Local Recurrence Of Rectal Cancer Research Articles

Local Recurrence in Rectal Cancer: Small Absolute Numbers in a BIG Problem.

Local Recurrence in Rectal Cancer: Small Absolute Numbers in a BIG Problem.

Modern Techniques in Re-Irradiation for Locally Recurrent Rectal Cancer: A Systematic Review.

Radiotherapy (RT) plays an important role in the treatment of patients with previously irradiated locally recurrent rectal cancer (LRRC). Over the years, numerous technologies and different types of RT have emerged. The aim of our systematic literature review was to determine whether the new techniques have led to improvements in both outcomes and toxicities. A computerized search was performed by MEDLINE and the Cochrane database. The studies reported data from patients treated with carbon ion radiotherapy (CIRT), intensity-modulated photon radiotherapy (IMRT), and stereotactic radiotherapy (SBRT). Seven publications of the 126 titles/abstracts that emerged from our search met the inclusion criteria and presented outcomes of 230 patients. OS was reported with rates of 90.0% and 73.0% at 1 and 2 years, respectively; LC was 89.0% and 71.6% at 1 and 2 years after re-RT, respectively. Toxicity data vary widely, with emphasis on acute and chronic gastrointestinal and urogenital toxicity, even with modern techniques. data on toxicity and outcomes of re-RT for LRRC with new technologies are promising compared with 3D techniques. Comparative studies are needed to define the best technique, also in relation to the site of recurrence.

Definitive carbon ion re-irradiation with pencil beam scanning in the treatment of unresectable locally recurrent rectal cancer.

This study aimed to evaluate the oncological outcomes and safety of carbon ion re-irradiation with pencil beam scanning (PBS) delivery technique for previously irradiated and unresectable locally recurrent rectal cancer (LRRC). Between June 2017 and September 2021, 24 patients of unresectable LRRC with prior pelvic photon radiotherapy who underwent carbon ion re-irradiation at our institute were retrospectively analyzed. Carbon ion radiotherapy was delivered by raster scanning with a median relative biological effectiveness-weighted dose of 72Gy in 20 fractions. Weekly CT reviews were carried out, and offline adaptive replanning was performed whenever required. The median follow-up duration was 23.8months (range, 6.2-47.1months). At the last follow-up, two patients had a local disease progression, and 11 patients developed distant metastases. The 1- and 2-year local control, progression-free survival and overall survival rates were 100 and 93.3%, 70.8 and 45.0% and 86.7 and 81.3%, respectively. There were no Grade 3 or higher acute toxicities observed. Three patients developed Grade 3 late toxicities, one each with gastrointestinal toxicity, skin reaction and pelvic infection. In conclusion, definitive carbon ion re-irradiation with PBS provided superior oncologic results with tolerable toxicities and may be served as a curative treatment strategy in unresectable LRRC.

Implementation of an Enhanced Recovery after Surgery Protocol in Advanced and Recurrent Rectal Cancer Patients after beyond Total Mesorectal Excision Surgery: A Feasibility Study.

The implementation of an Enhanced Recovery After Surgery (ERAS) protocol in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) has been deemed unfeasible until now because of the heterogeneity of this disease and low caseloads. Since evidence and experience with ERAS principles in colorectal cancer care are increasing, a modified ERAS protocol for this specific group has been developed. The aim of this study is to evaluate the implementation of a tailored ERAS protocol for patients with LARC or LRRC, requiring beyond total mesorectal excision (bTME) surgery. Patients who underwent a bTME for LARC or LRRC between October 2021 and December 2022 were prospectively studied. All patients were treated in accordance with the ERAS LARRC protocol, which consisted of 39 ERAS care elements specifically developed for patients with LARC and LRRC. One of the most important adaptations of this protocol was the anaesthesia procedure, which involved the use of total intravenous anaesthesia with intravenous (iv) lidocaine, iv methadone, and iv ketamine instead of epidural anaesthesia. The outcomes showed compliance with ERAS care elements, complications, length of stay, and functional recovery. A follow-up was performed at 30 and 90 days post-surgery. Seventy-two patients were selected, all of whom underwent bTME for either LARC (54.2%) or LRRC (45.8%). Total compliance with the adjusted ERAS protocol was 73.6%. Major complications were present in 12 patients (16.7%), and the median length of hospital stay was 9 days (IQR 6.0-14.0). Patients who received multimodal anaesthesia (75.0%) stayed in the hospital for a median of 7.0 days (IQR 6.8-15.5). These patients received fewer opioids on the first three postoperative days than patients who received epidural analgesia (p < 0.001). The implementation of the ERAS LARRC protocol seemed successful according to its compliance rate of >70%. Its complication rate was substantially reduced in comparison with the literature. Multimodal anaesthesia is feasible in beyond TME surgery with promising effects on recovery after surgery.

