Hydronephrosis Does Not Preclude Curative Resection of Pelvic Recurrences After Colorectal Surgery

Conversion therapy with pembrolizumab for a peritoneal metastasis of rectal cancer causing hydronephrosis in a patient with Lynch syndrome

A 44-year-old woman with Lynch syndrome was referred to our hospital for treatment of recurrence of microsatellite instability-high rectal cancer. [18F]Fluorodeoxyglucose (18FDG)-positron emission tomography revealed a peritoneal metastasis with invasion to the small intestine and left ureter. The peritoneal metastasis was diagnosed initially as unresectable because of extensive invasion to the left ureter requiring nephrectomy. Hence, first-line treatment with pembrolizumab was started. After the first course of pembrolizumab, she developed hydronephrosis and a resulting urinary tract infection (UTI). A percutaneous nephrostomy was performed to control the UTI. After six courses of pembrolizumab, 18FDG-positron emission tomography showed that the peritoneal metastasis was smaller with significantly reduced 18FDG uptake, and it was then diagnosed as resectable without nephrectomy. She underwent R0 resection of the peritoneal metastasis with partial resection of the small intestine. Intraoperatively, the peritoneal metastasis showed no invasion of the left ureter, allowing its preservation. The percutaneous nephrostomy was removed postoperatively, and she has not developed any subsequent UTIs. Histopathologically, the tumor showed a pathological complete response to pembrolizumab. To the best of our knowledge, this is the first case of conversion therapy with pembrolizumab for peritoneal metastasis with hydronephrosis.

Treatment efficacy and prognosis analysis in locally advanced or metastatic colorectal cancer patients with hydronephrosis

The effect of hydronephrosis, a common complication of metastatic colorectal cancer (CRC), on the treatment outcome and prognosis of locally advanced or metastatic CRC remains to be elucidated. The present study investigated the clinical characteristics, outcomes, and prognoses of patients with locally advanced or metastatic colorectal cancer (CRC) with hydronephrosis. Clinical data of patients with locally advanced or metastatic CRC who were attending Peking University Shenzhen Hospital and Shenzhen Cancer Hospital between January 2016 and December 2020 were retrospectively collected. A total of 52 patients with hydronephrosis based on CT or MRI findings were selected, and their clinical characteristics, treatment outcomes, and survival times were analyzed. Of the 52 patients, 33 were male (63.5%), and the median age was 49 years (range, 31-76 years). A total of 15 (28.8%) patients with CRC had synchronous hydronephrosis and the remaining 37 patients had metachronous hydronephrosis. Ureters were either compressed by peritoneal or abdominal cavity metastatic lymph nodes in 34 cases (65.4%) or by direct tumor invasion in 18 cases (34.6%). However, objective response rate (ORR) was higher in the group in which ureters were compressed by peritoneal or abdominal cavity metastatic lymph nodes; ORR, disease control rate and median progression-free survival (PFS) between the two groups were not statistically different. (P>0.05). The median survival period was only 27.0 months (95% CI, 20.549-33.451) in patients complicated with malignant hydronephrosis. Univariate and multivariate analyses showed that CA19-9 might be a prognostic factor for locally advanced and metastatic CRC patients with hydronephrosis. Metachronous metastatic CRC has a high incidence rate of complicated hydronephrosis. Targeted drugs in combination with chemotherapy improve the treatment efficacy and prognosis of patients. Notably, the present study found that CA19-9 level might be a prognostic factor in CRC patients with hydronephrosis.

Intentionally curative treatment of locally recurrent rectal cancer: a systematic review

BACKGROUND

There is a lack of outcome data beyond local recurrence rates after primary treatment in rectal cancer, despite more information being necessary for clinical decision-making. We sought to determine patient selection, therapeutic modalities and outcomes of locally recurrent rectal cancer treated with curative intent.

METHODS

We searched MEDLINE (1990-2010) using the medical subject headings "rectal neoplasms" and "neoplasm recurrence, local." Selection of cohort studies was based on the primary intention of treatment and availability of at least 1 outcome variable.

RESULTS

We included 55 cohort studies comprising 3767 patients; 8 studies provided data on the rate of intentionally curative treatment from an unselected consecutive cohort of patients (481 of 1188 patients; 40%). Patients were symptomatic with pain in 50% (796 of 1607) of cases. Overall, 3088 of 3767 patients underwent resection. The R0 resection rate was 56% (1484 of 2637 patients). The rate of external beam radiotherapy was 100% in 9 studies, 0% in 5 studies, and ranged from 12% to 97% in 37 studies. Overall postoperative mortality was 2.2% (57 of 2515 patients). Five-year survival was at least 25%, with an upper limit of 41% in 11 of 18 studies including at least 50 resections. We found a significant increase in reported survival rates over time (r2 = 0.214, p = 0.007).

CONCLUSION

More uniformity in treatment protocols and reporting on outcomes for locally recurrent rectal cancer is warranted. The observed improvement of reported survival rates in time is probably related to better patient selection and optimized multimodality treatment in specialized centres.

Surgical management of locally recurrent rectal cancer

Developments in chemotherapeutic strategies and surgical technique have led to improved loco regional control of rectal cancer and a decrease in recurrence rates over time. However, locally recurrent rectal cancer continues to present considerable technical challenges and results in significant morbidity and mortality. Surgery remains the only therapy with curative potential. Despite a hostile intra-operative environment, with meticulous pre-operative planning and judicious patient selection, safe surgery is feasible. The potential benefit of new techniques such as intra-operative radiotherapy and high intensity focussed ultrasonography has yet to be thoroughly investigated. The future lies in identification of predictors of recurrence, development of schematic clinical algorithms to allow standardised surgical technique and further research into genotyping platforms to allow individualisation of therapy. This review highlights important aspects of pre-operative planning, intra-operative tips and future strategies, focussing on a multimodal multidisciplinary approach.

Current management of locally recurrent rectal cancer

AIM

A review of the literature was undertaken to provide an overview of the surgical management of locally recurrent rectal cancer (LRRC) after the introduction of total mesorectal excision (TME).

METHOD

A systematic literature search was undertaken using PubMed, Embase, Web of Science and Cochrane databases. Only studies on patients having surgery for their primary tumour after 1995, or if more than half of the patients were operated on after 1995, were considered for analysis. Studies concerning only palliative treatments were excluded.

RESULTS

A total of 19 studies fulfilled the inclusion criteria. Locally recurrent rectal cancer still occurred in 5-10% of the patients and was a major clinical problem, due to severe symptoms and poor survival. In most studies, 40-50% of all patients with LRRC could be expected to undergo surgery with a curative intent and of those, 30-45% would have R0 resection. Thus, only 20-30% of all patients with LRRC would have a potentially curative operation. The postoperative complication rate varied considerably, from 15 to 68%. The rate of re-recurrence varied from 4 to 54% after curative surgery. The 5-year overall survival varied between 9 and 39% and the median survival between 21 and 55 months.

CONCLUSION

Compared with previous studies, the proportion of potentially curative resections seems to have increased, probably due to improved staging, neoadjuvant treatment and increased surgical experience in dedicated centres, which has resulted in a tendency to improved survival.

[Locally recurrent rectal cancer]

Over the last decades the therapy of rectal carcinoma has shown continuous improvement. Due to improvements in operative techniques, such as the establishment of total mesorectal excision (TME) and the combination of surgery and (neo-) adjuvant radiochemotherapy, the incidence of locally recurrent rectal cancer could be improved from nearly 50% to less then 10%. Nevertheless recurrent rectal carcinoma remains a severe problem. Predictive factors relating to locally recurrent rectal cancer are surgical experience, localization of the tumor, circumferential resection margins, stage-oriented multimodal therapy and a suitable oncological procedure for the primary tumor. In addition the tumor-specific biology also seems to be a relevant risk factor for recurrence. Operative treatment of locally recurrent rectal cancer was seen for a long time as a palliative procedure. Newer data show that resection of locally recurrent rectal cancer can be carried out with a curative intention in experienced institutions with a long-term 5 year survival of about 30% and mortality around 5%. The composite sacropelvic resection technique is a reasonable option in the curative treatment of locally recurrent rectal cancer. For the future the focus must be on improvements in the primary therapy of rectal carcinoma to avoid local recurrence. In addition early diagnosis of local recurrence and multimodal therapies will be of decisive importance.

Reoperation for recurrent colorectal cancer

Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.

Prediction of residual disease or distant metastasis after resection of locally recurrent rectal cancer

PURPOSE

It is important to preoperatively identify patients at high risk of relapse at extrapelvic sites or residual disease after salvage surgery for locally recurrent rectal cancer to maximize the survival benefit by indicating whether a surgical approach might be successful.

METHODS

Data from 101 consecutive patients who underwent exploration with curative intent for local recurrence after radical resection of rectal cancer were retrospectively collected. Preoperative factors were examined in univariate and multivariate analyses for their ability to predict resectability and distant disease-free survival.

RESULTS

The 5-year disease-specific survival rates of R0, R1, and R2 resection were 43.3%, 19.5%, and 10.0%, respectively (P < .001). In a logistic regression analysis, upper sacral (above the inferior margin of the second sacrum)/lateral invasive type and high-grade lymphatic invasion of the primary tumor were associated with palliative surgery. A Cox regression analysis revealed that upper sacral/lateral invasive type, extrapelvic disease, hydronephrosis at recurrence, and high-grade lymphatic or venous invasion of the primary tumor were associated with a lower distant disease-free survival rate. Patients with one or more of these risk factors had a 3-year distant disease-free survival rate of 6.2% compared with 54.1% for those with none of these risk factors.

CONCLUSION

It was possible to preoperatively identify patients at high risk of relapse or residual disease. This system might be used on an individual basis to select patients with locally recurrent rectal cancer for chemotherapy or radiotherapy before surgical intervention with curative intent.

Resection of isolated pelvic recurrences after colorectal surgery: long-term results and predictors of improved clinical outcome

BACKGROUND

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of perioperative morbidity and potential mortality. Clinical decision making remains difficult.

METHODS

Patients resected with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathologic factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome.

RESULTS

Ninety patients underwent an attempt at curative resection of a pelvic recurrence with median follow-up of 31 months. Complications occurred in 53% of patients. Operative mortality was 4.4% (4 of 90). Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome.

CONCLUSIONS

The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.

Resection of Isolated Pelvic Recurrences After Colorectal Surgery: Long-Term Results and Predictors of Improved Clinical Outcome

BACKGROUND

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of marked perioperative morbidity and potential mortality. Clinical decision making remains difficult.

METHODS

Patients who underwent resection with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathological factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome.

RESULTS

Ninety patients underwent an attempt at curative resection of a pelvic recurrence; median follow-up was 31 months. Complications occurred in 53% of patients. Operative mortality occurred in 4 (4.4%) of 90 patients. Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome.

CONCLUSIONS

The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.