Group
Classification
Description
Wanebo et al. [4]
Based on the UICC TNM system
TR1 and 2: Intraluminal local recurrence at the primary resection site
TR3: Anastomotic recurrence with full thickness penetration beyond the bowel wall and into the perirectal soft tissue
TR4: Invasion into either adjacent organs including vagina, uterus, prostate, bladder, seminal vesicles, or presacral tissues with tethering but not fixation
TR5: Invasion in the bony ligamentous pelvis including sacrum, low pelvic sidewalls, or sacrotuberous/ischial ligaments
Mayo Clinic [5]
Based on the degree of fixation
Site (anterior, sacral, right, or left) and number of points of fixation (F0-3)
Yamada et al. [6]
Based on location
Localized (adjacent pelvic organs or connective tissue) Sacral (S3-5, coccyx, or periosteum), Lateral (lateral pelvic wall, S1 or 2, sciatic nerve, or greater sciatic foramen)
Jimenez et al. [7]
Based on location and involvement of other structures
1. Axial, which can be subdivided into anastomotic, mesorectal or perirectal soft tissue, or perineum following APE
2. Anterior, involving the GU tract including bladder, vagina, uterus, seminal vesicles, and prostate
3. Posterior, involving sacrum and presacral fascia; and lateral, involving the soft tissues of the pelvic sidewall and lateral bony pelvis
4. Lateral, involving the soft tissues of the pelvic sidewall and lateral bony pelvis
6.2 Ongoing Studies
For patients with rectal cancer, preoperative chemoradiotherapy followed by total mesorectal excision (TME) can provide durable 10-year overall survival (OS) of 58% and recurrence-free survival (RFS) of 62% [3]. Preoperative treatment is a highly controversial topic, and some studies are ongoing. One of these is V-shoRT, a phase I/II study of valproic acid and short-course radiotherapy (RT) plus capecitabine as preoperative treatment for patients with low–moderate risk rectal cancer (Avallone et al., Istituto Nazionale Tumori, Naples, Italy). The purpose of that study is first to determine the maximum tolerated dose of capecitabine given alone or in combination with valproic acid during preoperative short-course RT (phase I); the second part (phase II) will explore whether the addition of valproic acid or capecitabine to short-course RT before optimal radical surgery might increase pathologic complete tumor regression rate in such patients (www.clinicaltrials.gov: NCT01898104).
Another ongoing trial is the RAPIDO trial (Rectal Cancer and Pre-operative Induction Therapy Followed by Dedicated Operation. Van Etten et al., University Medical Centre, Groningen, The Netherlands). Current standard treatment for patients at high risk of failing locally and/or systemically includes preoperative long-course RT (5 weeks) in combination with chemotherapy (neoadjuvant). Neoadjuvant chemoradiotherapy has been demonstrated to improve local control, but it has no effect on OS because a substantial proportion of patients cannot receive chemotherapy postoperatively due to TME complications. An alternative approach is to administer systemic therapy preoperative and short-course RT to guarantee control of the rectal tumor. In this trial, the investigators will compare short-course RT followed six cycles of chemotherapy with capecitabine + oxaliplatin, followed by TME with the standard treatment of neoadjuvant chemoradiotherapy followed by TME surgery and optional adjuvant chemotherapy (www.clinicaltrials.gov: NCT01558921).
6.3 Recurrence Risk and Surveillance Strategies
Despite optimal treatment with neoadjuvant therapy and a complete TME, some rectal cancers still recur locally. Risk factors include bulky tumors (T3/T4), node positivity, and unfavorable pathology such as lymphovascular or perineural invasion [9]. Then, distance of mesorectal extension (DME), circumferential resection margin (CRM), lymphatic invasion (positive Ly), and venous invasion (positive V) are independent risk factors for LR in patients who undergo curative resection for rectal cancer without preoperative chemoradiation therapy (CRT). Moreover, a combination of these factors can identify a group of patients who are at high risk of LR.
Surveillance strategies after curative treatment for primary rectal and colorectal cancer are controversial, and the optimal combination of timing has not been established. Among patients who had undergone curative surgery for primary CRC, intensive imaging and carcinoembryonic antigen (CEA) screening (CEA every 3 months for 2 years then every 6 months for 3 years plus computed tomography (CT) total body scan every 6 months for 2 years then annually for 3 years) each provided an improved rate of recurrence treated with curative intent compared with minimal follow-up (no scheduled follow-up except a single total body CT scan at 12–18 months); there was no advantage to combining both strategies. If there is a survival advantage to any strategy, it is likely to be small [10].
Over the last two decades, the rates of LR have been reduced in patients with rectal cancer. This is a result of a variety of different approaches, including improved surgery and the use of adjuvant chemotherapy and radiotherapy [11]. Surgical management of locally recurrent CRC has evolved with advances in surgical strategy and multimodal therapies [12]. Published series document 5-year survival rates of 30–60%, with acceptable rates of morbidity and mortality [13]. Methods of managing these patients are contentious, with no established algorithms. In order to identify optimal treatment strategy, patients can be divided into four clinical groups: resectable, potentially resectable, and nonresectable with or without intensive treatment.
6.3.1 Resectable Disease
In the resectable category, patients are further categorized as having resectable or potentially resectable disease:
Group 0: resectable disease (usually includes limited liver or lung disease). The option of upfront surgical intervention was offered to a selected subset of patients with LR. The operative strategy was determined by the anatomical extension of the tumor as mapped by preoperative radiological imaging [14]. Curative resection was carried out safely in the majority of patients, and postoperative mortality and morbility rates were acceptable [1]. Most reasons for unresectability were anatomically unresectable disease, presence of distant metastasis, or poor fitness for surgery [15]. The R0 resection rate following surgery for recurrent CRC was the best predictor of long-term survival. There was no survival difference between patients undergoing palliative (R2) resection compared with nonoperated patients. In disease limited to the liver, two chemotherapy options are available: postoperative chemotherapy after surgical resection (6 months), or a perioperative approach (3 months before and 3 months after surgical resection of liver metastases) [16].
Group 1: potentially resectable disease with curative intention. There is no consensus about neoadjuvant therapy for recurrence. Options are chemotherapy, external-beam RT (EBRT), brachytherapy, or intraoperative radiotherapy (IORT). Many patients with previous rectal cancer received RT at the time of primary resection, so further irradiation was limited to a small subset of patients. Reirradiation for pelvic recurrences is controversial because of concerns of late toxicity. Brachytherapy, EBRT, and IORT show promising single-center results, but there is no evidence from randomized trials for the use of any of these modalities, and further randomized trials are needed [17]. Chemo therapy treatment in this group of patients is similar to first-line chemotherapy for patients with metastatic CRC (mCRC). Recently, findings of several key studies on first-line che -motherapy for CRC have been reported.Related posts:
Role of Positron Emission Tomography/Computed Tomography
Follow-Up Strategy After Primary and Early Diagnosis
Techniques of Urological Reconstruction
Pain Control and Palliative Treatments
Clinical Presentation and Classifications
Italian Survey on the Surgical Treatment of Locally Recurrent Colorectal Cancer
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