Advances in surgical management for locally recurrent rectal cancer: How far have we come?

Abstract

Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.

Keywords: Pelvic exenteration; Pelvic sidewall; Radical resection; Recurrent rectal cancer; Sacrectomy.

Figure 1

Patterns of pelvic recurrence. 1: Central; 1A: Anastomotic site; 1B: Perineal region, seen after abdominal perineal resection; 1C: Invasion to adjacent soft tissue involving genitourinary organs, or to pubic bone; 2: Lateral Pelvic Side Wall; 3: Posterior/Sacral Recurrence.

Figure 2

Central recurrence rectal cancer (T) involving the bladder (B).

Figure 3

Various myocutaneous flaps used to cover perineal/sacral defect. A: Vertical rectus abdominis myocutaneous flap; B: Gluteal muscle flap; C: Latissimus dorsi free flap.

Figure 4

Posterior recurrence involving the presacral fascia (outlined in red).

Figure 5

Posterior recurrence invading into distal sacrum.

Figure 6

Recurrent rectal cancer in the lower left lateral compartment invading the obturator internus muscle (white arrow) and posteriorly involving the superior gluteal nerve (red arrow).

Figure 7

Recurrent rectal cancer at right lateral side wall (yellow arrow), with close proximity to iliac vessels (red arrow); this requires excision of involved vascular segment and reconstruction.