Locally recurrent rectal cancer

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio Texas, May 2 to 7, 1998.     

Local tumor recurrence after curative resection for rectal cancer

Local tumor recurrence rates after curative rectal cancer surgery with the end-to-end anastomosis stapler (EEA^®) are reportedly high. Therefore, a retrospective review in ten Yale-affiliated hospitals was undertaken to establish the outcome of surgical resection for rectal cancer in this patient population. Of those 373 patients who had had curative resections, 192 (52 percent) were abdominoperineal resections (APR); 105 patients (28 percent) had restorative resections with sutured anastomoses, and the EEA stapler was used in 76 patients (20 percent). There was an equal distribution of tumors in the various Dukes' stages in all three procedures. Local tumor recurrence was: APR 19 percent, SUT 17 percent, and EEA 24 percent, but local tumor recurrence was more frequent after EEA than APR for tumors 7 to 10 cm from the anal verge (32 vs. 13 percent, respectively,P<0.05), and the time to recurrence was least in EEA patients. It is concluded that local tumor recurrence is higher than expected for all three procedures and that the EEA stapler was associated with a greater risk of local tumor recurrence. These findings are attributed to surgeon-related technical operative factors rather than to the nature of the tumors themselves.     

Pelvic resection of recurrent rectal cancer

PURPOSE: Pelvic recurrence of rectal cancer is an ominous event for the patient and a formidable challenge to the managing surgeon. We reviewed the results of abdominosacral resection to manage these patients and correlated outcome (survival and recurrence) with known prognostic factors. METHODS: An abdominosacral resection was performed on 61 patients with pelvic recurrence (53 with curative intent and 6 for palliation; 2 had extended pelvic resection). Of the 53 patients (32 males; average age, 59 years) previous resection included abdominoperineal resection in 27 patients, abdominoperineal resection plus hepatic lobectomy in 2 patients, low anterior resection in 19 patients, plus trisegmentectomy in 1 patient, and advanced primary cancers in 4 patients. Initial primary stage was Dukes B (64 percent) and Dukes C (36 percent). All had been irradiated (3,000–6,500 in 50 patients, 8,300 and 11,000 in 2 patients, and unknown dose in 3 patients). Preoperative carcinoembryonic antigen was elevated (>5 ng/ml) in 54 percent. Extent of resection: high sacral resection S-1–S-2 was done in 32 patients, midsacrum in 14 patients, and low S-4–S-5 in 6 patients. Twenty-eight patients (60 percent) required partial or complete bladder resection with or without adjacent viscera, and all had internal iliac and obturator node dissection. RESULTS: There were four postoperative (within 60 days) deaths, 8 percent in curative groups (5.4 percent overall). Major complications included prolonged intubation (20 percent), sepsis (34 percent), posterior wound infection or flap separation (38 percent). The survival rate in the curative group (49 postoperative survivors) was 31 percent at five years, with 13 patients surviving beyond five years. Seven of these patients survived from 5 to 21 years, whereas six patients recurred again and died within 5.5 to 7.5 years after abdominosacral resection. Disease-free survival rate at five years was 23 percent. Recent reconstruction with large composite myocutaneous gluteal flaps in 5 patients permitted complete sacral wound coverage, resulting in earlier ambulation and reduced hospital stay. CONCLUSIONS: Abdominosacral resection permits removal of pelvic recurrence of rectal cancer that is fixed to the sacrum and is associated with long-term survival in 31 percent of patients. Recent technical advances have improved the short-term outcome and have made the procedure more feasible for surgical teams familiar with these techniques.Presented at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Abdominoperineal resection for locally recurrent rectal cancer

