chemotherapy) has few side-effects and complements radical resection of recurrent rectal cancer.

Single-stage anterior high sacrectomy for locally recurrent rectal cancer

STUDY DESIGN

A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC).

OBJECTIVE

To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC.

SUMMARY OF BACKGROUND DATA

High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC.

METHODS

A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival.

RESULTS

Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%).

CONCLUSION

Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes.

LEVEL OF EVIDENCE

N/A.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer

AIM

A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer.

METHOD

An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers.

RESULTS

Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy.

CONCLUSION

Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Prognostic factors associated with locally recurrent rectal cancer following primary surgery (Review)

Locally recurrent rectal cancer (LRRC) is defined as an intrapelvic recurrence following a primary rectal cancer resection, with or without distal metastasis. The treatment of LRRC remains a clinical challenge. LRRC has been regarded as an incurable disease state leading to a poor quality of life and a limited survival time. However, curative reoperations have proved beneficial for treating LRRC. A complete resection of recurrent tumors (R0 resection) allows the treatment to be curative rather than palliative, which is a milestone in medicine. In LRRC cases, the difficulty of achieving an R0 resection is associated with the post-operative prognosis and is affected by several clinical factors, including the staging of the local recurrence (LR), accompanying symptoms, patterns of tumors and combined therapy. The risk factors following primary surgery that lead to an increased rate of LR are summarized in this study, including the surgical, pathological and therapeutic factors.

Outcome in patients with resectable locally recurrent rectal cancer after total mesorectal excision with and without previous neoadjuvant radiotherapy for the primary rectal tumor

BACKGROUND

The widespread use of neoadjuvant radiotherapy (nRTx) followed by total mesorectal excision (TME) introduced the problem of treating locally recurrent rectal cancer (LRRC) after nRTx and TME. Few data exist on the outcome of the surgical treatment of this type of LRRC and the influence of nRTx for the primary tumor on the outcome is unclear.

METHODS

All patients receiving multimodality treatment (including intraoperative radiotherapy) for LRRC in our center between 1996 and 2012 were analyzed retrospectively. The outcome of patients with nonmetastasized resectable LRRC who received nRTx and TME for the primary tumor was compared to the outcome of patients who did not receive nRTx for the primary tumor.

RESULTS

During this period, 139 patients underwent surgery for LRRC; 93 of these patients underwent curative surgery for LRRC after TME for the primary tumor. Sixty-five patients did not receive nRTx for the primary tumor, whereas 28 patients received nRTx for the primary tumor. There were no significant differences in the number of incomplete resections or perioperative morbidities. There was no significant difference in 5-year overall survival (28 vs. 43%, p = 0.81), recurrence-free survival (55 vs. 48%, p = 0.5), and disease-free survival (27 vs. 40%, p = 0.59).

CONCLUSIONS

Surgical treatment of carefully selected patients with nonmetastasized resectable LRRC after nRTx and TME for the primary tumor is feasible and can result in sustained local control and overall survival. Patients with resectable LRRC who received nRTx for the primary tumor do not have a poorer outcome than patients who did not.

The different biological effects of single, fractionated and continuous low dose rate irradiation on CL187 colorectal cancer cells

PURPOSE

To determine the biological effectiveness of single, fractionated and continuous low dose rate irradiation on the human colorectal cancer cell line CL187 in vitro and explore the cellular mechanisms.

MATERIALS AND METHODS

The CL187 cells were exposed to radiation of 6 MV X-ray at a high dose rate of 4Gy/min and 125I seed at a low dose rate of 2.77 cGy/h. Three groups were employed: single dose radiation group (SDR), fractionated dose radiation group (FDR) by 2Gy/f and continuous low dose rate radiation group (CLDR). Four radiation doses 2, 4, 6 and 8Gy were chosen and cells without irradiation as the control. The responses of CL187 cells to distinct modes of radiation were evaluated by the colony-forming assay, cell cycle progression as well as apoptosis analysis. In addition, we detected the expression patterns of DNA-PKcs, Ku70 and Ku80 by Western blotting.

