title: Multimodality salvage of recurrent disease after local excision for rectal cancer.
abstract: BACKGROUND
  Local excision, alone or in combination with chemoradiation, is increasingly considered for rectal cancer. Higher risks of disease recurrence have been demonstrated after local excision.
  
  
  OBJECTIVE
  The aim of this study was to examine the outcomes of current-era multimodality salvage for recurrent rectal cancer after local excision.
  
  
  METHODS
  This was a single-institutional retrospective study.
  
  
  METHODS
  This study was conducted at a tertiary-referral cancer center between 1993 and 2011.
  
  
  METHODS
  Forty-six patients with recurrent rectal cancer after initial local excision were included.
  
  
  METHODS
  Multimodality salvage treatment was performed as appropriate.
  
  
  METHODS
  The primary outcomes measured were the pattern of disease recurrence, salvage treatments, and resultant overall and re-recurrence-free survival.
  
  
  RESULTS
  After the initial local excision, recurrent disease was diagnosed after a median interval of 1.9 years: local/regionally in 67%, distantly in 18%, and both in 15%. Four patients (9%) had recurrence that was unsalvageable, 2 (4%) declined treatment, and 40 (87%) underwent surgical salvage. Preoperative chemoradiation was given in 30 (75%) patients. The R0 resection rate was 80%, requiring multivisceral resection (33%), total pelvic exenteration (5%), and metastasectomy (25%). The rate of sphincter preservation was 33%, and perioperative morbidity was 50%. The first site of failure after salvage was distant in 38% and was local only in 10%. The 5-year overall and 3-year re-recurrence-free survival were 63% and 43%. Pathologic stage at initial local excision, receipt of neoadjuvant chemoradiation before local excision, recurrence pattern after local excision, pathologic stage at salvage, and R0 resection at salvage influenced re-recurrence-free survival.
  
  
  CONCLUSIONS
  This study was limited by the referral and selection biases inherent in a small study cohort.
  
  
  CONCLUSIONS
  Failure after local excision for rectal cancer may not be salvageable. When feasible, multimodality treatment, including multivisceral resection, pelvic irradiation, and chemotherapy, was associated with potentially lasting treatment-related morbidities and only modest success in long-term disease control. These findings should be compared with the expected stage-specific outcomes of standard proctectomy for early-stage rectal cancer, when local excision is being considered.
authors.affiliation: Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 77230-4008, USA. ynyou@mdanderson.org
authors.forename: Y Nancy
authors.initials: YN
authors.lastname: You
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
authors.forename: George J
authors.initials: GJ
authors.lastname: Chang
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Rodriguez-Bigas
authors.forename: Barry W
authors.initials: BW
authors.lastname: Feig
authors.forename: Rebecca
authors.initials: R
authors.lastname: Slack
authors.forename: Sa
authors.initials: S
authors.lastname: Nguyen
authors.forename: John M
authors.initials: JM
authors.lastname: Skibber
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000628:therapy*; D009367:Neoplasm Staging; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome