Treatment of Local Recurrences

Local recurrent RC represents a major problem to the surgical oncologist, occurs in 4-5% of patients after apparently curative resection and is resectable in only 15-20% of cases. This type of pelvic tumour causes significant morbidity and accounts for 90% of disease-related deaths within five years. Surgical resection is the initial choice of treatment. The objective, if feasible, is removal of both the tumour and primary nodal drainage with as wide a margin around them as possible. If recurrence occurs in patients not previously treated with radiation therapy, pre-operative radiochemotherapy is highly recommended and it is possible to complete the radiation treatment in case of suboptimal resection of the tumour with intraoperative radiation therapy boost (IORT). Patients who achieve a gross total resection at the time of IORT have a markedly better prognosis than those with residual gross disease. The major IORT-related post-operative complications are leakage from anastomoses, deep pelvic abscesses and peripheral nerve injury causing lower extremity weakness. Other complications including perineal pain, hydronephrosis and bladder perforations are less common [17]. In previously heavily irradiated patients the treatment is mainly palliative with hypofractionated radiation therapy regimens and chemotherapy. The Dutch Hyperthermia group investigated with a randomised trial the effect of additional hyperthermia in recurrent inoperable tumours of the rectum. In this trial 50% of the patients were randomised to standard radiation alone and 50% to combined treatment. The complete response rate was 13% following radiotherapy alone and 19% following combined treatment. This difference was not significant so it did not lead to any definitive conclusion [18]. At our department we have also treated a consecutive series of 44 patients for RC local recurrences with regional hyperthermia plus radiochemotherapy with a good complete pathological response rate in patients not previously irradiated, and a good palliation of symptoms without any relevant toxicity in those previously irradiated for more advanced disease [19].

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