Locally recurrent rectal cancer (LRRC), which occurs in 6-12% of patients previously treated with surgery, with or without pre-operative chemoradiation therapy, represents a complex and heterogeneous disease profoundly affecting the patient's quality of life (QoL) and long-term survival. Its management usually requires a multidisciplinary approach, to evaluate the several aspects of a LRRC, such as resectability or the best approach to reduce symptoms. Surgical treatment is more complex and usually needs high-volume centers to obtain a higher rate of radical (R0) resections and to reduce the rate of postoperative complications. Multiple factors related to the patient, to the primary tumor, and to the surgery for the primary tumor contribute to the development of local recurrence. Accurate pre-treatment staging of the recurrence is essential, and several classification systems are currently used for this purpose. Achieving an R0 resection through radical surgery remains the most critical factor for a favorable oncologic outcome, although both chemotherapy and radiotherapy play a significant role in facilitating this goal. If a R0 resection of a LRRC is not feasible, palliative treatment is mandatory to reduce the LRRC-related symptoms, especially pain, minimizing the effect of the recurrence on the QoL of the patients. The aim of this manuscript is to provide a comprehensive narrative review of the literature regarding the management of LRRC.

Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. 'Selective' patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates.

A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes.

Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/- 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/- 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5-17.5 months) and 25.9 months (IQR 6.2-39.7 months), respectively.

Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.

Patients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment.

Consecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases.

A total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15-2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039).

LRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.

Patients with locally recurrent rectal cancer (LRRC) frequently present with either synchronous metastases or a history of metastases. This study was conducted to evaluate whether LRRC patients without metastases have a different oncological outcome compared to patients with a history of metastases treated with curative intent or patients with potentially curable synchronous metastases.

All consecutive LRRC patients who underwent intentionally curative surgery between 2005 and 2017 in a large tertiary hospital were retrospectively reviewed and categorized as having no metastases, a history of (curatively treated) metastases or synchronous metastases. Patients with unresectable distant metastases were excluded from the analysis.

Of the 349 patients who were analysed, 261 (75%) had no metastases, 42 (12%) had a history of metastases and 46 (13%) had synchronous metastases. The 3-year metastasis-free survival was 52%, 33% and 13% in patients without metastases, with a history of metastases, and with synchronous metastases, respectively (P < 0.001) A history of metastases did not influence overall survival (OS), but there was a trend towards a worse OS in patients with synchronous metastases compared with patients without synchronous metastases (hazard ratio 1.43; 95% CI 0.98-2.11).

LRRC patients with a history of curatively treated metastases have an OS comparable to that in patients without metastases and should therefore be treated with curative intent. However, LRRC patients with synchronous metastases have a poor metastasis-free survival and worse OS; in these patients, an individualized treatment approach to observe the behaviour of the disease is recommended.

Locally recurrent rectal cancer (LRRC) is a complex problem requiring multidisciplinary consultation and specialized surgical care. Given the paucity of published longer-term survival data, skepticism persists regarding the benefit of major extirpative surgery. We investigated ultra-long-term (~15 years) outcomes following radical resection of LRRC and sought relevant clinicopathologic prognostic variables.

A cohort of 52 consecutive patients who underwent resection of LRRC at our institution between 1997 and 2005 were followed with serial exams and imaging up to the point of death, or 30/06/2019.

Median follow-up time was 16.5 years (9.9-18.3) for patients who were alive at last follow-up; only one patient was lost to follow-up, at 9.9 years. For the entire cohort of 52 patients, disease-specific survival (DSS) at 5, 10, and 15 years following salvage surgery was 41%, 33%, and 31%, respectively. All patients who had distant metastatic disease at the time of LRRC resection (n = 6) subsequently died of cancer, at a median of 21 months (4-46). In those without distant metastases at time of salvage surgery (n = 46), DSS at 5, 10, and 15 years was 47%, 38%, and 35%, respectively, median 60 months. Negative resection margin (R0) was independently predictive of superior outcomes. In patients with M0 disease who had R0 resection (n = 37), DSS at 5, 10 and 15 years was 58%, 47%, and 44%, respectively, median 73 months. No patient developed re-recurrence after 5.5 years.

