Locally Recurrent Rectal Cancer: Prognostic Factors and Long-Term Outcomes of Multimodal Therapy

Clinical Significance of Preoperative and Postoperative Serum CEA and Carbohydrate Antigen 19-9 Levels in Patients Undergoing Curative Resection of Locally Recurrent Rectal Cancer

BACKGROUND

Local recurrence is common after curative resection for rectal cancer. Although one expects radical resection of locally recurrent rectal cancer to be curative, the postoperative re-recurrence rate is relatively high. Therefore, identifying risk factors for recurrence may improve the prognosis of locally recurrent rectal cancer with early therapeutic intervention.

OBJECTIVE

This study aimed to evaluate the relationship between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis in locally recurrent rectal cancer to validate their usefulness for postoperative surveillance in locally recurrent rectal cancer.

DESIGN

This was a single-center retrospective cohort study.

SETTING

The study is based on data obtained from procedures at the Osaka University Hospital.

PATIENTS

Ninety patients underwent radical resection for locally recurrent rectal cancer between January 2000 and January 2015.

MAIN OUTCOME MEASURES

We evaluated the correlation between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis after complete resection of locally recurrent rectal cancer and the serum CEA and carbohydrate antigen 19-9 levels at the diagnosis of postoperative re-recurrence.

RESULTS

The median preoperative serum CEA level was 4 ng/mL and carbohydrate antigen 19-9 level was 12 U/mL. Of the 90 patients, 43.3% had serum CEA ≥5 ng/mL, and 15.6% had serum carbohydrate antigen 19-9 ≥37 U/mL. Preoperatively, this serum carbohydrate antigen 19-9 level strongly correlated with poorer prognoses regarding cancer-specific survival. Postoperatively, serum CEA ≥5 ng/mL significantly correlated with a worse prognosis. At the time of diagnosis of re-recurrence after resection of locally recurrent rectal cancer, 53.2% of patients had serum CEA ≥5 ng/mL, and 23.4% of patients had serum carbohydrate antigen 19-9 ≥37 U/mL.

LIMITATIONS

The study was limited by its single-center retrospective design, an insufficient sample size, and a relatively long study period.

CONCLUSIONS

High serum levels of carbohydrate antigen 19-9 preoperatively and CEA postoperatively are associated with poor prognosis after locally recurrent rectal cancer. Furthermore, we found a high rate of serum CEA elevation in the diagnosis of postoperative re-recurrence. See Video Abstract at http://links.lww.com/DCR/C106 .

IMPORTANCIA CLNICA DE LOS NIVELES SRICOS PREOPERATORIOS Y POSOPERATORIOS DE CEA Y CA EN PACIENTES SOMETIDOS A RESECCIN CURATIVA DE CNCER DE RECTO LOCALMENTE RECURRENTE

ANTECEDENTES:La recurrencia local es común después de la resección curativa del cáncer de recto. Aunque se espera que la resección radical del cáncer rectal localmente recurrente sea curativa, la tasa de recurrencia posoperatoria es relativamente alta. Por lo tanto, la identificación de los factores de riesgo de recurrencia puede mejorar el pronóstico del cáncer de recto localmente recurrente con una intervención terapéutica temprana.OBJETIVO:Evaluamos la relación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico en el cáncer de recto localmente recurrente para validar su utilidad para la vigilancia posoperatoria en el cáncer de recto localmente recurrente.DISEÑO:Este fue un estudio de cohorte retrospectivo de un solo centro.AJUSTE:El estudio se basa en datos obtenidos de procedimientos en el Hospital Universitario de Osaka.PACIENTES:Noventa pacientes fueron sometidos a resección radical por cáncer de recto localmente recurrente entre Enero de 2000 y Enero de 2015.PRINCIPALES MEDIDAS DE RESULTADOS:Evaluamos la correlación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico después de la resección completa del cáncer de recto localmente recurrente y los niveles séricos de CEA y CA19-9 en el diagnóstico de recurrencia posoperatoria.RESULTADOS:La mediana de los niveles séricos preoperatorios de CEA y CA19-9 fueron de 4 ng/mL y 12 U/mL, respectivamente. De los 90 pacientes, el 43,3 % tenía CEA sérico ≥5 ng/mL y el 15,6 % tenía CA19-9 sérico ≥37 U/mL. Antes de la operación, este nivel sérico de CA19-9 se correlacionó fuertemente con peores pronósticos con respecto a la supervivencia específica del cáncer. Después de la operación, el CEA sérico ≥5 ng/mL se correlacionó significativamente con un peor pronóstico. En el momento del diagnóstico de recurrencia después de la resección del cáncer de recto localmente recurrente, el 53,2 % de los pacientes tenían CEA sérico ≥5 ng/mL y el 23,4 % de los pacientes tenían CA19-9 sérico ≥37 U/mL.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro, un tamaño de muestra insuficiente y un período de estudio relativamente largo.CONCLUSIONES:Los niveles séricos altos de CA19-9 antes de la operación y de CEA después de la operación están asociados con un mal pronóstico después del cáncer de recto localmente recurrente. Además, encontramos una alta tasa de elevación del CEA sérico en el diagnóstico de recurrencia posoperatoria. Consulte el Video Resumen en http://links.lww.com/DCR/C106 . (Traducción-Dr. Yesenia Rojas-Khalil ).

A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer

BACKGROUND

Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery.

METHODS

A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool.

RESULTS

Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report.

CONCLUSION

Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.

MRI for Rectal Cancer: Staging, mrCRM, EMVI, Lymph Node Staging and Post-Treatment Response

Rectal cancer is a relatively common malignancy in the United States. Magnetic resonance imaging (MRI) of rectal cancer has evolved tremendously in recent years, and has become a key component of baseline staging and treatment planning. In addition to assessing the primary tumor and locoregional lymph nodes, rectal MRI can be used to help with risk stratification by identifying high-risk features such as extramural vascular invasion and can assess treatment response for patients receiving neoadjuvant therapy. As the practice of rectal MRI continues to expand further into academic centers and private practices, standard MRI protocols, and reporting are critical. In addition, it is imperative that the radiologists reading these cases work closely with surgeons, medical oncologists, radiation oncologists, and pathologists to ensure we are providing the best possible care to patients. This review aims to provide a broad overview of the role of MRI for rectal cancer.

