Local Recurrence Of Rectal Cancer Research Articles

Effect of Surgery on Health-Related Quality of Life of Patients With Locally Recurrent Rectal Cancer

Local recurrences of rectal cancer are best treated with surgical resection. Health-related quality of life is an important outcome measure in rectal cancer, but it has been poorly investigated in local recurrences. The purpose of this study was to assess quality of life in patients receiving or not receiving surgery for locally recurrent rectal cancer. This was a prospective cohort study. The study was conducted at a single tertiary care institution. Patients presenting with local recurrent rectal cancer between December 2002 and December 2011 were included. A control group of patients with nonrecurrent rectal cancer was prospectively enrolled (planned ratio, 1:2). All of the patients received the core Quality of Life Questionnaire C30 of the European Organisation for Research and Treatment of Cancer preoperatively or at diagnosis and then 1 and 3 years later. We compared results according to oncologic clearance (R0 vs R1 vs R2 vs no surgery). Confounding variables were tested with a multivariate logistic regression. Forty-five patients (27 men), median age 62 years (range, 34-80 years), with recurrence were observed. Twelve (26.7%) were not fit for surgery. Twenty one (63.6%), 7 (21.2%), and 5 (15.2%) received R0, R1, and R2 resections. Data for 30 (90.9%) and 25 operated patients (75.75%) were available at 1- and 3-year follow-ups. Irrespective of type of surgery and multimodal treatments, patients receiving R0/R1 resections had improvement in quality of life in all of the domains compared with the R2 and no-surgery groups. Outcomes were inferior compared with nonrecurrent control subjects (N = 71). At 3 years, R0 patients reported scores equal to those of control subjects, with superior emotional functioning. R1 patients had worse symptoms and quality of life at 3-year follow-up. Surgery impaired survival and quality of life of R2 patients compared with those who were not operated on. The study was limited because it involved a single center with a single senior surgeon. Quality of life of patients with locally recurrent rectal cancer is improved by R0 and ameliorated with R1 resection, irrespective of surgical extent. Full recovery, similar to that of nonrecurrent cancer survivors, can be expected in R0 patients but requires longer follow-up times. Surgery with macroscopic involvement of resection margins accelerates quality of life decline and shortens survival.

Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area.

BackgroundTumor lesions in previously irradiated area may have a less favorable response to chemotherapy compared to tumor sites outside the radiation field. The aim of the present study was to evaluate the response to chemotherapy of locally recurrent rectal cancer (LRRC) within the previous radiation field compared to the response of distant metastases outside the radiation field.Patients and methodsAll patients with LRRC referred between 2000 and 2012 to our tertiary university hospital were reviewed. The response to chemotherapy of LRRC within previously irradiated area was compared to the response of synchronous distant metastases outside the radiation field according to the Response Evaluation Criteria in Solid Tumors (RECIST).ResultsOut of 363 cases with LRRC, 29 previously irradiated patients with distant metastases were treated with chemotherapy and eligible for analysis. Twenty-six patients (89 %) suffered a first recurrence and three patients (11 %) a second recurrence. These patients were followed with a median of 22 months (IQR, 9–40 months) and had a median survival of 33 months (IQR, 14–42). In 23 patients (79 %), the local recurrence showed stable disease, but the overall response rate of the local recurrences in the previously irradiated area was significantly lower than the response rate of distant metastases outside the radiation field (10 vs. 41 %,p = 0.034).ConclusionsPreviously irradiated patients with LRRC have a lower response rate to chemotherapy of the local recurrence within the radiation field compared to the response rate of distant metastases outside the radiation field. This suggests that chemotherapy for local palliation may not have the desired effect.

Copy number alterations and allelic ratio in relation to recurrence of rectal cancer.