This study demonstrates exceptionally durable long-term cancer-free survival following salvage surgery for LRRC, indicating that cure is possible.

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.

Surgery is the only curative treatment in patients with locally recurrent rectal cancer (LRRC). The aim of this study was to evaluate the outcome and the prognostic factors of tumour-free resection margin (R0) and overall survival (OS) in LRRC.

Consecutive LRRC patients observed between 1987 and 2005 in three Italian university hospitals were evaluated. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. In order to identify factors associated with both R0 resection and OS, a logistic regression analysis was performed in patients who underwent surgery with curative intent.

Out of 150 patients with LRRC, 107 underwent surgery, but since 7 were found to have unresectable disease only 100 underwent surgical resection. Of them, 51 underwent radical and 49 extended resection. Sixty of the 107 patients underwent multimodality treatment. In 61 patients, R0 resection was achieved. Median OS after surgery was 43.4 months. In patients, who had surgery with curative intent, independent variables associated with R0 resection were: surgery for the primary tumour performed in other hospitals (p = 0.042) extended resection (p = 0.025) and use of positron emission tomography (PET) as a staging modality (p = 0.03). Independent variables associated with OS were: post-operative radiotherapy (p = 0.004), stage of the primary tumour (p = 0.004), R0 resection (p = 0.00001), and use of PET (0.02).

Resection for LRRC results in improved survival. Other than the well-known prognostic factors R0 resection and OS, PET scan has an independent impact both on OS and R0 resection. It should therefore be included in routine clinical practice when staging LRRC.

Patients who have liver metastasis and extrahepatic metastatic disease (EMD) have been considered as a patient subgroup with a very poor prognosis. Therefore, the presence of EMD was traditionally considered a contraindication for liver resection. But, survivals of around 30% at 5 years, and higher than that achieved with chemotherapy only obtained in some patients with liver metastasis of colorectal origin and EMD who had a resection performed on the hepatic and extrahepatic disease, obliges us to re-think what we must do in these patients. We have carried out an exhaustive review of the literature in an attempt to establish some working guidelines based on current scientific evidence. In summary, we can say that the presence of resectable EMD in patients with liver metastasis must not be considered as an absolute contraindication for liver resection, although the results are inferior to those obtained in patients without EMD. Patients with EMD localised in the ganglia of the coeliac trunk or aorto-cava have a short survival. The use of chemotherapy prior to the surgery is recommended to operate stable patients, or who respond to the chemotherapy and not in progression.

Radical resection is the only potential cure for patients with locally advanced primary and recurrent rectal cancer and is considered curative only when the histologic margins are clear of tumour. Early diagnosis of the disease is essential as it increases the likelihood of a potentially curative resection and prevention of dissemination. Clinical examination, tumour markers and radiologic modalities such as ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography are routinely used in an effort to accurately stage these patients and provide useful information for the selection of patients for further treatment/management. This review describes the methods of staging patients with locally advanced primary and recurrent rectal cancer prior to surgery emphasizing the role that radiologists have in this process.

A literature review has been made on the pelvic recurrence of rectal cancer using the MedLine, Ovid, EMBASE, Cochrane and Cinahl data bases. Assessment of the locoregional recurrence must be made using imaging tests in order to rule out the presence of metastasis, as well as for locating its exact location within the pelvis. As the only curative treatment should be complete resection of the recurrence with negative margins, a pre-operative CT, NMR, endorectal ultrasound and PET-CT must be performed to determine its resectability. For a potential cure, radical resections must be made, with the technique varying according to whether the location is central (axial), posterior (presacral) or lateral, as well as treatment directed at the primary tumour. Neoadjuvant treatments, brachiterapy and intra-operative radiotherapy improve the local control results and survival in these patients.

Although locoregional recurrence after rectal cancer resection has been extensively investigated, studies of salvage surgery for locoregionally recurrent colon cancer are scarce. This study aimed to determine the predictors of postsalvage survival for locoregionally recurrent colon cancer.

