Surgery for locally recurrent rectal cancer

BACKGROUND Local recurrence still remains a major problem after radical resection of rectum for cancer with TME. At the same time the poor evidence due to lack of randomized trials enrolling patients with local recurrence has lead to a wide spectrum of treatments for such patients, who are often managed in multidisciplinary framework programs. METHODS Between January 2004 and July 2014, 577 patients were treated with TME for rectal cancer (within 12 cm of the anal verge).All these patients underwent a strict follow-up program comprising instrumental and clinical controls every 6 months for at least 5 years. With a median follow-up of 50 months (range 9-120 months), 56 local recurrences were diagnosed. In all but 8 patients recurrence was asymptomatic. The local recurrence rates registered were 7%, 9% and 10% respectively at 2, 3 and 5 years. Seven patients (12,5%) with distant recurrence at the same time were excluded from the following, analysis, for a total of 49 patients examined with local recurrence only. RESULTS Among the remaining 49 patients, 30 (61%) underwent surgery comprising Miles operation in 14 cases (29%), Hartmann procedure in 7(14%), repeated low anterior resection with coloanal anastomosis in other 3 cases (6%) and palliative colostomy or other palliative procedure in 6 cases (12. Eight patients (16%) were excluded from surgery and underwent some form of CT or associated RT-CT, whilst 11 patients (23%) were addressed to palliative treatment. Overall survival (OS) rates were 48%, 29% and 22% respectively at 2, 3 and 5 years. On univariate analysis, resection of recurrent disease was the only significant factor associated with prognosis with a 5 years OS of 30% vs 22% for resected and non resected cases respectively (p=0.04). CONCLUSIONS Despite early diagnosis due to an intensive follow-up program after TME for rectal cancer, only a half of patients are amenable for reresection. Surgical resection still remains the mainstay of treatment for locally recurrent rectal cancer.