Salvage therapy for pelvic recurrence following curative rectal cancer resection

Site-specific risk factors for local recurrence after rectal cancer surgery

BACKGROUND

Quite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites.

METHODS

Local recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the "other" type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the "other" type of local recurrence.

RESULTS

Univariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the "other" type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the "other" type of local recurrence.

CONCLUSION

Risk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors.

TRIAL REGISTRATION NUMBER

UMIN000021353.

Salvage surgery for locally recurrent rectal cancer: total mesorectal excision during the primary operation does not influence the outcome

AIM

This study investigated whether total mesorectal excision (TME), when carried out at the original operation for rectal cancer, influenced the effectiveness of subsequent salvage treatment for pelvic recurrence.

METHOD

Between September 1990 and January 2006, 124 patients underwent radiotherapy and salvage surgery at the Norwegian Radium Hospital for locally recurrent rectal cancer without known distant metastases. Most of the primary operations had been performed at other hospitals: 62 patients had undergone a non-TME procedure (most operations in this group of patients were carried out before 1994); and 62 patients had undergone a TME procedure (all operations in this group of patients were carried out after 1992). In the TME group, 17 patients also received radiosensitizing chemotherapy.

RESULTS

A lower proportion of primary abdominoperineal resection and more sensitizing chemotherapy seemed to be to the advantage of the TME group, while a higher frequency of intra-operative radiotherapy might be beneficial in the non-TME group. The 5-year survival and R0 stage achievement were 30/24% and 44/40% for non-TME/TME groups. The local re-recurrence rates were nearly identical, at around 50%, for both groups. There was no change in R stage over time.

CONCLUSION

A primary operation which includes TME does not reduce the effectiveness of subsequent salvage treatment for locally recurrent rectal cancer.

Interstitial permanent implantation of 125I seeds as salvage therapy for re-recurrent rectal carcinoma

PURPOSE

To assess the feasibility, efficacy, and morbidity of (125)I seeds interstitial permanent implant as salvage therapy for re-recurrent rectal cancer.

METHODS AND MATERIALS

From September 2003 to October 2007, (125)I seeds implant procedures were performed under CT or ultrasound guidance for thirteen patients with locally re-recurrent rectal carcinoma. The minimal peripheral doses (MPD) of (125)I seeds implanted ranged from 120 to 160 Gy, with a median MPD of 140 Gy to total decay. Three patients also received two to four cycles of chemotherapy after seed implantation.

RESULTS

After a median follow-up of 10 months (range 3-45), the pain-free interval was 0-14 months with a median of 7 months (95% CI: 3-11 months). The response rate of pain relief was 46.2% (6/13). Local control was 3-14 months with a median of 7 months (95% CI: 3.5-10.5 months). The 1- and 2-year local control rates were 14.4% and 0%, respectively. Three (23.1%) patients died of local recurrence; seven (53.8%) patients died of local recurrence and metastases; one (7.7%) patient died of metastases. Two (15.4%) patients survived to follow-up. At the time of analysis, the median survival was 10 months (95% CI: 3.9-16.1 months). The 1- and 2-year actuarial overall survival rates were 46.2% and 11.5%, respectively. Two (15.4%) patients experienced a grade 4 toxic event. Seed migration to the pelvic wall was observed in one (7.7%) patient. There was no associated neuropathy.

CONCLUSION

(125)I seed implantation is feasible, effective, and safe as a salvage or palliative treatment for patients with re-recurrent rectal cancer.

Resection of isolated pelvic recurrences after colorectal surgery: long-term results and predictors of improved clinical outcome

BACKGROUND

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of perioperative morbidity and potential mortality. Clinical decision making remains difficult.

METHODS

Patients resected with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathologic factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome.

RESULTS

Ninety patients underwent an attempt at curative resection of a pelvic recurrence with median follow-up of 31 months. Complications occurred in 53% of patients. Operative mortality was 4.4% (4 of 90). Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome.

