The Management of Recurrent Rectal Cancer: A European Perspective

  • Giovanni M. Romano
  • Francesco Bianco
  • Silvia De Franciscis
  • Andrea Belli


Over recent decades there has been an extraordinary improvement in the management of rectal cancer leading to principally as an end-point to a marked reduction in the local recurrence rate. Thanks to the introduction in clinical practice of standardized total mesorectal excision (TME) and the implementation of both adjuvant and especially neo-adjuvant therapies, the incidence of local pelvic recurrence has effectively dropped from 20% to 30% down to an average of 6–10% and even lower in many dedicated colorectal units [1, 2]. These figures vary widely in population-based studies from 4% to 40% as well as in single-center and reported single surgeon series [2, 3]. The treatment of locally recurrent rectal cancer is still a major issue and a clinical challenge which deserves a multi-disciplinary approach and careful selection of patients suitable for surgery. Local recurrence generally occurs within the first 5 years after the primary surgery, with almost 70% of cases presenting within 2 years and 85% within the first 3 years [4, 5]. Nevertheless with the improvement in the effectiveness of adjuvant therapies and neoadjuvant chemoradiation (CRT) regimens, recurrences have been rarely reported to occur up to 10 years after the primary surgery [3].


  1. 1.
    Manfredi S, Benhamiche AM, Meny B, et al. Population-based study of factors influencing occurrence and prognosis of local recurrence after surgery for rectal cancer. Br J Surg. 2001;88:1221–7.CrossRefGoogle Scholar
  2. 2.
    Palmer G, Martling A, Cedermark B, et al. A population based study on the management and outcome in patients with locally recurrent rectal cancer. Ann Surg Oncol. 2007;14:447–54.CrossRefGoogle Scholar
  3. 3.
    Bakx R, Visser O, Josso J, et al. Management of recurrent rectal cancer: a population based study in greater Amsterdam. World J Gastroenterol. 2008;14:6018–23.CrossRefGoogle Scholar
  4. 4.
    Boyle KM, Sagar PM, Chalmers AG, et al. Surgery for locally recurrent rectal cancer. Dis Colon Rectum. 2005;48:929–37.CrossRefGoogle Scholar
  5. 5.
    Wells BJ, Stotland P, Ko MA, et al. Results of an aggressive approach to resection of locally recurrent rectal cancer. Ann Surg Oncol. 2007;14:390–5.CrossRefGoogle Scholar
  6. 6.
    Stocchi L, Nelson H, Sargent DJ, et al. Impact of surgical and pathologic variables in rectal cancer: a United States community and cooperative group report. J Clin Oncol. 2001;19:3895–902.CrossRefGoogle Scholar
  7. 7.
    Peeters KC, Marijnen CA, Nagtegaal ID, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.CrossRefGoogle Scholar
  8. 8.
    Folkesson J, Birgisson H, Pahlman L, et al. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol. 2005;23:5644–50.CrossRefGoogle Scholar
  9. 9.
    Holm T, Cedermark B, Rutqvist LE. Local recurrence of rectal adenocarcinoma after ‘curative’ surgery with and without preoperative radiotherapy. Br J Surg. 1994;81:452–5.CrossRefGoogle Scholar
  10. 10.
    Pilipshen SJ, Heilweil M, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer. 1984;53:1354–62.CrossRefGoogle Scholar
  11. 11.
    Wibe A, Eriksen MT, Syse A, Tretli S, Myrvold HE, Soreide O. Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level. Br J Surg. 2005;92:217–24.CrossRefGoogle Scholar
  12. 12.
    Iversen LH, Harling H, Laurberg S, Wille-Jorgensen P; Danish Colorectal Cancer Group. Influence of caseload and surgical specialty on outcome following surgery for colorectal cancer: a review of evidence: parts 1 short-term outcome and II long-term outcome. Color Dis. 2007;9:28–37, 38–46.Google Scholar
  13. 13.
