Clinical presentation

The vast majority of local recurrences occur within the first 2 to 3 years after curative surgery. Nevertheless, local recurrence can occur after longer intervals. In fact, in patients treated with local excision with or without chemoradiation, local recurrences have been reported at intervals of more than 6 years after primary treatment. The majority of patients who develop local recurrence will be symptomatic. The most common symptoms include new onset of pelvic or perineal pain, change in bowel habits, rectal bleeding, and urinary symptoms. In patients who have undergone an abdominoperineal resection, a nonhealing wound could be a sign of locally recurrent disease.

Evaluation and imaging

For the group of patients who may be candidates for potential surgical resection, careful staging and treatment planning should be performed by a multidisciplinary team. This team includes the surgeon, medical oncologist, radiation oncologist, urologist, plastic and reconstructive surgeon, radiologist, pathologist, enterostomal nurses, social workers, and at times a psychiatrist. A thorough evaluation should be performed to select patients in whom a complete surgical resection can be achieved with negative margins, because these patients will be the ones most likely to benefit. Surgical salvage procedures for LRRC include en bloc resection of adjacent organs or structures, such as total pelvic exenterations (TPE) and abdominosacral resection (AR), which are highly morbid, and thus could lead to worse quality of life for patients than symptomatic management.

A careful history and physical examination should be performed. In patients presenting with pain, the quality and characteristics of the pain are important in determining the potential for resectability. Patients with LRRC presenting with pain radiating to the back of the leg will most likely have involvement of the sciatic nerve and most likely will not be amenable to resection as opposed to patients presenting with just pelvic discomfort. It is important to elicit symptoms and signs regarding adjacent structures, such as pneumaturia, fecaluria, vaginal bleeding, abdominal pain with cramps, recurrent fever or chills, and weight loss, among others. Once a careful history has been taken, a physical examination, including rectal and vaginal examination and proctoscopy (in those patients who have had a sphincter-saving procedure), should be performed. This examination will allow evaluation for whether or not the recurrence is fixed, and may give the clinician an idea of the extent of the recurrence, such as involvement of the bladder or prostate, vagina, perineum, and on occasion metastatic disease to the groins. An effort should be made to obtain prior medical records, including operative reports, radiation therapy treatment plans and dosage given, as well as documentation regarding chemotherapy administered. As discussed later, patients with LRRC are candidates for reirradiation, and thus, prior radiotherapy records are important in planning re-treatment. At times it is difficult to evaluate patients in the office or clinic setting, and thus, an examination under anesthesia is necessary. In the authors’ practice, every effort is made to tissue document a local recurrence before embarking in the multimodality treatment of a local recurrence.

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  Evaluation of patients with locally recurrent rectal cancer should include

  
  
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  History and physical examination (obtain previous medical records, including operative reports, radiation schedule and portals, and chemotherapy schedules)

  
  
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  Proctoscopy

  
  
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  Colonoscopy

  
  
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  Imaging

  
  
  
  
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    Computerized axial tomography (CAT)

    
    
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    MRI

    
    
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    Positron emission tomography (PET)

    
    
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    Positron emission tomography and CAT scan (PET/CT).

  
  

Evaluation and imaging

For the group of patients who may be candidates for potential surgical resection, careful staging and treatment planning should be performed by a multidisciplinary team. This team includes the surgeon, medical oncologist, radiation oncologist, urologist, plastic and reconstructive surgeon, radiologist, pathologist, enterostomal nurses, social workers, and at times a psychiatrist. A thorough evaluation should be performed to select patients in whom a complete surgical resection can be achieved with negative margins, because these patients will be the ones most likely to benefit. Surgical salvage procedures for LRRC include en bloc resection of adjacent organs or structures, such as total pelvic exenterations (TPE) and abdominosacral resection (AR), which are highly morbid, and thus could lead to worse quality of life for patients than symptomatic management.

