Local recurrences of rectal cancer

Data from cancer registries show that incidence of rectal cancer is still high in Italy, while mortality rates are slightly decreasing in most recent years. Surgery is the treatment of choice and in most cases with curative intent. The rectum may be defined as the tract of the large bowel distal to 12 cm from the anal verge. Tumors located in that segment show local recurrence rates higher than those for tumors located proximally. Pelvic recurrence is evident as a regrowth of cancer in and around the tumor bed. Powerful imaging techniques have been developed for the early and appropriate evaluation of pelvic recurrences. A wide range of recurrence rates after operation for rectal cancer are reported, spanning from 3% to over 30%. The main determinants of local recurrence are related to the tumor and to the treatment. Among the former, stage at diagnosis and number of lymph nodes involved are the most important, along with inadvertent perforation of the intestine and location of tumor in the rectum. Among treatment factors, type of operation and experience of the operator should be mentioned. A major advancement in rectal surgery has been the implementation of total excision of the mesorectum. This technique has decreased dramatically recurrence rates of rectal cancer, though increasing the risk of local complications. Preoperative radiotherapy seems to confer a slight further advantage in selected cases. Management of locally recurrent tumors is still unsatisfactory and surgery is feasible only in less than 10% of cases.     

Local excision of stratified T1 rectal cancer

BACKGROUND: Local excision has been accepted therapy for T1 rectal cancers. A recent study demonstrated that primary tumors with deeper submucosal invasion were associated with a higher rate of lymph node metastases than those with shallow invasion. Our aim was to determine the effect of the depth of submucosal penetration on recurrence and mortality rates following transrectal excision of T1 tumors. METHODS: This was a 34-year retrospective review of patients who had transrectal excision with clear margins for T1 rectal cancer. Tumors were stratified into submucosal (SM) levels, and recurrence and mortality rates were determined. RESULTS: Of 101 patients with T1 rectal cancer undergoing local excision, 31 had a full-thickness transrectal excision. Eight (26%) of the 31 patients developed a local recurrence, 2 of whom had both a local and distant recurrence. Four patients (13%) died from metastatic rectal cancer. CONCLUSIONS: The recurrence rate for transrectal excision of T1 rectal cancer is high. It may be beneficial for patients with early rectal cancer to have postoperative chemoradiation therapy or a more radical surgical procedure.     

Locally recurrent rectal cancer.

Local recurrence (LR) varies from less than 4% to greater than 50%; several tumor factors and operative techniques may influence rate of LR. Of greatest interest has been the considerable inter-surgeon variation, even within the same institution. An LR rate of less than 10% has been consistently reported by those who use total mesorectal excision even without any form of adjuvant therapy, either preoperatively or postoperatively. These findings raise important questions about surgical technique, subspecialty teaching, place of adjuvant therapy and quality assurance. The management of LR by a multispecialty team and multimodality treatment including preoperative chemoradiation, surgical resection and intraoperative radiotherapy provides encouraging results in terms of better local control and prolonged survivorship in carefully selected patients. These uncontrolled results justify further evaluation of these salvage operations in a more controlled manner that should include repercussions on the quality of life of the patients.     

Oncological outcome of T1 rectal cancer undergoing standard resection and local excision

Aim We studied the outcome and prognostic factors for T1 rectal cancer patients undergoing standard resection or transanal excision. Method One hundred and twenty‐four patients with T1 rectal cancer were included in the study, of whom 66 (53.2%) underwent standard resection and 58 (46.8%) underwent transanal excision. Survival analysis was performed to compare the outcome. Results The 5‐year local recurrence rate was 11.0% in the transanal excision group versus 1.6% in the standard resection group (P = 0.031) but the 5‐year disease‐free survival and overall survival rates were not significantly different between the two groups. Multivariate analysis suggested that a high tumour grade and perineural or lymphovascular invasion were independent risk factors for local recurrence and recurrence‐free survival. For high‐risk patients (with at least one of the above risk factors), the 5‐year local recurrence and 10‐year recurrence‐free survival rates were 21.2% and 74.5%, versus 1.2% and 92.0% in low‐risk patients (P = 0.00003 and P = 0.003). In patients undergoing transanal excision, none in the low‐risk group had local recurrence during follow up, while 40% (6 of 15) of patients in the high‐risk group developed local recurrence within 5 years after surgery. The 5‐year local recurrence rate was 45.0%. Conclusion Transanal excision in T1 rectal cancer may result in a high rate of local failure for patients with a high‐grade tumour, or perineural or lymphovascular invasion. Local excision should be avoided as a curative treatment in high‐risk patients.     