BackgroundIn rectal cancer, total mesorectal excision surgery combined with preoperative (chemo)radiotherapy reduces local recurrence rates but does not improve overall patient survival, a result that may be due to the harmful side effects and/or co-morbidity of preoperative treatment. New biomarkers are needed to facilitate identification of rectal cancer patients at high risk for local recurrent disease. This would allow for preoperative (chemo)radiotherapy to be restricted to high-risk patients, thereby reducing overtreatment and allowing personalized treatment protocols. We analyzed genome-wide DNA copy number (CN) and allelic alterations in 112 tumors from preoperatively untreated rectal cancer patients. Sixty-six patients with local and/or distant recurrent disease were compared to matched controls without recurrence. Results were validated in a second cohort of tumors from 95 matched rectal cancer patients. Additionally, we performed a meta-analysis that included 42 studies reporting on CN alterations in colorectal cancer and compared results to our own data.ResultsThe genomic profiles in our study were comparable to other rectal cancer studies. Results of the meta-analysis supported the hypothesis that colon cancer and rectal cancer may be distinct disease entities. In our discovery patient study cohort, allelic retention of chromosome 7 was significantly associated with local recurrent disease. Data from the validation cohort were supportive, albeit not statistically significant, of this finding.ConclusionsWe showed that retention of heterozygosity on chromosome 7 may be associated with local recurrence in rectal cancer. Further research is warranted to elucidate the mechanisms and effect of retention of chromosome 7 on the development of local recurrent disease in rectal cancer.Electronic supplementary materialThe online version of this article (doi:10.1186/s12864-015-1550-0) contains supplementary material, which is available to authorized users.

PWE-308 Pelvic exenteration for primary advanced and locally recurrent rectal cancer: outcomes and experience at a single institution

<h3>Introduction</h3> Pelvic exenteration is a potential curative treatment for primary advanced rectal cancer (PARC) and locally recurrent rectal cancer (LRRC). The aim of such extensive radical surgery is to achieve clear resection margins. <h3>Method</h3> A retrospective study was performed of pelvic exenteration procedures carried out between 2004 and 2014 in St Thomas’ Hospital for PARC and LRRC. Factors evaluated included age, sex, neo-adjuvant therapy, type of operation, intraoperative blood loss, resection margins, 30day morbidity and mortality and overall survival. <h3>Results</h3> Pelvic exenteration was performed in 71 patients. 51 patients were treated with neoadjuvant chemoradiation. Of the 71 patients, 52 had total, 6 had anterior and 13 had posterior pelvic exenteration; sacrectomy was performed in 4 patients. Thirty nine (39) patients (27males) with median age 61(29–80) years underwent pelvic exenteration for PARC and thirty two (32) patients (10 males) with median age 62(41–80) years had pelvic exenteration for LRRC. The median blood loss was 3700 ml (range 150015000) for PARC and 3750 ml (range 1500–15000) for LRRC. A complete resection (R0) was achieved in 67.6% of all patients; 74.4% for patients with PARC and 59.4% for patients with LRRC. Major complications (Clavien-Dindo, Grade III-IV) were 35.9% and 34.4% respectively. One patient died within 30 days. Overall survival was 32.5 months for PARC and 21.1 months for LRRC. <h3>Conclusion</h3> Pelvic exenteration is associated with considerable morbidity but low mortality and acceptable overall survival, in the absence of other effective treatment modalities. Careful preoperative assessment and a multidisciplinary approach make this extensive surgical technique safe and feasible in an experienced centre. <h3>Disclosure of interest</h3> None Declared.

Lokalna ponovitev bolezni pri bolnikih operiranih zaradi nemetastatskega raka danke, zbolelih v obdobju 2003 - 2005

Background: In the last decades outcomes of rectal cancer treatment are improving due to better understanding of tumor biology, neoadjuvant and adjuvant treatment and precise surgical technique, considering pathologic anatomical lines. Proportion of rectal cancer local recurrence (LR) has been substantially decreasing. Objectives of this study are, first, to find out whether two groups, with and without rectal local recurrence, are statistically important different in certain risk factors and, second, to define prognostic factors of rectal local recurrence.Methods: Total of 787 nonmetastatisc rectal cancer patients, diagnosed between 2003 and 2005, treated with surgery in all Slovenian hospitals, were enrolled retrospectively. The recurrence-free survival rates were calculated with Kaplan-Meier method. For statistical comparison of survival of two groups according to prognostic factors log-rank test was used. The adjusted hazard ratios for significant survival prognostic factors were calculated using Cox multivariate analysis.Results: Patients with LR had more tumors in the lower third of rectum (p=0,045), more abdominoperineal, Hartmann's and local excisions (p=0,000) and less radical operations (p=0,005), more of them were operated in hospitals with lesser caseload of patients (p=0,000), more often were treated only surgically (p=0,048), had more colon defects after excision of tumors (p=0,025) and had more distant disease recurrences (p=0,000). In follow up period of 5,3 years LR occurred in 13,1% and in 54% of those in 1,9 years after surgery. In the multivariate analysis, the statistically significant prognostic factors for recurrence-free survival were tumor's rectal position, regional lymph nodes status and the hospital of surgery.Conclusions: Proportion of LR is an appropriate indicator of optimal multidisciplinary rectal cancer treatment.