Prognostic Factors of Recurrence and Survival in Operated Patients with Colorectal Cancer

BACKGROUND: The recurrence of colorectal cancers is considered to be one of the greatest post-surgical complications that is affected by various factors. This study was designed to investigate the prognostic factors that affect the recurrence and survival of patients with colon and rectal cancers. METHODS: A retrospective study was performed on 380 patients with colorectal cancers who underwent surgery were enrolled in the study (152 patients with colon cancer and 228 patients with rectal cancer). Preoperative serum albumin level, type of surgery, tumor size, differentiation grade, proximal, distal and radial, and marginal involvement, the total number of excised lymph nodes, the number of involved lymph nodes, and tumor stage were recorded. Also, the incidences of recurrence and metastasis were recorded during the study. RESULTS: 380 patients with a mean age of 57.11 years were enrolled in the study. 152 patients with an average age of 57.57 years were diagnosed as having colon cancer. Recurrence and metastasis occurred in two patients (1.3%) and five patients (3.3%), respectively. 18 patients (11.8%) died because of colon cancer. 228 patients with a mean age of 56.81 had rectal cancer. Recurrence was seen in 19 patients (8.3%) and metastasis in 33 patients (14.5%). 38 patients (16.7%) died because of rectal cancer. Tumor size and involved lymph nodes were independent prognostic factors for the recurrence and metastases of colon cancer. Only involved lymph nodes were associated with death due to colon cancer. Independent prognostic factors for rectal cancer metastasis include serum albumin level and age. The total number of excised lymph nodes was the only predictor of tumor recurrence and death in rectal cancer. The median survival times of colon and rectal cancers were 90 and 110 months, respectively. CONCLUSION: The size of the tumor and the number of involved lymph nodes were independent prognostic factors for recurrence and metastasis of colon cancer. Also, the number of involved lymph nodes was associated with colon cancer-related deaths. In the case of rectal cancer, serum albumin levels and age predicted metastases. Only the total number of excised lymph nodes had a reverse relationship with recurrence and rectal cancer-related death.

Impact of the preoperative prognostic nutritional index as a predictor for postoperative complications after resection of locally recurrent rectal cancer

BACKGROUND

Local recurrence is common after curative resections for rectal cancer. Surgical intervention is among the best treatment choices. However, achieving a negative resection margin often requires extensive pelvic organ resections; thus, the postoperative complication rate is quite high. Recent studies have reported that the inflammatory index could predict postoperative complications. This study aimed to validate the correlation between clinical factors, including inflammatory markers, and severe complications after surgery for local recurrent rectal cancer.

METHODS

This retrospective study included 99 patients that underwent radical resections for local recurrences of rectal cancer. Postoperative complications were graded according to the Clavien-Dindo classification. Grades ≥3 were defined as severe complications. Risk factors for severe complications were identified with univariate and multivariate logistic regression models and assessed with receiver-operating characteristic curves.

RESULTS

Severe postoperative complications occurred in 38 patients (38.4%). Analyses of correlations between inflammatory markers and severe postoperative complications revealed that the strongest correlation was found between the prognostic nutrition index and severe postoperative complications. The receiver-operating characteristic analysis showed that the optimal prognostic nutrition index cut-off value was 42.2 (sensitivity: 0.790, specificity: 0.508). In univariate and multivariate analyses, a prognostic nutrition index ≤44.2 (Odds ratio: 3.007, 95%CI:1.171-8.255, p = 0.02) and a blood loss ≥2850 mL (Odds ratio: 2.545, 95%CI: 1.044-6.367, p = 0.04) were associated with a significantly higher incidence of severe postoperative complications.

CONCLUSIONS

We found that a low preoperative prognostic nutrition index and excessive intraoperative blood loss were risk factors for severe complications after surgery for local recurrent rectal cancer.

A phase III randomized controlled trial comparing surgery plus adjuvant chemotherapy with preoperative chemoradiotherapy followed by surgery plus adjuvant chemotherapy for locally recurrent rectal cancer: Japan Clinical Oncology Group study JCOG1801 (RC-SURVIVE study)

A randomized phase III trial was initiated in Japan in August 2019 to confirm the superiority of preoperative chemoradiotherapy followed by surgery plus adjuvant chemotherapy compared to the standard treatment, i.e. surgery plus adjuvant chemotherapy, for locally recurrent rectal cancer in local relapse-free survival. In all, 110 patients from 43 Japanese institutions will be recruited over a period of 6 years. Eligible patients would be registered and randomly assigned to each group with an allocation ratio of 1:1. The primary endpoint is local relapse-free survival. The secondary endpoints are overall survival, relapse-free survival, proportion of local relapse, proportion of distant relapse, proportion of patients with pathological R0 resection, response rate of preoperative chemoradiotherapy (preoperative chemoradiotherapy arm), pathological complete response rate (preoperative chemoradiotherapy arm), proportion of patients who completed the protocol treatment, incidence of adverse events (adverse reactions) and quality of life after surgery. This trial has been registered at the Japan Registry of Clinical Trial: jRCTs031190076 [https://jrct.niph.go.jp/latest-detail/jRCTs031190076] and ClinicalTrials.gov: NCT04288999 [https://clinicaltrials.gov/ct2/show/NCT04288999].

Improved Outcomes for Rectal Cancer in the Era of Preoperative Chemoradiation and Tailored Mesorectal Excision: A Series of 338 Consecutive Cases

Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N1 disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.

Chemoradiotherapy for Local Recurrence of Rectal Cancer: A Single Center Study of 18 Patients

BACKGROUND/AIM

When possible, surgical resection is recommended for local recurrence after resection of colorectal cancer. In unresectable cases, chemotherapy is usually indicated, although the success of chemoradiotherapy (CRT) in this setting is unclear.

PATIENTS AND METHODS

We retrospectively reviewed the treatment outcomes of 18 patients who received CRT for unresectable local recurrence after radical colorectal cancer surgery at our hospital between January 2000 and May 2016.

RESULTS

Of these 18 patients, three experienced complete response and four experienced partial response, resulting in a 39% overall response. With a median follow-up time of 42 months, the 5-year progression-free survival and overall survival were 34.8% and 54.4%, respectively; associated with a median local failure-free survival time of 40.9 months. Two of the three patients that underwent CRT remained local failure free for 5 years.

CONCLUSION

CRT for local recurrence of rectal cancer without distant metastasis produces similar overall survival rates and local control as conventional surgical resection.

Practical effectiveness of re-irradiation with or without surgery for locoregional recurrence of rectal cancer: A meta-analysis and systematic review

BACKGROUND AND PURPOSE

Re-irradiation might yield local control (LC) or palliation for locoregionally recurrent rectal cancer (LRRC), but iatrogenic complications are a possible hindrance. We aimed to evaluate the efficacy of re-irradiation to determine optimal treatment of LRRC.

METHODS

We performed a systematic review of PubMed, MEDLINE, Cochrane Library, and Embase.

