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

Novel and Innovative Surgical Strategies for Recurrent Rectal Cancer: Uncommon Resections, Local Interventions for Pelvic Reoccurrence, and Intraoperative Radiation Therapy

The frequency of recurrent rectal cancer has dropped significantly with improved surgical approaches and adjunctive therapies. These recurrences have proven challenging to obtain R0 resection with salvage operations. Meticulous planning, clear understanding of anatomy with imaging, and multispecialty support have become essential in local control and long-term survival with pelvic recurrence of rectal cancer. Technical considerations and prognosis indicators along with role of intraoperative radiation or boost radiation are discussed within.

High dose stereotactic body radiotherapy using three fractions for colorectal oligometastases

BACKGROUND AND OBJECTIVES

This study evaluated the treatment result of high dose stereotactic body radiation therapy (SBRT) for colorectal oligometastases.

METHODS

Between 2003 and 2009, 41 patients with 50 lesions confined to one organ from colorectal cancer (CRC) and treated with high dose SBRT ≥45 Gy were retrospectively reviewed. Lymph nodes (LNs) (18 patients) were the most frequent sites followed in order by lung (12) and liver (11). SBRT doses ranged from 45 to 60 Gy in three fractions (median 48 Gy). The cumulative gross tumor volume (GTV) ranged from 2 to 123 ml (median 13 ml).

RESULTS

The median follow-up period from the SBRT date was 28 months (range, 6-65 months). The 3-year local control and overall survival rates were 64 and 60%, and the respective 5-year rates were 57 and 38%. Cumulative GTV and SBRT dose were statistically significant prognostic factors for local control. The grade 3 or 4 complications occurred in three patients (7%).

CONCLUSIONS

High dose SBRT for colorectal oligometastases was found to produce results comparable with surgical series. To improve local control, dose higher than 48 Gy are recommend when possible, but further study will be required to define the optimal normal tissue constraints and acceptable toxicity.

Utilization of Interventional Radiology in the Postoperative Management of Patients after Surgery for Locally Advanced and Recurrent Rectal Cancer

The surgical management of locally advanced primary rectal cancer and locally recurrent rectal cancer requires complex operations frequently resulting in complicated postoperative courses. We sought to evaluate the utilization of interventional radiologic (IR) procedures in the management of postoperative complications. Under Institutional Review Board approval, a prospective database of colorectal cancer patients undergoing resection from July 1999 to January 2010 was analyzed. Data collected included demographics, operative procedure, complications, length of stay, and IR utilization. Fisher's exact tests and logistic regression explored associations with necessitating an IR procedure during the postoperative period. Continuous variables were analyzed using Wilcoxon rank sum tests. One hundred and one patients underwent surgery and 66 received intraoperative electron radiotherapy (IOERT). Primary procedures included pelvic exenteration (n = 35), abdominoperineal resection (n = 25), low anterior resection (n = 23), paraaortic node dissection (n = 7), resection of isolated pelvic/retroperitoneal tumor (n = 7), and colectomy (n = 4). Sixty-two patients required multivisceral resection including partial/total cystectomy (n = 30), small bowel resection (n = 25), oophorectomy (n = 15), vaginectomy (n = 12), hysterectomy (n = 12), hepatectomy (n = 3), and nephrectomy (n = 3). Seventeen partial sacral resections and 47 pelvic sidewall resections were also required. One hundred and thirty-eight complications were identified in 72 patients, 30 of which required a procedural intervention. Twenty-seven IR procedures were performed including drainage of fluid collections (n = 14), nephrostomy tube placement (n = 8), arterial embolization (n = 2), inferior vena cava filter placement (n = 2), and pleural drainage (n = 1). Only three reoperations were required, none related to failure of IR procedures. There were no deaths. Estimated blood loss > 2000 mL ( P = 0.002), IOERT ( P = 0.03), and incomplete resection ( P = 0.02) were found to be associated with postoperative IR utilization. Surgery for locally advanced primary rectal cancer and locally recurrent rectal cancer is associated with significant morbidity but low mortality. IR procedures play a significant role in the postoperative management of these patients and may decrease the need for reoperation.

Laparoscopic salvage surgery for recurrent and metachronous colorectal cancer: 15 years' experience in a single center

BACKGROUND

Laparoscopic salvage surgery for colorectal cancer is a novel but technically challenging option for surgeons. The aim of this study was to evaluate the feasibility and safety of laparoscopic surgery in patients with recurrent or metachronous colorectal cancer in comparison with an open approach.

METHODS

The data used in this study were obtained from databases, the data of which were collected prospectively from January 1996 to February 2010. Data pertaining to patients, operations, and short-term outcomes were analyzed and compared between open and laparoscopic salvage groups.

RESULTS

Among the 3,425 patients studied, colorectal cancer recurred in 565 patients (16.5%) and 41 patients had colorectal salvage operations. Twenty-six patients with recurrence underwent open surgery and 15 cases underwent laparoscopic surgery. The short-term outcomes of the laparoscopic group were comparable with those of the open surgery group or were partly favorable. The five-year disease-free interval and overall survival of recurrent cancer patients were not significantly different from those of the open patients. Metachronous colorectal cancer occurred in 13 patients (0.38%), 5 of whom had open surgery and 6 had laparoscopic salvage. The only significant difference between the groups was a shorter operating time for the laparoscopic group. Late in the study, four patients in the laparoscopic recurrent group and one patient in the metachronous group were converted to open surgery.

CONCLUSIONS

Laparoscopic surgery yielded short-term outcomes that were comparable to those of conventional open surgery, in both recurrent and metachronous colorectal cancer patients. Thus, minimally invasive salvage approaches should be considered as a treatment option for the recurrent and the metachronous colorectal cancer patient.

Prognostic factors for survival after salvage surgery for locoregional recurrence of colon cancer

BACKGROUND

Although locoregional recurrence after rectal cancer resection has been extensively investigated, studies of salvage surgery for locoregionally recurrent colon cancer are scarce. This study aimed to determine the predictors of postsalvage survival for locoregionally recurrent colon cancer.

METHODS

We studied 45 consecutive patients who underwent macroscopically complete resection of locoregionally recurrent colon cancer between April 1988 and December 2007. The primary end point was cancer-specific survival, and 20 clinical variables were analyzed for their prognostic significance.

RESULTS

Cancer-specific 5-year survival for the entire cohort of 45 patients was 46%. Multivariate survival analysis showed that margin status (P = .0311), number of locoregional recurrent tumors (P = .0002), pathological grade (P = .0416), largest tumor diameter (P = .0247), and distant metastasis (P = .0006) were independently associated with cancer-specific survival.

CONCLUSIONS

Salvage surgery for locoregional recurrence of colon cancer can provide a chance for long-term survival in selected patients.