    Archampong D, Borowski DW, Dickinson HO. Impact of surgeon volume on outcomes of rectal cancer surgery: a systematic review and meta-analysis. J R Coll Surg. 2010;8:341–52.Google Scholar
  14. 14.
    Harji DP, Griffiths B, McArthur DR, Sagar PM. Current UK management of locally recurrent rectal cancer. Color Dis. 2012;14:1479–82.CrossRefGoogle Scholar
  15. 15.
    Heriot AG, Byrne CM, Lee P, et al. Extended radical resection: the choice for locally recurrent rectal cancer. Dis Colon Rectum. 2008;51:284–91.CrossRefGoogle Scholar
  16. 16.
    Hahnloser D, Nelson H, Gunderson LL, et al. Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg. 2003;237:502–8.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Nagtegaal ID, Marijnen CA, Kranenbarg EK, et al. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol. 2002;26:350–7.CrossRefGoogle Scholar
  18. 18.
    Dent OF, Haboubi N, Chapuis PH, et al. Assessing the evidence for an association between circumferential tumour clearance and local recurrence after resection of rectal cancer. Color Dis. 2007;9:112–21.CrossRefGoogle Scholar
  19. 19.
    Kim YW, Kim NK, Min BS, et al. Factors associated with anastomotic recurrence after total mesorectal excision in rectal cancer patients. J Surg Oncol. 2009;99:58–64.CrossRefGoogle Scholar
  20. 20.
    Valentini V, van Stiphout RG, Lammering G, et al. Nomograms for predicting local recurrence, distant metastases, and overall survival for patients with locally advanced rectal cancer on the basis of European randomized clinical trials. J Clin Oncol. 2011;29:3163–72.CrossRefGoogle Scholar
  21. 21.
    Evans AC, Zorbas HM, Keaney MA, Sidhom MA, Goodwin HE, Petersen JC. Medicolegal implications of a multidisciplinary approach to cancer care: consensus recommendations from a national workshop. Med J Aust. 2008;188:401–4.PubMedGoogle Scholar
  22. 22.
    Romano G, de Rosa P, Vallone G, et al. Intrarectal ultrasound and computed tomography in the pre- and postoperative assessment of patients with rectal cancer. Br J Surg. 1985;72(Suppl):S117–9.CrossRefGoogle Scholar
  23. 23.
    Moore HG, Shoup M, Riedel E, et al. Colorectal cancer pelvic recurrences: determinants of resectability. Dis Colon Rectum. 2004;47:1599–606.CrossRefGoogle Scholar
  24. 24.
    Su BB, Shi H, Wan J. Role of serum carcinoembryonic antigen in the detection of colorectal cancer before and after surgical resection. World J Gastroenterol. 2012;18:2121–6.CrossRefGoogle Scholar
  25. 25.
    Flanagan FL, Dehdashti F, Ogunbiyi OA, Kodner IJ, Siegel BA. Utility of FDG-PET for investigating unexplained plasma CEA elevation in patients with colorectal cancer. Ann Surg. 1998;227:319–23.CrossRefGoogle Scholar
  26. 26.
    Romano G, Belli G, Rotondano G. Colorectal cancer – diagnosis of recurrence. Gastrointest Endosc Clin N Am. 1995;5:831–41.CrossRefGoogle Scholar
  27. 27.
    Beets-Tan RG, Beets GL, Borstlap AC, et al. Preoperative assessment of local tumor extent in advanced rectal cancer: CT or high-resolution MRI? Abdom Imaging. 2000;25:533–41.CrossRefGoogle Scholar
  28. 28.
    Chen CC, Lee RC, Lin JK, et al. How accurate is magnetic resonance imaging in restaging rectal cancer in patients receiving preoperative combined chemoradiotherapy? Dis Colon Rectum. 2005;48:722–8.CrossRefGoogle Scholar
  29. 29.
