Advanced Treatment Strategies for Locally Recurrent Rectal Cancer

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• Recurrence Risk Reduction
• Complex Treatment Challenges
• Accurate Staging and Referral
• Multimodal Treatment Approach
• Extensive Surgery Requirements
• Multidisciplinary Team Necessity
• Radical Resection Outcomes
• Specialized Center Importance

Recurrence Risk Reduction Through Improved Surgery

Modern methods of rectal cancer treatment have significantly decreased the risk of local recurrence. Dr. Torbjorn Holm, MD, confirms that advancements in surgical technique, correct selection of procedures, and the integration of radiation and chemotherapy have reduced local recurrence rates from 25% to just 5% or 10%.

Complex Treatment Challenges of Local Recurrence

Treating locally recurrent rectal cancer is extremely difficult and the chance of a cure is not great. Dr. Torbjorn Holm, MD, explains that while recurrence is now less common, the cases that do occur are often more complex. Historically, recurrences were central and easier to resect, but modern recurrences often involve growth into the pelvic wall, sacrum, prostate, or urinary bladder, making them much more challenging to treat.

Accurate Staging and Essential Referral

The first and most crucial step in managing a local recurrence is correct staging. Dr. Torbjorn Holm, MD, emphasizes that staging must begin with an MRI. Following accurate staging, it is imperative that patients are immediately referred to a specialized colorectal cancer center. Dr. Anton Titov, MD, agrees that this referral to surgeons experienced in these complex operations is a critical factor for a successful outcome.

Multimodal Treatment Approach for Recurrence

Treatment for locally recurrent rectal cancer is rarely surgery alone. Dr. Torbjorn Holm, MD, states that patients often require repeat radiation therapy. If a patient has not received radiotherapy previously, they should all have a combination of radiotherapy and chemotherapy administered before any surgical intervention is planned.

Extensive Surgery Requirements for Cure

Surgical resection for recurrence is typically extensive and involves multi-organ resection. Dr. Torbjorn Holm, MD, details that surgeons must be prepared to perform major procedures like pelvic exenteration (pelvic evisceration) or a sacrectomy (resection of the sacrum). These operations are complex, and patients often experience significant bleeding during the procedure.

Multidisciplinary Team Necessity for Surgery

Success in these complex cases hinges on a multidisciplinary surgical team. Dr. Torbjorn Holm, MD, explains that the team must include colorectal surgeons, orthopedic surgeons, and plastic surgeons, and may also require a urologist. This variety of surgical expertise is essential to safely plan and execute the operation required to remove the recurrent tumor.

Radical Resection and Positive Outcomes

The absolute prerequisite for curing locally recurrent rectal cancer is achieving a radical operation with negative margins, known as an R0 resection. Dr. Torbjorn Holm, MD, states that when an R0 resection is achieved, it is possible to cure 65% to 70% of patients. Conversely, an operation that leaves positive margins (R1 or R2) will not cure the patient.

Specialized Treatment Center Importance

The overarching theme in managing this condition is the necessity of care at a highly specialized center. Dr. Torbjorn Holm, MD, concludes that because these operations are so difficult and complex, all patients must be referred to a center with a high volume of such cases. This is the most crucial factor for achieving a successful treatment outcome and the potential for a cure.

Full Transcript

Dr. Anton Titov, MD: "Better cancer surgery technique decreased the risk of local recurrence of rectal cancer from 25% to 5% or 10%." Why should local relapse of rectal cancer only be treated by few specialized colorectal surgeons? How to achieve 70% cure rate in locally recurrent rectal cancer?

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Video interview with leading expert in rectal cancer treatment surgery and locally recurrent rectal cancer treatment. Rectal cancer local recurrence treatment prognosis. Modern methods of rectal cancer treatment, correct selection of the surgical procedure, radiation therapy and chemotherapy for each patient reduce risks of rectal cancer coming back. However, 5% to 10% of rectal cancer patients have local recurrence of rectal cancer.

