Recent Updates on Management Perspective of Recurrent rectal cancer..

1. Recurrent Rectal Cancer: A
Management Perspective
Dr. Dhan Bahadur Shrestha (Intern)
Col. Dr. Sushil Rawal
Shree Birendra hospital, Chhauni

2. Burden of the recurrence
• Rectal cancer recurrence is common even on the hand of experts
• Recurrence can be: distant metastasis or local recurrence
• It recur locally in up to 10% of the patients undergoing definitive
resection of primary cancer.
• Re-Surgery as salvage procedure or palliative intent possible in
appropriate setting .
• Outcome of salvage resection depends on R0 resection of the
disease.
Warrier SK. et al. Clin Colon Rectal Surg 2016;29:114–122. DOI: http://dx.doi.org/10.1055/s-0036-1580723.

3. Local recurrence
• Different system of classifying the recurrence is there.
• Moore and colleagues described LRs based on whether the recurrence is
axial (involving anastomosis, perineum, perirectal soft tissues), anterior
(involving genitourinary), posterior (sacrum or coccyx), or lateral (bony
sidewall).
Moore HG, et al. Dis Colon Rectum 2004;47(10):1599–1606

4. Distribution of recurrence
• Recurrent rectal cancer was most commonly central/anastomotic
(43.2%), followed by mesorectal/ presacral/ perineal (36.2%), lateral
pelvis (13.6%), and multi-site (7.0%).
• Oligometastatic disease can occur in the liver, para-aortic nodes, and
in a periumbilical mass.
You NY, et al. Br J Surg. 2016 May ; 103(6): 753–762. doi:10.1002/bjs.10079.

5. Preoperative evaluation
• To obtain and thorough review of their previous records to understand the
patient’s current anatomy and evaluation for comorbidities.
• Through physical examination including rectal examination and
sigmoidoscopy to rule out synchronous colonic malignancies.
• CEA level: Prognostic and other basic lab parameter for operative plan
• Magnetic resonance imaging (MRI) and computed tomographic (CT) scans
are principal diagnostic radiological imaging for staging recurrent rectal
cancers
• CT: sensitivity of 70% and specificity of 85%. MRI: sensitivity approx. 95%
and specificity 76 -100% for detecting local invasion.
• Systemic metastasis by evaluation by Positron emission tomography CT
Beets-Tan RG, et al. Abdom Imaging 2000;25:533–41.
Bouchard P, et al. Ann Surg Oncol (2010) 17:1343–56. DOI: 10.1245/s10434-009-0861-2

6. Management
• Management of rectal cancer is multidisciplinary with intention to
improve quality of life (QOL) by symptom control, prolong survival,
and provide a cure wherever possible, minimizing associated
morbidity.
• Nonoperative options like external beam radiotherapy or palliative
chemotherapy do not provide cure, with poor median survival.*
Warrier SK. et al. Clin Colon Rectal Surg 2016;29:114–122. DOI: http://dx.doi.org/10.1055/s-0036-1580723.
*Moriya Y. Jpn J Clin Oncol 2006;36(3):127–131

7. Curative treatment
• If intentionally curative treatment in a patient with locally recurrent
rectal cancer is considered by the multidisciplinary team, a standardized
approach with optimal neoadjuvant treatment is indicated.
• Full-dose neoadjuvant chemoradiotherapy or an adapted schedule
depending on previous EBRT maximizes the chance of an R0 resection,
which is the most important prognostic factor improving overall and
disease free survival.
• While, postoperative chemotherapy did not alter outcomes.
Tanis PJ, et al. Can j Surg. 2013 Apr;56(2):135. DOI: 10.1 503/cjs.025911
Rahbari NN, et al. Annals of surgery. 2011 Mar 1;253(3):522-33.doi: 10.1097/SLA.0b013e3182096d4f
Harris CA, et al. Annals of surgery. 2016 Aug 1;264(2):323-9. doi: 10.1097/SLA.0000000000001524

8. Outlook of exenterative surgery
• Though, previously in many contexts like peritoneal carcinomatosis, high
sacral involvement, encasement of external iliac vessels, invasion of the
sciatic notch, bilateral ureteral obstruction with bilateral hydronephrosis,
and the presence of gross lower limb edema (in addition to unresectable
distant metastases) were considered absolute contraindications to pelvic
exenterative surgery.
• But, in modern time in many exenterative centers the boundaries of
resection is challenged and outcome also is better.
Sagar PM et al. Br J Surg 1996;83(3):293–304.
Warrier SK. et al. Clin Colon Rectal Surg 2016;29:114–122. DOI: http://dx.doi.org/10.1055/s-0036-1580723.