    Messiou C, Chalmers AG, Boyle K, et al. Preoperative MR assessment of recurrent rectal cancer. Br J Radiol. 2008;81(966):468–73.CrossRefGoogle Scholar
  30. 30.
    Engin G, Sharifov R. Magnetic resonance imaging for diagnosis and neoadjuvant treatment evaluation in locally advanced rectal cancer: a pictorial review. World J Clin Oncol. 2017;8:214–29.CrossRefGoogle Scholar
  31. 31.
    Dzik-Jurasz A, Domenig C, George M, et al. Diffusion MRI for prediction of response of rectal cancer to chemoradiation. Lancet. 2002;360:307–8.CrossRefGoogle Scholar
  32. 32.
    Petrillo A, Fusco R, Petrillo M, et al. Dynamic contrast enhanced-MRI in locally advanced rectal cancer: value of time intensity curve visual inspection to assess neoadjuvant therapy response. J Physiol Health Photon. 2014;110:255–67.Google Scholar
  33. 33.
    Chessin DB, Kiran RP, Akhurst T, et al. The emerging role of 18F-fluorodeoxyglucose positron emission tomography in the management of primary and recurrent rectal cancer. J Am Coll Surg. 2005;201:948–56.CrossRefGoogle Scholar
  34. 34.
    Watson AJ, Lolohea S, Robertson GM, Frizelle FA. The role of positron emission tomography in the management of recurrent colorectal cancer: a review. Dis Colon Rectum. 2007;50:102–14.CrossRefGoogle Scholar
  35. 35.
    Maas M, Rutten IJ, Nelemans PJ, Lambregts DM, Cappendijk VC, Beets GL, et al. What is recurrent disease in colorectal cancer? A meta-analysis: imaging for recurrent colorectal cancer. Eur J Nucl Med Mol Imaging. 2011;38:1560–71.CrossRefGoogle Scholar
  36. 36.
    Gade M, Kubik M, Fisker RV, Thorlacius-Ussing O, Petersen LJ. Diagnostic value of 18FDG PET/CT as first choice in the detection of recurrent colorectal cancer due to rising CEA. Cancer Imaging. 2015;15:11.CrossRefGoogle Scholar
  37. 37.
    Suzuki M, Dozois RR, Devine RM, et al. Curative reoperations for locally recurrent rectal cancer. Dis Colon Rectum. 1996;39:730–6.CrossRefGoogle Scholar
  38. 38.
    Yamada K, Ishizawa T, Niwa K, et al. Patterns of pelvic invasion are prognostic in the treatment of locally recurrent rectal cancer. Br J Surg. 2001;88:988–93.CrossRefGoogle Scholar
  39. 39.
    Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013;100:1009–14.CrossRefGoogle Scholar
  40. 40.
    Rödel C, Grabenbauer GG, Matzel KE, et al. Extensive surgery after high-dose preoperative chemoradiotherapy for locally advanced recurrent rectal cancer. Dis Colon Rectum. 2000;43:312–9.CrossRefGoogle Scholar
  41. 41.
    Fresichlag K, Sun Z, Adam MA, Palta M, Czito BG, Migaly J, Mantyh CR. Association between incomplete neoadjuvant radiotherapy and survival for patients with locally advanced rectal cancer. JAMA Surg. 2017;152:558–64.CrossRefGoogle Scholar
  42. 42.
    Glimelius B. Recurrent rectal cancer. The pre-irradiated primary tumour: can more radiotherapy be given? Color Dis. 2003;5:501–3.CrossRefGoogle Scholar
  43. 43.
    Mohiuddin M, Marks G, Marks J. Long-term results of reirradiation for patients with recurrent rectal carcinoma. Cancer. 2002;95:1144–50.CrossRefGoogle Scholar
  44. 44.
    Valentini V, Morganti AG, Gambacorta MA, et al.; Study Group for Therapies of Rectal Malignancies (STORM). Preoperative hyperfractionated chemoradiation for locally recurrent rectal cancer in patients previously irradiated to the pelvis: a multicentric phase II study. Int J Radiat Oncol Biol Phys. 2006;64:1129–39.CrossRefGoogle Scholar
  45. 45.