Redo Pelvic Surgery and Combined Metastectomy for Locally Recurrent Rectal Cancer with Known Oligometastatic Disease: A Multicentre Review.

Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. 'Selective' patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates. A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes. Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/- 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/- 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5-17.5 months) and 25.9 months (IQR 6.2-39.7 months), respectively. Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.

Utility of circulating tumour DNA for prognosis and prediction of therapeutic effect in locally recurrent rectal cancer: study protocol for a multi-institutional, prospective observational study (JCOG1801A1, CAP-LR study)

IntroductionIn locally recurrent rectal cancer (LRRC), surgery is a standard treatment for resectable disease. However, short-term and long-term outcomes are unsatisfactory due to the invasive nature of surgical procedures and...

Pathological determinants of outcome following resection of locally advanced or locally recurrent rectal cancer

IntroductionPathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance. Materials and methodsA retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS). Results388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49–67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC. ConclusionsA positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.

Pattern of care for re-irradiation in locally recurrent rectal cancer: a national survey on behalf of the AIRO gastrointestinal tumors study group

PurposeRadical resection (R0) represents the best curative treatment for local recurrence (LR) rectal cancer. Re-irradiation (re-RT) can increase the rate of R0 resection. Currently, there is a lack of guidelines on Re-RT for LR rectal cancer. The Italian Association of Radiation and clinical oncology for gastrointestinal tumors (AIRO-GI) study group released a national survey to investigate the current clinical practice of external beam radiation therapy in these patients.Material and methodsIn February 2021, the survey was designed and distributed to members of the GI working group. The questionnaire consisted of 40 questions regarding center characteristics, clinical indications, doses, and treatment techniques of re-RT for LR rectal cancer.ResultsA total of 37 questionnaires were collected. Re-RT was reported as an option for neoadjuvant treatment in resectable and unresectable disease by 55% and 75% of respondents, respectively. Long-course treatment with 30–40 Gy (1.8–2 Gy/die, 1.2 Gy bid) and hypofractionated regimen of 30–35 Gy in 5 fractions were used in most centers. A total dose of 90–100 Gy as EqD2 dose (α/β = 5 Gy) was delivered by 46% of the respondents considering the previous treatment. Modern conformal techniques and daily image-guided radiation therapy protocols were used in 94% of centers.ConclusionOur survey showed that re-RT treatment is performed with advanced technology that allow a good management of LR rectal cancer. Significant variations were observed in terms of dose and fractionation, highlighting the need for a consensus on a common treatment strategy that could be validated in prospective studies.

Local Recurrences in Rectal Cancer: MRI vs. CT

Rectal cancers are often considered a distinct disease from colon cancers as their survival and management are different. Particularly, the risk for local recurrence (LR) is greater than in colon cancer. There are many factors predisposing to LR such as postoperative histopathological features or the mesorectal plane of surgical resection. In addition, the pattern of LR in rectal cancer has a prognostic significance and an important role in the choice of operative approach and. Therefore, an optimal follow up based on imaging is critical in rectal cancer. The aim of this review is to analyse the risk and the pattern of local recurrences in rectal cancer and to provide an overview of the role of imaging in early detection of LRs. We performed a literature review of studies published on Web of Science and MEDLINE up to January 2023. We also reviewed the current guidelines of National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO). Although the timing and the modality of follow-up is not yet established, the guidelines usually recommend a time frame of 5 years post surgical resection of the rectum. Computed Tomography (CT) scans and/or Magnetic Resonance Imaging (MRI) are the main imaging techniques recommended in the follow-up of these patients. PET-CT is not recommended by guidelines during post-operative surveillance and it is generally used for problem solving.