Mo1623 A Retrospective Study of 45 Patients Who Underwent Surgical Treatment for Local Recurrence of Rectal Cancer

Mo1623 A Retrospective Study of 45 Patients Who Underwent Surgical Treatment for Local Recurrence of Rectal Cancer

Effect of particle beam radiotherapy on locally recurrent rectal cancer: Three case reports.

Surgical resection is the most effective therapy for locally recurrent rectal cancer (LRRC); however, it often necessitates invasive procedures that may lead to major complications. Particle beam radiotherapy (RT), including carbon ion RT (C-ion RT) and proton beam RT, is a promising new modality that exhibits considerable efficacy against various types of human cancer. C-ion RT reportedly offers a therapeutic alternative for LRRC. In the present study, we describe three cases of LRRC treated by particle beam RT. In all the cases, LRRC was diagnosed by computed tomography, magnetic resonance imaging and positron emission tomography imaging. No serious adverse effects were observed during RT. One patient experienced re-recurrence of LRRC, but survived for 6 years following particle beam RT; the second patient remains recurrence-free after a 2-year follow-up; and the third patient has developed recurrence at different sites in the pelvis but, to date, has survived for 4 years following particle beam RT. Therefore, LRRC was controlled by particle beam RT in two of the three cases, suggesting that particle beam RT is a safe alternative treatment for patients with LRRC.

Individual features of blood supply and lateral metastasis of colorectal cancer

One of the main causes of local recurrence of rectal cancer is the regional lymphatic nodes metastasis. Existing methods of staging does not have absolute sensitivity and specificity with regard to lesion of regional lymphatic nodes in general, and of lateral group in particular. It is necessary to look for new methods of diagnosis, to identify risk factors and unfavorable prognosis of lateral metastasis in colorectal cancer, which will provide a more differentiated approach to the choice of treatment policy, indications for neoadjuvant chemoradiotherapy and/or lymphatic node dissection. The work on the two groups of patients (control and basic) was performed on the basis of CT performed in angio mode and MRI investigated anatomical variability of middle rectal arteries, proved its impermanence, and studied the relationship between presence of the middle rectal artery and lesion of regional lymphatic nodes in rectal cancer. Prognostic risk factors for lateral metastasis in rectal cancer were proposed, comparative analysis techniques allowing for visualization of the middle rectal vessels was performed.

A systematic review on the role for reirradiation in locally recurrent rectal cancer

Objective This article reviews the clinical outcomes of patients who have received reirradiation to the pelvis for a local recurrence of rectal cancer to better define clinical settings where radiotherapy would be optimal.

Time to local recurrence as a prognostic factor in patients with rectal cancer

AimsSurvival after the local recurrence of rectal cancer is influenced by several factors. The aim of this study was to ascertain whether the time interval from primary surgery for rectal cancer to local recurrence diagnosis has any impact on survival. MethodsPopulation-based data was collected from the Swedish Colorectal Cancer Registry. 7410 patients were operated with radical abdominal surgery for rectal cancer during the period 1995–2002. Of these, 386 (5%) developed a local recurrence as a first event. The patients were divided into two groups: early local recurrence (ELR), diagnosed <12 months after primary surgery, and late local recurrence (LLR), diagnosed ≥12 months after primary surgery. Kaplan–Meier curves and hazard ratios were calculated for survival analyses. Survival was calculated from the date of the local recurrence diagnosis to death or end of follow-up. ResultsNinety-five patients had ELR and 291 patients LLR. Median time to local recurrence was 1.7 (0.1–7.9) years. Patients with a stage III primary tumour and non-irradiated patients were more common in the ELR compared with the LLR group. Factors that influenced survival were age at diagnosis of local recurrence (p < 0.001), stage of primary tumour (p = 0.027), and surgical resection of local recurrence (p < 0.001). Time to diagnosis of local recurrence had no influence on survival. ConclusionsNo difference in survival from date of diagnosis of local recurrence was seen between patients with ELR and patients with LLR. All patients with local recurrence should therefore be assessed for potential curative surgery, disregarding time to local recurrence.

What more do we want from neoadjuvant treatment strategies in rectal cancer?