RESULTS

A total of 17 studies involving 744 patients with LRRC were included; median OS ranging from 10 to 45 months (median: 24.5 months). Pooled 1-, 2-, and 3-year OS rates for all patients were 76.1%, 49.1%, and 38.3%, respectively. For patients who underwent re-irradiation and surgery (OP group), these pooled rates were 85.9%, 71.8%, and 51.7%, respectively. For patients who underwent re-irradiation but not surgery (non-OP group), pooled 1-, 2-, and 3-year OS rates were 63.5%, 34.2%, and 23.8%, respectively. The OS difference between both groups was significant for all 3 years (P < 0.05). Pooled 1-, 2-, and 3-year LC rates for the OP group were 84.4%, 63.8%, and 46.9%, and for the non-OP group were 72.0%, 54.8%, and 44.6%, respectively, without significant differences. Pooled grade ≥3 acute and late complication rates were 11.7% and 25.5% in the OP and non-OP groups, respectively. Patients who underwent surgery had a higher risk of grade ≥3 late complications (odds ratio: 6.39). Pooled symptomatic palliation rate was 75.2%.

CONCLUSIONS

Re-irradiation with or without surgery for LRRC showed oncologic and palliative efficacy. Salvage treatment including re-irradiation and surgery showed higher survival, but the late complication was significantly increased with concomitant surgery.

A novel approach to inoperable or recurrent rectal cancer by chemoembolization: A new arrow in our quiver?

Purpose

Assess the feasibility, safety and efficacy of TACE with irinotecan loaded micro particles (debiri) for the treatment of locally advanced rectal cancer patients.

Results

We assessed the Edmonton Symptom Assessment System (ESAS). The tool is designed to assess nine common symptoms in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. The ESAS score was 7 in 10/12 (83%) patients before treatment and 6 in 2/12 (16.5%) patients. After treatment in 6/12 (50%) patients the score dropped to 3; 3/12 (33%) reported 4, 1/12 (8%) reported 2. All patients experienced local control disease with a degree of citoreduction; in 4 cases (33%) we observed outstanding responses with a dramatic reduction in the tumors size which led us to surgical radical resections.

Materials and methods

We run a prospective mono-institutional study where we recruited, 12 non- consecutive patients with histology confirmation of rectal cancer, inoperable and not treatable due to severe comorbidities, or pelvic recurrence/progression after curative treatment, chemotherapy, radiotherapy and/or surgery. Their performance status (PS) ECOG was 2-3. Twelve patients (10 male and 2 female) with a median age 71 (range 56-89) were recruited in the study.

Conclusions

The study has met the primary endpoint and showed encouraging activity. Debiri could be a possible option for locally advanced/inoperable or recurred rectal cancer patients. Further trials are warranted to validate this methodic in early stages.

Prognostic Impact of Intra-abdominal/Pelvic Inflammation After Radical Surgery for Locally Recurrent Rectal Cancer

BACKGROUND

The influence of postoperative infectious complications, such as anastomotic leakage, on survival has been reported for various cancers, including colorectal cancer. However, it remains unclear whether intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is relevant to its prognosis.

OBJECTIVE

The purpose of this study was to evaluate factors associated with survival after radical surgery for locally recurrent rectal cancer.

DESIGN

The prospectively collected data of patients were retrospectively evaluated.

SETTINGS

This study was conducted at a single-institution tertiary care cancer center.

PATIENTS

Between 1983 and 2012, patients who underwent radical surgery for locally recurrent rectal cancer with curative intent at the National Cancer Center Hospital were reviewed.

MAIN OUTCOME MEASURES

Factors associated with overall and relapse-free survival were evaluated.

RESULTS

During the study period, a total of 180 patients were eligible for analyses. Median blood loss and operation time for locally recurrent rectal cancer were 2022 mL and 634 minutes. Five-year overall and 3-year relapse-free survival rates were 38.6% and 26.7%. Age (p = 0.002), initial tumor stage (p = 0.03), pain associated with locally recurrent rectal cancer (p = 0.03), CEA level (p = 0.004), resection margin (p < 0.001), intra-abdominal/pelvic inflammation (p < 0.001), and surgery period (p = 0.045) were independent prognostic factors associated with overall survival, whereas CEA level (p = 0.01), resection margin (p = 0.002), and intra-abdominal/pelvic inflammation (p = 0.001) were associated with relapse-free survival. Intra-abdominal/pelvic inflammation was observed in 45 patients (25.0%). A large amount of perioperative blood loss was the only factor associated with the occurrence of intra-abdominal/pelvic inflammation (p = 0.007).

LIMITATIONS

This study was limited by its retrospective nature and heterogeneous population.

CONCLUSIONS

Intra-abdominal/pelvic inflammation after radical surgery for locally recurrent rectal cancer is associated with poor prognosis. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

A systematic review of the impact of pain on overall survival in patients with cancer

PURPOSE

Pain commonly occurs in cancer patients, and has been associated with shorter survival. However, the importance of pain is less clear when analyzed with other known prognostic variables. This systematic review was performed to better understand how pain impacts overall survival (OS) in common cancers when key clinical variables are included in multivariate analysis.

METHODS

A Medline search was completed to find studies examining the relationship between pain, clinical variables, and OS in patients with breast, colorectal, lung, or prostate cancer. Multivariate analysis included known prognostic variables including age, performance status, disease burden, and laboratory parameters.

RESULTS

Fifty studies met inclusion criteria. In patients with breast, colorectal, and lung cancer, pain was not a significant prognostic factor for OS on multivariate analysis in most studies. In contrast, several studies suggest that pain is an independent prognostic factor for OS in advanced prostate cancer, even when relevant clinical prognostic variables are included. However, analgesic use was often used as a surrogate for prostate cancer pain, making it difficult to determine whether pain or opioid exposure was more important in influencing survival.

CONCLUSIONS

Pain may be associated with shorter survival in patients with cancer, but the mechanism for this relationship is unknown. The available evidence is insufficient to definitively determine if pain independently influences survival in patients with breast, colorectal, or lung cancer. The majority of studies in prostate cancer show pain to be an independent prognostic factor for OS, and often also incorporate opioid analgesic use in multivariate analysis. Prospective studies are needed to better understand how opioid utilization and pain may affect cancer progression and survival in diverse malignancies.

Phase II study of computed tomography-guided (125)I-seed implantation plus chemotherapy for locally recurrent rectal cancer

BACKGROUND AND PURPOSE

This trial evaluated the efficacy and safety of CT guided (125)I-seed implantation (CTII) plus chemotherapy with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment for locally recurrent rectal cancer (LRRC).

MATERIAL AND METHODS

Patients with LRRC who received one prior chemotherapy regimen were enrolled and divided randomly assigned to FOLFORI alone (Arm A) and FOLFORI plus CTII (Arm B). The primary endpoint was local control time (LCT). Overall survival (OS) and treatment related adverse events (TRAEs) were also observed.

RESULTS

Fifty-seven patients were enrolled from October 2008 and December 2014. Twenty-seven were assigned into Arm A and 30 into Arm B. The overall response rate of locally recurrent tumor was improved to 100% in Arm B versus 29.6% in Arm A (P<0.001). A significant longer LCT was observed in Arm A (P<0.001); median LCT was 12 months in Arm B versus 4 months in Arm A. A borderline significant improvement in OS was also observed in Arm B (P=0.0464); median OS was 25 months in Arm B versus 19 months in Arm A. For patients without distant metastases, median OS was 37 months in Arm B versus 21 months in Arm A (P=0.0101). For patients with (neo)adjuvant radiotherapy (ART), a longer LCT and OS were also found in Arm B (P<0.001 and P=0.0217, respectively). TRAEs were not serious generally. There was no statistically significant difference in treatment related toxicity between Arm A and B both for all patients and patients receiving ART.

CONCLUSIONS

CTII plus FOLFIRI improves the LCT with tolerable toxicities as a second-line treatment in patients with local recurrent rectal cancer, and is helpful to prolong the OS, particularly in patients without distant metastases or with a history of radiotherapy.

MRI of Rectal Cancer: An Overview and Update on Recent Advances

OBJECTIVE

MRI is the modality of choice for rectal cancer staging. The high soft-tissue contrast of MRI accurately assesses the extramural tumor spread and relation to mesorectal fascia and the sphincter complex. This article reviews the role of MRI in the staging and treatment of rectal cancer. The relevant anatomy, MRI techniques, preoperative staging, post-chemoradiation therapy (CRT) imaging, and tumor recurrence are discussed with special attention to recent advances in knowledge.

CONCLUSION

MRI is the modality of choice for staging rectal cancer to assist surgeons in obtaining negative surgical margins. MRI facilitates the accurate assessment of mesorectal fascia and the sphincter complex for surgical planning. Multiparametric MRI may also help in the prediction and estimation of response to treatment and in the detection of recurrent disease.

The Importance of a Minimal Tumor-Free Resection Margin in Locally Recurrent Rectal Cancer

BACKGROUND

The importance of the circumferential resection margin has been demonstrated in primary rectal cancer, but the role of the minimal tumor-free resection margin in locally recurrent rectal cancer is unknown.

OBJECTIVE

The purpose of this work was to evaluate the prognostic importance of a minimal tumor-free resection margin in locally recurrent rectal cancer.

DESIGN

This was a single-institution, retrospective study.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

Based on the final pathology report, surgically treated patients with locally recurrent rectal cancer between 1990 and 2013 were divided into 4 groups: 1) tumor-free margins of >2 mm, 2) tumor-free margins of >0 to 2 mm, 3) microscopically involved margins, and 4) macroscopically involved margins.

MAIN OUTCOME MEASURES

Local control and overall survival were the main outcome measures.

RESULTS

A total of 174 patients with a median follow-up of 27 months (range, 0-144 months) were eligible for analysis. There was a significant difference in 5-year local re-recurrence-free survival in favor of 41 patients with tumor-free margins of >2 mm compared with 34 patients with tumor-free margins of >0 to 2 mm (80% vs 62%; p = 0.03) and a significant difference in 5-year overall survival (60% vs 37%; p = 0.01). The 5-year local re-recurrence-free and overall survival rates for 55 patients with microscopically involved margins were 28% and 16%, and for 20 patients with macroscopically involved margins the rates were 0% and 5%. On multivariable analysis, tumor-free margins of >0 to 2 mm were independently associated with higher re-recurrence rates (HR, 2.76 (95% CI, 1.06-7.16)) and poorer overall survival (HR, 2.57 (95% CI, 1.27-5.21)) compared with tumor-free margins of >2 mm.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

Resection margin status is an independent prognostic factor for re-recurrence rate and overall survival in surgically treated, locally recurrent rectal cancer. In complete resections, patients with tumor-free resection margins of >0 to 2 mm have a higher re-recurrence rate and a poorer overall survival than patients with tumor-free resection margins of >2 mm.

Inferior mesenteric artery chemoembolization and chemotherapy for advanced rectal cancer: report of a clinical case

Patients with advanced and incurable colorectal cancer have a very poor prognosis. Curative-intent resection was performed in 70%-90% of cases in reported series of colorectal cancer, sometimes after neoadjuvant chemotherapy and radiotherapy. The remaining 10%-30% of patients are treated with palliative intent, where treatment is aimed at relieving disease-related symptoms and improving quality of life. The provision of palliative care for these patients is complicated and outcomes are often disappointing. Although there are many available options including a variety of surgical and nonsurgical interventions, the best management remains controversial. Transarterial chemoembolization with irinotecan-loaded drug-eluting beads (DEBIRI) is an effective, minimally invasive procedure performed by interventional radiologists that allows intra-arterial drug delivery to stop vascular feeding and exert local cytotoxic effects. We here report on a patient treated with DEBIRI followed by systemic chemotherapy with the FOLFOX regimen for locally advanced, inoperable colorectal cancer.

Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into "regular life." This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of patients achieves optimal outcomes.

Stereotactic body radiotherapy (SBRT) reirradiation for pelvic recurrence from colorectal cancer

BACKGROUND AND OBJECTIVES

When surgery is not adequate or feasible, stereotactic body radiotherapy (SBRT) reirradiation has been used for recurrent cancers. We report the outcomes of a series of patients with pelvic recurrences from colorectal cancer reirradiated with SBRT.

METHODS

The Cyberknife(TM) Robotic Stereotactic Radiosurgery system with fiducial based real time tracking was used. Patients were followed with imaging of the pelvis.

RESULTS

Four women and 14 men with 22 lesions were included. The mean dose was 25 Gy in median of five fractions. The mean prescription isodose was 77%, with a median maximum dose of 32.87 Gy. There were two local failures, with a crude local control rate of 89%. The median overall survival was 43 months. One patient had small bowel perforation and required surgery (Grade IV), two patients had symptomatic neuropathy (1 Grade III) and one patient developed hydronephrosis from ureteric fibrosis requiring a stent (Grade III).

CONCLUSIONS

Local recurrence in the pelvis after modern combined modality treatment for colorectal cancer is rare. However it presents a therapeutic dilemma when it occurs; often symptomatic and eventually life threatening. SBRT can be a useful non-surgical modality to control pelvic recurrences after prior radiation for colorectal cancer.

Aggressive surgical treatment with bony pelvic resection for locally recurrent rectal cancer

BACKGROUND

In the current era of total mesorectal excision, local relapse remains a main cause of recurrence. Although standard treatment for locally recurrent rectal cancer (LRRC) has not been established, R0 resection represents the only potentially curative treatment. However, extended surgery accompanying bony pelvic resection is technically demanding and is still challenging.