Construction and validation of a prognostic nomogram for locally recurrent rectal cancer: a population-based study.

Postoperative recurrence was a life-threatening condition for patients with rectal cancer. Due to the heterogeneity of locally recurrent rectal cancer (LRRC) and controversy of the optimal treatment for patients, it was difficult to predict the prognosis of LRRC. This study aimed to develop and validate a nomogram that could accurately predict the survival probability of LRRC. Patients diagnosed with LRRC between 2004 and 2019 from the Surveillance, Epidemiology, and End Results (SEER) database were included in the analysis. Multiple imputations with chained equations were used for missing values. These patients were further randomized into training set and testing set. Cox regression was used for univariate and multivariate analysis. Potential predictors were screened by the least absolute shrinkage and selection operator (LASSO). The Cox hazards regression model was constructed and it was visualized by nomogram. C-index, calibration curve, and decision curve were used to evaluate the model's predictive ability. Then X-tile was used to calculate the optimal cut-off values for all patients and the cohort was divided into three groups. A total of 744 LRRC patients were enrolled and allocated to the training set (n=503) and the testing set (n=241). Cox regression analysis of the training set yielded meaningfully clinicopathological variables. A survival nomogram was created based on the identification of ten clinicopathological features in the LASSO regression analyses of the training set. The C-index of 3-, 5-year survival probabilities were 0.756, 0.747 in training set, and 0.719, 0.726 in testing set, respectively. The calibration curve and decision curve both demonstrated the satisfactory performance of the nomogram for prognosis prediction. Moreover, the prognosis of LRRC could be well distinguished according to the grouping of risk scores (P<0.001 in three groups). This nomogram was the first prediction model to preliminarily evaluate the survival of LRRC patients, which could provide more accurate and efficient treatment in clinical practice.

Development and validation of a patient reported outcome measure for health-related quality of life for locally recurrent rectal cancer: a multicentre, three-phase, mixed-methods, cohort study

Locally recurrent rectal cancer (LRRC) occurs in 5-10% of patients following previous treatment of rectal cancer. It has a significant impact on patients' overall health-related quality of life (HrQoL). Major advances in surgical treatments have led to improved survival outcomes. However, due to the lack of disease-specific, validated patient-reported outcome measure (PROM), HrQoL, is variably assessed. The aim of this study is to develop a disease-specific, psychometrically robust, and validated PROM for use in LRRC. A multicentre, three phase, mixed-methods, observational study was performed across five centres in the UK and Australia. Adult patients (>18 years old) with an existing or previously treated LRRC within the last 2 years were eligible to participate. Patients completed the proposed LRRC-QoL, EORTC QLQ-CR29, and FACT-C questionnaires. Scale structure was analysed using multi-trait scaling analysis and exploratory factor analysis, reliability was assessed using Cronbach's and the intra-class coefficient, convergent validity was assessed using Pearson's correlation, and known-groups comparison was assessed using the student t-test or ANOVA. Between 01/03/2015 and 31/12/2019, 117 patients with a diagnosis of LRRC were recruited. The final scale structure of the LRRC-QoL consisted of nine multi-item scales (healthcare services, psychological impact, pain, urostomy-related symptoms, lower limb symptoms, stoma, sexual function, sexual interest, and urinary symptoms) and three single items. Cronbach's Alpha and Intraclass correlation values of >0.7 across the majority of scales supported overall reliability. Convergent validity was demonstrated between LRRC-QoL Pain Scale and FACT-C Physical Well Being scale (r=0.528, p<0.001), LRRC-QoL Psychological Impact scale with EORTC QLQ CR29 Body Image (r=0.680, p<0.001) and the FACT-C Emotional Well Being scale (r=0.326, p<0.001), and LRRC-QoL Urinary Symptoms scale with EORTC QLQ-CR29 Urinary Frequency scale (r=0.310, p<0.001). Known-groups validity was demonstrated for gender, disease location, treatment intent, and re-recurrent disease. The LRRC-QoL has demonstrated robust psychometric properties and can be used in clinical and academic practice. None.

