Rectal Cancer pp 127-140 | Cite as

Locoregional Recurrence of Rectal Cancer: Biological and Technical Aspects of Surgical Failure

  • P. Hohenberger
Part of the Recent Results in Cancer Research book series (RECENTCANCER, volume 146)


The advantages of sphincter-saving treatment of rectal cancer are counterbalanced when local recurrences develop requiring abdominal-perineal excision of the rectum for salvage. Biological properties of the primary tumor contribute to this problem together with the surgeon’s technique and overall oncological strategy. Adverse factors of the primary tumor are lymphatic, perineural, and venous invasion as well as mucinous type of adenocarcinoma and poor differentiation. Although tumor cells can adhere to suture material there is not sufficient evidence that the suture material contributes significantly to local relapse. Intraoperative tumor cell spillage is often provoked by the surgeon’s technique in handling the tumor and the non-use of methods to prevent the seeding of exfoliated cells. Adequate operative techniques such as complete mesorectal excision, washing of rectal stump, and complete eradication of lymphatic spread of the tumor are prerequisites for low recurrence rates. Distal margins of clearance alone are of less importance than expected previously. Surgeons are the leaders in taking care of patients suffering from rectal cancer and they must apply their knowledge of tumor biological factors to their operative technique to avoid local recurrence of tumors.