Preoperative endorectal brachytherapy in the treatment of locally advanced rectal cancer: Rethinking neoadjuvant treatment

Prior to the introduction of preoperative treatment and modern surgical technique, recurrence rates for locally advanced rectal cancer ranged from 30% to 50%. Since the widespread adoption of total mesorectal excision and preoperative chemoradiation therapy (CRT), local recurrence rates have reduced considerably to only 5–10%. However, preoperative treatment comes at a cost with significant acute and late toxicity. Additionally, 2 standards of care have emerged—1 week of radiation alone vs 5 weeks of concurrent chemoradiation. In this review, we evaluate toxicity associated with preoperative treatment as well as the key pathological factors that influence outcome in patients with locally advanced rectal cancer. Additionally, we discuss endorectal brachytherapy, an alternative preoperative treatment that may result in equivalent or improved response rates with less toxicity when compared to conventional CRT.     

Surgery for local recurrence of rectal cancer

OBJECTIVE: Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes. METHOD: A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated. RESULTS: Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential.     

Current evidence does not support routine adjuvant radiotherapy for rectal cancer

Background: There is widespread support in the published literature for routine adjuvant radiotherapy for rectal cancer. Methods: In the present paper, the current evidence regarding adjuvant radiotherapy is reviewed, particularly the most recent studies of preoperative radiotherapy (usually including patients with Stage I, II and III disease) and postoperative radiotherapy (usually for Stage II and III disease), and meta‐analyses. Two questions in particular are addressed: Does radiotherapy improve survival when surgeons are able to achieve low local recurrence rates with surgery alone? Does radiotherapy improve patients’ quality of life? Results: Radiotherapy has only been demonstrated to significantly improve survival in one individual study and one recent meta‐analysis. The local recurrence rates in the no‐radiotherapy arm of these studies were 27% and 21?36.5%, respectively. In more recent studies, with lower local recurrence rates reflecting modern surgical standards, no survival advantage has been found. It is currently unknown whether radiotherapy improves patients’ quality of life. Studies have demonstrated that radiotherapy has acute and long‐term detrimental effects on quality of life. While local recurrence can be very debilitating, it can also be asymptomatic, and the overall effect of the local recurrence statistics found in adjuvant therapy studies on quality of life has not been systematically investigated. The most recent studies demonstrate that 17?20 patients need to undergo adjuvant radiotherapy to prevent one local recurrence. Conclusion: Current evidence does not support the widespread advocacy for routine adjuvant radiotherapy as used in the treatment arms of recent trials.     

Surgical resection and high dose rate intraoperative radiation therapy for locally recurrent rectal cancer

For intra-pelvic recurrence of rectal cancer, surgical resection is technically difficult and must be aggressive to achieve a high rate of negative resection margins. Resection with clear margins can be curative, particularly for those patients with true anastomotic recurrence. HDR-IORT is a safe, feasible, versatile, logistically sound modality that is highly reliable in delivering radiation to at-risk surgical margins in the pelvis. Despite surgery and IORT, overall local failure rates in this population are 33 to 50 percent. The most important prognostic variable is the state of surgical resection margins. At our institution, in patients with negative and positive resection margins the 2-year actuarial local recurrence rates are 33 percent versus 73 percent and 5-year survival rates are 51 percent versus 16 percent, respectively. On subset analysis, the most favorable outcome was seen in patients with true anastomotic recurrences (78 percent 5-year survival).     

Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes

PURPOSE: Rectal cancer outcome depends on stage, technical aspects of surgical excision, and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific survival and recurrence.METHODS: We reviewed all 495 rectal cancer patients registered in British Columbia in 1996.RESULTS: There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers, P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened survival, P = 0.0007, and overall recurrence, P =0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19.CONCLUSIONS: Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome.     

Recurrence and survival after surgical management of rectal cancer.

BACKGROUND: Reported local recurrence rates for rectal cancer are significantly reduced using a combination of superior surgical technique, in the form of total mesorectal excision, and routine radiotherapy. In an attempt to determine the effectiveness of current local management strategies, a review of Vancouver Island Cancer Centre patients with rectal cancer was performed and the overall local recurrence rate was identified. METHODS: We retrospectively reviewed the charts of 272 rectal cancer patients from 1988 to 1998. Two hundred and twenty-nine patients met inclusion criteria. Analysis of patient factors included age, gender, type of surgery, and adjuvant therapy. Tumors were assessed for level, stage, and grade. Local recurrence and distant metastases were also documented. Variables influencing local recurrence in this group were identified and disease-free and actuarial survival determined. RESULTS: Of 229 patients analyzed, 12.7% (29) had local recurrences. Variables influencing local recurrence were number of positive lymph nodes, vascular invasion, and neural invasion. There was no significant difference in local recurrence between patients having anterior resection and those having abdominoperineal resection. None of the patients who received preoperative radiotherapy had a local recurrence. Actuarial disease-free survival was 87% at 5 years. CONCLUSIONS: Limiting local recurrence is one of the most important goals in the treatment of rectal cancer. It is essential to identify those patients with "high risk" tumors as identified by endorectal ultrasound or pathologic features. These patients comprise the group most likely to benefit from a routine mesorectal excision combined with adjuvant radiotherapy.     

Local excision of rectal cancer: review of literature

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision, however specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1 stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multi-centre trials comparing radical surgery with local excision, with or without adjuvant therapy.     

低位Ⅰ期直肠癌患者的外科治疗与预后分析

目的探讨低位Ⅰ期直肠癌的外科治疗效果及影响复发和预后的因素。方法回顾性分析166例低位Ⅰ期直肠癌患者的临床资料。结果本组根治性手术138例，均按直肠全系膜切除（TME）手术原则进行；其中93例行腹会阴联合根治术，45例行保肛手术；肿瘤局部切除术28例。局部复发率根治性手术者为5．1％（7／138），其中腹会阴联合根治术组为6．5％（6／93），保肛术组为2．2％（1／45）；局部切除术组为17．9％（5／28）。X^2检验显示，肿瘤分化程度（P=0．009）和手术方式（P=0．039）与局部复发相关。腹会阴联合根治术组5年生存率为90．4％，保肛术组为95．5％。局部切除术组为82．6％。单因素分析显示，肿瘤分化程度（P=0．000）和局部复发（P=0．000）与预后相关；多因素分析显示，局部复发是影响预后的主要因素（P=0．000）。结论低位Ⅰ期直肠癌根治性手术切除复发率低、预后好。局部切除术的选择应严格把握指征。     

Transanal endoscopic microsurgery: local recurrence rate following resection of rectal cancer

Objective Transanal endoscopic microsurgery (TEM) is a safe and effective treatment for the excision of benign rectal adenomas. In recent years it has been used for the excision of malignant lesions, although its use in this context remains controversial. The aim of this study was to investigate the local recurrence of rectal cancers following local excision by TEM. Method Forty‐two patients with rectal cancer were treated by TEM between 1998 and 2005. However, six patients went on to have immediate radical surgery and are excluded from the study. Of the remaining 36 the treatment intention was for cure in 16 (38.1%), compromise in 17 patients unfit for radical surgery (40.5%), and palliation in three (7.1%). Results The mean age of patients was 75 years (range 41–90). The mean lesion area was 15 cm² (range 0.8–42) and mean distance from the dentate line was 6.6 cm (range 0–11). The mean follow up was 34 months (range 4–94). During the follow‐up period there have been eight local recurrences (22%). The recurrence rates were 26% (6/23) for pT1, 22% (2/9) for pT2 and 0% (0/4) for pT3 lesions. The mean time to recurrence was 18.3 months (range 5–42). Conclusion Transanal endoscopic microsurgery is a safe procedure with obvious advantages over radical procedures. However, in this study the local recurrence rate is high. The recurrence rate may be an acceptable compromise in elderly or medically unfit patients but is hard to justify for curative intent.     