A careful history and physical examination should be performed. In patients presenting with pain, the quality and characteristics of the pain are important in determining the potential for resectability. Patients with LRRC presenting with pain radiating to the back of the leg will most likely have involvement of the sciatic nerve and most likely will not be amenable to resection as opposed to patients presenting with just pelvic discomfort. It is important to elicit symptoms and signs regarding adjacent structures, such as pneumaturia, fecaluria, vaginal bleeding, abdominal pain with cramps, recurrent fever or chills, and weight loss, among others. Once a careful history has been taken, a physical examination, including rectal and vaginal examination and proctoscopy (in those patients who have had a sphincter-saving procedure), should be performed. This examination will allow evaluation for whether or not the recurrence is fixed, and may give the clinician an idea of the extent of the recurrence, such as involvement of the bladder or prostate, vagina, perineum, and on occasion metastatic disease to the groins. An effort should be made to obtain prior medical records, including operative reports, radiation therapy treatment plans and dosage given, as well as documentation regarding chemotherapy administered. As discussed later, patients with LRRC are candidates for reirradiation, and thus, prior radiotherapy records are important in planning re-treatment. At times it is difficult to evaluate patients in the office or clinic setting, and thus, an examination under anesthesia is necessary. In the authors’ practice, every effort is made to tissue document a local recurrence before embarking in the multimodality treatment of a local recurrence.

• 
  

  Evaluation of patients with locally recurrent rectal cancer should include

  
  
• 
  

  History and physical examination (obtain previous medical records, including operative reports, radiation schedule and portals, and chemotherapy schedules)

  
  
• 
  

  Proctoscopy

  
  
• 
  

  Colonoscopy

  
  
• 
  

  Imaging

  
  
  
  
  • 
    

    Computerized axial tomography (CAT)

    
    
  • 
    

    MRI

    
    
  • 
    

    Positron emission tomography (PET)

    
    
  • 
    

    Positron emission tomography and CAT scan (PET/CT).

  
  

Imaging

To adequately stage patients with LRRC, once the initial evaluation is completed, imaging studies are performed. Although some investigators have advocated endorectal ultrasound (EUS) in patients with LRRC after local excision, the authors have not been able to demonstrate its utility in routine practice. EUS can be useful to perform needle-guided biopsy of a pelvic recurrence. CAT and MRI scans should be used to evaluate patients. The authors usually start evaluating patients with a CAT scan of the chest, abdomen, and pelvis. The advantage of doing this is that not only will local disease information be provided but distant disease can be identified. A pelvic MRI provides improved ability to distinguish posttreatment changes from viable tumor in comparison to CT imaging and provides excellent detail of surrounding pelvic structures, including sacral nerve roots, major pelvic vasculature, and bone, all of which are the parameters that need to be evaluated to determine resectability. It is important to note that with both of these modalities, the extent of involvement by the LRRC may be underestimated. Although not routinely part of the initial surgical staging, positron emission tomography fused with CAT scan (PET/CT) is employed in those cases where equivocal radiographic evidence of both local and distant disease is present. PET/CT has been reported to change the management in up to 14% of patients with LRRC.

Classification of the recurrence

Several classifications have been proposed for LRRC. The purpose of these classifications has been to define the structures that the LRRC involves, assess resectability, plan the extent of resection, and compare outcomes. The Mayo Clinic classification relies on the degree of fixation of the recurrence, and encompasses the earliest type of recurrences with no fixation to advanced recurrence with 3 or more points of fixation. Wanebo and colleagues proposed a classification based on modified criteria from the TNM staging system. In this classification, recurrences are described as local/minimal (within the bowel wall) to extensive invasion of the pelvis, including bony structures and sidewall. Yamada and colleagues classified the recurrences as localized, sacral invasive, and lateral invasive types and correlated survival with each type. None of the subjects with a lateral invasive recurrence survived 5 years. The Memorial Sloan Kettering classification is based on the anatomic location of the recurrence.

