Management of recurrent rectal cancer: practical insights in planning and surgical intervention

Over the last two decades the oncologic treatment results for primary rectal cancer have improved due to refinements in neoadjuvant chemotherapy, radiation, and surgery. Nevertheless, there is still a 10% rate of local recurrence, threatening the survival and quality of life of affected patients. Due to variability of anatomy and clinical presentation, detection, staging, and clinical management are complex. Without treatment, patients will suffer from progressive local symptoms-pain, obstruction, hemorrhage, sepsis-and rarely survive beyond five years. The overall goals of surgical treatment-complete tumor resection, preservation of function, and avoidance of complications-are identical to those of surgery for primary rectal cancer, but are unfortunately much more difficult to achieve in the setting of recurrence. Tumor resection is highly challenging, as the surgical field has generally been anatomically disrupted and irradiated, and the tumors are typically adherent or invasive into organs in the middle and low pelvis. Standard total mesorectal excision (TME) resections are rarely sufficient, and therefore techniques to achieve extended multivisceral resections are required. While aggressive resections offer the best opportunity for local control, palliation, and cure, they also carry a high risk of complications and long-term morbidity. The aim of this review is to provide an updated look at surgical resection for recurrent rectal cancer, its indications, preoperative considerations, operative technique, intraoperative radiotherapy (IORT) and long-term outcomes and sequelae.