METHODS

Studied were 35 patients with LRRC who underwent combined resection of bony pelvis between August 2006 and October 2013. Safety and prognostic factors for survival were analyzed. Median follow-up was 33 months.

RESULTS

Sacrectomy was performed in 32 patients and 3 patients underwent combined resection of the pubis and ischium. The dominant operative procedure was total pelvic exenteration in 30 (86%) patients. R0 resection was achieved in 27 (77%) patients. No patients died. Pelvic sepsis was the most frequent complication (40%). Recurrence developed in 20 (57%), with the lung the most frequent site (10 patients). Three-year local relapse-free survival (LRFS) and disease-free survival (DFS) were 72.1% and 32.7%, respectively. On multivariate analysis, R1 resection was the only independent risk factor for local recurrence (p = 0.010), and concomitant liver metastasis and initial non sphincter-preserving surgery were independent predictors of worse DFS (p = 0.008 and p = 0.042, respectively).

CONCLUSIONS

Aggressive surgical treatment combined with bony resection for carefully selected patients with LRRC was safe with a high rate of R0 resection and favorable LRFS. However, DFS was not satisfactory even after R0 resection and the main cause was lung metastasis. Preventing distant recurrence might be a key to improve survival.

Outcome and prognostic factors of local recurrent rectal cancer: a pooled analysis of 150 patients

BACKGROUND

Surgery is the only curative treatment in patients with locally recurrent rectal cancer (LRRC). The aim of this study was to evaluate the outcome and the prognostic factors of tumour-free resection margin (R0) and overall survival (OS) in LRRC.

METHODS

Consecutive LRRC patients observed between 1987 and 2005 in three Italian university hospitals were evaluated. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. In order to identify factors associated with both R0 resection and OS, a logistic regression analysis was performed in patients who underwent surgery with curative intent.

RESULTS

Out of 150 patients with LRRC, 107 underwent surgery, but since 7 were found to have unresectable disease only 100 underwent surgical resection. Of them, 51 underwent radical and 49 extended resection. Sixty of the 107 patients underwent multimodality treatment. In 61 patients, R0 resection was achieved. Median OS after surgery was 43.4 months. In patients, who had surgery with curative intent, independent variables associated with R0 resection were: surgery for the primary tumour performed in other hospitals (p = 0.042) extended resection (p = 0.025) and use of positron emission tomography (PET) as a staging modality (p = 0.03). Independent variables associated with OS were: post-operative radiotherapy (p = 0.004), stage of the primary tumour (p = 0.004), R0 resection (p = 0.00001), and use of PET (0.02).

CONCLUSIONS

Resection for LRRC results in improved survival. Other than the well-known prognostic factors R0 resection and OS, PET scan has an independent impact both on OS and R0 resection. It should therefore be included in routine clinical practice when staging LRRC.

A rare presentation of locally re-recurrent colon cancer involving the iliac bone and a review of the literature

Colorectal cancer is a leading cause of cancer death in the USA. While locally advanced rectal cancer involving bone has been described extensively, colon cancer locally involving bone has only been described, to our knowledge, in a single case report. In this case report, we describe the presentation and treatment of locally advanced re-recurrent colon cancer involving the iliac bone. We also discuss the available literature on treatment for recurrent and re-recurrent colorectal cancer.

Multidisciplinary therapy for patients with locally oligo-recurrent pelvic malignancies

PURPOSE

To analyze prognostic factors and long-term outcomes in patients with locally recurrent pelvic cancer (LRPC) treated with a multidisciplinary approach.

METHODS AND MATERIALS

From January 1995 to December 2011, 81 patients [rectal (47 %); gynecologic (39 %); retroperitoneal sarcoma (14 %)] underwent extended surgery [multiorgan (58 %), bone (35 %), vascular (9 %), soft tissue (63 %)] and intraoperative electron beam radiation therapy (IOERT) to treat recurrent tumors in the pelvic region. Thirty-five patients (43 %) received external beam radiotherapy (EBRT). Survival was estimated using the Kaplan-Meier method, and risk factors were identified using univariate and multivariate analysis.

RESULTS

Median follow-up was 39 months (6-189 months); the 1- 3- and 5-year rates of locoregional control (LRC) were 83, 53, and 41 %, respectively. Univariate Cox proportional hazard analysis revealed worse LRC in patients who did not receive integrated EBRT as rescue treatment of pelvic recurrence (p = 0.003) or underwent non-radical resection (p = 0.01). In the multivariate analysis EBRT, non-radical resection, and tumor fragmentation retained significance (p = 0.002, p = 0.004, and p = 0.05, respectively).

CONCLUSIONS

Radical resection, absence of tumor fragmentation and addition of EBRT for rescue are associated with improved LRC in patients with LRPC. Our results suggest that this group can benefit from EBRT combined with extended surgical resection and IOERT.

Extended sacropelvic resection for locally recurrent rectal cancer: can it be done safely and with good oncologic outcomes?

BACKGROUND

A multimodality approach to patients with locally recurrent rectal cancer that includes surgery is associated with a significant survival advantage when tumor-free margins are achieved. Patients with advanced tumors will require extended sacropelvic resection to optimize oncologic outcomes.

OBJECTIVE

The aim of this study was to assess the safety, feasibility, and oncologic outcomes of extended sacropelvic resection for locally recurrent rectal cancer at our institution.

DESIGN

A retrospective review identified 406 patients who had surgery for locally recurrent rectal cancer between 1997 and 2007. From this group, all patients who underwent a curative-intent sacropelvic resection were analyzed.

SETTINGS

This investigation was conducted at an academic tertiary referral center.

PATIENTS

Thirty patients (24 male) were identified. Median age was 59 years (range, 25-84). Operations were performed for a first local recurrence (n = 24), a second recurrence (n = 5) and for a third recurrence (n = 1).

INTERVENTIONS

Twenty-six patients underwent neoadjuvant radiation, and 20 received intraoperative radiation therapy. All patients underwent extended sacropelvic resection.

MAIN OUTCOME MEASURES

The primary outcomes measured were early (<30 days) and late (>30 days) surgical complications. Overall and disease-free survivals were estimated by using the Kaplan-Meier technique.

RESULTS

Margin-negative resection was achieved in 93%. The most proximal level of spinal transection was the fourth lumbar space, and 4 patients underwent lower extremity amputation. There was no mortality, and early morbidity was seen in 76%. Median follow-up was 2.7 years (range, 2 months to 10.8 years). Overall survival at 2 and 5 years was 86% and 46%. Disease-free survival at 2 and 5 years was 79% and 43%.

