Locally recurrent rectal cancer: Role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence

• Published in: Journal of surgical oncology 2000-01, Vol.73 (1), p.47-58
• Main Authors: Temple, Walley J., Saettler, Elizabeth B.
• Format: Article
• Language: English
• Subjects: Biological and medical sciences; Brachytherapy; Chemotherapy, Adjuvant; composite resection; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Intraoperative Care; Medical sciences; Neoplasm Recurrence, Local - prevention & control; Neoplasm Recurrence, Local - surgery; Palliative Care; Patient Selection; Pelvic Exenteration - methods; Prospective Studies; Radiotherapy, Adjuvant; Reconstructive Surgical Procedures; Rectal Neoplasms - prevention & control; Rectal Neoplasms - surgery; Rectum - surgery; recurrent rectal cancer; Risk Factors; Salvage Therapy; Stomach, duodenum, intestine, rectum, anus; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Survival Rate; total mesorectal excision; Tumors
• ISSN: 0022-4790; 1096-9098
• DOI: 10.1002/(SICI)1096-9098(200001)73:1<47::AID-JSO12>3.0.CO;2-M

Locally recurrent cancer of the rectum has been under‐recognized as a complication, although it affects up to 40% of patients treated with surgery alone. Even in the best centers, rates average 25%. While radiotherapy may reduce recurrence, it is now apparent that total mesorectal excision is the most effective modality, with rates as low as 5%. The dramatic decrease in local recurrence can also be linked to increased survival in prospective studies, an effect more significant than any adjuvant therapy. The options, however, for patients with locally recurrent cancer are limited. Fifteen percent of patients with this complication die without systemic spread. Salvage by surgery offers potential cure. Other than anastomotic recurrences that can be locally resected, the best approach for long‐term survival is an extensive surgical procedure requiring en bloc removal of adjacent organs and pelvic structures—so‐called composite resection. With careful selection, 30% 5‐year survival can be achieved and palliation is considerable, with 50% long‐term local control. Intraoperative radiotherapy and brachytherapy, and/or preoperative chemoradiation may provide better results in future. Newer techniques of coloanal anastomosis, improved urinary diversion, and myocutaneous flaps for perineal reconstruction radically reduce the morbidity of these procedures. The approach to recurrent rectal cancer requires a sophisticated multidisciplinary team to obtain optimum results. J. Surg. Oncol. 2000;73:47–58. © 2000 Wiley‐Liss, Inc.