RESULTS

The relative biological effect for 125I seeds compared with 6 MV X-ray was 1.42. 48 hrs after 4Gy irradiation, the difference between proportions of cells at G2/M phase of SDR and CLDR groups were statistically significant (p = 0.026), so as the FDR and CLDR groups (p = 0.005). 48 hrs after 4Gy irradiation, the early apoptotic rate of CLDR group was remarkably higher than SDR and FDR groups (CLDR vs. SDR, p = 0.001; CLDR vs. FDR, p = 0.02), whereas the late apoptotic rate of CLDR group increased significantly compared with SDR and FDR group (CLDR vs. SDR, p = 0.004; CLDR vs. FDR, p = 0.007). Moreover, DNA-PKcs and Ku70 expression levels in CLDR-treated cells decreased compared with SDR and FDR groups.

CONCLUSIONS

Compared with the X-ray high dose rate irradiation, 125I seeds CLDR showed more effective induction of cell apoptosis and G2/M cell cycle arrest. Furthermore, 125I seeds CLDR could impair the DNA repair capability by down-regulating DNA-PKcs and Ku70 expression.

Meta-analysis of survival based on resection margin status following surgery for recurrent rectal cancer

AIM

To determine the presence and duration of survival advantages was investigated for resection margin status (R0, R1 or R2) following surgery for locally recurrent rectal cancer (LRRC).

METHOD

A systematic review of the literature was performed for studies comparing resection margin status for LRRC. Weighted mean differences and meta-analysis of hazard ratios were used as a measure of median and overall cumulative survival.

RESULTS

Twenty-two studies were included, providing outcome for 1460 patients undergoing surgery for LRRC. 57% underwent an R0 resection, 25% an R1 resection and 11% an R2 resection. The most commonly performed operations were abdominoperineal excision (35%), exenteration (23%) and anterior resection (21%). The range of median survival per resection margin was R0 28-92 months, R1 12-50 months, R2 6-17 months. Patients undergoing an R0 resection survived on average for 37.6 (95% confidence interval: 23.5-51.7) months longer than those undergoing R1 resection and 53.0 (31.2-74.8) months longer than those undergoing R2 resection. This correlated to a hazard ratio of 2.03 (1.73-2.38) for R0 vs R1 and 3.41 (2.21-5.25) for R0 vs R2. Patients undergoing R1 resection survived on average 13.3 (7.23-19.4) months longer than those undergoing R2 resection [hazard ratio of 1.68 (1.33-2.12)].

CONCLUSION

Patients undergoing R0 resection have the greatest survival advantage following surgery for recurrent rectal cancer. There is a survival advantage for R1 over R2 resection, but there may be no benefit of R2 resection over palliative treatment.

Therapeutic potential of surgery for metastatic colorectal cancer

Evidence of the clinical benefit of surgery or metastasectomy for metastatic colorectal cancer to disease sites including the liver, lung, peritoneum, and pelvis as a potentially curative option is now available in the literature. The oncologic outcome of this treatment strategy achieves 5-year survival ranging between 20% and 50%. These survival gains have not been previously observed in the management of metastatic colorectal cancer. Treatment of potential surgical candidates requires a combined modality approach with systemic therapies to achieve macroscopic tumor removal and microscopic targeting of tumor deposits to achieve disease control. In nonsurgical candidates, systemic therapy, radiation therapy, and interventional oncology procedures may potentially facilitate sufficient disease downstaging for surgery. The purpose of this article is to provide a comprehensive review of the therapeutic advances in the surgical management of metastatic colorectal cancer.

[Rectal cancer: situation where a referral center is needed]

One of the objectives of the French strategic plan for cancer 2009-2013 is to structure the need for referral surgery, particularly for low rectal carcinoma. However, low rectal cancer is not the only situation in the field of rectal surgery where expert unit are needed for the referral of appropriate patients. We developed the multidisciplinary strategies for low rectal cancer, advanced rectal cancer, recurrent rectal cancer and peritoneal carcinomatosis. Optimal management of these difficult situations can give a chance of long term survival while a non-optimal management could jeopardise the future of patients by changing a potentially curable disease into an incurable one.