CONCLUSIONS

The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.

Resection of Isolated Pelvic Recurrences After Colorectal Surgery: Long-Term Results and Predictors of Improved Clinical Outcome

BACKGROUND

Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of marked perioperative morbidity and potential mortality. Clinical decision making remains difficult.

METHODS

Patients who underwent resection with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathological factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome.

RESULTS

Ninety patients underwent an attempt at curative resection of a pelvic recurrence; median follow-up was 31 months. Complications occurred in 53% of patients. Operative mortality occurred in 4 (4.4%) of 90 patients. Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome.

CONCLUSIONS

The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.

Salvage rectal surgery--overview

Recurrence of the disease represents the major problem in patients who undergo "curative" resection for rectal cancer, with published rate ranging from 3 to 50%. Most relapses occur within first two years of follow-up. Depending on the site of the recurrence, it can be local or distant. It also can be solitary or diffuse. In terms of potential surgical cure the best results are achieved with solitary, localized metastases. The most common sites of the solitary metastases are pelvis, liver and lung, with a fairly even distribution among these three sites. Other sites of the localized metastases can be peritoneum, lymph nodes, brain, bone, abdominal wall, ureter and kidney. These sites are less common, but not so amenable to resection. Local recurrence varies depending on the original type of surgery. It can be stated that surgical technique directly influences local recurrence rate in patients with rectal cancer. According to the results from a number of different authors 5-year survival rate after reresection is 2-13% of all patients with locally recurrent cancer, both alone and associated with distant metastases. The most important moment in this problem is to decide when not to operate. The absolute contraindications for salvage surgery are: "frozen pelvis", aneuploid tumors and those with mucinous component, clinical or CT evidence of invasion of the pelvic nerves, lymphatics or veins, or ureter bilaterally. Also, evidence of involvement of the lateral pelvic sidewalls and/or upper sacral marrow, and/or S2 is an absolute contraindication for surgery. Thus, main goals of this type of surgery are respectively: palliation of symptoms, a good quality of life and, if possible, cure with low treatment-related complication rates.

Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns

BACKGROUND

Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns.

METHODS

Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted.

RESULTS

Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8-28]), a local disease-free interval of <12 months (4.2 [1.8-9.8]), and pain radiating to the buttock or further (4.2 [1.6-11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4-40]). Of the patients with recurrence, 56% had failures confined locally or to the lung.

CONCLUSIONS

ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease-free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.

Prognostic factors after surgery for locally recurrent rectal cancer: an overview

PURPOSE

Local recurrence of rectal cancer occurs in a considerable group of patients who have undergone radical treatment for primary tumour. The treatment of choice is surgical resection but the prognosis remains poor, as a negative margin excision is possible in only a small subset of patients. A review of prognostic factors for locally recurrent rectal cancer (LRRC) after surgery is presented.

METHODS

We systematically reviewed the literature for reports on prognostic factors after surgical excision of LRRC. These reports were identified through a review of the Medline database from 1982 to 2004.

RESULTS

This review highlights the most important prognostic factors for LRRC patients treated with surgery. Data are grouped on the basis of the prognostic factors investigated.

CONCLUSIONS

R0 resection seems to be the only reliable prognostic factor; however, symptoms, pre-operative CEA doubling time, performance status and pre-operative radiotherapy can help patient selection before surgery. The results of this review provide the basis for improved outcome, aiming to assess patients who would benefit from reoperation.

Tumor budding and evidence-based treatment of T2 rectal carcinomas

BACKGROUND

The validity of the histological criteria in deciding additional bowel resection after local excision of T2 rectal carcinomas is questioned.

METHODOLOGY

In 72 T2 colorectal carcinomas resected by major surgery, the associations between lymph node metastasis (LNM) and clinicopathologic parameters were examined statistically, a prediction formula for LNM was constructed and decision analysis was attempted.