To evaluate whether surgical resection confers survival advantages in selected patients with resectable locally recurrent rectal cancer, data on 430 patients who underwent R0 resection for primary rectal cancer were prospectively collected over a 14-year period. Resection of recurrent disease was considered R0 when all cancer tissue was resected with microscopically tumor-free surgical margins. Microscopic evidence of disease at resection margins was considered an R1 resection. Recurrent disease was detected in 158 of 430 patients. Local recurrence was found in 91 patients, including (79%) with resection-site relapse only. These patients were considered for surgery unless defined unresectability criteria were met. A total of 35 patients who had abdominoperineal excision following anterior resection were studied retrospectively. Mortality associated with the procedure was 3% and morbidity was 20%. The resection was R0 in 12 patients, while microscopic margins were involved in 23 patients. 10 patients had extended resection of one or several adjacent organs Median operating time and blood loss were 250 min and 500 ml respectively. Median hospital stay was 25 days. 21/23 R1 patients received postoperative radiotherapy. Return to normal activity occurred at 8.2 (SD 4.2) weeks. No patients were lost to follow-up. Overall median survival was 26.4 months; 5-year survival was 25.4%. In spite of several survival predictors at univariate analysis, R0 or R1 resection was the only independent predictor of survival at multivariate analysis (add ratio 112.7, 95% CI 3.6–3500, p=0.007). Median survival rate was not reached at the 146-month follow-up in patients with R0 resection. Median survival rate was 16.6 months in patients with R1 resection. In conclusion, uninvolved microscopic margins produce long-term survivors after surgical resection for locally recurrent rectal cancer. Received: 24 June 2001 / Accepted: 13 July 2001     

Surgical outcome after curative resection of rectal leiomyosarcoma

PURPOSE: The aim of this study is to present the prognosis and possible associated prognostic factors after curative resection of rectal leiomyosarcoma. METHODS: From 1979 to 1996 our hospital saw 40 patients with rectal leiomyosarcoma, including 19 females, who did not have metastasis initially and received curative resection and regular postoperative follow-up. RESULTS: The mean age of the 40 patients was 58.7 years. Anal bleeding and perianal pain were the two most common symptoms at initial diagnosis. Twenty-nine patients received a radical surgical resection, such as abdominoperineal resection or low anterior resection; the other 11 patients received a wide local excision, such as transrectal excision or Kraske's operation. Sixteen tumors were classified as high-grade leiomyosarcoma, and 23 as low grade. Nineteen patients (48 percent) developed recurrence or metastasis postoperatively (median follow-up, 35 months). The overall and disease-free (1-year, 3-year, and 5-year) survival rates were 97, 90, and 75 percent and 90, 59, and 46 percent, respectively. In univariate analysis, younger group (<50 years, n=9,P=0.033) and high-grade leiomyosarcoma (P=0.043) showed poorer prognosis in the disease-free survival curve. In the multivariate Cox model, gender, tumor size, tumor location, and operation type did not significantly affect disease-free survival, whereas histologic grade (P=0.037) and age divided by a level of 50 years (P=0.009) were shown to be independent factors. There was a strong trend toward higher local recurrence rate for the wide local excision group than for the radical resection group (55vs. 24 percent,P=0.067) despite the wide local excision group being composed of smaller tumors (5.1vs. 7.5 cm,P=0.069). There was no difference in the incidence of distant metastasis between the two groups with different operation types. The metastasis rates of the wide local excision and radical resection groups were 27 and 38 percent, respectively. CONCLUSION: A younger age (<50 years) and a high histologic grade of tumor were the two most significant poor prognostic factors for rectal leiomyosarcoma. Radical resection may be superior to wide local excision in the prevention of local recurrence but not distant metastasis.     

Predictors of survival in recurrent rectal cancer after resection and intraoperative radiotherapy

