Impact of a history of metastases or synchronous metastases on survival in patients with locally recurrent rectal cancer

Oligometastatic Disease Is Not an Absolute Contraindication to Pelvic Exenteration in Selected Patients With Locally Recurrent Rectal Cancer

BACKGROUND

The treatment of locally recurrent rectal cancer has evolved dramatically in recent decades. As the boundaries of exenterative surgery continue to be pushed, one of the unanswered and controversial questions is the role of radical salvage surgery for locally recurrent rectal cancer in the setting of oligometastatic disease.

OBJECTIVE

To investigate the impact of synchronous or previously treated distant metastases on survival after pelvic exenteration for locally recurrent rectal cancer.

DESIGN

Retrospective analysis of a prospectively maintained database.

SETTINGS

A high-volume specialist exenteration center.

PATIENTS

Consecutive adult patients undergoing pelvic exenteration with curative intent for locally recurrent rectal cancer between 1994 and 2023.

MAIN OUTCOME MEASURES

Overall survival from time of pelvic exenteration.

RESULTS

Of the 300 patients included, 193 (64%) were men, and the median age at the time of pelvic exenteration was 62 years (range, 29-86). The median time from primary rectal cancer surgery to pelvic exenteration was 35 months (range, 4-191). In total, 56 patients (19%) had a history of metastatic disease, of whom 42 (14%) had previously treated metastases and 18 patients (6%) had synchronous metastatic disease (including 4 patients with both synchronous and previously treated metastases). Five-year overall survival rate and median overall survival was 41% and 45 months, respectively. There was a trend toward poorer 5-year overall survival in patients with a history of metastatic disease compared to those without (25% vs 45%); however, this did not reach statistical significance ( p = 0.110), possibly due to a lack of statistical power. Five-year overall survival was 27%, 25%, and 45% for patients with synchronous metastases, previously treated metastases, and no history of metastases, respectively ( p = 0.260).

LIMITATIONS

Findings may not be applicable beyond highly selected patients treated at specialized exenteration centers.

CONCLUSIONS

Long-term survival is achievable in highly selected patients with locally recurrent rectal cancer and synchronous or previously treated distant metastases. Therefore, oligometastatic disease should not be considered an absolute contraindication to exenterative surgery. See Video Abstract .

LA ENFERMEDAD OLIGOMETASTSICA NO ES UNA CONTRAINDICACIN ABSOLUTA PARA LA EXENTERACIN PLVICA EN PACIENTES SELECCIONADOS CON CNCER RECTAL LOCALMENTE RECURRENTE

ANTECEDENTES:El tratamiento del cáncer rectal localmente recurrente ha evolucionado drásticamente en las últimas décadas. A medida que se siguen ampliando los límites de la cirugía exenterativa, una de las preguntas sin respuesta y controvertidas es el papel de la cirugía radical de rescate para el cáncer rectal localmente recurrente en el contexto de la enfermedad oligometastásica.OBJETIVO:Investigar el impacto de las metástasis distantes sincrónicas o tratadas previamente en la supervivencia después de la exenteración pélvica para el cáncer rectal localmente recurrente.DISEÑO:Análisis retrospectivo de una base de datos mantenida prospectivamente.ESTABLECIMIENTO:Un centro de exenteración especializado de alto volumen.PACIENTES:Pacientes adultos consecutivos sometidos a exenteración pélvica con intención curativa para cáncer rectal localmente recurrente entre 1994 y 2023.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia general desde el momento de la exenteración pélvica.RESULTADOS:De los 300 pacientes incluidos, 193 (64%) eran varones y la edad media fue de 62 años (rango 29-86). La mediana de tiempo desde la cirugía del cáncer rectal primario hasta la exenteración pélvica fue de 35 meses (rango 4-191). En total, 56 pacientes (19%) tenían antecedentes de enfermedad metastásica; de los cuales 42 (14%) habían sido tratados por metástasis previamente y 18 pacientes (6%) tenían enfermedad metastásica sincrónica (incluidos 4 pacientes con metástasis tanto sincrónicas como tratadas previamente). La supervivencia global a 5 años y la mediana de supervivencia global fueron del 41% y 45 meses, respectivamente. Hubo una tendencia hacia una peor supervivencia global a 5 años en pacientes con antecedentes de enfermedad metastásica en comparación con los que no la tenían (25% frente a 45%); sin embargo, esto no alcanzó la significación estadística ( p = 0,110), posiblemente debido a la falta de poder estadístico. La supervivencia global a los 5 años fue del 27%, 25% y 45% para los pacientes con metástasis sincrónicas, metástasis tratadas previamente y sin antecedentes de metástasis, respectivamente ( p = 0,260).LIMITACIONES:Los hallazgos pueden no ser aplicables más allá de pacientes altamente seleccionados tratados en centros de exenteración especializados.CONCLUSIONES:La supervivencia a largo plazo es alcanzable en pacientes altamente seleccionados con cáncer rectal localmente recurrente y metástasis distantes sincrónicas o tratadas previamente. Por lo tanto, la enfermedad oligometastásica no debe considerarse una contraindicación absoluta para la cirugía de exenteración. (Traducción-Dr. Felipe Bellolio ).