Surgical skills and precautions of pelvic exenteration combined with pelvic wall resection

The treatment of locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) has been a difficulty and challenge in the field of advanced rectal cancer, while pelvic exenteration (PE), as an important way to potentially achieve radical treatment of LARC and LRRC, has been shown to significantly improve the long-term prognosis of patients. The implementation of PE surgery requires precise assessment of the extent of invasion of LARC or LRRC and adequate preoperative preparation through multidisciplinary consultation before surgery. The lateral pelvis involves numerous tissues, blood vessels, and nerves, and resection is most difficult, and the ureteral and Marcille triangle approaches are recommended; while the supine transabdominal approach combined with intraoperative change to the prone jacket position facilitates adequate exposure of the surgical field and enables precise overall resection of the bony pelvis and pelvic floor muscle groups invaded by the tumor. Empty pelvic syndrome has always been an major problem to be solved during PE. The application of extracellular matrix biological mesh to reconstruct pelvic floor defects and isolate the abdominopelvic cavity is expected to reduce postoperative pelvic floor related complications. Reconstruction of the urinary system and important vessels after PE is essential, and the selection of appropriate reconstruction methods helps to improve the patient's postoperative quality of life, while more new methods are also being continuously explored.

Interpretation of Chinese expert consensus on the pelvic exenteration for primary rectal cancer beyond total mesorectal excision planes and locally recurrent rectal cancer (2023 edition)

The China PelvEx Collaborative, under the direction of Colorectal Cancer Committee of the Chinese Medical Doctor Association, Gastrointestinal Surgery Committee of China International Exchange and Promotive Association for Medical and Health, has formulated and issued the Chinese expert consensus for primary rectal cancer beyond total mesorectal excision planes and locally recurrent rectal cancer (2023 edition) , with the academic support of the Chinese Journal of Gastrointestinal Surgery and Chinese Journal of Colorectal Disease (Electronic Edition). This Consensus refers to the expert consensus developed by the International PelvEx Collaboration, incorporates the latest international multi-center research results and combines the latest research results in China. The Consensus unifies some definitions, clarifies the surgical indications, and puts forward the definition and preventive measures of "empty pelvic syndrome" earlier. For the controversial classification of local recurrent rectal cancer, the Chinese classification was proposed for the first time in Consensus. At the same time, the definition of pelvic exenteration is controversial, and a more consistent cognition is proposed. It is believed that, with the in-depth research on complicated rectal cancer, C-PelvEx will gather more higher-level data from clinical research in several domestic centers, so as to further enrich the content of the updated Consensus.

Locally recurrent rectal cancer and distant metastases: is there still a chance ofcure?

IntroductionPatients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment. MethodsConsecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases. ResultsA total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15–2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039). ConclusionLRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.

Radiomic Features from Post-Operative 18F-FDG PET/CT and CT Imaging Associated with Locally Recurrent Rectal Cancer: Preliminary Findings

Locally Recurrent Rectal Cancer (LRRC) remains a major clinical concern; it rapidly invades pelvic organs and nerve roots, causing severe symptoms. Curative-intent salvage therapy offers the only potential for cure but it has a higher chance of success when LRRC is diagnosed at an early stage. Imaging diagnosis of LRRC is very challenging due to fibrosis and inflammatory pelvic tissue, which can mislead even the most expert reader. This study exploited a radiomic analysis to enrich, through quantitative features, the characterization of tissue properties, thus favoring an accurate detection of LRRC by Computed Tomography (CT) and 18F-FDG-Positron Emission Tomography/CT (PET/CT). Of 563 eligible patients undergoing radical resection (R0) of primary RC, 57 patients with suspected LRRC were included, 33 of which were histologically confirmed. After manually segmenting suspected LRRC in CT and PET/CT, 144 Radiomic Features (RFs) were generated, and RFs were investigated for univariate significant discriminations (Wilcoxon rank-sum test, p < 0.050) of LRRC from NO LRRC. Five RFs in PET/CT (p < 0.017) and two in CT (p < 0.022) enabled, individually, a clear distinction of the groups, and one RF was shared by PET/CT and CT. As well as confirming the potential role of radiomics to advance LRRC diagnosis, the aforementioned shared RF describes LRRC as tissues having high local inhomogeneity due to the evolving tissue's properties.