9. Resection
• Radical resection of the recurrent tumour is crucial for long-term cure
• Only 40–50% of all patients with LRRC can undergo surgery with curative
intent among them, 30–45% will have an R0 resection
• So, 20–30% of all patients with LRRC will have a potentially curative
operation.
Nielsen MB, et. al. Colorectal Disease. 2011 Jul 1;13(7):732-42. doi:10.1111/j.1463-1318.2009.02167.x

10. Survival
• Among 533 Five-year cancer-specific survival for patients with a
complete (R0) resection was 44%, achieved in 59% of patients.
• But those with R1 and R2 resections, the 5-year survival was 26% and
10%, respectively.
• Chemoradiotherapy before exenteration was associated with a
significant (P < 0.05) improvement in overall 5-year cancer-specific
survival for those patients with an R0 resection.
Harris CA, et al. Annals of surgery. 2016 Aug 1;264(2):323-9. doi: 10.1097/SLA.0000000000001524

11. Algorithm
Dis Colon Rectum 2010; 53: 1248 –
1257

12. Br J Surg. 2016 May; 103(6): 753–762.
doi: 10.1002/bjs.10079

13. Newer advances
• Carbon-ion radiotherapy is an effective treatment with high rate of
local control, and may constitute a promising alternative to surgical
resection.
• Concurrent irinotecan and capecitabine with intensity-modulated
radiation therapy (IMRT) significantly relieves local symptoms and
exhibits promising efficacy with manageable toxicities in recurrent
rectal cancer without prior pelvic irradiation with progression free
survival rate of 74.2% and 33.9% at 1 and 3 years after
chemoradiation, respectively
Yamada S, et al. International Journal of Radiation Oncology Biology Physics. 2016 Sep 1;96(1):93-101. doi:10.1016/j.ijrobp.2016.04.022.
Cai et al. Radiation Oncology (2015) 10:57. DOI 10.1186/s13014-015-0360-5

14. Oligometastatic disease
• Although metastatic colorectal cancer is typically incurable, in a good
percentage of patients (20% to 50%) who have oligometastatic disease
confined to a single organ like liver, complete metastasectomy can result
in cure.
• As summarized in this review article, oxaliplatin-based chemotherapy
with or without pelvic radiation therapy, followed by either resection of
primary and liver disease or consideration of non-surgical modalities
appear to be the most well-supported treatment approaches in the
literature.
Weiser MR, et al. Oncology. 2013 Nov 1;27(11):1074.
J Gastrointest Oncol. 2015 Apr; 6(2): 201–207. doi: 10.3978/j.issn.2078-6891.2014.086

15. Prevention of recurrence
• Neo-adjuvant chemoradiotherapy reduces relative risk of local recurrence
by about 50% in patients with T3 and T4 rectal cancer compared with
postoperative CRT.
• But if inappropriate to select the CRT has havoc of toxicity as well.
• Even who receive neoadjuvant chemotherapy alone followed by TME and
have reported down staging in 25%-58%, with 74%-84%disease free
survival and 85%-91% overall survival 4-5 years follow up.
• Local recurrence rates at intervals of 48 to 75 months have been reported
in 0%-11.5% of patients.
• Increased Local Recurrence and Reduced Survival is associated with
Anastomotic Leak so anastomosis should be properly done
Gaertner WB et al. World J Gastroenterol 2015 July 7; 21(25): 7659-7671. DOI: 10.3748/wjg.v21.i25.7659
Mirnezami A, et al. Ann Surg 2011;253:890–899. DOI: 10.1097/SLA.0b013e3182128929

16. Thank
you