Floris T. J. Ferenschild

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer.

PURPOSE: The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer. METHODS: Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome. RESULTS: Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4–50) months. Median age at diagnosis of recurrence was 74 (range, 56–84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2–112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%. CONCLUSIONS: Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

High-dose-rate intraoperative radiotherapy for close or positive margins in patients with locally advanced or recurrent rectal cancer.

PURPOSE A high-dose-rate intraoperative radiotherapy (HDR-IORT) technique for rectum cancer was developed and the technique, local failure, and survival were analyzed. METHODS AND MATERIALS After the exclusion of metastatic patients, 37 patients were treated with external beam RT, surgery, and HDR-IORT between 1997 and 2000. Primary locally advanced rectum cancer was found in 18 patients and recurrent disease in 19. HDR-IORT was only administered if the resection margins were < or =2 mm. The flexible intraoperative template is a 5-mm-thick pad with 1-cm-spaced parallel catheters. Clips were placed during surgery to define the target area. A dose of 10 Gy was prescribed at a 1 cm depth from the template surface and calculated using standard plans. After treatment, the dose at the clips was calculated using the reconstructed template geometry and the actual treatment dwell times. The median follow-up of surviving patients was 3 years. No patients were lost to follow-up. RESULTS Overall, 12 patients (32%) had local recurrence, 5 (14%) of which were in the HDR-IORT field. The 3-year local failure rate for primary tumors and recurrent tumors was 19% and 52%, respectively (p = 0.0042). The 3-year local failure rate was 37% for negative margins and 26% for positive margins (p = 0.51). A high mean dose at the clip (17.3 Gy) was found. The overall survival was significantly different for primary vs. recurrent tumors, stage, and grade. CONCLUSION Because of the HDR technique, a high dose at the clips was found, with good local control. More out-of-field than in-field failures were seen. The local failure rate was significantly different for primary vs. recurrent disease.

Salvage Abdominoperineal Resection and Perineal Wound Healing in Local Recurrent or Persistent Anal Cancer

The primary treatment for anal cancer is chemoradiation (CRT). Failures after CRT are potentially curable with an abdominoperineal resection (APR). A major problem of surgery in the anal area is poor healing of the perineal wound. Between 1985 and 2000, 129 patients treated for anal cancer were retrospectively reviewed. Of the 24 patients with local failure, 18 patients were treated with an APR. The aim of this study was to review the results and long-term outcome after salvage APR, with special emphasis on perineal wound healing. Mean age at diagnosis was 59 (range: 41–83) years. After a median of 16 months, only 2 patients developed a local recurrence. The 5-year overall survival was 30%. In 11 patients the perineal wound was closed primarily, in 3 patients the perineal wound was left open, and in 4 patients a vertical rectus abdominus musculocutaneous (VRAM) flap was used. Perineal wound breakdown occurred in 5 of the 14 patients (36%) not treated with primary muscle reconstruction. In all patients treated with a VRAM flap the perineal wound healed primarily. In the present study salvage APR in recurrent or persistent anal cancer results in good local control and 5-year overall survival of 30%. When performing an APR a VRAM flap reconstruction should be considered to prevent disabling perineal wound complications.

Preoperative Radiotherapy Improves Outcome in Recurrent Rectal Cancer

PURPOSEWhen local recurrent rectal cancer is diagnosed without signs of metastases, a potentially curative resection can be performed. This study was designed to compare the results of preoperative radiotherapy followed by surgery with surgery only.METHODSBetween 1985 and 2003, 117 patients with recurrent rectal cancer were prospectively entered in our database. Ninety-two patients were suitable for resection with curative intent. Preoperative radiation with a median dosage of 50 Gy was performed in 59 patients; 33 patients did not receive preoperative radiotherapy. The median age of the patients was respectively 66 and 62 years.RESULTSThe median follow-up of patients alive for the total group was 16 (range, 4–156) months. Tumor characteristics were comparable between the two groups. Complete resections were performed in 64 percent of the patients who received preoperative radiation and 45 percent of the nonirradiated patients. A complete response after radiotherapy was found in 10 percent of the preoperative irradiated patients (n = 6). There were no differences in morbidity and reintervention rate between the two groups. Local control after preoperative radiotherapy was statistically significantly higher after three and five years (P = 0.036). Overall survival and metastases-free survival were not different in both groups. Complete response to preoperative radiotherapy was predictive for an improved survival.CONCLUSIONSPreoperative radiotherapy for recurrent rectal cancer results in a higher number of complete resections and an improved local control compared with patients treated without radiotherapy. Preoperative radiotherapy should be standard treatment for patients with recurrent rectal cancer.

Abdominosacral resection for locally advanced and recurrent rectal cancer

The results of resection of locally advanced and recurrent rectal cancers, including sacral resection, were analysed critically.

Reirradiation, surgery and IORT for recurrent rectal cancer in previously irradiated patients

A total of 11 patients with recurrent rectal cancer who had been previously irradiated were treated with preoperative reirradiation (median dose 30Gy), surgery and IORT. This treatment was related with high morbidity, a short pain-free survival (5 months) and poor local control (27% after 3 years), although some patients have long-term distant control and survival.

Management of locally advanced primary and recurrent rectal cancer.

Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.

Preoperative Radiotherapy Has No Value for Patients with T2–3, N0 Adenocarcinomas of the Rectum

Background: Treatment of rectal cancer with preoperative radiotherapy followed by total mesorectal excision is nowadays the standard treatment. It reduces local recurrences and improves overall survival. However, in patients with T2–3, N0 rectal cancer, the role of preoperative radiotherapy remains controversial. The aim of this study was to review the benefit of radiotherapy in T2 and T3, N0 rectal cancer patients. Methods: Between 1996 and 2003, 103 patients with T2–3, N0 rectal cancer were identified in our prospective database. This study evaluated time to local recurrence, distant metastases and overall survival. Results: Median follow-up was 4.3 years. The 5-year local control rate was 94%. The 5-year overall survival was 65%. The 5-year disease-free survival rate was 82%. Preoperative radiotherapy did not show any statistical differences. Abdominal perineal resection and T3 tumors negatively influenced overall survival (p = 0.02). Advanced age was of significant importance in overall survival. Conclusions: Preoperative radiotherapy does not seem to be of significant importance in patients with T2–3, N0 rectal cancer regarding local recurrence and survival. Since preoperative radiotherapy is associated with short- and long-term morbidity, patients with T2–3, N0 tumors should be identified and treated with surgery alone.

Präoperative Strahlentherapie verbessert das Ergebnis bei Rezidiven eines Rektumkarzinoms