Locally Recurrent Rectal Cancer: Toward a Second Chance at Cure? A Population-Based, Retrospective Cohort Study

BackgroundIn current practice, rates of locally recurrent rectal cancer (LRRC) are low due to the use of the total mesorectal excision (TME) in combination with various neoadjuvant treatment strategies. However, the literature on LRRC mainly consists of single- and multicenter retrospective cohort studies, which are prone to selection bias. The aim of this study is to provide a nationwide, population-based overview of LRRC after TME in the Netherlands.Patients and MethodsIn total, 1431 patients with nonmetastasized primary rectal cancer diagnosed in the first six months of 2015 and treated with TME were included from the nationwide, population-based Netherlands Cancer Registry. Data on disease recurrence were collected for patients diagnosed in these 6 months only. Competing risk cumulative incidence, competing risk regression, and Kaplan–Meier analyses were performed to assess incidence, risk factors, treatment, and overall survival (OS) of LRRC.ResultsThree-year cumulative incidence of LRRC was 6.4%; synchronous distant metastases (LRRC-M1) were present in 44.9% of patients with LRRC. Distal localization, R1–2 margin, (y)pT3-4, and (y)pN1-2 were associated with an increased LRRC rate. No differences in LRRC treatment and OS were found between patients who had been treated with or without prior n(C)RT. Curative-intent treatment was given to 42.9% of patients with LRRC, and 3-year OS thereafter was 70%.ConclusionsNationwide LRRC incidence was low. A high proportion of patients with LRRC underwent curative-intent treatment, and OS of this group was high in comparison with previous studies. Additionally, n(C)RT for primary rectal cancer was not associated with differences in treatment and OS of LRRC.

Outcomes and Prognostic Factors for Locally Recurrent Rectal Cancer Treated With Proton Beam Therapy

Our objective was to report the outcome and prognostic factors for patients with locally recurrent rectal cancer (LRRC) treated with proton beam therapy (PBT) at our institution. The study included PBT-treated patients with LRRC between December 2008 and December 2019. Treatment response was stratified using an initial imaging test after PBT. Overall survival (OS), progression-free survival (PFS), and local control (LC) were estimated using the Kaplan-Meier method. Each outcome's prognostic factors were verified using the Cox proportional hazards model. Twenty-three patients were enrolled (median follow-up, 37.4 months). There were 11 patients with complete response (CR) or complete metabolic response (CMR), 8 with partial response or partial metabolic response, 2 with stable disease or stable metabolic response, and 2 with progressive disease or progressive metabolic disease. Three- and 5-year OS, PFS, and LC were 72.1% and 44.6%, 37.9% and 37.9%, and 55.0% and 47.2%, respectively, with 54.4 months' median survival time. The maximum standardized uptake value of fluorine-18-fluorodeoxyglucose-positron emission tomography-computed tomography (18F-FDG-PET/CT) before PBT (cutoff value, 10) showed significant differences in OS (P=.03), PFS (P=.027), and LC (P=.012). The patients who achieved CR or CMR after PBT had significantly better LC than those with non-CR or non-CMR (hazard ratio, 4.49; 95% confidence interval, 1.14-17.63; P=.021). Older patients (aged ≥65 years) had significantly higher LC and PFS rates. Patients with pain before PBT and larger tumors (≥30 mm) also had significantly lower PFS. Of 23 patients, 12 (52%) experienced further local recurrence after PBT. One patient developed grade 2 acute radiation dermatitis. Regarding late toxicity, grade 4 late gastrointestinal toxic effects were recorded in 3 patients, in 2 of whom reirradiation was associated with further local recurrence after PBT. The results showed that PBT may have potential to be a good treatment option for LRRC. 18F-FDG-PET/CT before and after PBT may be useful for assessing tumor response and predicting outcomes.

