title: Surgery for locally recurrent rectal cancer in the era of total mesorectal excision: is there still a chance for cure?
abstract: OBJECTIVE
  To evaluate the perioperative outcome and long-term survival of patients who underwent surgical resection for recurrent rectal cancer within a multimodal approach in the era of total mesorectal excision (TME).
  
  
  BACKGROUND
  Introduction of TME has reduced local recurrence and improved oncological outcome of patients with rectal cancer. Local recurrence after TME still occurs in 2% to 8% of patients and presents a challenge to surgical and medical oncologists. However, there has been very limited data on the perioperative and long-term outcome of patients who are operated for local recurrence in the era of TME.
  
  
  METHODS
  A total of 107 patients who were identified from a prospective rectal cancer database underwent surgical exploration for recurrent rectal cancer after previous TME between October 2001 and April 2009. Risk factors of perioperative morbidity were analyzed using a multivariate logistic regression model. Independent predictors of disease-specific survival were identified by a Cox proportional hazards regression model, as were those of local recurrence and disease recurrence at any site.
  
  
  RESULTS
  Surgical resection was performed in 92 patients and negative resection margins were achieved in 54 (58.7%) of these. Recurrent disease was located intraluminally and extraluminally in 35 (38.0%) patients and 57 (62.0%) patients, respectively. A total of 19 (20.6%) patients had metastatic extrapelvic disease at the time of surgery. Perioperative surgical morbidity and in-hospital mortality accounted for 42.4% and 3.3%, respectively. On multivariate analysis, partial sacrectomy was associated with surgical morbidity (P = 0.004). Three- and 5-year disease-specific survival rates were 61% and 47%. Three-year survival rate of patients with extrapelvic disease who underwent R0 resection was 42%. On multivariate analysis, surgical morbidity (P = 0.001), presence of extrapelvic disease (P = 0.006), and noncurative (R1; R2) resection (P < 0.0001) were identified as independent adverse predictors of disease-specific survival, whereas a transabdominal resection (as opposed to an abdominoperineal resection/pelvic exenteration) was associated with a more favorable prognosis (P = 0.04).
  
  
  CONCLUSIONS
  Surgical resection of local recurrence from rectal cancer in the era TME can be carried out with acceptable morbidity and curative resection rates. Curative resection remains the major prognostic factor and may enable long-term survival even in patients with extrapelvic disease.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
authors.forename: Nuh N
authors.initials: NN
authors.lastname: Rahbari
authors.forename: Alexis B
authors.initials: AB
authors.lastname: Ulrich
authors.forename: Thomas
authors.initials: T
authors.lastname: Bruckner
authors.forename: Marc
authors.initials: M
authors.lastname: Münter
authors.forename: Axel
authors.initials: A
authors.lastname: Nickles
authors.forename: Pietro
authors.initials: P
authors.lastname: Contin
authors.forename: Thorsten
authors.initials: T
authors.lastname: Löffler
authors.forename: Christoph
authors.initials: C
authors.lastname: Reissfelder
authors.forename: Moritz
authors.initials: M
authors.lastname: Koch
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Jürgen
authors.initials: J
authors.lastname: Weitz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D009367:Neoplasm Staging; D010386:Pelvic Neoplasms / Q000401:mortality / Q000473:pathology / Q000556:secondary / Q000601:surgery; D011379:Prognosis; D011446:Prospective Studies; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery*