Locally recurrent rectal cancer: Role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence

Locally recurrent cancer of the rectum has been under-recognized as a compl ication, although it affects up to 40% of patients treated with surgery alo ne. Even in the best centers, rates average 25%. While radiotherapy may red uce recurrence, it is now apparent that total mesorectal excision is the mo st effective modality, with rates as low as 5%. The dramatic decrease in lo cal recurrence can also be linked to increased survival in prospective stud ies, an effect more significant than any adjuvant therapy. The options, how ever, for patients with locally recurrent cancer are limited. Fifteen perce nt of patients with this complication die without systemic spread. Salvage by surgery offers potential cure. Other than anastomotic recurrences that c an be locally resected, the best approach for long-term survival is an exte nsive surgical procedure requiring en bloc removal of adjacent organs and p elvic structures-so-called composite resection. With careful selection, 30% 5-year survival can be achieved and palliation is considerable, with 50% l ong-term local control. Intraoperative radiotherapy and brachytherapy, and/ or preoperative chemoradiation may provide better results in future. Newer techniques of coloanal anastomosis, improved urinary diversion, and myocuta neous flaps for perineal reconstruction radically reduce the morbidity of t hese procedures. The approach to recurrent rectal cancer requires a sophist icated multidisciplinary team to obtain optimum results. J. Surg. Oncol. 20 00;73:47-58. (C) 2000 Wiley-Liss, Inc.