Loco-regional relapses from rectal cancer

Background. Loco-regional relapses (LRRs) from rectal cancer still represent a major issue in colo-rectal surgery. With the introduction of Total Mesorectal Excision (TME), LRR incidence after curative resection for rectal cancer dramatically decreased from 20–40% of cases to 2–12%. Several factors are involved in predicting LRRs, the most important of these being Dukes stage. When no treatment is performed, median survival for these patients is about 8 months. In 50% of cases LRRs are confined to the pelvis; so, the recurrent tumour can be amenable to potentially curative surgical removal, with minimal mortality and a 5 year survival rate around 20–40%. Surgery is not recommended for patients with unresectable metastases and/or infiltration of sciatic nerve, sacrum above S2–S3, and pelvic bones. We hereby report our personal experience with management of LRRs from rectal cancer. Materials and methods. We retrospectively reviewed the clinical records of 289 rectal cancer patients, treated with curative resection between 1998 and 2007. Patients were divided in two groups: A (206 patients), younger than 74 y.o.; and B (83 patients), older than 75 years old. A total of 31 patients (10.7%) developed a LRR: 24 patients of group A (11.6%) and 7 of group B (8.4%). We also included in the study 11 patients (8 in group A, 3 in group B) treated elsewhere for the primary; we thus managed in total 42 LRR patients (26 males, 16 females; mean age 64 y.). LRR was anastomotic in 37.1% of cases, central-pelvic in 31.4%, presacral in 25.7% and perineal in 5.7%. In 88.5% of patients a R0 resection had been achieved at former surgery. Mean DFS was 13.4 months. We focused on the 35 patients assessed as metastases-free at the time of the first surgery. Results. Surgical management with curative intention was possible for 23 patients (65.7%), 17 of which in group A, and consisted either of exeresis of the recurrent neoplasm (10 cases), re-resection (7 cases) or Miles operation (6 cases). In18 of these patients (15 of group A) a R0 resection was achieved. Postoperative morbidity was 42.8%; perioperative mortality was 7.1%. 3 years – OS was 28%, but it was 60% for R0 patients. Conclusion. In selected patients, especially if younger than 75, LRRs may be amenable to a multimodal approach that, in a relevant rate of cases, can lead to a potentially curative R0 resection; for the other cases a palliative management is possible, to improve overall survival and quality of life.