Rectal Cancer Anterior Resection Local Recurrence Rate Locoregional Recurrence Suture Material 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, Johnston D, Dixon MF, Quirke P (1994) Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 344:707–711PubMedCrossRefGoogle Scholar
  2. Aitken RJ (1996) Mesorectal excision for rectal cancer. Br J Surg 83:214–216PubMedCrossRefGoogle Scholar
  3. Arbman G, Nilsson E, Hallbook O, Sjödahl R (1996) Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 83:375–379PubMedCrossRefGoogle Scholar
  4. Baker DG, Masterson TM, Pace R, Constable WC, Wanebo H (1989) The influence of the surgical wound on local tumor recurrence. Surgery 106:525–532PubMedGoogle Scholar
  5. Bognel C, Rekacewicz C, Mankarios H, Pignon JP, Elias D, Duvillard P, Prade M, Ducreux M, Kac J, Rougier P, et al (1995) Prognostic value of neural invasion in rectal carcinoma: a multivariate analysis on 339 patients with curative resection. Eur J Cancer 31A:894–898PubMedCrossRefGoogle Scholar
  6. Clogg HS (1908) Cancer of the colon. A study of 72 cases. Lancet 11:1007–1011CrossRefGoogle Scholar
  7. Corder AP, Karanjia ND, Williams JD, Heald RJ (1992) Flush aortic tie versus selective preservation of the ascending left colic artery in low anterior resection for rectal carcinoma. Br J Surg 79:680–682PubMedCrossRefGoogle Scholar
  8. Cosimelli M, Mannella E, Giannarelli D, Casaldi V, Wappner G, Cavalière F, Consolo S, Appetecchia M, Cavaliere R (1994) Nerve-sparing surgery in 302 resectable rectosigmoid cancer patients: genitourinary morbidity and 10-year survival. Dis Colon Rectum 37:S42–46PubMedCrossRefGoogle Scholar
  9. Enker WE, Thaler HT, Cranor ML, Polyak T (1995) Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 181:335–346PubMedGoogle Scholar
  10. Galandiuk S, Wieand HS, Moertel CG, Cha SS, Fitzgibbons RJ Jr., Pemberton JH, Wolff BG (1992) Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet 174:27–32PubMedGoogle Scholar
  11. Gertsch P, Baer HU, Kraft R, Maddern GJ, Altermatt H J (1992) Malignant cells are collected on circular staplers. Dis Colon Rectum 35:238–241PubMedCrossRefGoogle Scholar
  12. Goligher JC (1951) Local recurrences after sphincter-saving excisions for carcinoma of the rectum and rectosigmoid. Br J Surg 39:199–211PubMedCrossRefGoogle Scholar
  13. Grinnell R (1965) Results of ligation of inferior mesenteric artery at the aorta in resections of carcinoma of the descending colon and rectum. Surg Gynecol Obstet 114:1031Google Scholar
  14. Hansen E, Wolff N, Knuechel R, Ruschoff J, Hofstaedter F, Taeger K (1995) Tumor cells in blood shed from the surgical field. Arch Surg 130:387–393PubMedGoogle Scholar
  15. Harnsberger JR, Vernava VM, Longo WE (1994) Radical abdominopelvic lymphadenectomy: historic perspective and current role in the surgical management of rectal cancer. Dis Colon Rectum 37:73–87PubMedCrossRefGoogle Scholar
  16. Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182:495–502PubMedGoogle Scholar
  17. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482PubMedCrossRefGoogle Scholar
  18. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery — the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  19. Hermanek P, Gall FP (1981) Safe aboral distance in the sphincter-preserving resection of the rectum. Chirurg 52:25–29PubMedGoogle Scholar
  20. Hermanek P Jr, Wiebelt H, Riedl S, Staimmer D, Hermanek P (1994) Long-term results of surgical therapy of colon cancer. Results of the Colorectal Cancer Study Group. Chirurg 65:287–297PubMedGoogle Scholar
  21. Hohenberger P, Schlag P, Kretzschmar U, Herfarth C (1991) Regional mesenteric recurrence of colorectal cancer after anterior resection or left hemicolectomy: inadequate primary resection demonstrated by angiography of the remaining arterial supply. Int J Colorectal Dis 6:17–23PubMedCrossRefGoogle Scholar
  22. Hohenberger P, Schlag P, Herfarth C (1992) Reoperation in colorectal carcinoma with curative intention. Schweiz Med Wochenschr 122:1079–1086PubMedGoogle Scholar
  23. Hojo K, Vernava AM 3d, Sugihara K, Katumata K (1991) Preservation of urine voiding and sexual function after rectal cancer surgery. Dis Colon Rectum 34:532–539PubMedCrossRefGoogle Scholar