PURPOSE: This study was designed to determine predictors of survival after surgery and intraoperative radiotherapy for recurrent rectal cancer. METHODS: From a prospective database, 634 patients undergoing resection for recurrent rectal cancer between January 1990 and June 2000 were identified. Of these, 111 received intraoperative radiotherapy with curative intent, and 100 were available for follow-up. Clinicopathologic variables from both the primary and recurrent operations were evaluated as predictors of disease-free and disease-specific survival by multivariate Cox regression and log-rank test. RESULTS: There were 54 males and 46 females, with a median age of 57 (range, 37–83) years. With a median follow-up of 23.2 months, 60 patients (60 percent) recurred: 20 (33 percent) locally, 27 (45 percent) distantly, and 13 (22 percent) at both sites. Of all variables analyzed, only complete resection with microscopically negative margins and the absence of vascular invasion in the recurrent specimen predicted improved disease-free and disease-specific survival (P < 0.01 for all). Median disease-free survival and median disease-specific survival were 31.2 and 66.1 months, respectively, for complete resection compared with 7.9 and 22.8 months for resection with microscopic or grossly positive margins (P < 0.01 for both). Median disease-free survival and median disease-specific survival were 6.4 and 16.1 months, respectively, in the presence of vascular invasion in the recurrent specimen compared with 23.3 and 57.3 months in the absence of vascular invasion (P < 0.01 and P < 0.05, respectively). Complete resection and the absence of vascular invasion were the only predictors of improved local control as well (P < 0.05 and P < 0.01, respectively). CONCLUSION: Resection with negative microscopic margins and absence of vascular invasion are independent predictors of local control and improved survival after resection and intraoperative radiotherapy for recurrent rectal cancer.     

Treatment of recurrent rectal cancer by electroresection/coagulation after low anterior resection

Fifteen patients with recurrent rectal cancer after low anterior resection were treated by electroresection/coagulation in order to avoid colostomy. Nine patients were alive without colostomy eight to 16 months after the first treatment and three died without colostomy from metastatic disease 24 to 36 months after the first electroresection. Electroresection/coagulation as treatment of inoperable recurrence after low anterior resection should be considered an alternative to colostomy.     

Long-term outcome of anastomosis leakage after curative resection for mid and low rectal cancer

BACKGROUND/AIMS: The aim of this study was to evaluate the relationship of the disease recurrence and prognosis of rectal cancer with anastomosis leakage after curative low anterior resection. METHODOLOGY: The records of 566 patients with primary rectal adenocarcinoma in the Veterans General Hospital-Taipei, Taiwan between 1991 and 1997 were reviewed. Patients who did not have anastomosis (abdominoperineal resection 72, Hartmann's operation 15), did not have curative resection (62) or expired within 30 days after operation (11) were excluded from the study. Another 34 patients were excluded because they did not visit our clinic or could not be reached by telephone or questionnaire after operation. 372 patients who received restorative curative resection with a colorectal anastomosis were analyzed. The product-limit method (Kaplan-Meier) and Cox proportional hazard model were used to analyze survival rate and tumor recurrence. RESULTS: Twenty-five out of the 406 patients had anastomosis leakage after the operation. The 5-year disease-free, local recurrence-free survival of the leakage group (32.5%, 58.7%) was significantly lower than that of the non-leakage group (71%, 88.3%). The multivariate analysis showed TNM staging (p = 0.0001) and histological differentiation (p = 0.0002) were associated with overall tumor recurrence. The factors affected local tumor recurrence were TNM staging (p = 0.006) and anastomosis leakage (p = 0.014). CONCLUSIONS: These results suggested that anastomotic leakage after curative rectal surgery is associated with the local tumor recurrence-free survival rate even after adjusting for stage.     

Abdominosacral resection of recurrent rectal cancer in the sacrum

PURPOSE: Resection of the sacrum is the only curative therapy of isolated sacral recurrence after primarily resected rectal cancer. The aim of the study was to assess whether there is a benefit in terms of overall survival, morbidity, and mortality when sacrum resection is performed more radically and in cooperation between colorectal and orthopedic surgeons. Possible prognostic factors were also assessed. METHODS: Twelve consecutive patients who underwent interdisciplinary partial sacral resection were included in a retrospective cohort study. Furthermore, overall survival rate and survival time were calculated. RESULTS: Histologic examination showed tumor-free resection margins in all cases. Extended resection was necessary in seven patients, including total pelvic exenteration in two. No perioperative death occurred and no patient required early reoperation. Complications were observed in 42 percent of patients, mainly caused by poor wound healing. All patients experienced relief from pain. One-year and three-year overall survival rates were 50 and 17 percent, respectively. The overall mean survival time was 21.7 months. Patients who died of recurrent disease within one year either underwent former resection for locoregional recurrence, had extensive local recurrent tumors affecting pelvic visceral structures, or retrospectively suffered from metastatic sacral tumor manifestation. CONCLUSION: The mortality and morbidity rates observed in the present study seem to justify partial sacral resection as a means to achieve palliation of perineosacral pain in spite of rare overall long-term survival.     