    Tan J, Heriot AG, Mackay J, et al. Prospective single-arm study of intraoperative radiotherapy for locally advanced or recurrent rectal cancer. J Med Imaging Radiat Oncol. 2013;57:617–25.CrossRefGoogle Scholar
  46. 46.
    Mirnezami R, Chang GJ, Das P, et al. Intraoperative radiotherapy in colorectal cancer: systematic review and meta-analysis of techniques, long-term outcomes, and complications. Surg Oncol. 2013;22:22–35.CrossRefGoogle Scholar
  47. 47.
    Dresen RC, Gosens MJ, Martijn H, et al. Radical resection after IORT-containing multimodality treatment is the most important determinant for outcome in patients treated for locally recurrent rectal cancer. Ann Surg Oncol. 2008;15:1937–47.CrossRefGoogle Scholar
  48. 48.
    Treiber M, Lehnert T, Oertel S, et al. Intraoperative radiotherapy – special focus: recurrent rectal carcinoma. Front Radiat Ther Oncol. 2004;38:52–6.CrossRefGoogle Scholar
  49. 49.
    Wiig JN, Tveit KM, Poulsen JP, et al. Preoperative irradiation and surgery for recurrent rectal cancer. Will intraoperative radiotherapy (IORT) be of additional benefit? A prospective study. Radiother Oncol. 2002;62:207–13.CrossRefGoogle Scholar
  50. 50.
    Miner TJ, Brennan MF, Jaques DP. A prospective symptom-related outcomes analysis of 1022 palliative procedures for advanced cancer. Ann Surg. 2004;240:719–27.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Troja A, El-Sourani N, Abdou A, Antolovic D, Raab HR. Surgical options for locally recurrent rectal cancer – review and update. Int J Colorect Dis. 2015;30:1157–63.CrossRefGoogle Scholar
  52. 52.
    Warrier SK, Hewriot AG, Lynch AC. Surgery for locally recurrent rectal cancer: tips, tricks and pitfalls. Clin Colon Rectal Surg. 2016;29:114–22.CrossRefGoogle Scholar
  53. 53.
    Masel EK, Berghoff AS, Schur S, Maehr B, Schrank B, Simanek R, Preusser M, Marosi C, Watzke HH. The PERS(2) ON score for systemic assessment of symptomatology in palliative care: a pilot study. Eur J Cancer Care (Engl). 2016;25:544–50.CrossRefGoogle Scholar
  54. 54.
    Hartley JE, Lopez RA, Paty PB, et al. Resection of locally recurrent colorectal cancer in the presence of distant metastases: can it be justified? Ann Surg Oncol. 2003;10:227–33.CrossRefGoogle Scholar
  55. 55.
    Rahbari NN, Ulrich AB, Bruckner T, et al. Surgery for locally recurrent rectal cancer in the era of total mesorectal excision: is there still a chance for cure? Ann Surg. 2011;253:522–53.CrossRefGoogle Scholar
  56. 56.
    Austin KK, Solomon MJ. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum. 2009;52:1223–33.CrossRefGoogle Scholar
  57. 57.
    Mirnezami AH, Sagar PM. Surgery for recurrent rectal cancer: technical notes and management of complications. Tech Coloproctol. 2010;14:209–16.CrossRefGoogle Scholar
  58. 58.
    You YN, Habiba H, Chang GJ, et al. Prognostic value of quality of life and pain in patients with locally recurrent rectal cancer. Ann Surg Oncol. 2011;18:989–96.CrossRefGoogle Scholar
  59. 59.
    Wilson RJ, Davies S, Yates D, et al. Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth. 2010;105:297–303.CrossRefGoogle Scholar
  60. 60.
    Harji DP, Griffiths B, McArthur DR, et al. Surgery for recurrent rectal cancer: higher and wider? Color Dis. 2013;15:139–45.CrossRefGoogle Scholar
  61. 61.
