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Clinical Nature and Prognosis of Locally Recurrent Rectal Cancer After Total Mesorectal Excision With or Without Preoperative Radiotherapy

From the Departments of Medical Decision Making, Surgery, and Radiotherapy, Leiden University Medical Center, Leiden; the Department of Pathology, University Medical Center St Radboud, Nijmegen; the Department of Surgery, Catharina Hospital, Eindhoven; and the Department of Surgical Oncology, Groningen University Hospital, Groningen, the Netherlands

Address reprint requests to C.J.H. van de Velde, PhD, MD, Department of Surgery, K6-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands; e-mail: C.J.H.van_de_Velde{at}lumc.nl

PURPOSE: To document the clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision (TME) with or without 5 x 5 Gy preoperative radiotherapy (PRT) and to identify patient-, disease-, and treatment-related factors associated with differences in prognosis after local recurrence.

PATIENTS AND METHODS: For 96 Dutch patients with a local recurrence who participated in a multicenter randomized clinical trial, data on treatments and follow-up were gathered from surgeons and radiation and medical oncologists. Twenty-three patients (24%) had previously been treated with PRT plus TME, and 73 patients (76%) had been treated with TME alone. Eighty-one patients (84%) were followed until death; median follow-up time of the alive patients after local recurrence was 21 months (range, 5 to 48 months).

RESULTS: Survival after local recurrence in the PRT + TME group was significantly shorter than in the TME group (median survival, 6.1 v 15.9 months; hazard ratio for death, 2.1; P = .008). Patients with a local recurrence in the PRT + TME group had distant metastases more often (74% v 40%; P = .004), underwent surgical resection of local recurrence less often (17% v 35%; P = .11), and received radiotherapy for local recurrence at a total dose 45 Gy less often (4% v 42%; P = .001) than patients without PRT. In a multivariate analysis, the difference in survival after local recurrence between randomization groups was no longer statistically significant (hazard ratio for death of PRT, 1.53; P = .16).

CONCLUSION: The clinical nature and prognosis of patients with locally recurrent rectal cancer has changed since the introduction of PRT. The majority of patients who present with a local recurrence after previous PRT have simultaneous distant metastases, and median survival has decreased to 6 months.

Supported by grant No. 97-026 from the Health Care Insurance Board, The Hague, the Netherlands, and by grant No. CKVO 95-04 from the Dutch Cancer Society, Amsterdam, the Netherlands.

Presented at the Second Multidisciplinary Colorectal Cancer Congress, Noordwijk, the Netherlands, February 15-17, 2004.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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