ZusammenfassungZiel:Wenn Lokalrezidive eines Rektumkarzinoms ohne Zeichen von Metastasen diagnostiziert werden, kann eine potenziell kurative Resektion durchgeführt werden. Diese Studie wurde durchgeführt, um die Ergebnisse von präoperativer Strahlentherapie plus nachfolgender Operation mit denen von ausschließlicher Operation zu vergleichen.Methodik:Zwischen 1985 und 2003 wurden 117 Patienten mit Rezidiv eines Rektumkarzinoms prospektiv in unserer Datenbank geführt. 92 Patienten kamen für eine Resektion mit kurativer Zielsetzung in Frage. Eine präoperative Bestrahlung mit einer mittleren Dosierung von 50 Gy wurde bei 59 Patienten durchgeführt; 33 Patienten erhielten keine präoperative Radiotherapie. Das mittlere Alter der Patienten war 66 bzw. 62 Jahre.Ergebnisse:Das mittlere Follow-up von überlebenden Patienten war für die Gesamtgruppe 16 (4–156) Monate. Tumorcharakteristika waren zwischen den beiden Gruppen vergleichbar. Komplette Resektionen wurden bei 64% der Patienten mit präoperativer Bestrahlung und 45% der nicht bestrahlten Patienten durchgeführt. Ein vollständiges Ansprechen auf die Radiotherapie wurde bei 10% der präoperativ bestrahlten Patienten (n = 6) festgestellt. Es gab keine Unterschiede in der Morbiditäts- und Reinterventionsrate zwischen den beiden Gruppen. Lokale Tumorfreiheit nach der präoperativen Radiotherapie war statistisch signifikant höher nach drei und fünf Jahren (p = 0,036). Es gab keinen Unterschied im Gesamtüberleben und metastasenfreien Überleben in beiden Gruppen. Das vollständige Ansprechen auf die präoperative Radiotherapie war entscheidend für die Prognose eines verbesserten Überlebens.Schlussfolgerung:Präoperative Radiotherapie beim Lokalrezidiv eines Rektumkarzinoms resultiert in einer höheren Anzahl kompletter Resektionen und einer verbesserten lokalen Tumorfreiheit verglichen mit Patienten, die ohne Bestrahlung behandelt wurden. Präoperative Radiotherapie sollte die Standardbehandlung für Patienten mit Lokalrezidiv eines Rektumkarzinoms sein.AbstractPurpose:When local recurrent rectal cancer is diagnosed without signs of metastases, a potentially curative resection can be performed. This study was designed to compare the results of preoperative radiotherapy followed by surgery with surgery only.Methods:Between 1985 and 2003, 117 patients with recurrent rectal cancer were prospectively entered in our database. Ninety-two patients were suitable for resection with curative intent. Preoperative radiation with a median dosage of 50 Gy was performed in 59 patients; 33 patients did not receive preoperative radiotherapy. The median age of the patients was 66 and 62 years, respectively.Results:The median follow-up of patients alive for the total group was 16 (range, 4–156) months. Tumor characteristics were comparable between the two groups. Complete resections were performed in 64% of the patients who received preoperative radiation and 45% of the nonirradiated patients. A complete response after radiotherapy was found in 10% of the preoperatively irradiated patients (n = 6). There were no differences in morbidity and reintervention rate between the two groups. Local control after preoperative radiotherapy was statistically significantly higher after three and five years (p = 0,036). Overall survival and metastases-free survival were not different in both groups. Complete response to preoperative radiotherapy was predictive for an improved survival.Conclusions:Preoperative radiotherapy for recurrent rectal cancer results in a higher number of complete resections and an improved local control compared with patients treated without radiotherapy. Preoperative radiotherapy should be standard treatment for patients with recurrent rectal cancer.

Total pelvic exenteration for primary locally advanced and recurrent rectal cancer

Aims: To report the role of total pelvic exenteration in a series of locally advanced and recurrent rectal cancers. Methods: In the period 1994e2004, TPE was performed in 35 of 296 patients with primary locally advanced and recurrent rectal cancer treated in the Daniel den Hoed Cancer Center; 23 of 176 with primary locally advanced and 12 of 120 with recurrent rectal cancer. All but one patient received pre-operative External Beam Radiation Therapy (EBRT). After 1997, Intra Operative Radiotherapy (IORT) was performed in case of a resection margin less than 2 mm. Results: Overall major complication rates were not significantly different between patients with primary and recurrent rectal cancer (26% vs. 50%, p ¼ 0.94). The hospital mortality rate was 3%. The 5-year local control and overall survival of patients with primary locally advanced rectal cancer were 88% and 52%, respectively. In patients with recurrent rectal cancer 3-year local control and survival rates were 60% and 32%, respectively. An incomplete resection, preoperative pain and advanced Wanebo stage for recurrent cancer were negative prognostic factors for both local control and overall survival. Conclusion: TPE in primary locally advanced rectal cancer enables good local control and acceptable overall survival, thereby justifying the use of the procedure. Patients with recurrent rectal cancer showed a high rate of major complications, a high distant metastasis rate, and a poor overall survival. 2006 Elsevier Ltd. All rights reserved.