In the authors’ experience, the classification of recurrences based on anatomic location is clinically most useful. In general, anastomotic (after low anterior resections and transanal excisions), inferior or perineal recurrences, and central recurrences (those involving the rectum or urogenital organs) are the most amenable to surgical salvage. Posterior recurrences are also amenable to surgical salvage when sacral involvement remains below the second sacral vertebrae (S2). Lateral recurrences are the most difficult to address because involvement of the lateral bony pelvic structures, the major blood vessels, and other lateral structures may preclude a resection with negative margins.

Surgical planning

Once patients have been evaluated and the images reviewed, a thorough and frank discussion between the surgeon and patients regarding the options for treatment and the expected treatment outcomes is essential. In addition, presentation at a tumor board or a multidisciplinary conference to discuss the options of treatment is preferred. It must be understood that whenever surgery is being considered, imaging is only one part of the decision making process. Many factors need to be considered in the decision-making process, including the general status of patients, the physical findings, the available treatment options, the biology or aggressiveness of the disease, and the patients’ opinion. The following list demonstrates nonresectability criteria for locally recurrent rectal cancer. Fig. 1 illustrates 2 examples of unresectable recurrences; whereas, Fig. 2 shows a posterior recurrence and its reconstruction after an abdominosacral resection.

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  Preoperative criteria for nonresectability of locally recurrent rectal cancer

  
  
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  Anatomic

  
  
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  Involvement

  
  
  
  
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    Above S2 or sacral ala

    
    
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    Acetabulum

    
    
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    Common and external iliac arteries

    
    
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    Sciatic nerve or sciatic notch

    
    
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    Bilateral hydronephrosis (relative)

  
  
  
  
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  Biologic

  
  
  
  
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    Metastatic disease not amenable to resection

    
    
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    Para-aortic lymph node involvement

  
  
  
  
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  Patient

  
  
  
  
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    Poor performance status

    
    
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    Unacceptable surgical risks because of comorbidities

  
  
  
  
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  Technical

  
  
  
  
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    Inability to obtain a negative margin of resection.

  
  

Unresectable local recurrences. ( A ) CAT scan axial view central local recurrence. ( B ) MRI sagittal view same patient recurrence involving S1–2. ( C ) CAT scan axial view of lateral recurrence involving sciatic notch.

Resectable local recurrence. ( A ) MRI axial view of locally recurrent rectal cancer at level of S3. ( B ) MRI sagittal view of locally recurrent rectal cancer at level of S3. ( C ) Defect after abdominosacral resection. ( D ) Vertical rectus abdominis flap to cover defect.

Courtesy of Patrick Garvey, MD, MD Anderson Cancer Center, Department of Plastic and Reconstructive Surgery, Houston, TX.) ( E ) Vertical Rectus Abdominis Flap sutured in place. ( Courtesy of Patrick Garvey, MD, MD Anderson Cancer Center, Department of Plastic and Reconstructive Surgery, Houston, TX.

If patients are considered to be potentially resectable with negative margins, both the surgeon and patients must understand that imaging is not perfect, and may underestimate the level of invasiveness or adherence by the recurrence. The surgeon must be prepared to remove the tumor and adjacent structures or organs adhered to the tumor. Surgical options for LRRC include local resection of the recurrence, bowel resection with primary anastomosis, abdominoperineal resection, pelvic exenteration, and abdominosacral resection.

In general, surgical resection of LRRC involves a multidisciplinary surgical team. In addition to the primary surgeon, the surgical team may include urologists, gynecologists, plastic and reconstructive surgeons, neurosurgeons, and radiation oncologists. Careful multidisciplinary planning will provide the most satisfactory results. Unfortunately, there are times where in order to intraoperatively assess resectability, the surgeon has to commit to performing the resection without knowing whether or not negative margins will be obtained. The authors’ call this the point of no return, and it is not an ideal situation because either microscopic or gross tumor will be left behind. If the procedure can be done with acceptable morbidity, it may indeed be a better situation than the potential complications resulting from trying to put back together structures that have been already severed or violated with the attendant complications and poor quality of life related to those potential complications or tumor-related issues.