  24. Horn A, Dahl O, Morild I (1991) Venous and neural invasion as predictors of recurrence in rectal adenocarcinoma. Dis Colon Rectum 34:798–804PubMedCrossRefGoogle Scholar
  25. Huddy SP, Husband EM, Cook MG, Gibbs NM, Marks CG, Heald RJ (1993) Lymph node metastases in early rectal cancer. Br J Surg 80:1457–1458PubMedCrossRefGoogle Scholar
  26. Hurst PA, Prout WG, Kelly JM, Bannister JJ, Walker RT (1982) Local recurrence after low anterior resection using the staple gun. Br J Surg 69:275–276PubMedCrossRefGoogle Scholar
  27. Juhl H, Stritzel M, Wroblewski A, Henne Bruns D, Kremer B, Schmiegel W, Neumaier M, Wagener C, Schreiber HW, Kalthoff H (1994) Immunocytological detection of microme-tastatic cells: comparative evaluation of findings in the peritoneal cavity and the bone marrow of gastric, colorectal and pancreatic cancer patients. Int J Cancer 57:330–335PubMedCrossRefGoogle Scholar
  28. Karanjia ND, Schache DJ, North WR, Heald RJ (1990) ‘Close shave’ in anterior resection. Br J Surg 77:510–512PubMedCrossRefGoogle Scholar
  29. Kenmotsu M, Gouchi A, Maruo Y, Murashima N, Hiramoto Y, Iwagaki H, Orita K (1994) The expression of neural cell adhesion molecule (NCAM), neural invasion and recurrence patterns in rectal cancer — a study using anti-NACM (neural cell adhesion molecule) antibody. Nippon Geka Gakkai Zasshi 95:66–70PubMedGoogle Scholar
  30. Koukouras D, Spiliotis J, Scopa CD, Dragotis K, Kalfarentzos F, Tzoracoleftherakis E, An-droulakis J (1991) Radical consequence in the sexuality of male patients operated for colorectal carcinoma. Eur J Surg Oncol 17:285–288PubMedGoogle Scholar
  31. Krasna MJ, Flancbaum L, Cody RP, Shneibaum S, Ben Ari G (1988) Vascular and neural invasion in colorectal carcinoma. Incidence and prognostic significance. Cancer 61:1018–1023PubMedCrossRefGoogle Scholar
  32. Krook JE, Moertel CG, Gunderson LL, Wieand HS, Collins RT, Beart RW, Kubista TP, Poon MA, Meyers WC, Mailliard JA (1991) Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 324:709–715PubMedCrossRefGoogle Scholar
  33. Ledesma EJ, Tseng M, Mittelman A (1982) Surgical treatment of isolated abdominal wall metastasis in colorectal cancer. Cancer 50:1884–1887PubMedCrossRefGoogle Scholar
  34. McArdle CS, Hole D, Hansell D, Blumgart LH, Wood CB (1990) Prospective study of colorectal cancer in the west of Scotland: 10-year follow-up. Br J Surg 77:280–282PubMedCrossRefGoogle Scholar
  35. McCue JL, Phillips RK (1993) Cellular proliferation at sutured and sutureless colonic anastomoses. Dis Colon Rectum 36:468–474PubMedCrossRefGoogle Scholar
  36. McGregor JR, Galloway DJ, Jarrett F, Brown IL, George WD (1991) Anastomotic suture materials and experimental colorectal carcinogenesis. Dis Colon Rectum 34:987–992PubMedCrossRefGoogle Scholar
  37. Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B, Saltz L, Sigurdson ER, Frankel J (1992) Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and high-dose leucovorin chemotherapy. J Clin Oncol 10:79–84PubMedGoogle Scholar
  38. Moynihan BGA (1908) The surgical treatment of cancer of the sigmoid flexure and rectum with special reference to the principles to be observed. Surg Gynecol Obstet 6:463Google Scholar
  39. O’Sullivan GC, Collins JK, O’Brien F, Crowley B, Murphy K, Lee G, Shanahan F (1995) Mi-crometastases in bone marrow of patients undergoing “curative” surgery for gastrointestinal cancer. Gastroenterology 109:1535–1540PubMedCrossRefGoogle Scholar
  40. Okuno M, Ikehara T, Nagayama M, Kato Y, Yui S, Umeyama K (1988) Mucinous colorectal carcinoma: clinical pathology and prognosis. Am Surg 54:681–685PubMedGoogle Scholar
  41. Pezim ME, Nicholls RJ (1984) Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer. Ann Surg 200:729–733PubMedCrossRefGoogle Scholar
  42. Phillips RK, Cook HT (1986) Effect of steel wire sutures on the incidence of chemically induced rodent colonic tumours. Br J Surg 73:671–674PubMedCrossRefGoogle Scholar
  43. Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP (1984 a) Local recurrence following ‘curative’ surgery for large bowel cancer. II. The rectum and rectosigmoid. Br J Surg 71:17–20PubMedCrossRefGoogle Scholar
  44. Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP (1984b) Large bowel cancer: surgical pathology and its relationship to survival. Br J Surg 71:604–610PubMedCrossRefGoogle Scholar
