Systematic review of classification systems for locally recurrent rectal cancer.

Z Rokan,C Simillis,P Tekkis,G Brown,C Kontovounisios,B J Moran

doi:10.1093/bjsopen/zrab024

Abstract

BackgroundClassification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes.MethodsA systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery.ResultsA total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR.ConclusionThis review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.

Highlights

The aim of this study was to review the most frequently used classification systems in describing locally recurrent rectal cancer (LRRC) and quantify the prognostic information provided by each system, with respect to the outcome measures described below
Thirty-seven did not classify local recurrence (LR) according to a defined system and were included in the primary outcome assessment but excluded from secondary outcome analysis
There is currently no single standardized classification system used to describe LRRC, the systems reviewed provide valuable information focusing on three main areas: disease ‘extent’ within the pelvis, symptoms associated with LR and more detailed anatomical information on disease location

Summary

Introduction

Rectal cancer remains a globally significant problem, with approximately 8000–9000 new patients diagnosed each year in the UK1. Surgical resection is still the best chance of cure for patients with resectable rectal cancer, despite the introduction of selective neoadjuvant chemoradiotherapy and ‘watch-andwait’ strategies, local recurrence (LR) rates remain between 5 and 18 per cent[2–4]. This is a significant issue and it can lead to significant morbidity, with symptoms including persistent pain, tenesmus, malodourous discharge and bleeding, resulting in death[2,5]. Reported survival rates following R0 resection of LRRC indicates a 3-year disease-free survival to be approximately 57 per cent[2] with 3-year overall survival between 48 and 65 per cent[2,4] This complex, often multivisceral surgery, may significantly impact a patient’s quality of life[6], so careful use of imaging for treatment planning is crucial. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes

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Conclusion