Radiation therapy (RT) delivered preoperatively has clearly shown to improve local disease control after radical surgery in rectal cancer [1–3]. In fact different options including short-course or long-course regimens have been extensively studied with similar good long-term local disease control [4–6]. Also, the addition of chemotherapy with fluoropyrimidine to radiation led to further improvement in local disease control of these patients [7,8]. At a first glance, the issue of local recurrence in rectal cancer had been solved with widespread introduction of preoperative RT with or without concomitant chemotherapy. So why do we keep searching for alternative treatment options for the already successful neoadjuvant approach? What are we looking for? First of all, the observation that neoadjuvant chemoradiation (CRT) could result in complete tumor eradication, also known as complete pathological response is now considered one of the major advantages of neoadjuvant therapy in patients with rectal cancer [9]. Patients with complete pathological response (pCR) are associated with improved oncological outcomes [10]. Therefore, development of alternative neoadjuvant strategies that could maximize pCR rates is highly desirable. Also, even though increased rates of sphincter preservation have been considered another advantage of the neoadjuvant strategy, none of the randomized studies have demonstrated any superiority in sphincter preservation rates in experimental arms of these studies [11]. However, in select patients with clinical and radiological evidence of pCR (complete clinical response [cCR]), alternative organ-preserving treatment strategies have been suggested [12,13]. Therefore, a substantial increase in pCR and cCR rates could benefit patients by improving oncological outcomes and truly affecting sphincter or even organ preservation rates [9]. Therefore, maximization of pCR/cCR rates is an excellent reason for the search of improved neoadjuvant treatment regimens. But radiation therapy comes at a significant cost for patients, even though some

Early and Late Outcomes of Surgery for Locally Recurrent Rectal Cancer: A Prospective 10-Year Study in the Total Mesorectal Excision Era.

The aim of this study was to assess the outcome of all locally recurrent rectal cancer (LRRC) patients who were referred to a tertiary care center. The study examined LRRC patients who underwent surgery after prior total mesorectal excision. The data of 213 consecutive LRRC patients who were registered in a database between 2001 and 2010 were accessed. A total of 115 patients (54%) with a median age of 63 (range 34-81) years underwent tumor resection. The 30-day mortality rate was 0.8% (95% CI 0.02-4%), and the complication rate was 42% (95% CI 33-51%). R0 resection was achieved in 70 patients (61%), R1 resection in 38 patients (33%), and R2 resection in 7 patients (6%). The 3- and 5-year survival rates for R0 resections were 55% (95% CI 41-66) and 40% (95% CI 26-53), respectively; 42% (95% CI 26-58) and 16% (95% CI 5-31), respectively, for R1 resections; no patients who received an R2 resection survived to the 3-year mark. Patients with prior abdominoperineal excision (APE) had significantly poorer survival rates than patients with prior resection with anastomosis (p=0.02). Acceptable long-term survival can be achieved for patients undergoing surgery for LRRC, but radical resection is mandatory. Prior APE was associated with poorer survival rates.

Mohs法が効果的であった会陰浸潤巣からの出血を伴う直腸癌の1例

Mohs法が効果的であった会陰浸潤巣からの出血を伴う直腸癌の1例

Standards for Local Recurrence Rates in Both Open and Laparoscopic Rectal Cancer Surgery. How do you Measure Up?

Local recurrence of rectal cancer is the result either of potentially removable tumor cells left in situ or cells already disseminated to areas where surgery cannot reach them. The first scenario infers inadequate surgery, the second implies unfavorable biology. Surgeons who operate for rectal cancer must know local recurrence rates in their patients, and be able to relate them to outcomes achieved by others. We have performed this study to facilitate such a comparison. Methods: Systematic review of the literature from 1990 to 2010 was performed for publications which reported local recurrence after proctectomy for rectal cancer. Inclusion criteria were: studies of more than 80 patients and local recurrence stratified by histopathologic stage. Pooled local recurrence rates were tabulated by 5 percentile levels, stratified according to TNM stage (I,II,III) and surgical technique (total mesorectal excision or standard), as well as laparoscopic versus open. Results: Thirty-six studies comprising 16425 patients were pooled for final analysis: Mean follow-up is 40.9 months (1.3-188mths). The table shows local recurrence stratified by tumor biology (stage), operative technique (total mesorectal excision vs. standard) and operative approach (open vs. laparoscopic). The percentiles provide standards against which surgeons can compare their own outcomes Conclusion: Oncologic outcome of the treatment of rectal cancer is the result of interaction of therapeutic expertise and tumor biology. The percentile tables allow the use of local recurrence rates as an indirect parameter of surgical quality.