RESULTS

Multivariate analysis showed that female gender and a greater number of tumor budding were significantly associated with LNM. The probability of LNM can be calculated as follows; Z = 0.037 x (budding number) + 2.08 x (SEX; male, 1; female, 2) - 5.736; Probability = 1/1 + e(-Z). When a 75-year-old patient has pulmonary complications, the operative risk is assumed to be over 2%. If a number of tumor budding is 0, the risk of LNM is calculated as 2.4% in a male and 17.1% in a female patient. On the assumption that the risk of liver metastasis is half of that of LNM, and the salvageabilities after LNM and liver metastasis are 20% and 50%, respectively, observation policy is justified for a male patient, whereas additional surgery should be undertaken for a female patient.

CONCLUSIONS

A number of tumor budding may be useful for determining the individualized treatment of T2 rectal carcinomas.

Radiological appearances in the pelvis following rectal cancer surgery

Radiology has a significant role in the evaluation of surgery for rectal cancer. With recent developments in surgical techniques, the number of neorectal reservoir configurations has increased. It is important to recognize the normal and abnormal appearances, both early and late, following pelvic surgery. The aim of this pictorial review is to demonstrate the imaging techniques that are used in both the investigation and the follow-up of patients who have undergone uncomplicated or complicated rectal resection.

Hydronephrosis as a prognostic factor in pelvic recurrence from rectal and colon carcinomas

BACKGROUND

After multimodal treatment estimated 5-year survival of locally recurrent rectal cancer is about 25%. Hydronephrosis secondary to pelvic recurrence of colorectal cancer is a condition claimed to represent a contraindication to surgery due to a dismal prognosis.

METHODS

Prospective registration of 193 consecutive patients operated for pelvic recurrence in rectal or colon cancer from January 1991 until March 2002 at a tertiary referral hospital, 121 men and 72 women, median age 67 years, all given irradiation preoperatively. Twenty-three of 193 had hydronephrosis prior to preoperative irradiation for recurrent disease.

RESULTS

R-0 stage resection was obtained in 22% of patients with hydronephrosis and in 41% without. The median survival times in patients without metastasis were 27 and 32 months, respectively, and 5-year survival rates were 11% and 25%.

CONCLUSIONS

An aggressive surgical approach offers patients with pelvic recurrence from rectal and colon cancer the best potential for survival. The presence of hydronephrosis probably indicates a lower chance for complete surgical resection of the recurrence, but local control and improved survival may still be achieved, and about two thirds of patients may benefit from the operation.

Operative treatment of locally recurrent rectal cancer

Few centres with varying regimens have published studies including more than 100 patients on the treatment of locally recurrent rectal cancer. The results vary considerably. Thus there seems to be a need for more studies to establish the potential benefit of a more widespread treatment of these cancers. In total, 193 patients had surgery for locally recurrent rectal cancers after preoperative irradiation 46-50 Gy in 2 Gy fractions. The patients were followed up and the data prospectively entered in a database. In 88 patients with primary low anterior resection, 3% had lower end of tumour located more than 2 cm above the anastomosis, 5% more than 2 cm below the anastomosis; 13% had exploratory laparotomy, 8% low anterior resections, the rest equally frequent abdomino-perineal resections, Hartmann's operations, and tumour resections. Nearly half had resection of part of the pelvic wall. Hysterectomy was performed in 15% and cystoprostatectomy in 9%. Three patients had en bloc prostatectomy. R0 resections were achieved in 39%, R1 in 36%, and R2 or no resection in 25%. R0 stage was twice as often achieved after a primary low anterior resection as after abdomino-perineal resections. The 30-days postoperative mortality was 1%. Postoperative morbidity was 48%, most frequently pelvic abscesses. Estimated 5-year survival was 18% for the total group. There was a statistically significant difference in survival and local re-recurrences between R0 / R1 and R2 stages. The results are discussed relative to recent studies. Patients in whom R0 resections can be achieved will benefit from the treatment, and probably patients with R1 resections would also benefit. Such operations should possibly be performed in specialised centres as joint ventures between various surgical subspecialities.

