Treatment of locally recurrent rectal adenocarcinoma
- Christopher G Willett, MD
Christopher G Willett, MD
- Section Editor — Radiation Therapy
- Duke University Medical School
- Miguel A Rodriguez-Bigas, MD
Miguel A Rodriguez-Bigas, MD
- Professor of Surgery
- MD Anderson Cancer Center
- David P Ryan, MD
David P Ryan, MD
- Professor of Medicine
- Harvard Medical School
Approximately 39,220 Americans are diagnosed with rectal cancer annually . The vast majority of these are adenocarcinomas.
Surgical resection is the cornerstone of curative therapy for patients with potentially resectable rectal cancer. Radiation therapy (RT) with concurrent fluoropyrimidine chemotherapy has emerged as an important component of curative therapy for transmural or node-positive rectal cancer because in contrast to colon cancer, in which the failure pattern is predominantly distant, the site of first failure in patients undergoing surgery for rectal cancer is equally distributed locally (ie, pelvis) and in distant sites (eg, liver, lung) . Chemoradiotherapy is often administered preoperatively for clinically staged T3 or T4 (table 1), or node-positive tumors, for distal tumors, in which tumor regression may allow successful conversion of a planned abdominopelvic resection (APR) to a sphincter-sparing surgical procedure, or if the preoperative staging evaluation suggests mesorectal invasion. Preoperative, as compared with postoperative, chemoradiotherapy results in a superior sphincter preservation rate, a lower rate of anastomotic stenosis, and better local control while providing similar long-term survival. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma", section on 'Indications for neoadjuvant treatment' and "Pretreatment local staging evaluation for rectal cancer", section on 'Assessing T and N stage, and the status of the CRM' and "Adjuvant therapy for resected rectal adenocarcinoma".)
Despite refinements in surgical techniques (such as total mesorectal excision [TME]) and optimal use of neoadjuvant and adjuvant therapies, the incidence of locoregional relapse after initial treatment of invasive rectal cancer is still 4 to 8 percent [3,4]. (See "Rectal cancer: Surgical principles", section on 'Total mesorectal excision'.)
Treatment of locally recurrent rectal cancer will be discussed here. Neoadjuvant chemoradiotherapy for potentially resectable primary adenocarcinomas, adjuvant therapy after resection of a primary rectal adenocarcinoma, pretreatment local staging evaluation, surgical principles, and recommendations for posttreatment surveillance are discussed elsewhere, as is the management of rectal squamous cell cancers. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma" and "Pretreatment local staging evaluation for rectal cancer" and "Rectal cancer: Surgical principles" and "Adjuvant therapy for resected rectal adenocarcinoma" and "Surveillance after colorectal cancer resection" and "Clinical features, staging, and treatment of anal cancer", section on 'Rectal squamous cell cancers'.)
THE CHALLENGE OF LOCALLY RECURRENT RECTAL CANCER
Management of locally recurrent rectal adenocarcinoma is a significant challenge for a number of reasons.
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- THE CHALLENGE OF LOCALLY RECURRENT RECTAL CANCER
- MODE OF PRESENTATION
- PRETREATMENT EVALUATION
- Classification of recurrence pattern
- Surgical resection
- Combined modality therapy
- - Patients with no prior RT
- Role of intraoperative RT
- - Outcomes in previously irradiated patients
- - Benefit of adjuvant chemotherapy
- PALLIATION OF OBSTRUCTIVE SYMPTOMS DUE TO LOCALLY ADVANCED DISEASE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS