Local Recurrence Of Rectal Cancer Research Articles

Unusual Case of Solitary Perineal Subcutaneous Metastasis From Sigmoid Colon Cancer

Subcutaneous metastasis from colorectal cancer is an unusual presentation. Most perineal subcutaneous metastases are found in extensive involvements of multiorgan metastases or local recurrences of rectal cancer. Subcutaneous metastasis from colon cancer is considered as a distant metastasis with poor prognosis. We report an unusual case of solitary subcutaneous metastasis beneath the perineum without solid organ involvement after a curative anterior resection for sigmoid colon cancer. The patient underwent a perineal resection, and chemotherapy with the FOLFOX (fluorouracil, leucovorin, and oxaliplatin) regimen was instituted. Eight months later, multiple lung metastases were found, and chemotherapy was restarted with the FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen. However, lung metastases progressed, and new metastases appeared at the adrenal glands, the kidneys and the cerebellum. The patient died 30 months after the diagnosis of perineal subcutaneous metastasis. He lived relatively long in comparison with patients in previous reports.

Current UK management of locally recurrent rectal cancer

The study aimed to determine current UK practice in the management of locally recurrent rectal cancer (LRRC). An electronic based survey was sent to UK based Association of Coloproctology of Great Britain and Ireland members to establish current management in this patient group. A total of 188 questionnaires were sent out to consultant surgeons in a total of 105 colorectal units. Seventy-nine consultants from 69 units responded, giving an overall response rate from consultants of 42% and from colorectal units of 66%. In all, 688 patients were managed by multidisciplinary teams in the 12 months prior to the survey. Seventy-four (94% of responders) surgeons had experience of operating on patients with LRRC. Fifty-nine (74.6%) operated on one to three per year and four (5%) operated on more than 10 patients per year. Central and anterior recurrences were most commonly undertaken locally, with most complex recurrences being referred to a tertiary centre. Forty-seven (61%) surgeons worked to an algorithm. A small number of specialist units in the UK manage the full spectrum of LRRC but the majority of patients are managed in small volume centres. The survey provides a snapshot of current activity in the UK and may provide a stimulus for discussion about how to expand and improve the care of a technically challenging group of patients.

Meta‐analysis of survival based on resection margin status following surgery for recurrent rectal cancer

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). 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. 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)]. 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.

P3-065 - Safety and Efficacy of Proton-Beam Radiation Therapy for Patients with Locally Recurrent rectal Cancer

ABSTRACT Background Radical surgical resection is considered as a standard therapy for locally recurrent rectal cancer (LRRC). Surgical procedures for LRRC, such as total pelvic exenteration, are highly invasive; however, the rate of curative resection is modest. As for definitive radiotherapy, it is often difficult to deliver a curative dose because local recurrences occur adjacent to radiosensitive areas such as the gastrointestinal tract. Proton-beam therapy involving intense and highly focused irradiation can effectively treat local recurrences while avoiding damage to the surrounding organ. Therefore, we investigated this therapy as a treatment option for LRCC patients who had unresectable LRCCs or had refused surgery. Objects We retrospectively reviewed 13 consecutive LRCC patients who (i) had unresectable LRCCs or had refused surgery, (ii) had received proton-beam radiation therapy at Shizuoka Cancer Center during November 2005–January 2011, and (iii) had not undergone pelvic irradiation earlier. The clinical course of all the patients was examined after the therapy. Methods All the patients had received a total dose of 70 GyE proton-beam irradiation (in 25 fractions) and were followed up to disease progression. Results The patient characteristics were as follows: median age, 58 years (range, 37 ∼ 82 years); men/women, 7/6; PS, 0/1, 10/3; recurrence site, anterior/Post-erior/lateral/anastomosis, 0/6/7/0; previous chemotherapy regimen number, 0/1/2/ > 3, 5/2/4/2; and histological types, tub1/tub2/por/unknown, 3/7/1/2.At a median follow-up time of 1264 days (range, 467–2105 days), the local control rate, median local control time, and median progression-free survival were 46%, 504 days (range, 128–2105 days), and 414 days (range, 58–2105 days), respectively. Grade 3/4 toxicity was observed in 1 patient with urinary tract obstruction; there were no treatment-related deaths. Conclusions Proton-beam radiation therapy was well tolerated for LRCC patients who had unresectable LRCCs or had refused surgery, and controlled LRRC in approximately 50% of the patients. Therefore, this therapy might be considered a treatment option for LRRC.

