Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer

Naruhiko Ikoma, Y Nancy You, Brian K Bednarski, Miguel A Rodriguez-Bigas, Cathy Eng, Prajnan Das, Scott Kopetz, Craig Messick, John M Skibber, George J Chang, Naruhiko Ikoma, Y Nancy You, Brian K Bednarski, Miguel A Rodriguez-Bigas, Cathy Eng, Prajnan Das, Scott Kopetz, Craig Messick, John M Skibber, George J Chang

Abstract

Purpose After preoperative chemoradiotherapy followed by total mesorectal excision for locally advanced rectal cancer, patients who experience local or systemic relapse of disease may be eligible for curative salvage surgery, but the benefit of this surgery has not been fully investigated. The purpose of this study was to characterize recurrence patterns and investigate the impact of salvage surgery on survival in patients with rectal cancer after receiving multidisciplinary treatment. Patients and Methods Patients with locally advanced (cT3-4 or cN+) rectal cancer who were treated with preoperative chemoradiotherapy followed by total mesorectal excision at our institution during 1993 to 2008 were identified. We examined patterns of recurrence location, time to recurrence, treatment factors, and survival. Results A total of 735 patients were included. Tumors were mostly midrectal to lower rectal cancer, with a median distance from the anal verge of 5.0 cm. The most common recurrence site was the lung followed by the liver. Median time to recurrence was shorter in liver-only recurrence (11.2 months) than in lung-only recurrence (18.2 months) or locoregional-only recurrence (24.7 months; P = .001). Salvage surgery was performed in 57% of patients with single-site recurrence and was associated with longer survival after recurrence in patients with lung-only and liver-only recurrence ( P < .001) but not in those with locoregional-only recurrence ( P = .353). Conclusion We found a predilection for lung recurrence in patients with rectal cancer after multidisciplinary treatment. Salvage surgery was associated with prolonged survival in patients with lung-only and liver-only recurrence, but not in those with locoregional recurrence, which demonstrates a need for careful consideration of the indications for resection.

Figures

Fig 1.
Fig 1.
Cumulative number of recurrences by site. ERLN, extraregional lymph node.
Fig 2.
Fig 2.
Recurrence patterns and salvage surgery. CRTx, chemoradiation therapy; ERLN, extraregional lymph node; TME, total mesorectal excision.
Fig 3.
Fig 3.
Overall survival after recurrence (A) by curative surgery, (B) among patients who had salvage surgery by disease site, (C) in lung-only recurrence, (D) in liver-only recurrence, and (E) in locoregional-only recurrence by curative surgery. OS, overall survival.
Fig 3.
Fig 3.
Overall survival after recurrence (A) by curative surgery, (B) among patients who had salvage surgery by disease site, (C) in lung-only recurrence, (D) in liver-only recurrence, and (E) in locoregional-only recurrence by curative surgery. OS, overall survival.

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