LIMITATIONS

This study was limited by its retrospective nature and the limited number of patients.

CONCLUSIONS

We found extended sacropelvic resection for locally recurrent rectal cancer to be feasible and safe with overall and disease-free survival rates in comparison with survival rates seen in patients undergoing nonsacropelvic resections for locally recurrent rectal cancer.

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.

Prognostic impact of external beam radiation therapy in patients treated with and without extended surgery and intraoperative electrons for locally recurrent rectal cancer: 16-year experience in a single institution

PURPOSE

To analyze prognostic factors associated with survival in patients after intraoperative electrons containing resective surgical rescue of locally recurrent rectal cancer (LRRC).

METHODS AND MATERIALS

From January 1995 to December 2011, 60 patients with LRRC underwent extended surgery (n=38: multiorgan [43%], bone [28%], soft tissue [38%]) or nonextended (n=22) surgical resection, including a component of intraoperative electron-beam radiation therapy (IOERT) to the pelvic recurrence tumor bed. Twenty-eight (47%) of these patients also received external beam radiation therapy (EBRT) (range, 30.6-50.4 Gy). Survival outcomes were estimated by the Kaplan-Meier method, and risk factors were identified by univariate and multivariate analyses.

RESULTS

The median follow-up time was 36 months (range, 2-189 months), and the 1-year, 3-year, and 5-year rates for locoregional control (LRC) and overall survival (OS) were 86%, 52%, and 44%; and 78%, 53%, 43%, respectively. On multivariate analysis, R1 resection, EBRT at the time of pelvic rerecurrence, no tumor fragmentation, and non-lymph node metastasis retained significance with regard to LRR. R1 resection and no tumor fragmentation showed a significant association with OS after adjustment for other covariates.

CONCLUSIONS

EBRT treatment integrated for rescue, resection radicality, and not involved fragmented resection specimens are associated with improved LRC in patients with locally recurrent rectal cancer. Additionally, tumor fragmentation could be compensated by EBRT. Present results suggest that a significant group of patients with LRRC may benefit from EBRT treatment integrated with extended surgery and IOERT.

Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

BACKGROUND

The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.

METHODS

Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus.

RESULTS

The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management.

CONCLUSION

The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Clinical, MRI, and PET-CT criteria used by surgeons to determine suitability for pelvic exenteration surgery for recurrent rectal cancers: a Delphi study

BACKGROUND

Surgical resection with clear margins is the major predictor of long-term survival in recurrent rectal cancer. The extent of pelvic exenteration surgery depends on many factors including clinical and radiological criteria.

OBJECTIVE

The aim of this study was to establish which clinical, MRI, and PET criteria were considered important by surgeons who perform pelvic exenteration surgery, when assessing a patient with recurrent rectal cancer for pelvic exenteration surgery.

DESIGN

A 2-stage Delphi study was conducted among an international panel of 36 colorectal surgeons recruited via a snowball-sampling method. Surgeons rated the importance of 99 clinical and radiological criteria by using a 9-point scale.

MAIN OUTCOME MEASURES

Consensus was attained when at least 85% of the panel rated criteria within 3 points.

RESULTS

Clinical factors suggestive of systemic disease, symptoms of advanced local recurrence such as pain, surgical fitness, and cognitive impairment were considered important by the panel when considering suitability for surgery. Agreement regarding the indication for surgery was reached for 20 radiological factors. Strong agreement was achieved for factors associated with tumor involvement in the axial and anterior compartments. For only 16 of these 20 radiological factors was there an agreement that a clear resection margin was likely to be achieved.

LIMITATIONS

Further rounds of Delphi may have yielded greater consensus.

CONCLUSION

This study has identified a set of criteria considered by experts to be important in evaluating patients' suitability for pelvic exenteration surgery. Evaluation of these criteria is required to determine their clinical utility in predicting a negative resection margin at pelvic exenteration surgery.

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 resection of recurrent colonic cancer

Background

Locoregional recurrence of colonic cancer includes anastomotic recurrence, associated nodal masses, masses that involve the abdominal wall and pelvic masses. The aim of this study was to report the outcome of resection of such recurrences and to provide guidance on the management of this disease.

Methods

Patients were identified from a prospectively maintained database. Data were obtained on demographics, surgical procedure, morbidity, histopathology and outcome. Univariable and multivariable analyses of factors influencing survival were performed using stepwise Cox logistic regression.

Results

Forty-two patients (21 men; median age 61 (range 41–82) years) underwent resection of recurrent colonic cancer between 2003 and 2011. The median interval between resection of the primary and recurrent colonic tumour was 37·5 (interquartile range 7–91) months. The recurrences developed at the previous anastomosis (9 patients), elsewhere within the abdominal cavity or wall (8) and as discrete masses within the pelvic cavity (25). Eighteen of 42 patients underwent resection of hepatic or pulmonary metastases at some stage after resection of the primary tumour. Median survival was 29 months after R0 resection and 26 months after R1 resection of the recurrent tumour (P = 0·226). The survival benefit depended on the location of the recurrence (median survival after resection of recurrent disease: anastomotic 33 months, pelvic 26 months, abdominal 19 months; P = 0·010).

Conclusion

This study described a classification system, management algorithm and prognostic factors for recurrent colonic cancer. The distribution of disease influenced survival. Long-term survival was achieved, including a subset of patients with drop metastases and/or previous metastasectomy.

Comparison of long-term survival outcome of operative vs nonoperative management of recurrent rectal cancer

AIM

Complete surgical resection is considered the best treatment for recurrent rectal cancer (RRC). The aim of the study was to compare survival outcomes from operative and nonoperative patients presenting with RRC.

METHOD

Patients with RRC whose management was discussed by a tertiary referral specialist multidisciplinary team between January 2007 and August 2011 were identified from a prospectively maintained database. The primary end-point was 3-year overall survival.

RESULTS

Of 127 patients with RRC, it was isolated to the pelvis in 105 and associated with distant disease at presentation in 22. From the time of primary surgery to first recurrence, 1-, 3-, 5- and 10-year local recurrence rates were 22%, 72%, 85% and 96%, respectively. The number of operated patients available at 1, 2 and 3 years' follow-up was 53, 34 and 23, respectively. Of 70 patients who underwent pelvic resection for recurrence, 64% received R0, 20% received R1 and 16% received R2 resections. Corresponding 3-year overall survival rates were 69%, 56% and 20% (P=0.011). There was no significant difference in survival between R2 resection and those managed nonoperatively (hazard ratio=1.258; P=0.579). Those undergoing surgery for pelvic recurrence affecting one or more compartments had a worse prognosis than those with single-compartment involvement (hazard ratio=2.640; P=0.027). Three-year local recurrence-free survival was 80% with R0 resection vs 60% with R1 resection.