Management of the pelvic recurrence of rectal cancer with radiofrequency thermoablation: a case report and review of the literature

INTRODUCTION

The results of rectal cancer surgery are limited by the development of local recurrence (LR) that represents a great challenge to the surgeon. In the presence of unfavourable conditions for performing a curative operation, various forms of palliative treatment are indicated to control the patient's symptoms and the disease's complications. Recently, radiofrequency thermoablation (RFTA) has become a complimentary alternative therapy for malignant inoperable liver tumours. The present paper reports the use of RFTA in the management of pelvic recurrence of rectal adenocarcinoma.

CASE REPORT

Fourteen months after abdominoperineal resection, a 32-year-old woman began to complain of progressive pelvic and lumbar pain. A large pelvic mass was found and serum CEA was elevated (66.4 ng/ml) at that time. Due to the dimensions of the presacral tumour (8 x 5 x 4 cm3) and the associated refractory pain, the patient underwent RFTA of the recurrent disease. Under epidural anaesthesia, a computed tomography-guided percutaneous needle electrode was introduced into the tumour. Although the procedure provided immediate pain control, the patient developed an intestinal obstruction 3 months later. This complication required surgical treatment to release adherences from the necrosed tumour.

CONCLUSION

Apart from this complication, RFTA allowed prolonged relief of the pelvic pain and improved quality of life. Faced with an unresectable pelvic recurrence, RFTA proved to be a viable option for controlling pain, although a relatively high cost and eventual complications may limit its use.

Locoregional recurrence (non hepatic abdominal recurrence) of rectal cancer

Thirty percent of deaths are related to locoregional recurrence. All patients with nonhepatic abdominal recurrence (NHAR) were considered as having locoregional failure. The aims of this study are firstly to retrospectively evaluate the results of potentially curative resection and palliative treatment modalities for a group of 25 patients with NHAR from rectal cancer. The second aim is to determine the effectiveness of R1 resection in these patients in terms of survival. In this study we have followed 25 patients with NHAR of which 10 were able to undergo potentially curative salvage resection, whilst the remaining 15 had either a palliative (R2) or no resection. The goals of treatment for recurrent rectal cancer are palliation of symptoms, a good quality of life, and if possible, cure with a low rate of treatment - related complications. Indications for salvage surgery depend on several factors in cluding the extent of disease, the presence of concomitant illness and the surgeons experience. Systemic disease, systemic disease with peritoneal implants, multiple hepatic metastases, or extensive pelvic involvement preclude surgical treatment for cure.6 Curative and noncurative surgical procedures were performed width acceptable complications in the series presented hereThe mean survival for the group undergoing R0 resection was 50 months versus 55 months for the group undergoing R1 resection (not significant). Mean survival were 7,3 and 6 months in the groups undergoing R2, NR and NS respectively. The 5-year survival for the 10 patients who had potentially curative resection was 30 per cent versus 0 per cent for 15 patients who had non-curative procedures (p=0.001). There was 1 post-operative 30 day mortality in the series of 19 patients who underwent surgery. Five patients (6 per cent) developed one or more post-operative complications. Two of them required reoperation.

Preoperative irradiation and surgery for recurrent rectal cancer. Will intraoperative radiotherapy (IORT) be of additional benefit? A prospective study

BACKGROUND

The therapeutic gain of surgery for recurrent rectal cancer is not clear, particularly with regard to the addition of intraoperative radiotherapy (IORT).

METHODS

Patients (107) with isolated pelvic recurrence of rectal cancer received preoperative external radiotherapy of 46-50 in 2 Gy fractions. At surgery 59 patients had IORT 12-18 Gy. Survival and local recurrence was analysed with regard to surgical resection stages and IORT.