74. The treatment of local recurrent rectal cancer in the TME Era

Background: In recent years, an improvement in prognosis for patients with rectal cancer is achieved, partly due to the Total Mesorectal Excision (TME) technique, and the introduction of preoperative radiotherapy and chemotherapy. Despite improved outcomes, some patients develop locally recurrent rectal cancer. The majority of patients with local recurrent rectal cancer have already received irradiation during the initial treatment for the primary tumour. This has led to the question whether reirradiation improves the local tumour response and survival or leads to late toxicity and a better outcome.

338. Correlation Between Lymph Node Status and Tumour Regression After Neoadyuvant Chemoradiation in Locally Advanced Rectal Cancer

Background: Tumour regression grading (TRG) is a predictive factor for local recurrence in rectal cancer. The correlaction of TRG with overall survival is more controversial. Lymph node status after chemoradiation is one of the most important predictors of disease-free and long-term survival. The aim of this study was to determine the correlation between TRG and lymph node status after neoadyuvant chemoradiation in the resected surgical specimens.

Concurrent Chemoradiotherapy in the Treatment of Locally Recurrent Rectal Cancer

Long course concurrent chemoradiotherapy provides potential tumor downstaging. When local recurrent rectal cancer without distant metastases is diagnosed, a potentially curative resection can be performed. The aim of this study was to assess the outcome of concurrent chemoradiotherapy in treating isolated local recurrent rectal cancer. Patients (n=102) with isolated local recurrent rectal cancer within the pelvis were scheduled for concurrent chemoradiotherapy, consisting of pelvic irradiation with a total dose of 50.4 Gy in 28 fractions. Chemotherapy was administered concurrently and included 85 mg/m2 oxaliplatin by venous infusion over 2 h on day 1, followed by 1,200 mg*m-2*day-1 of continuous venous infusion for 2 days. This regimen was repeated every 2 weeks for 6 cycles. The overall survival rate, responses, disease-free interval and toxicities were assessed. A total of 96 patients completed planned concurrent chemoradiation. Complete clinical responses were found in 13 of the 96 patients (14%), partial responses in 59 (61%), stable disease in 21 (22%) and disease progression in 3 (3%). The overall survival and disease-free survival rates in all the 96 patients were 45% and 14%, respectively. The treatment of locally recurrent rectal cancer is complicated. Concurrent chemoradiation can increase disease-free survival and overall survival by increasing complete resection rate of locally recurrent tumors and even complete response of the tumors. Ongoing treatment strategies aim to enhance response rates and to accurately assess the extent of local recurrent tumor response to concurrent chemoradiation.

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

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

Right Colon to Rectal Anastomosis (Deloyers Procedure) as a Salvage Technique for Low Colorectal or Coloanal Anastomosis

