Colorectal Cancer: Management of Local Recurrence
Local recurrence after surgery for colorectal cancer remains a challenging clinical problem. Modern imaging has allowed for better patient selection and gives the surgeon a higher degree of certainty about his or her ability to achieve a curative resectio
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Key Concepts • Patients with colorectal cancer at the highest risk for local recurrence are those who present with obstruction or perforation, higher-stage disease, and adverse pathologic features, or undergo an operation that does not adhere to standard oncologic principles. • The most significant predictor of survival following surgery for local recurrence is the ability to achieve a negative-margin (R0) resection. • The probability of achieving an R0 resection is much greater in patients with recurrences involving an anastomosis or urogynecologic structures compared with those involving para-aortic tissue, sacrum, or lateral pelvic sidewall. • A dedicated multidisciplinary team at an institution experienced in the management of patients with local colorectal cancer recurrence can facilitate complex surgical decision-making and greatly enhance patient outcomes. • A multimodality approach that includes chemotherapy and radiotherapy improves local control and improves 5-year survival in patients with local recurrence.
Introduction The medical and surgical management of colorectal cancer has a rich history, and treatment paradigms have evolved significantly over the last 100 years [1–6]. Major advances have been made in our understanding of tumor biology, the role of chemoradiotherapy, and most importantly, the significance of precise surgical technique. These advances have dramatically decreased local recurrence and increased 5-year survival in patients with primary colorectal cancer [1, 6–9]. Despite these advances, local recurrence following surgery remains a significant problem [4, 10–18]. In addition to its impact on survival, major morbidity from local recurrence
can have a dramatic detrimental impact on quality of life [19–21]. In the United States, approximately 90,000 patients are diagnosed with colon cancer each year, and in those that undergo surgery, somewhere between 8 and 12 % will develop a local recurrence [22, 23]. Of the 40,000 patients diagnosed with rectal cancer each year, approximately 5–30 % will develop a local recurrence [24–28]. Patients with colorectal cancer at the highest risk for local recurrence are those that have higher-stage disease, high-grade tumors, and lymphovascular involvement or present with obstruction, perforation, or a locally advanced tumor at the time of presentation [29–34]. Operations done by noncolorectaltrained surgeons, or by surgeons who perform less than 20 rectal cancer resections per year, have been reported to have higher local recurrence rates [30]. Recently, the importance of a threatened or violated circumferential margin as an independent predictor of future recurrence has reinforced the importance of meticulous surgical technique [15, 35, 36]. All efforts to reduce the risk of local recurrence should be made when managing primary colorectal cancer, and the best results are achieved when patients are managed by experienced teams [37, 38]. When patients with colorectal cancer develop local recurrence, surgery offers the best opportunity for cure [15, 24, 3
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