RESULTS

Patients (44) had R0- and 39 R1-resections, 24 R2-resections or exploratory laparotomy. IORT was given most often after R1-resections, least in R0-patients. Estimated 5-year survival was overall around 30%, around 60% in the R0-, around 25% for R1- and 0% in R2-patients. Local recurrence was around 30% in the R0- and around 65% in R1-stage patients. R0-/R1-stage patients survived statistically significantly longer than the R2-group otherwise there was no statistical significant difference between IORT and non-IORT groups in any R-stages regarding overall survival or local recurrence.

CONCLUSIONS

Macroscopic removal of the recurrence improves survival. Whether R0- is better than R1-resections is not clear. The effect of IORT is not a major one. IORT need be evaluated in randomised controlled trials.

Treatment of locally recurrent rectal cancer

PURPOSE

This study was designed to analyze the outcome for patients with isolated local recurrence after radical treatment of rectal cancer and to identify predictors of curative resection.

METHODS

The medical records of 87 patients who developed isolated local recurrence after curative radical surgery for primary rectal cancer were retrospectively reviewed. Survival rates from the time of recurrence were calculated using the Kaplan-Meier method. Tumor stage and histology, patient characteristics, and treatment variables were analyzed using logistic regression to identify predictors of curative surgery.

RESULTS

Symptomatic treatment alone or chemotherapy and/or radiation therapy was provided to 23 patients (26 percent), and surgical exploration was performed in 64 patients. In 22 patients (25 percent), the tumor was considered unresectable at surgery (n = 13) or was resected for palliation with gross or microscopic positive margins (n = 9). In 42 patients (48 percent), curative-intent resection was performed. The only independent predictors of resectability were younger age at diagnosis, earlier stage of the primary tumor, and initial treatment by sphincter-saving procedure. There was no difference in survival between patients who had no surgery and those who had palliative surgery. The estimated five-year survival rate for patients who had curative-intent resection was better than for those who had no surgery or palliative surgery (35 vs. 7 percent; P = 0.01). Of the 42 patients who underwent curative-intent resection, 14 (33 percent) developed a second recurrence at a mean of 15 +/- 11 months after reoperation. Twenty-five percent of patients developed major complications.

CONCLUSIONS

Salvage surgery for locally recurrent rectal cancer may be helpful in a selected group of patients. The stage and treatment of the primary tumor may help to identify patients with the best chance for curative-intent resection.

Benefits of radioimmunoguided surgery for pelvic recurrence

AIM

Surgery for recurrent rectal cancer is usually traumatic and of questionable curative value. The use of radioimmunoguided surgery (RIGS) in enhancing the surgeon's assessment of the extent of disease in these patients was investigated.

METHODS

Twenty-one patients diagnosed with recurrent pelvic cancer were operated using the RIGS(O)system. Preoperative assessment included CTs of chest, abdomen and pelvis as well as colonoscopy. Patients were injected with CC49, a monoclonal antibody (MoAb) labelled with 125I. Surgical exploration was followed by survey with the gamma-detecting probe.

RESULTS

Surgical exploration identified eight intra-colorectal recurrences, nine extra-colonic pelvic recurrences and five extra-pelvic lymph node metastases. RIGS exploration confirmed all intra-colonic recurrences except for one (patient with no MoAb localization), identified 13 pelvic recurrences and 10 lymph node metastases. There were seven patients with occult findings (33%), resulting in a modified surgical procedure. Surgery included five abdomino-perineal resections, six low anterior resections, seven excisions of presacral tumour, eight total abdominal hysterectomy and bilateral salpingo-oophorectomy, one pelvic exenteration and one post-exenteration. There were no operative deaths. Eight patients had minor complications, and one patient had a major complication with reoperation due to urinary leak. The mean follow-up was 18 months. Ten patients died of disease.