Reducing the incidence and managing the consequences of anastomotic leakage after rectal resection

Anastomotic dehiscence is a serious, life-threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as reported in the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of the anastomosis from the anal verge and the leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning by a loop stoma mitigates the consequences of leakage and probably reduces, but does not abolish, the risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre-operative chemotherapy or chemo-radiotherapy. A high index of suspicion is required in detecting the early non-specific signs of a leak and urgent surgical intervention is usually required to avert a life-threatening situation. Faecal diversion should be regarded as the optimal safety measure to reduce the consequences of leakage and to mange leakage of an unprotected anastomosis.     

Curative surgery for local pelvic recurrence of rectal cancer

BACKGROUND/AIMS: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. METHODS: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. RESULTS: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. CONCLUSIONS: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.     

低位直肠癌局部切除术后复发因素分析

目的探讨低位直肠癌局部切除术后复发的相关因素。方法回顾分析1975年4月至2005年4月间收治的97例早期低位直肠癌行局部切除治疗患者的临床资料。结果全组Tis、T1和T2期病变者分别为28例、48例和21例;有17例（17．5％）患者出现复发,其中局部复发13例．局部复发伴远处转移2例．局部复发率15．5％;Tis、T1和T2期病变者局部复发率分别为7．1％、12．5％和33．3％：另有2例远处转移。局部切除术后复发时问为4～173（中位时间27）个月。肿瘤大体类型和T分期为局部切除术后局部复发的相关因素（P〈0．05）。T2期病变者局部切除术后行和未行辅助治疗的局部复发率分别为21．4％和57．1％（P=0．127）。带蒂肿瘤、无蒂肿瘤和溃疡型肿瘤的局部复发率分别为10．5％、13．7％和3／5。15例局部复发者经治疗后的5年生存率为59．6％。结论低位直肠癌局部切除术后T分期和肿瘤的大体类型是局部复发的主要因素,T2期病变局部切除后需行辅助治疗或行根治性切除术。     

Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection

Anastomotic dehiscence is a serious, life‐threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as supported by the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of anastomoses from the anal verge and leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning mitigates the consequences of leakage but does not abolish risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre‐operative chemotherapy or chemo‐radiotherapy. A high index of suspicion is required in detecting the early nonspecific signs of a leak and urgent surgical intervention is usually required to avert a life‐threatening situation. Judicious use of faecal diversion should never be regarded as surgical timidity.     

Long-term results of local excision for rectal cancer

OBJECTIVE: To review the authors' experience with local excision of early rectal cancers to assess the effectiveness of initial treatment and of salvage surgery. SUMMARY BACKGROUND DATA: Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome. METHODS: Patients with T1 and T2 adenocarcinomas of the rectum treated by local excision as definitive surgery between 1969 to 1996 at the authors' institution were reviewed. Pathology slides were reviewed. Among 125 assessable patients, 74 were T1 and 51 were T2. Thirty-one patients (25%) were selected to receive adjuvant radiation therapy. Fifteen of these 31 patients received adjuvant radiation in combination with 5-fluorouracil chemotherapy. Median follow-up was 6.7 years. One hundred fifteen patients (92%) were followed until death or for greater than 5 years, and 69 patients (55%) were followed until death or for greater than 10 years. Recurrence was recorded as local, distant, and overall. Survival was disease-specific. RESULTS: Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.