EDUCATIONAL REVIEW – COLORECTAL CANCER Management of Recurrent Rectal Cancer

Background. Here we present a concise review on the evaluation and management of locally recurrent rectal cancer, which despite marked reductions in the rate of recurrent rectal cancer remains an important problem. Methods. This educational review discusses the diagnosis, evaluation, and management of recurrent rectal cancer. Results. Despite improvements in both the neoadjuvant and surgical management of rectal cancer, local recurrence is still an important problem, with documented recurrence rates of 4% to 8%. The local management of recurrence requires a team of specialist. Accurate detection and diagnosis followed by chemoradiotherapy and surgical resection may result in 5-year survival rates of up to 35%. Conclusions. We discuss the diagnosis, evaluation, and management of locally recurrent rectal cancer. Locally recurrent rectal cancer can be successfully managed with multimodal therapy leading to successful palliation and often cure. Over the last 40 years there has been a marked evolution in the management of rectal cancer, resulting in great reductions in local recurrence and permanent colostomy formation. With the implementation of the anatomic mesorectal dissection, adjuvant, and neoadjuvant therapy, local recurrence rates have decreased from 20–40% to 4–8%. This decrease in local recurrence has improved overall survival at 10 years. Similarly, randomized controlled trials have demonstrated that the use of both neoadjuvant and adjuvant therapy decreases local recurrence, while neoadjuvant therapy may decrease late toxicity and increase sphincter preservation. Locally recurrent rectal cancer has devastating consequences such as disabling pain or obstruction, and[50% of patients with local recurrence will have concomitant metastatic disease at the time of diagnosis. Untreated patients with recurrent rectal cancer have a median survival of 3– 8 months. If external-beam radiotherapy (EBRT) and/or chemotherapy are provided without surgical intervention, then median survival improves to 12–15 months. Untreated disease tends to progress, with local invasion of the pelvic organs and nerve roots causing severe pain. Radical surgery for metastatic rectal cancer isolated to the lung or liver is well accepted, but skepticism remains about aggressive surgical intervention for recurrent rectal cancer. Resection of recurrent rectal cancer is a challenging operation. Planes are not obvious, the result of scarring form previous surgery, and the patients have usually received additional doses of EBRT, further complicating the dissection. Despite these factors, safe surgical resection of locally recurrent rectal cancer is feasible with long-term survival and possible cure. Here, we discuss the diagnosis, evaluation, and management of locally recurrent rectal cancer. RISK FACTORS ASSOCIATED WITH LOCAL RECURRENCE Many risk factors have been identified as predictors for increasing the risk of patients developing local recurrence of a resected rectal cancer. Two well-known anatomic factors that increase the risk of local recurrence after resection are a positive circumferential resection margin (CRM) and/or a positive distal margin at the initial resection (Table 1). Local recurrence rates decline markedly as the distance between the tumor and the surgical margin increases, with this benefit ending at a distance of [5 mm of clear margin. A positive microscopic margin is defined as histological evidence of tumor in the line of resection and results in local recurrence rates ranging from 31 to 55%. Some authors have advocated that a CRM of \1 or 2 mm should be viewed as a positive margin because Society of Surgical Oncology 2009 First Received: 12 May 2009; Published Online: 30 December 2009 J. Efron, MD, FACS, FASCRS e-mail: [email protected] Ann Surg Oncol (2010) 17:1343–1356 DOI 10.1245/s10434-009-0861-2