CONCLUSION

Although not curative, RIGS can help the surgeon in the decision-making process through better disease staging.

Locally recurrent rectal cancer: predictors and success of salvage surgery

PURPOSE

After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome.

METHOD

We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes.

RESULTS

Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2.

CONCLUSION

Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.

Quality of life and cost effectiveness analysis of therapy for locally recurrent rectal cancer

PURPOSE

This study was performed to determine the quality of life and cost-effectiveness of therapeutic options for patients with locally recurrent rectal carcinoma, determined from the perspectives of patients and health care providers.

METHODS

We reviewed the records of patients (N = 68) with locally recurrent rectal carcinoma evaluated from 1992 through 1995. We constructed a decision-analytic model incorporating outcomes, survival, and costs. Utilities were elicited from convenience samples of health care providers and patients using the standard gamble technique.

RESULTS

The median survival for patients undergoing surgical resection (n = 40) was 42 months, compared with 16.8 months for patients undergoing diagnostic or palliative surgery (n = 16) and 18.3 months for patients treated nonoperatively (n = 12; P < 0.005). The mean cost of treatment per patient was $19,283 for the nonoperative group, $45,647 for the diagnostic or palliative surgery group, and $70,878 for the surgical resection group. The diagnostic or palliative surgical strategy was dominated by the nonoperative strategy because the former had greater costs with fewer health benefits. The incremental cost-utility ratio of surgical resection compared with nonoperative management using health care provider utilities was $109,777 per quality-adjusted life year gained; it was reduced to $56,698 using per quality-adjusted life year using mean patient utilities.

CONCLUSIONS

Patients with recurrent rectal carcinoma view surgery and morbidity to be less severe than health care providers. Diagnostic or palliative surgery is expensive and affects quality-adjusted survival adversely compared with nonoperative therapy. Surgical resection may be a cost-effective use of resources, particularly when cost-effectiveness is calculated using patient preferences.

Rectal cancer: changing patterns of referral for radiation therapy 1982-1997

BACKGROUND

The purpose of the present study was to evaluate the changing role of radiation therapy in rectal cancer and to determine the patterns of referral of patients during a 15-year period.

METHODS

From 1982 to 1997, 464 patients with carcinoma of the rectum were referred to the Department of Radiation Oncology, Royal Prince Alfred Hospital: 79% of patients had locoregional disease alone and 21% had distant metastasis. Radiation therapy consisted of irradiation (definitive or palliative) alone to the primary tumour in 9.7% of cases; preoperative radiation in 7.3% of cases: preoperative chemoradiation in 7.5% of patients: postoperative radiation in 15.3% of patients: postoperative chemoradiation in 12.31% of patients: treatment of pelvic recurrence in 23.5% of patients and treatment of metastases in 9.1% of patients. The remainder were treated elsewhere (1.9%) or not treated (13.4%).

RESULTS

There was an average annual 14% increase in referrals over the accrual period. Recurrent rectal cancer decreased from approximately 30% of referrals during 1982-91 to approximately 10% in 1995-7. The use of postoperative adjuvant radiation reached a peak of 50% in 1993. The use of preoperative radiation increased suddenly in 1994 from < 10% to a sustained rate of approximately 30% of referrals. The use of chemoradiation commenced in 1990 for postoperative adjuvant treatment and in 1994 for preoperative treatment. The median survival time from initial diagnosis was 35 months, with 2- and 5-year survival rates of 62 and 28%, respectively. Survivals at 5 years for patients treated with preoperative and postoperative radiation (with or without chemotherapy) and with recurrent disease were 56, 44 and 21%, respectively.

CONCLUSIONS

The present study illustrates the changing role of radiation therapy in the management of rectal cancer. The increase in referrals over the observation period was due to increased multidisciplinary input into the initial management of these patients, based on reported clinical trials. The steady increase in the use of adjuvant therapy has paralleled a decrease in referrals for treatment of recurrence and reflects current clinical results. The sequencing of adjuvant therapy is changing currently, with greater emphasis on preoperative adjuvant treatment. Currently most adjuvant therapy includes chemotherapy.

Influence of the surgical treatment on local recurrence of rectal cancer: a prospective study (1980-1992)

BACKGROUND AND OBJECTIVES

The incidence of locoregional recurrences (LR) following radical surgery of rectal cancer varies from 5% to 30% according to the literature. The purpose of this prospective study was to compare the outcome of the Abdomino-Perineal Excision (APE) vs. the Anterior Resection (AR) in a consecutive series of 188 patients who underwent surgery for cure from 1980 to the end of 1992 (81 APE and 107 AR), followed for 5 years, evaluating their influence on the incidence of the recurrences.

METHODS

The patients were enrolled at random in the two surgical groups, provided that a radical excision of the tumour, with only two limits: the level of the lesion from the anal verge and the presence of a severe incontinence instrumentally proven. TNM, Dukes staging, grading, and tumour location were statistically evaluated. Further primary suture vs. packing of the perineal wound in APE and handsewn vs. stapled anastomosis in AR were compared in relation with the incidence of LR.

RESULTS

The overall local recurrence rate was 19.2% (32/167), in details 19.7% for APE and 18.5% for AR. Similar recurrence rates were observed following both procedures, matching the patients according to the Dukes stage and different details of techniques. A slight statistically significant difference was found as far as the tumour location is concerned in the group treated with anterior resection (p = <0.05) because of the higher recurrence observed in AR performed for tumours of the lower third of the rectum in comparison with the more proximal level.

CONCLUSIONS

The AA conclude that the choice of the right surgical procedure in the rectal carcinoma depends on the characteristics of the tumour and the conditions of the patients, provided that the oncologic indications were respected, because recurrence and survival rate are independent from the surgical approaches.

Intraoperative electron beam radiation therapy for locally recurrent rectal carcinoma

PURPOSE

Treatment results for locally recurrent rectal cancers are poor. This is a result of the fact that surgery is hampered due to the severance of the anatomical planes during the primary procedure and that radiotherapy is limited by normal tissue tolerance, especially after previous irradiation. This paper describes the results of a combined treatment modality in this patient group.

METHODS AND MATERIALS

From 1994 to 1998, 37 patients with locally recurrent rectal cancer, but without distant metastatic disease, received a combined treatment consisting of 50.4 Gy preoperative irradiation or, in case of previous radiotherapy, 30 Gy reirradiation or no irradiation, followed by radical surgery and intraoperative electron beam radiotherapy boost.

RESULTS

Fifteen patients received a radical resection (R0), eight a microscopic irradical resection (R1), and 14 a macroscopic irradical resection (R2). The overall 3-year local control (LC), disease-free survival (DFS), and overall survival rates were 60%, 32%, and 58% respectively. Radicality of resection (R0/R1 vs. R2) turned out to be the significant factor for improved survival (p < 0.05), DFS (p = 0.0008), and LC (p = 0.01). Preoperative (re-)irradiation is the other significant factor in survival (p = 0.005) and DFS (p = 0.001) and was almost significant for LC (p = 0.08). After external beam radiation therapy (EBRT) a significantly higher resection rate was obtained (R0/R1 vs. R2 p = 0.001). Symptomatic peripheral local recurrences have a significantly worse prognosis and higher rate of R2-resection (p = 0.0005).

CONCLUSION

Centralization of locally recurrent rectal cancer patients enabled the development of an aggressive multimodality treatment, which in turn led to promising results. Distant failure is still a drawback.

Decision analysis as an aid to determining the management of early low rectal cancer for the individual patient

PURPOSE

Because there are no data available from randomized controlled trials (RCT), a decision analysis was performed to aid in the decision of which option, a local excision with or without radiotherapy or an abdominal perineal resection (APR), should be offered to medically fit patients with early (suspected T1/T2) low (< 5 cm) rectal cancer.