Dr. Anton Titov, MD: How do you treat locally recurrent rectal cancer? What are the treatment options for patients who have rectal cancer come back in the pelvis?

Dr. Torbjorn Holm, MD: First of all, we have to remember that the treatment of locally recurrent rectal cancer is extremely difficult. The chance of curing the patient with the local recurrence of rectal cancer is not great. When rectal cancer returns locally, it is very difficult to treat and it is difficult to cure.

However, now we see much fewer patients with local recurrence of rectal cancer. Because the risk of recurrence has gone from 25% to 5% or 10%, as you said. Reduced risk of rectal cancer recurrence means this. It is now even more challenging to treat patients with rectal cancer recurrences than before.

Before, we saw local recurrence of rectal cancer in the remaining mesorectum or close to anastomosis after surgical operation. Recurrence was happening centrally in the pelvis. Those patients with recurrent rectal cancer were easy to cure. Because you could just do the complementary total mesorectal excision and get the locally recurrent rectal cancer out. This would cure the colorectal cancer patient.

Now the local recurrence of rectal cancer is much more complex. Recurrent rectal cancer often grows into the pelvic wall, or into the sacrum or into the prostate or into the urinary bladder. These patients are much more difficult to cure.

But some patients will have local recurrence of rectal cancer. The first and most important thing is to stage rectal cancer correctly in these patients. Surgeon should begin recurrent rectal cancer staging with an MRI. Then these patients should be referred to a specialized colorectal cancer centre.

You have to send patients with recurrent rectal cancer to surgeons who are used to operate and treat locally recurrent rectal cancer. Because it's a very difficult situation. So good staging of recurrent rectal cancer tumor is important.

Dr. Anton Titov, MD: Patients must be referred to specialist centre for recurrent rectal cancer treatment.

Dr. Torbjorn Holm, MD: Often such patients should have radiation therapy again to treat recurrence of rectal cancer. We hope there is a possibility for radiotherapy. Sometimes patients with locally recurrent rectal cancer have not received radiotherapy before. Then they should all have radiotherapy and chemotherapy before surgery.

Surgeons should plan for usually a multi-organ resections. Nowadays for local rectal cancer recurrence you have to be prepared to do pelvic exenteration (pelvic evisceration) surgical operation. Or you have to do sacrectomy (resection of sacrum). Sometimes cancer surgeon has to remove a part of the pelvic sidewall.

You have to do extensive surgery. Usually patients with recurrent rectal cancer bleed quite a lot. You need a multidisciplinary surgical team consisting of colorectal surgeons, orthopedic surgeons, plastic surgeons. Maybe you need a urologist too. So a variety of surgical expertise is required.

Then you can plan to treat locally recurrent rectal cancer patient. Even if you have such comprehensive surgical team, a prerequisite for cure of locally recurrent rectal cancer is a radical operation with R0 resection margins. Sometimes you can achieve R0 resection. Then you can cure 65% to 70% of patients with local recurrence of rectal cancer.

Dr. Anton Titov, MD: You can cure those rectal cancer patients who already have the cancer come back locally? That requires performing the correct method of surgical operation.

Dr. Torbjorn Holm, MD: Sometimes you do the correct operation in the correct way in local recurrence of rectal cancer. When you achieve R0 resection, the prognosis can still be good. But if you do a bad operation and have a positive tumor margin (R1 or R2), you would not cure the patient.

Because surgical operations in patients with locally recurrent rectal cancer are much more difficult and much more complex. All patients with recurrent rectal cancer have to be referred to a highly specialized center. This is crucial for success in treatment of locally recurrent rectal cancer.

Dr. Anton Titov, MD: Rectal cancer. Local recurrence treatment requires highly specialized colorectal cancer surgeon and multidisciplinary team method. 70% cure rate in skilled hands of cancer surgeon.