We studied 45 consecutive patients who underwent macroscopically complete resection of locoregionally recurrent colon cancer between April 1988 and December 2007. The primary end point was cancer-specific survival, and 20 clinical variables were analyzed for their prognostic significance.

Cancer-specific 5-year survival for the entire cohort of 45 patients was 46%. Multivariate survival analysis showed that margin status (P = .0311), number of locoregional recurrent tumors (P = .0002), pathological grade (P = .0416), largest tumor diameter (P = .0247), and distant metastasis (P = .0006) were independently associated with cancer-specific survival.

Salvage surgery for locoregional recurrence of colon cancer can provide a chance for long-term survival in selected patients.

Advances in surgical practice have helped expand the options for patients with locally recurrent rectal cancer through improvements in reconstructive options, management of operative complications, addition of intraoperative adjuvant therapies, and postoperative care. This review outlines the presentation and management of patients with locally recurrent rectal cancer, and it describes easy-to-apply clinical algorithms to aid management.

The electronic literature was searched for studies reporting outcomes for locally recurrent rectal cancer limited to the English language.

Prospective and retrospective case series and single-center experiences were identified. A total of 106 articles were selected for full-text review of which 82 fulfilled the inclusion criteria. No randomized studies were identified. We found that multimodality treatment of locally recurrent rectal cancer can improve 5-year survival from 0% to over 40%, and selected patients may survive up to 10 years. A mixture of imaging modalities is used in patient selection for surgery. An R0 resection is consistently a favorable prognostic factor. R1 resection and surgery in the setting of oligometastases compare favorably with nonoperative palliation. Although mortality figures remain low, morbidity is significant and mostly wound related.

Improvements in radiological imaging modalities and technical improvements in surgical and reconstructive options have facilitated more accurate staging, better selection of patients for surgery, reduced morbidity and mortality, and higher R0 resections. Optimal management is in specialist units with a multidisciplinary approach with the use of multimodal therapy.

Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.

The presence of extrahepatic disease has a great effect on the management of patients with metastatic colorectal cancer in the liver. FDG-PET scanning is currently the most sensitive way of detecting extrahepatic metastases in such patients. This is supported by 10 studies, which show that FDG-PET scan will discover extrahepatic disease in about one in six patients who have completed standard imaging. Staging laparoscopy is another means of detecting extrahepatic disease. Its role remains undefined especially in patients who have had FDG-PET scans. It should probably be restricted to patients with high clinical risk scores. In terms of treatment, patients with recurrence at the primary colorectal site as well as resectable liver metastases appear to benefit from resection of both sites provided that R0 resections can be obtained. Resection of involved hepatic pedicle lymph nodes in patients with resectable liver metastases is associated with poor outcome. The situation regarding patients with peritoneal and liver metastases bears a strong resemblance to that of primary site recurrence and liver metastases. Very acceptable survival can be expected if the peritoneal disease can be eradicated. Information regarding treatment of lung and liver metastases is the most complete of any of these areas. Good results may be expected if all the disease can be cleared. Caution is required in interpreting claims of good survival when study numbers are small and confidence intervals of data are not provided.

We sought to further elucidate the survival impact of cytoreductive surgery among patients with colon cancer metastatic to the ovary.

All women diagnosed with primary colon cancer metastatic to the ovary at a single institution from 1980 to 2005 were retrospectively identified. Survival analyses and comparisons were performed using Kaplan-Meier plots and the log rank test.

A total of 39 patients with 40 cases of colon cancer metastatic to the ovary were identified. Patients with metastatic disease confined to the ovaries (n=11) had a median overall survival (OS) time of 61 months (range 15-120) compared to 17 months (range 0.5-73) for those with more extensive metastases (n=24) (p=0.0428). Patients undergoing optimal cytoreduction (residual < or =1 cm) had a median progression-free survival (PFS) of 11 months (range 0.5-120, n=26) compared to 2.5 months (range 0.5-12, n=9) for those receiving suboptimal cytoreduction (p=0.0001). Optimal cytoreduction was also associated with a significantly longer median OS (35 months, range 0.5-120) compared to suboptimal cytoreduction (median OS=7 months, range=0.5-17) (p<0.0001). The peri-operative mortality rate was 5%. Significant morbidity occurred in 10% of the cases. All major complications occurred in women with diffuse disease who underwent extensive cytoreductive surgery.

