Locally recurrent rectal cancer; long-term outcome of curative surgical and non-surgical treatment of 447 consecutive patients in a tertiary referral centre.

INTRODUCTION: The majority of patients with locally recurrent rectal cancer (LRRC) present with extensive metastatic disease or an unresectable recurrence, and will be treated palliatively. Only a minority of patients will be eligible for potential cure by surgical treatment. The aim of this study is to evaluate the long-term outcome of surgical treatment and non-surgical treatment of patients with LRRC. METHODS: All patients with LRRC referred to our tertiary institute between 2000 and 2015 were retrospectively analysed. Patients were discussed in a multidisciplinary tumour board (MDT) and eventually received curative surgical or non-surgical treatment. Overall survival (OS) was compared by resection margin status and non-surgical treatment. RESULTS: A total of 447 patients were discussed in our MDT of which 193 patients underwent surgical treatment and 254 patients received non-surgical treatment. Surgically treated patients were significantly younger, received less neoadjuvant therapy for the primary tumour, had less metastasis at diagnosis and more central recurrences. The 5-year OS was 51% for R0-resections and 34% for R1-resections. Although numbers with R2-resections were too small to implicate prognostic significance, there was no difference in 5-year OS between R2-resections and non-surgical treatment (10% vs. 4%, p = 0.282). In a subgroup analysis the OS of R2-patients was even poorer compared to optimal palliative treated patients with combined chemotherapy and radiotherapy (22 vs 29 months, p = 0.413). CONCLUSION: R2-resections do not result in a survival benefit compared to non-surgical treatment in this non-randomized series. Patients with a high chance on a R2-resection could be offered non-surgical treatment, without local resection.

Hospital volume and outcome in rectal cancer patients; results of a population-based study in the Netherlands.

BACKGROUND: Clinically staged T1-3 rectal cancer (cT1-3) is generally treated by total mesorectal excision(TME) with or without neoadjuvant therapy and sometimes requires beyond TME-surgery, whereas cT4 rectal cancer often requires both. This study evaluates the outcome of cT1-3 and cT4 rectal cancer according to hospital volume. METHODS: Patients undergoing rectal cancer surgery between 2005 and 2013 in the Netherlands were included from the National Cancer Registry. Hospitals were divided into low(1-20), medium(21-50) and high(>50 resections/year) volume for cT1-3 and low(1-4), medium(5-9) and high(≥10 resections/year) volume for cT4 rectal cancer. Cox-proportional hazards model was used for multivariable analysis of overall survival (OS). RESULTS: A total of 14.050 confirmed cT1-3 patients and 2.104 cT4 patients underwent surgery. In cT1-3 rectal cancer, there was no significant difference in 5-year OS related to high, medium and low hospital volume (70% vs. 69% vs. 69%). In cT4 rectal cancer, treatment in a high volume cT4 hospital was associated with a survival benefit compared to low volume cT4 hospitals (HR 0.81 95%CI 0.67-0.98) adjusted for non-treatment related confounders, but this was not significant after adjustment for neoadjuvant treatment. Patients with cT4-tumours treated in high volume hospitals had a significantly lower age, more synchronous metastases, more patients treated with neoadjuvant therapy and a higher pT-stage. CONCLUSION: Hospital volume was not associated with survival in cT1-3 rectal cancer. In cT4 rectal cancer, treatment in high volume cT4 hospitals was associated with improved survival compared to low volume cT4 hospitals, although this association lost statistical significance after correction for neoadjuvant treatment.

Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma.

BACKGROUND & AIMS: Neoadjuvant chemoradiotherapy (NACRT) has increased local control in locally advanced rectal cancer. Reduced skeletal muscle mass (sarcopenia), or ongoing muscle wasting, is associated with decreased survival in cancer. This study aims to assess the change in body composition during NACRT and its impact on outcome using computed tomography (CT) imaging in locally advanced rectal cancer (LARC) patients. METHODS: LARC patients treated with NACRT were selected from a prospectively maintained database and retrospectively analyzed. One-hundred twenty-two patients who received treatment between 2004 and 2012 with available diagnostic CT imaging obtained before and after NACRT were identified. Cross-sectional areas for skeletal muscle was determined, and subsequently normalized for patient height. Differences between skeletal muscle areas before and after NACRT were computed, and their influence on overall and disease-free survival was assessed. RESULTS: A wide distribution in change of body composition was observed. Loss of skeletal muscle mass during chemoradiotherapy was independently associated with disease-free survival (HR0.971; 95% CI: 0.946-0.996; p = 0.025) and distant metastasis-free survival (HR0.942; 95% CI: 0.898-0.988; p = 0.013). No relation was observed with overall survival in the current cohort. CONCLUSIONS: Loss of skeletal muscle mass during NACRT in rectal cancer patients is an independent prognostic factor for disease-free survival and distant metastasis-free survival following curative intent resection.

Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area.

BACKGROUND: Tumor lesions in previously irradiated area may have a less favorable response to chemotherapy compared to tumor sites outside the radiation field. The aim of the present study was to evaluate the response to chemotherapy of locally recurrent rectal cancer (LRRC) within the previous radiation field compared to the response of distant metastases outside the radiation field. PATIENTS AND METHODS: All patients with LRRC referred between 2000 and 2012 to our tertiary university hospital were reviewed. The response to chemotherapy of LRRC within previously irradiated area was compared to the response of synchronous distant metastases outside the radiation field according to the Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS: Out of 363 cases with LRRC, 29 previously irradiated patients with distant metastases were treated with chemotherapy and eligible for analysis. Twenty-six patients (89 %) suffered a first recurrence and three patients (11 %) a second recurrence. These patients were followed with a median of 22 months (IQR, 9-40 months) and had a median survival of 33 months (IQR, 14-42). In 23 patients (79 %), the local recurrence showed stable disease, but the overall response rate of the local recurrences in the previously irradiated area was significantly lower than the response rate of distant metastases outside the radiation field (10 vs. 41 %,p = 0.034). CONCLUSIONS: Previously irradiated patients with LRRC have a lower response rate to chemotherapy of the local recurrence within the radiation field compared to the response rate of distant metastases outside the radiation field. This suggests that chemotherapy for local palliation may not have the desired effect.