CONCLUSION

Most recurrences occur within 5 years of primary surgery, although some occur up to 10 years later. R0 resection is the treatment of choice. There was no survival benefit of R2 resection over nonresected recurrences.

Is curative resection and long-term survival possible for locally re-recurrent colorectal cancer in the pelvis?

BACKGROUND

A multimodality approach for locally recurrent colorectal cancer in the pelvis provides a significant survival advantage when negative margins are achieved. However, outcomes of surgical resection in patients who have locally re-recurrent disease in the pelvis are not well studied. Our aim was to assess the safety, feasibility of a negative margin resection, and survival outcomes in patients with pelvic locally re-recurrent colorectal cancer.

DESIGN

A retrospective review identified 406 patients who underwent surgery for locally recurrent colorectal cancer between 1997 and 2007. Patients who had locally re-recurrent disease in the pelvis who underwent curative-intent resection were identified.

RESULTS

Forty-seven patients (31 male) were identified. Median age was 57 years (range, 30-84 years). Median time to re-recurrence was 2.4 years (range, 0.5-5.6 years). Margin status following re-resection was R0 60%, R1 32%, and R2 8%. Nonbowel organs were resected en bloc in 81%, including 7 sacral resections. Intraoperative radiation was given to 77%. Morbidity occurred in 42%, with 6% requiring reoperation for complications. Thirty-day mortality was nil. Overall survival at 2 and 5 years was 83% and 33%. Disease-free survival at 2 and 5 years was 55% and 27%. Five-year survival for patients who had R0 and R1 resections was 37% and 42%, whereas no patients having an R2 resection survived beyond 2 years (p = 0.002).

CONCLUSIONS

In highly selected patients with re-recurrent colorectal cancer in the pelvis, we found that surgery could be performed safely and that a curative (R0) resection was possible in more than 50%. Two- and 5-year survival rates are comparable to results seen when surgery is done for first-time recurrences.

Intraoperative Electron Radiation Therapy (IOERT) in the management of locally recurrent rectal cancer

BACKGROUND

To evaluate disease control, overall survival and prognostic factors in patients with locally recurrent rectal cancer after IOERT-containing multimodal therapy.

METHODS

Between 1991 and 2006, 97 patients with locally recurrent rectal cancer have been treated with surgery and IOERT. IOERT was preceded or followed by external beam radiation therapy (EBRT) in 54 previously untreated patients (median dose 41.4 Gy) usually combined with 5-Fluouracil-based chemotherapy (89%). IOERT was delivered via cylindric cones with doses of 10-20 Gy. Adjuvant CHT was given only in a minority of patients (34%). Median follow-up was 51 months.

RESULTS

Margin status was R0 in 37%, R1 in 33% and R2 in 30% of the patients. Neoadjuvant EBRT resulted in significantly increased rates of free margins (52% vs. 24%). Median overall survival was 39 months. Estimated 5-year rates for central control (inside the IOERT area), local control (inside the pelvis), distant control and overall survival were 54%, 41%, 40% and 30%. Resection margin was the strongest prognostic factor for overall survival (3-year OS of 80% (R0), 37% (R1), 35% (R2)) and LC (3-year LC 82% (R0), 41% (R1), 18% (R2)) in the multivariate model. OS was further significantly affected by clinical stage at first diagnosis and achievement of local control after treatment in the univariate model. Distant failures were found in 46 patients, predominantly in the lung. 90-day postoperative mortality was 3.1%.

CONCLUSION

Long term OS and LC can be achieved in a substantial proportion of patients with recurrent rectal cancer using a multimodality IOERT-containing approach, especially in case of clear margins. LC and OS remain limited in patients with incomplete resection. Preoperative re-irradiation and adjuvant chemotherapy may be considered to improve outcome.

Outcome of surgical resection of second-time locally recurrent rectal cancer

BACKGROUND

Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer.

METHODS

Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences.

RESULTS

Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection).

CONCLUSION

Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.

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.

Locally recurrent colorectal cancer: results of surgical therapy

PURPOSE

Up to 20 % of colorectal cancer patients develop recurrent disease despite standardized surgical techniques and multimodal treatment strategies. Radical resection is the central component of curative therapy in these cases. The aim of this study was to evaluate treatment results in patients with locoregionally recurrent colorectal cancer.

METHODS

From January 1995 to December 2007, surgery was performed for recurrent colorectal cancer in 82 patients who had undergone curative (R0) resection of their primary tumor. Assessment included patient, tumor and treatment characteristics, postoperative complications, and time without re-recurrence; recurrence-free and overall survival rates were calculated according to the Kaplan-Meier method.

RESULTS

Resection was performed in 60 of the 82 patients (73 %), repeat R0 resection in 52 % (31/60). Patients had a postoperative morbidity of 39 % (31/82), a relaparotomy rate of 13 % (11/82), and a lethality of 7 % (6/82). Forty-eight percent of all surgically-treated patients received a permanent stoma. Re-recurrence was seen in 52 % (16/31). R0 resection was associated with a 5-year survival rate of 35 % (11/31).

CONCLUSIONS

Extensive reinterventions often enable repeat R0 resection. Despite relevant morbidity, the lethality appears to be acceptable. Decisive for the prognosis is re-recurrence.

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.

Local recurrence of rectal cancer: a population-based cohort study of diagnosis, treatment and outcome

AIM

Local recurrence is an important endpoint of rectal cancer treatment, but details of this form of treatment failure are less well described. The aim of this study was to acquire deeper knowledge of local recurrence regarding symptoms, diagnostic work-up, clinical management, health-care utilization and outcome.

METHOD

Of 671 patients with rectal cancer, 57 were diagnosed with local recurrence within 5 years after surgery. Their records were analysed.

RESULTS

At diagnosis of local recurrence 49 (86%) of 57 patients were symptomatic and 40 (70%) were diagnosed between scheduled follow-up visits. The predominant symptom was pain. Forty-five of the 57 (79%) had a palpable tumour. Most were deemed incurable at presentation and 10 (18%) were operated on with curative intent. Five years after the initial rectal cancer surgery, two patients were alive, with one free of disease. Despite the need for multiple interventions, including surgery, only four out of 40 patients were classified as being well-palliated in the terminal stage.

CONCLUSION

Follow-up after rectal cancer surgery by annual clinical examination is not sufficient to detect local recurrence when it is asymptomatic. Local recurrence of rectal cancer is often associated with intractable symptoms. These patients require frequent interventions and can rarely be cured if diagnosed at an advanced stage. Strategies for early detection of local recurrence and the management thereof require improvement.