After extended left colectomy, it may be difficult to take down a well-vascularized colon into the pelvis and perform a tension-free colorectal or coloanal anastomosis. The Deloyers procedure comprising complete mobilization and rotation of the right colon while maintaining the ileocolic artery may be used in this circumstance. The aim of this study is to report postoperative and long-term outcomes after the Deloyers procedure as a salvage technique for colorectal anastomosis or coloanal anastomosis. From a prospective database, we retrospectively reviewed all patients who underwent a Deloyers procedure. This study was conducted at the Colorectal Unit in a tertiary referral teaching hospital. Between 1998 and 2011, 48 consecutive patients underwent a Deloyers procedure. Indications were as following: Hartmann reversal (n = 17), previous colorectal anastomosis-related complications (n = 11), diverticular disease (n = 6), left colon cancer (n = 6), ischemic colitis (n = 3), iterative colectomy for cancer (n = 3), rectal cancer local recurrence (n = 1), and synchronous colon cancer (n = 1). There were 38 men and 10 women (median age at surgery, 67 years). Colorectal anastomosis and coloanal anastomosis were performed in 38 and 10 patients. Thirty-one patients had defunctioning stoma. Mortality and early morbidity rate was 2% and 23%. Three patients (6%) had severe complications (Dindo ≥ 3). There was no anastomotic leakage. Reoperation was required in 2 patients for intra-abdominal hemorrhage. The median hospital stay was 12 days. The median follow-up was 26 months. All patients had their ileostomy closed. Twenty-three percent of patients developed late complications. The median number of bowel movements per day was 3 (range, 1-7), but 67% of patients had fewer than 3. One patient required an ileostomy refashioning because of poor functional results, and 23% of patients routinely take loperamide-based medication. The retrospective nature of the study was a limitation. The Deloyers procedure is safe, associated with low morbidity and good long-term functional results. It represents a safe alternative to total colectomy and ileorectal anastomosis.

Should laparoscopic-assisted proctectomy be the standard of care for patients with resectable rectal cancer?

3 ISSN 1758-194X 10.2217/CRC.11.4 © 2012 Future Medicine Ltd Colorect. Cancer (2012) 1(1), 3–6 *University of Wisconsin Department of Surgery, Section of Colon & Rectal Surgery, 600 Highland Avenue, K4/736 CSC, Madison, WI 53792, USA; kennedyg@surgery.wisc.edu Cancer of the large intestine is often referred to as colorectal cancer. The problem with using the term ‘colorectal’ when referring to the large intestine is it fails to draw a distinction between the abdominal colon and the rectum. Those who routinely treat cancers of the colon and rectum will be the first to agree that the surgical approach and oncological priorities for colon and rectal cancer are different. For example, local–regional recurrence of cancer is much more prevalent when treating rectal cancer and likely reflects surgical technique [1,2]. Highquality surgical studies have found the rates of local recurrence for colon cancer to be in the order of 1% [3,4]. However, similar high-quality surgical studies have found rates of local recurrence of rectal cancer to vary between 5 and 30% [2,5,6]. In addition, rates of postoperative anastomotic leak for patients under going surgery for colon cancer differ from those of patients undergoing surgery for rectal cancer by a factor of 2–30 [7–9]. Finally, the preoperative evaluation and treatment of patients with rectal cancer is more involved than patients with colon cancer [10,11]. Given the obvious difference between cancers of the colon and rectum, the next task is to consider the operative approach of these distinct problems. We know from high-quality randomized controlled trials that a laparoscopic surgical approach to colon cancer does not lead to inferior oncological outcomes compared with open surgery [3,12,13]. We also know that laparoscopic colon surgery is more difficult than open colon surgery and involves a steep learning curve [14,15]. However, once surgeons learn the technique, the oncologic outcomes with laparoscopy are the same outcomes as with open surgery and low-volume experts perform as well as high-volume experts [13,16]. Finally, multiple investigators have reported highquality studies from large national databases demonstrating measurable benefits of laparoscopy over open surgery for the treatment of colon cancer and other colon diseases [17–19]. “Those who routinely treat cancers of the colon and rectum will be the first to agree that the surgical approach and oncological priorities for colon and rectal cancer are different.” EDITORIAL

Patterns and prognosis of locally recurrent rectal cancer following multidisciplinary treatment