    West NP, Anderin C, Smith KJ, et al. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg. 2010;97:588–99.CrossRefGoogle Scholar
  62. 62.
    Wanebo HJ, Marcove RC. Abdominal sacral resection of locally recurrent rectal cancer. Ann Surg. 1981;194:458–71.CrossRefGoogle Scholar
  63. 63.
    Moriya Y, Akasu T, Fujita S, et al. Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis. Dis Colon Rectum. 2004;47:2047–54.CrossRefGoogle Scholar
  64. 64.
    Bhangu A, Brown G, Akmal M, et al. Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer. Br J Surg. 2012;99:1453–61.CrossRefGoogle Scholar
  65. 65.
    Milne T, Solomon MJ, Lee P, et al. Assessing the impact of a sacral resection on morbidity and survival after extended radical surgery for locally recurrent rectal cancer. Ann Surg. 2013;258:1007–13.CrossRefGoogle Scholar
  66. 66.
    Tanis PJ, Doeksen A, van Lanschot JJ. Intentionally curative treatment of locally recurrent rectal cancer: a systematic review. Can J Surg. 2013;56:135–44.CrossRefGoogle Scholar
  67. 67.
    Bhangu A, Ali SM, Cunningham D, et al. Comparison of long-term survival outcome of operative vs nonoperative management of recurrent rectal cancer. Color Dis. 2013;15:156–63.CrossRefGoogle Scholar
  68. 68.
    Walma MS, Burbach JP, Verheijen PM, Pronk A, van Grevenstein WM. Vacuum-assisted closure therapy for infected perineal wounds after abdominoperineal resection: a retrospective cohort study. Int J Surg. 2016;26:18–24.CrossRefGoogle Scholar
  69. 69.
    Nielsen MB, Laurberg S, Holm T. Current management of locally recurrent rectal cancer. Color Dis. 2011;13:732–42.CrossRefGoogle Scholar
  70. 70.
    Bhangu A, Ali SM, Brown G, et al. Indications and outcome of pelvic exenteration for locally advanced primary and recurrent rectal cancer. Ann Surg. 2014;259:315–22.CrossRefGoogle Scholar
  71. 71.
    Nielsen MB, Rasmussen PC, Lindegaard JC, et al. A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database. Color Dis. 2012;14:1076–83.CrossRefGoogle Scholar
  72. 72.
    Palmer G, Martling A, Lagergren P, et al. Quality of life after potentially curative treatment for locally advanced rectal cancer. Ann Surg Oncol. 2008;15:3109–17.CrossRefGoogle Scholar
  73. 73.
    Esnaola NF, Cantor SB, Johnson ML, et al. Pain and quality of life after treatment in patients with locally recurrent rectal cancer. J Clin Oncol. 2002;20:4361–7.CrossRefGoogle Scholar
  74. 74.
    Guren MG, Wiig JN, Dueland S, et al. Quality of life in patients with urinary diversion after operation for locally advanced rectal cancer. Eur J Surg Oncol. 2001;27:645–51.CrossRefGoogle Scholar
  75. 75.
    Thaysen HV, Jess P, Laurberg S. Health-related quality of life after surgery for primary advanced rectal cancer and recurrent rectal cancer: a review. Color Dis. 2012;14:797–803.CrossRefGoogle Scholar
  76. 76.
    Wibe A, Eriksen MT, Syse A, Tretli S, Myrvold HE, Soreide O, Norwegian Rectal Cancer Group. Effect of hospital case load on long-term outcome after standardization of rectal cancer surgery at a national level. Br J Surg. 2005;92:217–24.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Giovanni M. Romano
    • 1
  • Francesco Bianco
    • 1
  • Silvia De Franciscis
    • 1
  • Andrea Belli
    • 1
  1. 1.Istituto Nazionale Tumori - “Fondazione G. Pascale” - IRCCSNapoliItaly

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