  45. Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathologic study of lateral tumour spread and surgical excision. Lancet 2:996–999PubMedCrossRefGoogle Scholar
  46. Reinbach D, McGregor JR, O’Dwyer PJ (1993) Effect of suture material on tumour cell adherence at sites of colonic injury. Br J Surg 80:774–776PubMedCrossRefGoogle Scholar
  47. Riess H, Löffel J, Wust P, Rau B, Gremmler M, Speidel A, Schlag P (1995) A pilot study of a new therapeutic approach in the treatment of locally advanced stages of rectal cancer: neoadjuvant radiation, chemotherapy and regional hyperthermia. Eur J Cancer 31A-.1356–1360PubMedCrossRefGoogle Scholar
  48. Sause WT, Pajak TF, Noyes RD, Dobelbower R, Fischbach RJ, Doggett S, Mohiuddin M (1994) Evaluation of preoperative radiation therapy in operable colorectal cancer. Ann Surg 220:668–675PubMedCrossRefGoogle Scholar
  49. Scott N, Jackson P, al Jaberi T, Dixon MF, Quirke P, Finan PJ (1995) Total mesorectal excision and local recurrence: a study of tumour spread in the mesorectum distal to rectal cancer. Br J Surg 82:1031–1033PubMedCrossRefGoogle Scholar
  50. Seki H, Koyama K, Tanaka J, Sato Y, Umezawa A (1995) Neural cell adhesion molecule and perineural invasion in gallbladder cancer. J Surg Oncol 58:97–100PubMedCrossRefGoogle Scholar
  51. Surtees P, Ritchie JK, Phillips RK (1990) High versus low ligation of the inferior mesenteric artery in rectal cancer. Br J Surg 77:618–621PubMedCrossRefGoogle Scholar
  52. Tonak J, Gall FP, Hermanek P, Hager TH (1982) Incidence of local recurrence after curative operations for cancer of the rectum. Aust N Z J Surg 52:23–27PubMedCrossRefGoogle Scholar
  53. Turnbull RB Jr (1975) Current concepts in cancer. Cancer of the GI tract: colon, rectum, anus. The no-touch isolation technique of resection. JAMA 231:1181–1182PubMedCrossRefGoogle Scholar
  54. Turnbull RB Jr, Kyle K, Watson FR, Spratt J (1967) Cancer of the colon: the influence of the no-touch isolation technic on survival rates. Ann Surg 166:420–427PubMedCrossRefGoogle Scholar
  55. Umpleby HC, Williamson RC (1984) The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl 66:192–194PubMedGoogle Scholar
  56. Umpleby HC, Williamson RC (1987) Anastomotic recurrence in large bowel cancer. Br J Surg 74:873–878PubMedCrossRefGoogle Scholar
  57. Umpleby HC, Fermor B, Symes MO, Williamson RC (1984) Viability of exfoliated colorectal carcinoma cells. Br J Surg 71:659–663PubMedCrossRefGoogle Scholar
  58. Umpleby HC, Ranson DL, Williamson RC (1985) Peculiarities of mucinous colorectal carcinoma. Br J Surg 72:715–718PubMedCrossRefGoogle Scholar
  59. Volpe C, Rodriguez Bigas M, Petrelli NJ (1996) Wide perineal dissection and its effect on local recurrence following potentially curative abdominoperineal resection for rectal adenocarcinoma. Cancer Invest 14:1–5PubMedCrossRefGoogle Scholar
  60. Westhues H (1934) Die pathologisch anatomischen Grundlagen der Chirurgie des Rektumkarzinoms. Thieme, LeipzigGoogle Scholar
  61. Wiggers T, Jeekel J, Arends JW, Brinkhorst AP, Kluck HM, Luyk CI, Munting JD, Povel JA, Rutten AP, Volovics A (1988) No-touch isolation technique in colon cancer: a controlled prospective trial. Br J Surg 75:409–415PubMedCrossRefGoogle Scholar
  62. Willett CG, Compton CC, Shellito PC, Efird JT (1994) Selection factors for local excision or abdominoperineal resection of early stage rectal cancer. Cancer 73:2716–2720PubMedCrossRefGoogle Scholar
  63. Wimmenauer S, Keller H, Ruckauer KD, Rahner S, Wolff Vorbeck G, Kirste G, von Kleist S, Farthman EH (1997) Expression of CD44, ICAM-1 and N-CAM in colorectal cancer. Cor-relation with the tumor stage and the phenotypical characteristics of tumor-infiltrating lymphocytes. Anticancer Res 17:2395–2400PubMedGoogle Scholar
  64. Zirngibl H, Husemann B, Hermanek P (1990) Intraoperative spillage of tumor cells in surgery for rectal cancer. Dis Colon Rectum 33:610–614PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag · Berlin Heidelberg 1998

Authors and Affiliations

  • P. Hohenberger
    • 1
  1. 1.Department of Surgery and Surgical Oncology, Robert Rössle HospitalCharité Humboldt University of BerlinBerlinGermany

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