Pancreatoduodenectomy after hepato-biliary resection for recurrent metastatic rectal carcinoma

Intrapancreatic bile duct metastasis from rectal carcinoma is rare. A 48-year-old man underwent extended left hepatic lobectomy and caudate lobectomy with extrahepatic bile duct resection for liver metastasis from a rectal carcinoma presenting with intrabiliary growth. A second recurrent tumor was successfully resected by pancreatoduodenectomy without injury to the jejunal loop for biliary reconstruction. Preservation of the previous bilio-enteric anastomosis was critical. Placing the jejunal limb of the hepaticojejunostomy through the retrogastric route was superior to placement through the common retrocolic and anteduodenal route, because the mesentery of the Roux-en Y jejunal limb did not obscure the pancreatic head. Histologic examination revealed a recurrent tumor growing into the remnant intrapancreatic bile duct. This suggested two possibilities: spontaneous shedding of cancer cells from the proximal metastasis, and implantation as a complication of percutaneous transhepatic biliary drainage. In both these circumstances, the metastatic lesion is not systemic, but is a local disease. An aggressive surgical approach for localized recurrence of this type may improve survival.     

Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection

BACKGROUND: Repeat endoscopic mucosal resection (EMR) to cure locally recurrent early gastric cancer (EGC) is difficult to perform because the initial EMR causes submucosal fibrosis; however, ESD allows submucosal dissection through the fibrosis and provides an en bloc specimen. OBJECTIVE: The objective was to determine the safety and efficacy of ESD and compare the results to historical controls. DESIGN: This was a retrospective, case-control study. PATIENTS: We used our prospectively entered database (1993-2003) to identify 64 patients who had locally recurrent EGC after EMR. MAIN OUTCOME MEASUREMENTS: We defined the resections as curative when the lateral and vertical margins were free of cancer and repeat endoscopy showed no recurrent disease. RESULTS: Among 46 patients who underwent ESD, 41 (89.1%) en bloc resections were achieved compared to none in 18 conventional procedures (P < .0001). The specimen of 1 lesion (2.4%) out of 41 en bloc resections was histologically nonevaluable, compared with 10 lesions (43.4%) in 23 piecemeal resections (P < .0001). Three residual tumors (27.3%) were found in the 11 nonevaluable specimens. Three perforations occurred during ESD; all were successfully treated endoscopically with endoclips. LIMITATIONS: The limitation of the study was retrospective design. CONCLUSIONS: ESD provides high en bloc resection rate for locally recurrent EGC after previous EMR. In turn, en bloc resections allow precise histological staging to be assessed and prevent residual disease and recurrence.     

Salvage therapy for pelvic recurrence following curative rectal cancer resection

INTRODUCTION: Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients. PURPOSE: In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection.METHODS: A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy. RESULTS: For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P = 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI group vs. the MSKCC group (34/51 vs. 9/25;P < 0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients. CONCLUSIONS: Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.     

Prognostic value of additional pathological variables for long-term survival after curative resection of rectal cancer

AIM: To evaluate the prognostic value of some pathological variables in rectal cancer survival. METHODS: 247 patients who underwent curative resection of rectal cancer were included in the study. The influence on survival of five pathological variables (histopathological tumor type, histopathological tumor grade differentiation, blood vessel invasion, perineural invasion and lymphatic invasion) was assessed using statistical analyses. RESULTS: Overall 5-year survival was 71.2%. Univariate analysis of all tested variables showed an effect on survival but only the effect of lymphatic invasion was statistically significant. At stages three and four it had a negative effect on survival (P = 0.0212). Lymphatic invasion also significantly affected cancer related survival in multivariate analysis at stages three and four. At lower stages (stage 0, stage 1 and stage 2) multivariate analysis showed a negative effect of perineural invasion on cancer related survival. CONCLUSION: Patients with lymphatic and perineural invasion have a higher risk for rectal cancer related death after curative resection. Examination of these variables should be an important step in detecting patients with a poorer prognosis.     