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

BackgroundIn 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. MethodsStudied 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. ResultsSacrectomy 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). ConclusionsAggressive 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.

Delayed abdominal wall abscess after abdomino-perineal resection simulating local recurrence of rectal cancer.

IntroductionWe report a rare case of delayed abdominal wall abscess after abdominoperineal resection (APR) for rectal cancer.Case descriptionA 63-year-old woman was diagnosed with rectal cancer and received chemo-radiotherapy, followed by APR. One year after surgery, the patient complained of pain and skin redness in the lower abdomen. A low-density mass lesion with 5.9-cm diameter was found in the lower abdominal wall by computed tomography, which showed high uptake on positron-emission tomography. These findings suggested the possibilities of either delayed abscess formation or abdominal wall recurrence of rectal cancer with central necrosis. Percutaneous drainage was performed. The content was a purulent exudate, without neoplastic cells in the cytology. The lesion quickly disappeared after the drainage, and no recurrence of the tumor was observed for more than 2 years.Discussion and evaluationIn this case, the un-absorbable yarn, such as silk, has not been used during the operation, no foreign body was retained in the abdominal wall, and there was no associated inflammatory bowel disease. Use of neoadjuvant chemoradiotherapy was the only possible cause of delayed abscess formation in this case.ConclusionIn case local recurrence is suspected by imaging modalities in the postoperative of colorectal cancer, especially those with precedent chemoradiotherapy or radiotherapy, although rare, the possibility of a delayed abscess formation should also be considered.

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

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. 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. 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 43.4months. 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). 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.

Update on the prevention of local recurrence and peritoneal metastases in patients with colorectal cancer.

The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of colon cancer patients and 25% of rectal cancer patients and should be prevented. Strategies to prevent colon or rectal cancer local recurrence and peritoneal metastases include cytoreductive surgery and hyperthermic perioperative chemotherapy (HIPEC). These strategies can be used at the time of primary colon or rectal cancer resection if the HIPEC is available. At institutions where HIPEC is not available with the treatment of primary malignancy, a proactive second-look surgery is recommended. Several phase II studies strongly support the proactive approach. If peritoneal metastases were treated along with the primary colon resection, 5-year survival was seen and these results were superior to the results of treatment after peritoneal metastases had developed as recurrence. Also, prophylactic HIPEC improved survival with T3/T4 mucinous or signet ring colon cancers. A second-look has been shown to be effective in two published manuscripts. Unpublished data from MedStar Washington Cancer Institute also produced favorable date. Rectal cancer with peritoneal metastases may not be so effectively treated. There are both credits and debits of this proactive approach. Selection factors should be reviewed by the multidisciplinary team for individualized management of patients with or at high risk for peritoneal metastases.

Extended follow-up following aggressive resection of locally recurrent rectal cancer.

3635 Background: The literature on resection of locally recurrent rectal cancer (LRRC) consists largely of case series based on retrospective data collection with median follow-up of less than 36 m...

Laparoscopic Salvage Surgery for Locally Recurrent Rectal Cancer

BackgroundSurgical treatment for locally recurrent rectal cancer is challenging, and the value of laparoscopic surgery in such cases is unknown. The purpose of this study was to compare the feasibility of laparoscopic surgery with that of open surgery for locally recurrent rectal cancer. MethodsThirty patients with local rectal cancer recurrence at the anastomotic site or lateral pelvic lymph nodes were evaluated. Perioperative outcomes were compared between the laparoscopic (n = 13) and open (n = 17) groups. ResultsThe median operation time was significantly longer (381 vs. 241 min) but the median estimated blood loss tended to be smaller (110 vs. 450 mL) in the laparoscopic than in the open group. There was only one converted case (7.7 %). The R0 resection rate (100 vs. 94 %) and postoperative complications (31 vs. 24 %) were not significantly different between the two groups. The median times to flatus (1 vs. 2 days), first stool (2 vs. 5 days), and oral intake (2 vs. 5 days) were significantly shorter in the laparoscopic than in the open group. ConclusionLaparoscopic surgery for locally recurrent rectal cancer has short-term benefits over open surgery and has potential as a treatment option for locally recurrent rectal cancer.