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Multimodality Salvage of Recurrent Disease After Local Excision for Rectal Cancer

You, Y. Nancy M.D., M.H.Sc.1; Roses, Robert E. M.D.1; Chang, George J. M.D., M.S.1; Rodriguez-Bigas, Miguel A. M.D.1; Feig, Barry W. M.D.1; Slack, Rebecca M.S.2; Nguyen, Sa M.S.1; Skibber, John M. M.D.1

doi: 10.1097/DCR.0b013e318270837f
Original Contribution: Colorectal/Anal Neoplasia

BACKGROUND: Local excision, alone or in combination with chemoradiation, is increasingly considered for rectal cancer. Higher risks of disease recurrence have been demonstrated after local excision.

OBJECTIVE: The aim of this study was to examine the outcomes of current-era multimodality salvage for recurrent rectal cancer after local excision.

DESIGN: This was a single-institutional retrospective study.

SETTINGS: This study was conducted at a tertiary-referral cancer center between 1993 and 2011.

PATIENTS: Forty-six patients with recurrent rectal cancer after initial local excision were included.

INTERVENTION: Multimodality salvage treatment was performed as appropriate.

MAIN OUTCOME MEASURES: The primary outcomes measured were the pattern of disease recurrence, salvage treatments, and resultant overall and re-recurrence-free survival.

RESULTS: After the initial local excision, recurrent disease was diagnosed after a median interval of 1.9 years: local/regionally in 67%, distantly in 18%, and both in 15%. Four patients (9%) had recurrence that was unsalvageable, 2 (4%) declined treatment, and 40 (87%) underwent surgical salvage. Preoperative chemoradiation was given in 30 (75%) patients. The R0 resection rate was 80%, requiring multivisceral resection (33%), total pelvic exenteration (5%), and metastasectomy (25%). The rate of sphincter preservation was 33%, and perioperative morbidity was 50%. The first site of failure after salvage was distant in 38% and was local only in 10%. The 5-year overall and 3-year re-recurrence-free survival were 63% and 43%. Pathologic stage at initial local excision, receipt of neoadjuvant chemoradiation before local excision, recurrence pattern after local excision, pathologic stage at salvage, and R0 resection at salvage influenced re-recurrence-free survival.

LIMITATIONS: This study was limited by the referral and selection biases inherent in a small study cohort.

CONCLUSIONS: Failure after local excision for rectal cancer may not be salvageable. When feasible, multimodality treatment, including multivisceral resection, pelvic irradiation, and chemotherapy, was associated with potentially lasting treatment-related morbidities and only modest success in long-term disease control. These findings should be compared with the expected stage-specific outcomes of standard proctectomy for early-stage rectal cancer, when local excision is being considered.

1 Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas

2 Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas

Financial Disclosure: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, June 2 to 6, 2012.

Correspondence: Y. Nancy You, M.D., M.H.Sc., Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, PO Box 301402, Unit 1484, Houston, TX 77230-4008. E-mail:

© The ASCRS 2012