Rectal cancer pelvic recurrence: imaging patterns and key concepts to guide treatment planning.

For rectal cancer, MRI plays an important role in assessing extramural tumor spread and informs surgical planning. The contemporary standardized management of rectal cancer with total mesorectal excision guided by imaging-based risk stratification has dramatically improved patient outcomes. Colonoscopy and CT are utilized in surveillance after surgery to detect intraluminal and extramural recurrence, respectively; however, local recurrence of rectal cancer remains a challenge because postoperative changes such as fat necrosis and fibrosis can resemble tumor recurrence; additionally, mucinous adenocarcinoma recurrence may mimic fluid collection or abscess on CT. MRI and 18F-FDG PET are problem-resolving modalities for equivocal imaging findings on CT. Treatment options for recurrent rectal cancer include pelvic exenteration to achieve radical (R0 resection) resection and intraoperative radiation therapy. After pathologic diagnosis of recurrence, imaging plays an essential role for evaluating the feasibility and approach of salvage surgery. Patterns of recurrence can be divided into axial/central, anterior, lateral, and posterior. Some lateral and posterior recurrence patterns especially in patients with neurogenic pain are associated with perineural invasion. Cross-sectional imaging, especially MRI and 18F-FDG PET, permit direct visualization of perineural spread, and contribute to determining the extent of resection. Multidisciplinary discussion is essential for treatment planning of locally recurrent rectal cancer. This review article illustrates surveillance strategy after initial surgery, imaging patterns of rectal cancer recurrence based on anatomic classification, highlights imaging findings of perineural spread on each modality, and discusses how resectability and contemporary surgical approaches are determined based on imaging findings.

Locally recurrent rectal cancer: towards a second chance at cure?

Background: Neoadjuvant (chemo)radiation (n(C)RT) in combination with total mesorectal excision (TME) for primary rectal cancer is associated with low rates of locally recurrent rectal cancer (LRRC), but can jeopardize LRRC management as there are limitations to the radiation dose. The primary aim of this study was to provide an overview of LRRC after TME in the Netherlands, with a secondary focus on the impact of n(C)RT for primary rectal cancer on outcomes of LRRC.

Chinese expert consensus on the pelvic exenteration for primary rectal cancer beyond total mesorectal excision planes and locally recurrent rectal cancer (2023 edition)

Pelvic exenteration is often required for primary rectal cancer beyond total mesorectal excision (PRC-bTME) and locally recurrent rectal cancer (LRRC). Some patients with radical resection can achieve long-term survival, but they need to face risks, such as huge surgical trauma, serious perioperative complications, permanent loss of organ function and decline in quality of life. Preoperative evaluation of PRC-bTME and LRRC should emphasize multidisciplinary collaboration, and develop individualized diagnosis and treatment strategies. The principles of function preservation and risk-benefit balance in surgery oncology should be followed, and R0 resection should be emphasized. Perioperative complications, surgical trauma and organ function loss should be minimized to achieve the best quality control and balance point. This consensus was formulated by the Colorectal Cancer Committee of the Chinese Medical Doctor Association and the Gastrointestinal Surgery Committee of China International Exchange and Promotive Association for Medical and Health Care. The draft was formed based on the summary of domestic and foreign research progress and expert experience. After discussion, review and modification by experts, an anonymous voting was conducted for each major opinion, and in-depth verification was carried out according to the principles of evidence-based medicine. Finally, the Chinese expert consensus on the pelvic exenteration with primary rectal cancer beyond total mesorectal excision planes and locally recurrent rectal cancer (2023 edition) was formed. This consensus mainly summarizes the indications and contraindications of PE for PRC-bTME and LRRC, preoperative diagnosis and evaluation, perioperative treatment, as well as the resection scope, surgical methods, reconstruction of related organs, safety and complications of PE, postoperative follow-up and other issues, in order to provide guidance for PE in patients with PRC-bTME and LRRC.