Sphincter-preserving surgery after preoperative radiochemotherapy for T3 low rectal cancers

The aim of this study was to evaluate the feasibility and the effectiveness of preoperative radiochemotherapy followed by total mesorectal excision (TME) and sphincter-preserving procedures for T3 low rectal cancer. Patients with rectal cancer and T3 tumors located within 1-6 cm of the dentate line received preoperative radiochemotherapy. Concurrent 5-fluorouracil-based radiochemotherapy was used. Radical resection with TME and sphincter-preserving procedures were performed during the six to eight weeks following radiotherapy. Survival was analyzed using the Kaplan-Meier method. The anal function was evaluated using the Wexner score. The clinical response rate was 83.5%, overall downstaging of T classification was 75.3% and pathological complete response was 15.3%. The anastomotic fistula rate was 4.7%. A median follow-up of 30 months showed the local recurrence rate to be 4.7% and the distant metastasis rate to be 5.9%. The three-year overall survival rate was 87%. The degree of anal incontinence as measured using the Wexner score decreased over time, and the anal sphincter function in the majority of patients gradually improved. Preoperative radiochemotherapy was found to improve tumor downstaging, reduces local recurrence, increase the sphincter preservation rate, and is therefore of benefit to patients with T3 low rectal cancer.

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.

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.

Clinical outcomes of chemoradiotherapy for locally recurrent rectal cancer

Background

To assess the clinical outcome of chemoradiotherapy with or without surgery for locally recurrent rectal cancer (LRRC) and to find useful and significant prognostic factors for a clinical situation.

Methods

Between January 2001 and February 2009, 67 LRRC patients, who entered into concurrent chemoradiotherapy with or without surgery, were reviewed retrospectively. Of the 67 patients, 45 were treated with chemoradiotherapy plus surgery, and the remaining 22 were treated with chemoradiotherapy alone. The mean radiation doses (biologically equivalent dose in 2-Gy fractions) were 54.6 Gy and 66.5 Gy for the chemoradiotherapy with and without surgery groups, respectively.

Results

The median survival duration of all patients was 59 months. Five-year overall (OS), relapse-free (RFS), locoregional relapse-free (LRFS), and distant metastasis-free survival (DMFS) were 48.9%, 31.6%, 66.4%, and 40.6%, respectively. A multivariate analysis demonstrated that the presence of symptoms was an independent prognostic factor influencing OS, RFS, LRFS, and DMFS. No statistically significant difference was found in OS (p = 0.181), RFS (p = 0.113), LRFS (p = 0.379), or DMFS (p = 0.335) when comparing clinical outcomes between the chemoradiotherapy with and without surgery groups.

Conclusions

Chemoradiotherapy with or without surgery could be a potential option for an LRRC cure, and the symptoms related to LRRC were a significant prognostic factor predicting poor clinical outcome. The chemoradiotherapy scheme for LRRC patients should be adjusted to the possibility of resectability and risk of local failure to focus on local control.

Can radiotherapy alone be effective for treating anastomotic recurrence of rectal cancer? When the patient decides?

Among pelvic recurrences of rectal cancer following surgical resection, anastomotic recurrences are relatively rare; the literature reports an incidence between 2.4% and 12% of all patients who underwent colorectal anastomosis. The authors report the case of a patient already treated for an early rectal cancer who 1 year after surgery developed a 2 cm recurrence at the colorectal anastomosis. As he refused reoperation, he underwent radiation therapy only (54 Gy) with complete remission. After 8 years of follow-up, the patient is free of any further distant or local recurrence. The authors did not find, to the best of their knowledge, in the literature any similar case of a patient with anastomotic rectal recurrence who has been positively treated by radiotherapy only. The authors focus on its diagnostic and therapeutic problems: although surgical reresection is undoubtedly the best therapeutic option, in the case reported here, radiotherapy alone proved effective.

Surgery for locally recurrent rectal cancer in the era of total mesorectal excision: is there still a chance for cure?

OBJECTIVE

To evaluate the perioperative outcome and long-term survival of patients who underwent surgical resection for recurrent rectal cancer within a multimodal approach in the era of total mesorectal excision (TME).

BACKGROUND

Introduction of TME has reduced local recurrence and improved oncological outcome of patients with rectal cancer. Local recurrence after TME still occurs in 2% to 8% of patients and presents a challenge to surgical and medical oncologists. However, there has been very limited data on the perioperative and long-term outcome of patients who are operated for local recurrence in the era of TME.

METHODS

A total of 107 patients who were identified from a prospective rectal cancer database underwent surgical exploration for recurrent rectal cancer after previous TME between October 2001 and April 2009. Risk factors of perioperative morbidity were analyzed using a multivariate logistic regression model. Independent predictors of disease-specific survival were identified by a Cox proportional hazards regression model, as were those of local recurrence and disease recurrence at any site.

RESULTS

Surgical resection was performed in 92 patients and negative resection margins were achieved in 54 (58.7%) of these. Recurrent disease was located intraluminally and extraluminally in 35 (38.0%) patients and 57 (62.0%) patients, respectively. A total of 19 (20.6%) patients had metastatic extrapelvic disease at the time of surgery. Perioperative surgical morbidity and in-hospital mortality accounted for 42.4% and 3.3%, respectively. On multivariate analysis, partial sacrectomy was associated with surgical morbidity (P = 0.004). Three- and 5-year disease-specific survival rates were 61% and 47%. Three-year survival rate of patients with extrapelvic disease who underwent R0 resection was 42%. On multivariate analysis, surgical morbidity (P = 0.001), presence of extrapelvic disease (P = 0.006), and noncurative (R1; R2) resection (P < 0.0001) were identified as independent adverse predictors of disease-specific survival, whereas a transabdominal resection (as opposed to an abdominoperineal resection/pelvic exenteration) was associated with a more favorable prognosis (P = 0.04).

CONCLUSIONS

Surgical resection of local recurrence from rectal cancer in the era TME can be carried out with acceptable morbidity and curative resection rates. Curative resection remains the major prognostic factor and may enable long-term survival even in patients with extrapelvic disease.

Multidisciplinary approach to recurrent/unresectable rectal cancer: how to prepare for the extent of resection

Local recurrence from rectal cancer is a complex problem that should be managed by a multidisciplinary team. Pelvic re-irradiation and intraoperative radiation should be considered in the management of these patients. Long-term survival can be achieved in patients who undergo radical surgery with negative margins of resections. The morbidity of these procedures is high and at times may compromise quality of life. Palliative surgical procedures can be considered; however, in some cases, palliative resections may not be better than nonsurgical palliation.

Pathologic complete response after neoadjuvant treatment for rectal cancer decreases distant recurrence and could eradicate local recurrence

BACKGROUND

The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer.

MATERIALS AND METHODS

A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence.

RESULTS

The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR.

CONCLUSIONS

Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.