Reoperation for intraluminal rectal cancer recurrence

Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into "regular life." This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of patients achieves optimal outcomes.

Intentionally curative treatment of locally recurrent rectal cancer: a systematic review

BACKGROUND

There is a lack of outcome data beyond local recurrence rates after primary treatment in rectal cancer, despite more information being necessary for clinical decision-making. We sought to determine patient selection, therapeutic modalities and outcomes of locally recurrent rectal cancer treated with curative intent.

METHODS

We searched MEDLINE (1990-2010) using the medical subject headings "rectal neoplasms" and "neoplasm recurrence, local." Selection of cohort studies was based on the primary intention of treatment and availability of at least 1 outcome variable.

RESULTS

We included 55 cohort studies comprising 3767 patients; 8 studies provided data on the rate of intentionally curative treatment from an unselected consecutive cohort of patients (481 of 1188 patients; 40%). Patients were symptomatic with pain in 50% (796 of 1607) of cases. Overall, 3088 of 3767 patients underwent resection. The R0 resection rate was 56% (1484 of 2637 patients). The rate of external beam radiotherapy was 100% in 9 studies, 0% in 5 studies, and ranged from 12% to 97% in 37 studies. Overall postoperative mortality was 2.2% (57 of 2515 patients). Five-year survival was at least 25%, with an upper limit of 41% in 11 of 18 studies including at least 50 resections. We found a significant increase in reported survival rates over time (r2 = 0.214, p = 0.007).

CONCLUSION

More uniformity in treatment protocols and reporting on outcomes for locally recurrent rectal cancer is warranted. The observed improvement of reported survival rates in time is probably related to better patient selection and optimized multimodality treatment in specialized centres.

Can radiotherapy alone be effective for treating anastomotic recurrence of rectal cancer? When the patient decides?

Among pelvic recurrences of rectal cancer following surgical resection, anastomotic recurrences are relatively rare; the literature reports an incidence between 2.4% and 12% of all patients who underwent colorectal anastomosis. The authors report the case of a patient already treated for an early rectal cancer who 1 year after surgery developed a 2 cm recurrence at the colorectal anastomosis. As he refused reoperation, he underwent radiation therapy only (54 Gy) with complete remission. After 8 years of follow-up, the patient is free of any further distant or local recurrence. The authors did not find, to the best of their knowledge, in the literature any similar case of a patient with anastomotic rectal recurrence who has been positively treated by radiotherapy only. The authors focus on its diagnostic and therapeutic problems: although surgical reresection is undoubtedly the best therapeutic option, in the case reported here, radiotherapy alone proved effective.

Clinicopathological features of anastomotic recurrence after an anterior resection for rectal cancer

PURPOSE

Anastomotic recurrence after an anterior resection for rectal cancer has not been analyzed in detail in the era of total mesorectal excision. This study tried to clarify the characteristics of patients with anastomotic recurrence when compared to the pelvic recurrence.

METHODS

This study compared the clinicopathological data of 21 isolated recurrent patients that were treated between 1998 and 2007, including eight with anastomotic recurrence and 13 with pelvic recurrence.

RESULTS

The rate of positive serum carcinoembryonic antigen level at the time of recurrence is 0% in the anastomotic recurrence group and 85% in the pelvic recurrence group (p < 0.001). The clinical symptoms presented in 13% in the anastomotic recurrence group, in comparison to 69% in the pelvic recurrence group (p = 0.024). The median time from the initial resection until recurrence was 14 months in the anastomotic recurrence group, whereas it was 12 months in the pelvic recurrence group (p = 0.992). The survival rate of patients with anastomotic recurrence was higher than those with pelvic recurrence (p = 0.005).

CONCLUSION

A difference was observed in the serum carcinoembryonic antigen, clinical symptom, and survival between patients with anastomotic and pelvic recurrence. Furthermore, according to these results, we should pay attention to these clinical features in the follow-up period.

Presentation and prognosis of local recurrence after total mesorectal excision

OBJECTIVE

The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma.

METHOD

Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively.

RESULTS

Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3-60 months. Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months. Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7-58), all patients were alive.

CONCLUSION

Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 itérative resection.

Low Local Recurrence Rates after Rectal Cancer Resection with Limited Use of Preoperative Radiotherapy

Background:

Local recurrence rates after curative rectal resection for rectal cancer have decreased after introduction of TME. In order to achieve even further reduction in local recurrence rates, several hospitals increase the use of preoperative radiotherapy. Thus, radiotherapy-related side effects will increase. The aim of the study was to evaluate the results of the TME-technique with minimal use of radiotherapy.

Materials and Methods:

A prospective observational study from 1993 to 2000 of 137 consecutive patients treated for rectal cancer at the Department of Surgery, Nordland Hospital HF, Bodø, Norway.

Results:

115 patients underwent curative resections (84%). Eight patients (6.4 %) received peri-operative radiotherapy: three preoperatively (2.4%) because of clinically fixed tumours and five patients (4%) postoperatively; four with pR1-resections and one patient after perforation of the rectum. The local recurrence rate was 3.4 % with an observation time of 5 years. The total survival rate was 74% in curative group. In 22 patients the treatment was palliative. Only one of these patient survived 5 years.

Conclusion:

With TME-technique it is possible to achieve low recurrence rates and high survival rates with a high curative rate with minimal use of additional radiotherapy.