Salvage Surgery Prolonged Survival for Select Patients After TME for Rectal Cancer

Salvage surgery for local or systemic relapse of rectal cancer after total mesorectal excision (TME) was associated with prolonged survival in patients with lung-only or liver-only recurrence, according to the results of a recent study. Patients with locoregional recurrence had no survival benefit from salvage surgery.

“The lack of benefit for salvage surgery for local recurrence after prior high quality TME as a result of a high rate of secondary distant recurrence suggests that biologic determinants of disease play an important role in these patients,” wrote Naruhiko Ikoma, MD, of the University of Texas MD Anderson Cancer Center, and colleagues, in the Journal of Clinical Oncology. “On the basis of these data, all patients with locally or distantly recurrent rectal cancer should be carefully evaluated by a multidisciplinary team with consideration of salvage surgery.”

The current standard of care for people with locally advanced rectal cancer is preoperative chemoradiotherapy followed by TME. However, there are still few data on the patterns of rectal cancer recurrence after these treatments and the potential role of salvage surgery for patients with recurrent disease.

To explore this further, the researchers identified 735 patients at their institution with locally advanced rectal cancer who had been treated with preoperative chemoradiotherapy followed by TME between 1993 and 2008. They looked at patterns of recurrence location, time to recurrence, treatment factors, and survival.

The median distance of the tumor from the anal verge was 5.0 cm; the majority of patients underwent sphincter-preserving procedures.

During a median follow-up of 96 months, 20.8% of the patients developed disease recurrence. Of those patients, 85.4% had single-site recurrence and the remainder had multiple-site recurrence. The most common site of recurrence was the lung (9.6%) followed by the liver (5.9%) and locoregional sites (5.1%). The 5-year cumulative incidence of lung recurrence was 10.2%.

The median time to recurrence was 17.5 months for all patients. Time to recurrence was shorter in patients with liver-only recurrence compared with lung-only or locoregional recurrence (11.2 vs 18.2 vs 24.7 months; P = .001).

“Of note, median TTR was 11.2 months for liver-only and 18.2 months for lung-only recurrence, and recurrence within the liver after 3 years was rare in this study, which may have implications for surveillance recommendations,” the researchers wrote.

More than half (57%) of patients with single-site recurrence underwent salvage surgery. Those patients who underwent salvage had a longer overall survival after recurrence than those who did not (median survival, 5.1 vs 2.3 years; P < .001). There was no significant difference in survival of patients who underwent salvage surgery for lung-only compared with liver-only metastases.

Salvage surgery was not associated with any improvement in survival for patients with locoregional-only recurrence.