To investigate the patterns and decisive prognostic factors for local recurrence of rectal cancer treated with a multidisciplinary team (MDT) modality. Ninety patients with local recurrence were studied, out of 1079 consecutive rectal cancer patients who underwent curative surgery from 1999 to 2007. For each patient, the recurrence pattern was assessed by specialist radiologists from the MDT using imaging, and the treatment strategy was decided after discussion by the MDT. The associations between clinicopathological factors and long-term outcomes were evaluated using both univariate and multivariate analysis. The recurrence pattern was classified as follows: Twenty-seven (30%) recurrent tumors were evaluated as axial type, 21 (23.3%) were anterior type, 8 (8.9%) were posterior type, and 13 (25.6%) were lateral type. Forty-one patients had tumors that were evaluated as resectable by the MDT and ultimately received surgery, and R0 resection was achieved in 36 (87.8%) of these patients. The recurrence pattern was closely associated with resectability and R0 resection rate (P < 0.001). The recurrence pattern, interval to recurrence, and R0 resection were significantly associated with 5-year survival rate in univariate analysis. Multivariate analysis showed that the R0 resection was the unique independent factor affecting long-term survival. The MDT modality improves patient selection for surgery by enabling accurate classification of the recurrence pattern; R0 resection is the most significant factor affecting long-term survival.

Mohs軟膏が著効した直腸がん術後遺残直腸断端再発出血の1例

Mohs軟膏が著効した直腸がん術後遺残直腸断端再発出血の1例

Local recurrence of rectal cancer in patients not receiving neoadjuvant therapy – the importance of resection margins

Local recurrence of rectal cancer reduces quality of life and survival. A multi-factorial linear logistic model was used to analyse risk factors for local recurrence in rectal cancer in patients not receiving preoperative chemo-radiation. A case-control study of patients with rectal cancer having surgery with curative intent, between 1996 and 2008. Eighteen putative risk factors for local recurrence were subjected to uni-variate analysis. Significant factors were selected for multi-factorial analysis. Twenty-one patients with local recurrence (cases) and 78 controls were selected. Uni-variate analysis showed significant associations with recurrence for nodal stage (N) (p=0.027), metastasis (M) (p=0.009), adjuvant chemotherapy (p=0.039), positive resection margin (R) (p=0.018) and American Joint Committee for Cancer (AJCC) tumours above stage II (p=0.043). Significant uni-variate odds ratios (OR) were obtained for the same factors. Two linear logistic models were fitted as (1) N, M, R1 status and adjuvant chemotherapy and (2) AJCC stage, R1 status and adjuvant chemotherapy. From both models, the only factor significantly associated (p ≤ 0.01) with local recurrence was found to be a positive resection margin (OR 4.81 and 5.51 respectively). A positive resection margin is the single factor affecting local recurrence of rectal cancer in patients not receiving neo-adjuvant therapy.

Reirradiation to the pelvis for recurrent rectal cancer

This study investigated late toxicity and infield progression-free survival in patients with locally recurrent rectal cancer (LRRC) who had previously received irradiation to the pelvis. Twenty-two patients were treated by reirradiation to the pelvis between January 2000 and August 2007. All patients received curative surgery with preoperative or postoperative chemoradiotherapy as an initial treatment. Five patients (23%) underwent surgical resection after reirradiation. The median follow-up duration was 20 months (range, 7-91 months). Two patients (9%) had grade-3 acute toxicity and eight patients (36%) had grade-3 to -4 late toxicity. The incidence of grade-3 to -4 late toxicity in the gastrointestinal and urinary system was 18% and 27%, respectively. Recurrent tumor location (axial or anterior) and surgical resection after reirradiation significantly influenced severe late toxicity (P = 0.024 and P = 0.039, respectively). In the 17 patients not undergoing surgery after reirradiation, median infield progression-free survival was 16 months. Reirradiation doses exceeding 50 Gy(αβ10) (equivalent dose in 2 Gy fractions) significantly increased the infield progression-free survival (P = 0.005). Tumor location (axial or anterior) and surgery after reirradiation may increase severe late toxicity. In addition, an EQD2 exceeding 50 Gy(αβ10) may improve infield control.