The observation that optimal cytoreduction was associated with prolonged PFS and OS in both patients with localized ovarian and widespread metastases of colon cancer suggests a role for surgical management of metastatic colon cancer in women.

Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes.

A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated.

Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential.

Locoregional recurrence after resection of colon carcinoma is an uncommon and difficult clinical problem. Outcome data to guide surgical management are limited. This investigation was undertaken to review our experience with surgical resection for patients with locoregional recurrence colon cancer, determine predictors of respectability, and define prognostic factors associated with survival.

A prospective database was queried for patients who had recurrent colon cancer between January 1991 and October 2002. Patients were selected for analysis if they had either isolated resectable locoregional recurrence or concomitant resectable distant disease. Disease-specific survival analysis was performed with the Kaplan-Meier actuarial method, and factors associated with outcome were determined by the log-rank test and Cox regression.

During this period of time, 744 patients with recurrent colon cancer were identified and 100 (13.4 percent) underwent exploration with curative intent for potentially resectable locoregional recurrence: 75 with isolated locoregional recurrence, and 25 with locoregional recurrence and resectable distant disease. The median follow-up for survivors was 27 months. Locoregional recurrence was classified into four categories: anastomotic; mesenteric/nodal; retroperitoneal; and peritoneal. Median survival for all patients was 30 months. Fifty-six patients had an R0 resection (including distant sites). Factors associated with prolonged disease-specific survival included R0 resection (P < 0.001); age <60 years (P < 0.01); early stage of primary disease (P = 0.05); and no associated distant disease (P = 0.03). Poor prognostic factors included more than one site of recurrence (P = 0.05) and involvement of the mesentery/nodal basin (P = 0.03). The ability to obtain an R0 resection was the strongest predictor of outcome, and these patients had a median survival of 66 months.

Salvage surgery for locoregional recurrence colon cancer is appropriate for select patients. Complete resection is critical to long-term survival and is associated with a single site of recurrence, perianastomotic disease, low presalvage carcinembryonic antigen level, and absence of distant disease.

The question of whether resection should be performed in Krukenberg tumors from gastric cancer has yet to be adequately examined. Despite some reports on the surgical treatment of Krukenberg tumors, the outcomes after resection are not well characterized.

Using a gastric cancer database, a total of 34 patients who underwent a resection of metastatic ovarian tumors after curative surgery for gastric cancer were identified. A prospective database of these patients was reviewed for the presentation, clinical features, and outcomes after resection.

The median age of 34 patients was 44 years (range, 24-66). The majority of patients was in the premenopausal state and had bilateral ovarian involvement. The most common presenting symptom was an abdominal mass (35.3%). Tumor size ranged from 3.5 to 20 cm with 61.8% measuring larger than 10 cm. In 17 patients who had metastatic disease confined to the pelvis, a complete gross resection (R0) was achieved. In the other 17 with the disease beyond the pelvis gross residual tumors remained after the resection (R1). The median survival of all patients was 11 months (95% confidence interval [CI] 8-14), and that of the patients rendered R0 was 18 months (95% CI, 14-22), in comparison with 9 months (95% CI, 3-15) for those with R1 resection (P = 0.0001; log-rank test). The median progression free survival was also significantly longer for the patients with R0 resection than those with R1 resection (8 months, 95% CI, 5-11 vs. 5 months, 95% CI, 4-6, P = 0.0103). Multivariate analysis identified R0 resection as the only significant factor predictive of survival.

In the management of Krukenberg tumors after gastric cancer, a metastasectomy may significantly improve the overall and progression free survival if it could render a complete gross resection. To define the patient group that benefits most from resection, the extent of disease and resectability must be carefully evaluated before surgery.