Abdominosacral resection for primary irresectable and locally recurrent rectal cancer

PURPOSE: The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation. METHODS: Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment,i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection. RESULTS: Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n=24, 48 percent). Other complications were postoperative urinary retention or incontinence (n=9, 18 percent), peritonitis (n=4), grade II neuropathy (n=1), and fistula formation (n=3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negativevs. positive margins) was a significant factor influencing survival (P=0.04), diseasefree survival (P=0.0006), and local control (P=0.0002). CONCLUSION: The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.Presented in part at the European Society of Surgical Oncology meeting in Groningen, the Netherlands, April 5 to 8, 2000.     

Factors associated with lateral pelvic recurrence after curative resection following neoadjuvant chemoradiotherapy in rectal cancer patients

Purpose

This study aims to determine the risk factors for lateral pelvic recurrence (LPR) in rectal cancer patients treated with neoadjuvant chemoradiotherapy (CRT) and curative surgery.

Methods

Four hundred forty-three patients treated with neoadjuvant CRT and curative surgery from October 1999 through June 2009 were analyzed. All patients underwent total mesorectal resection without lateral pelvic lymph node (LPLN) dissection. Recurrence patterns and lateral pelvic recurrence-free survival (LPFS) were evaluated relative to clinicopathologic parameters including pelvic LN status.

Results

Median follow-up was 52 months, with locoregional recurrence in 53 patients (11.9 %). Of the 53 patients, 28 (52.8 %) developed LPR, of which eight had both central and lateral PR. Multivariate analysis showed a significant relationship between LPFS and the number of lateral pelvic LN (p?=?0.010) as well as the ratio of the number of positive LN/number of dissected LN (p?=?0.038). The relationship between LPFS and LPLN size had a marginal trend (p?=?0.085). Logistic regression analysis showed positive relationships between LPR probability and the number of LPLN (odds ratio [OR] 1.507; 95 % confidence interval [CI] 1.177–1.929; p?=?0.001) as well as LPLN size (OR 1.124; CI 1.029–1.227, p?=?0.009).

Conclusions

LPLN?≥?2 and a ratio of the number of positive LN/number of dissected LN?>?0.3 were prognostic of poor LPFS. The prediction curve of LPR according to the number and size of LPLN could be useful for determining the benefit of additional lateral pelvic treatment.     

Anastomotic recurrence after sphincter-saving resection for rectal cancer

A retrospective study of anastomotic recurrence after sphincter-saving resection for rectal cancer is presented. During the 21 years from 1962 to 1982, 273 patients with rectal cancer underwent sphincter-saving resection and 30 (11 percent) of them had anastomotic recurrences. Computer analysis of 69 variables was undertaken to identify factors contributing to the anastomotic recurrence, with special reference to the length of distal clearance of the bowel. There was no significant correlation between the incidence of recurrence and the length of distal clearance of the bowel, if the latter was over 2 cm. There appears to be justification for carrying out a curative sphincter-saving operation for cases in which more than a 2-cm distal margin can be afforded. However, for cancers of the infiltrating type, annular growths, invasion to adjacent organs or mucinous features, a more extensive distal clearance of the bowel is necessary, and the Miles operation should be performed.     

Micturitional dysfunction after anterior resection for rectal cancer

A clinical study was made of 21 patients (13 men and eight women) who had undergone anterior resection of the rectum for cancer at the National Tumour Institute of Milan between April 1984 and April 1985. After surgery, 13 patients (including three men with benign prostatic hypertrophy) showed voiding dysfunctions (hesitancy, dysuria, and weak stream) and bladder areflexia. Two of them also had positive Lapides' tests. An early rehabilitative treatment was started after surgery and the entire group was thoroughly reexamined one year later. Only the two patients with positive Lapides' tests still had bladder areflexia with residual urine greater than 100 ml. One of them also had a urinary tract infection. None of them showed decreased renal function.