Improvement of the survival rate and life quality of patients with local recurrence of rectal cancer

Despite progress in the understanding of perirectal anatomy and subsequent adoption of total mesorectal excision,local recurrence after curative resection for rectal cancer continues to be a significant concern.Local recurrence of rectal cancer is associated with a wide spectrum of clinical symptoms and morbidities,and decreased quality of life.The management of locally recurrent rectal cancer is challenging because of the altered pelvic anatomy,postoperative adhesion and difficulty in obtaining a definite diagnosis before surgery.Surgery is the mainstay treatment for locally recurrent rectal cancer,and the use of radiation and chemotherapeutic agents provides significant improvement in survival rate and quality of life. Key words: Rectal neoplasms ; Local recurrence; Life quality; Survival rate

PP 6 The metabolic response using FDG/PET for predicting tumor response and prognosis after pre-operative chemoradiotherapy (CRT) in patients with locally recurrent rectal cancer (LRRC)

PP 6 The metabolic response using FDG/PET for predicting tumor response and prognosis after pre-operative chemoradiotherapy (CRT) in patients with locally recurrent rectal cancer (LRRC)

Management of local recurrence of rectal cancer

Management of local recurrence of rectal cancer

Surgical outcomes for 187 patients with locally recurrent rectal cancer and analysis of prognostic factors

To evaluate the surgical outcomes for patients with locally recurrent rectal cancer (LRRC) and to analyze the prognostic factors. Clinical data of 187 patients with LRRC undergoing surgery at the First Hospital of peking University from January 1985 to December 2009 were retrospectively reviewed. Procedures performed included local resection(n=34), abdominoperineal resection (n=35), posterior pelvic exenteration (n=17), total pelvic exenteration(TPE, n=98), TPE with sacrectomy (n=2), and TPE with internal hemipelvectomy (n=1). The operation was R0 in 87 patients, R1 in 60, and R2 in 40. The degree of radical resection was associated with the initial surgery and the degree of pelvic fixation (P<0.05). The pelvic recurrence rate was 44.4%(64/144). The operative morbidity and mortality were 47.5%(89/187) and 2.7%(5/187), respectively. The overall 3- and 5-year survival rates were 42.2% and 30.7%, respectively. The degree of radical resection and lymph node metastasis were independent risk factors associated with prognosis. The 5-year survival rates of R0, R1 and R2 were 42.6%, 17.2% and 0, respectively(P<0.01). The 5-year survival rates of patients with and without lymph node metastasis were 5.6% and 40.5%(P<0.01) respectively. Accurate evaluation of extent of pelvic fixation and achievement of R0 resection are critical to improve the surgical outcomes for LRRC.

Clinical outcomes of chemoradiotherapy for locally recurrent rectal cancer

BackgroundTo 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.MethodsBetween 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.ResultsThe 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.ConclusionsChemoradiotherapy 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.

Tumour budding correlates with local recurrence of rectal cancer

Predictive tools for local recurrence (LR) of rectal cancer are needed. This study assessed the predictive value of tumour budding detected by MNF-116 and laminin-5 γ2 chain (Ln-5 γ2). In a case-control study, the surgical specimens of 48 patients with LR after from primary resection of rectal carcinoma and 82 control patients matched for gender and preoperative radiation from a population of 1180 patients operated with total mesorectal excision were studied. The presence of budding was examined using immunohistochemistry with Ln-5 γ2 and pan-cytokeratin staining with MNF-116. Tumour budding counts ranged from 0 to 106 buds (mean 43, median 38) for all patients. Significantly more tumours with more than 35 buds were seen in the LR than in the control group (67 vs 44%; P = 0.02). The spread of budding was also more extensive in the LR than in the control group (63 vs 49%, P = 0.03). In a multivariate analysis with tumour, node, metastasis stage, MNF-116-stained budding was an independent predictor of local failure (P = 0.02). The budding frequency was higher in irradiated tumours in comparison with tumours that had not received irradiation (mean 53 vs 38, P = 0.03). For Ln-5 γ2, more tumours with ≥ 10 buds were seen in the group with LR than among the control patients, but this difference was not statistically significant (73 vs 57%; P = 0.09). No additive value was found in the multivariate logistic regression model when Ln-5 γ2-stained budding frequency was added to MNF-116 and tumour, node, metastasis stage. The agreement between budding frequency determined by MNF-116 and Ln-5 γ2 was moderate, with a κ-coefficient of 0.34 (0.16-0.51). Tumour budding determined by MNF-116 staining may serve as a predictive marker for LR in rectal cancer.