Multimodality management of locally recurrent colorectal cancer

Local recurrence will be defined here as any tumor recurrence that occurs at the tumor bed, anastomosis, regional lymphatics, drain sites, or surgical wound [1]. In the United States colorectal cancer has an incidence of 44 cases per 100,000 [2]. Following curative resection, anywhere from 4% to 18% of colonic carcinomas, and from 3% to 32% of rectal carcinomas can be expected to recur locally [3]. Only about one quarter of local recurrences can be resected with curative intent [4], and 80% to 90% of those with local recurrence will die within five years [3]. Particularly in the case of pelvic recurrence, disease that cannot be resected can eventually cause significant pain and suffering [5]. The challenge for clinicians seems to be to prevent local recurrence and, if not successful, then to recognize and treat local recurrence while it is still curable. In too many patients, the challenge becomes one of palliation and maintaining quality of life. Having defined the problem and its scope, it is useful to consider certain aspects of the underlying biology of recurrent colorectal cancer. Biological determinants of treatment We believe that a rational approach to recurrent colorectal cancer should be framed in the context of an understanding of its biology. In one autopsy series of people dying from colorectal cancer, those with right-colon tumors exhibited both local and distant spread in 90% of cases, and distant metastasis alone in 10%; those with rectal cancers exhibited isolated local disease in 25% of cases, distant metastasis in 25%, and both local and distant spread in 50% [6]. The biological behavior of recurrent colon and rectal cancer seem different in this respect, and this will influence both management and results.