METHODS

All clinically relevant outcomes, including complications of surgery and radiotherapy, cure, salvageability after local recurrence, distant disease, and death, were modeled for both options. The probabilities of complications and outcomes after radiotherapy and/or local excision were derived from weighted averages of results from studies conducted between 1969 and 1997. The probabilities for the APR option were extracted from relevant RCTs. Long- and short-term patient-centered utilities for each complication and outcome were extracted from the literature and from expert opinion.

RESULTS

The expected utility of local excision (EU = 0.81) for the base case was higher than the expected utility for APR (EU = 0.78). Although the result was sensitive to all variables, local excision was always favored over APR within the plausible ranges of the variables taken one, two, or three at a time. The model illustrated the tension between the patient's perception of a colostomy and the higher recurrence rates with local excision.

CONCLUSION

The results of this decision analysis suggest that local therapy for early low rectal cancer is the preferred method of treatment. However, there must be careful preoperative assessment, patient selection, and consideration of patient concerns. In addition, decision analysis may be useful in providing patient information and assisting in decision making.

Multidisciplinary management of recurrent colorectal cancer

Isolated pelvic recurrence of rectal carcinoma may occur in up to one third of patients following definitive resection of primary disease. The means by which recurrence is diagnosed, methods by which it may be treated, and reported outcomes are all evolving and improving. Current data indicate that a substantial proportion of patients treated by aggressive multi-modality salvage therapy may be provided with durable survival. This review highlights current concepts in the diagnosis and management of locally recurrent rectal carcinoma.

Treatment of locally recurrent rectal carcinoma--results and prognostic factors

PURPOSE

To assess the local control and survival in patients who received pelvic irradiation for locally recurrent rectal carcinoma.

METHODS AND MATERIALS

The records of 519 patients with locally recurrent rectal carcinoma treated principally with external-beam radiation therapy between 1975 to 1985 at a single institute were retrospectively reviewed. These included 326 patients who relapsed locally following previous abdominoperineal resection, 151 after previous low anterior resection, and 42 after previous local excision or electrocoagulation for the primary. No patients had received adjuvant radiation therapy or chemotherapy for the primary disease. Concurrent extrapelvic distant metastases were found in 164 (32%) patients at local recurrence and, in the remaining 355, the relapse was confined to the pelvis. There were 290 men and 229 women whose age ranged from 23 to 91 years (median = 65). Median time from initial surgery to radiation therapy for local recurrence was 18 months (3-138 months). Radiation therapy was given with varying dose-fractionation schedules, total doses ranging from 4.4 to 65.0 Gy (median = 30 Gy) over 1 to 92 days (median = 22 days). For 214 patients who received a total dose > or = 35 Gy, radiation therapy was given in 1.8 to 2.5 Gy daily fractions.

RESULTS

The median survival was 14 months and the median time to local disease progression was 5 months from date of pelvic irradiation. The 5-year survival was 5%, and the pelvic disease progression-free rate was 7%. Twelve patients remained alive and free of disease at 5 years after pelvic irradiation. Upon multivariate analysis, overall survival was positively correlated with ECOG performance status (p = 0.0001), absence of extrapelvic metastases (p = 0.0001), long intervals from initial surgery to radiation therapy for local recurrence (p = 0.0001), total radiation dose (p = 0.0001), and absence of obstructive uropathy (p = 0.0013). Pelvic disease progression-free rates were positively correlated with ECOG performance status (p = 0.0001), total radiation dose (p = 0.0001), and previous conservative surgery for the primary (p = 0.02).

CONCLUSIONS

Survival is poor for patients who develop local recurrence following previous surgery for rectal carcinoma. Pelvic radiation therapy provides only short-term palliation, and future efforts should be directed to the use of effective adjuvant therapy for patients with rectal carcinoma who are at high risk of local recurrence.