[General information].
Patient, male, 52 years old
Complaint】
6 months after low anterior resection for rectal cancer, found local recurrence of anastomosis for 4 months
Treatment history
PET-CT showed hypermetabolic soft tissue shadow in the right perirectal space, which was still active, slight thickening of the intestinal wall in the anastomotic area, no hypermetabolic signs, small lymph nodes in the mesenteric area, small nodes in the perirectal space, and no increased metabolism. The metabolism of small lymph nodes in the mesenteric area and small nodules in the perirectal space was not increased. After multidisciplinary discussion, the diagnosis of “rectal cancer (pT2N0M0) after low anterior resection with local recurrence” was made. Considering that the patient’s lesion was limited and the XELOX regimen was effective, the next treatment plan was formulated, i.e., preoperative simultaneous radiotherapy and chemotherapy to reduce the extent of the tumor and strive for a second surgery.
On May 9, 2010, the patient started concurrent radiotherapy (intensity-modulated radiotherapy 50.6Gy/22f, oxaliplatin 50mg/w, capecitabine 1000mgbid). The patient discontinued oxaliplatin during treatment due to grade II peripheral neuritis and discontinued local radiotherapy with capecitabine when the total radiotherapy dose reached 39.1Gy/17f due to intolerance of diarrhea and perianal pain. The patient’s discomfort resolved 5 weeks after radiotherapy. Repeat pelvic magnetic resonance imaging (MRI) showed postoperative rectal cancer with a right anterior wall thickening of about 2 cm at the anastomosis, mild enhancement on enhanced scan, close relationship with the prostate, and lymph nodes visible in the proximal colonic mesentery. After multidisciplinary discussion, the preoperative treatment was considered effective and a second operation was feasible.
On July 20, 2010, a combined abdominoperineal resection for recurrent rectal cancer was performed under general anesthesia, and the recurrent mass was found to be located at the level of the anastomosis, 3 cm from the anus, hard, about 3 cm in size, with serious adhesions to the surrounding tissues. Postoperative pathology showed: rectal anastomotic ulcer, 3.0*0.8 cm, chronic inflammation of mucosa, focal mucus pool formation, no cancer, 0/11 peri-intestinal lymph nodes, no cancer at the end of the intestinal canal and perianal skin cut edge. The outcome was assessed as pathologic complete remission (ypCR).
Postoperatively, the patient’s physical condition was poor, along with diarrhea, so adjuvant chemotherapy was not administered and regular follow-up was performed.
[Case study].
This case of a patient with postoperative local recurrence of rectal cancer who obtained complete pathological remission after multidisciplinary treatment seems to be a successful case, but looking at the whole treatment process, there are many regrets.
The necessity of preoperative staging examination and postoperative circumferential margin description
Currently, multidisciplinary treatment has become the recommended mode of oncologic treatment, which is particularly evident in the treatment of low to intermediate rectal cancer. Accurate preoperative staging is essential for selecting a reasonable treatment modality, and the depth of local invasion of rectal cancer (i.e. T-stage) is equally important in addition to distant metastasis. Intraluminal ultrasound and pelvic MRI have been widely accepted as a means to accurately determine the depth of local invasion, and the National Comprehensive Cancer Network (NCCN) guidelines also clearly recommend this. The NCCN guidelines recommend that for preoperative T1-2N0 rectal cancer, direct tumor resection should be performed, while for preoperative T3N0, TanyN1-2, T4 or local unresectable cancer, preoperative radiotherapy should be administered simultaneously. For those with preoperative stage T3N0, TanyN1~2, T4 or local unresectable, simultaneous radiotherapy should be given before surgery. It can be seen that there is a big difference in the treatment plan for rectal cancer for different preoperative stages.
Although the patient’s postoperative pathology suggests negative cut margins, tumor residue is still theoretically not excluded. A 2008 review of more than 15,700 rectal cancer patients showed that peri-annular margins were more predictive of local recurrence in those who received preoperative treatment, and the NCCN The pathology section of the NCCN guidelines clearly states this. Also, the circumferential margin is a predictor of distant metastasis and overall survival (OS). Therefore, it is essential to describe the circumferential margin in the pathology report after rectal cancer surgery.
Controversy in the choice of preoperative chemotherapy drugs
After more than a decade of exploration, several studies have gradually confirmed that preoperative simultaneous radiotherapy is superior to postoperative radiotherapy alone and preoperative radiotherapy with postoperative simultaneous radiotherapy in reducing the local recurrence rate. Based on this, there is a consensus on the use of preoperative concurrent radiotherapy for locally progressive rectal cancer, and the NCCN guidelines have recommended it as the standard treatment mode. However, the choice of preoperative chemotherapy drugs is still controversial. Although oxaliplatin + fluorouracil regimen is superior to fluorouracil alone in advanced colorectal cancer, whether oxaliplatin + fluorouracil regimen for preoperative concurrent radiotherapy in rectal cancer can further improve the local control and OS rates is yet to be supported by more evidence-based medical evidence. Currently, NCCN guidelines still recommend 5-fluorouracil (5-FU) + calcium folinic acid (CF) or capecitabine as the choice of preoperative concurrent radiotherapy for rectal cancer.
The reason for choosing oxaliplatin + fluorouracil-based for the synchronous radiotherapy regimen in this case was mainly due to tumor recurrence, not excluding the presence of distant micrometastases, and the clear objective efficacy of the previous XELOX regimen.
Differences in tolerability between primary treatment and those with local recurrence
Patients with intolerable anal pain and diarrhea with preoperative concurrent radiotherapy have not completed the total planned dose of radiotherapy. At present, the targets of simultaneous radiotherapy are patients with primary locally progressive rectal cancer rather than postoperative locally recurrent patients, and there may be some differences in the tolerance of local radiotherapy between the two. Therefore, more consideration should be given by radiotherapists on how to formulate a reasonable radiotherapy plan for these patients to reduce adverse effects.
The result of ypCR in this patient with a second surgery is encouraging, but the question arises whether adjuvant chemotherapy is required after surgery for those who achieve ypCR. There is no clear answer to this question. However, the prognosis of this patient, who had a recurrent tumor and achieved ypCR after a second surgery combined with concurrent radiotherapy, is relatively worse than that of the patient who achieved ypCR with the initial treatment, therefore, considering the effectiveness of the preoperative XELOX regimen and the peripheral neuritis that limited the continued use of oxaliplatin, postoperative adjuvant chemotherapy with capecitabine alone may be more appropriate.
In addition, considering the actual postoperative situation of this patient, no adjuvant chemotherapy measures were given, subject to close follow-up.