Carbon-Ion Radiation Therapy for Unresectable Locally Recurrent Colorectal Cancer: A Promising Curative Treatment for Both Radiation Therapy: Naïve Cases and Reirradiation Cases

PURPOSE

It is difficult to effectively cure patients with unresectable locally recurrent colorectal cancers (LRCRCs) using conventional chemotherapy or chemoradiation therapy. Furthermore, treatment options vary depending on the patient's history of radiation therapy. Carbon-ion radiation therapy (CIRT) is a potentially curative treatment for these patients. Here, we compare the treatment outcomes of radiation therapy-naïve cases (nRT) and re-irradiation cases (reRT).

METHODS AND MATERIALS

Patients with LRCRC treated with CIRT at QST Hospital between 2003 and 2019 were eligible. CIRT was administered daily 4 d/wk for 16 fractions. The total irradiated dose was set at 73.6 Gy (relative biologic effectiveness-weighted dose [RBE]) for nRT and 70.4 Gy (RBE) for reRT patients.

RESULTS

We included 390 nRT cases and 83 reRT cases. The median follow-up period from the initiation of CIRT was 48 (5-208) months. The 3-year overall survival (OS) rates for nRT and reRT were 73% (95% CI, 68%-77%) and 76% (65%-84%), respectively. The 5-year OS rates were 50% (45%-55%) and 50% (38%-61%), respectively. These rates did not differ significantly (P = .55). The 3-year local control (LC) rates for nRT (73.6 Gy) and reRT (70.4 Gy) cases were 80% (75%-84%) and 80% (68%-88%), respectively. The 5-year LC rates were 72% (67%-78%) and 69% (55%-81%), respectively, without a significant difference (P = .56).

CONCLUSIONS

Our results suggest that CIRT for LRCRC is a very effective and promising treatment for both nRT and reRT cases.

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

INTRODUCTION

Patients 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.

METHODS

Consecutive 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.

RESULTS

A 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).

CONCLUSION

LRRC 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.

Locally recurrent rectal cancer: Oncological outcomes for patients with a pathological complete response after neoadjuvant therapy

BACKGROUND

For patients with locally recurrent rectal cancer, it is an ongoing pursuit to establish factors predicting or improving oncological outcomes. In locally advanced rectal cancer, a pCR appears to be associated with improved outcomes. The aim of this retrospective cohort study was to compare the oncological outcomes of patients with locally recurrent rectal cancer with and without a pCR.

METHODS

Patients who underwent neoadjuvant treatment and surgery for locally recurrent rectal cancer with curative intent between January 2004 and June 2020 at a tertiary referral hospital were analysed. Primary outcomes included overall survival, disease-free survival, metastasis-free survival, and local re-recurrence-free survival, stratified according to whether the patient had a pCR.

RESULTS

Of a total of 345 patients, 51 (14.8 per cent) had a pCR. Median follow-up was 36 (i.q.r. 16-60) months. The 3-year overall survival rate was 77 per cent for patients with a pCR and 51.1 per cent for those without (P < 0.001). The 3-year disease-free survival rate was 56 per cent for patients with a pCR and 26.1 per cent for those without (P < 0.001). The 3-year local re-recurrence-free survival rate was 82 and 44 per cent respectively (P < 0.001). Surgical procedures (for example soft tissue, sacrum, and urogenital organ resections) and postoperative complications were comparable between patients with and without a pCR.

CONCLUSION

This study showed that patients with a pCR have superior oncological outcomes to those without a pCR. It may therefore be safe to consider a watch-and-wait approach in highly selected patients, potentially improving quality of life by omitting extensive surgical procedures without compromising oncological outcomes.

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

BACKGROUND

In 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 METHODS

In 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.

RESULTS

Three-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%.

CONCLUSIONS

Nationwide 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.