ABSTRACT
(1) Background: The classification of locally recurrent rectal cancer (LRRC) is not currently standardized. The aim of this review was to evaluate pelvic LRRC according to the Beyond TME (BTME) classification system and to consider commonly associated primary tumour characteristics. (2) Methods: A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE, and CENTRAL databases. The primary outcome was to assess the location and frequency of previously classified pelvic LRRC and translate this information into the BTME system. Secondary outcomes were assessing primary tumour characteristics. (3) Results: A total of 58 eligible studies classified 4558 sites of LRRC, most commonly found in the central compartment (18%), following anterior resection (44%), in patients with an 'advanced' primary tumour (63%) and following neoadjuvant radiotherapy (29%). Most patients also classified had a low rectal primary tumour. The lymph node status of the primary tumour leading to LRRC was comparable, with 52% node positive versus 48% node negative tumours. (4) Conclusions: This review evaluates the largest number of LRRCs to date using a single classification system. It has also highlighted the need for standardized reporting in order to optimise perioperative treatment planning.
ABSTRACT
SUMMARY BACKGROUND DATA: MRI assessment of rectal cancer not only assesses tumor depth and surgical resectability but also extramural disease which affects prognosis. We have observed that nonnodal tumor nodules (tumor deposits; mrTDs) have a distinct MRI appearance compared to lymph node metastases (mrLNMs). OBJECTIVE: We aimed to assess whether mrTDs and mrLNMs have different prognostic implications and compare these to other known prognostic markers. METHODS: This was a retrospective cohort study of 233 patients undergoing resection for rectal cancer from January 2007 to October 2015. Data were obtained from electronic records and MRIs blindly rereported. Survival was determined using Kaplan-Meier method. Prognostic markers were evaluated using Cox regression and competing risks analysis. Inter-observer agreement for mrTD was measured using Cohen Kappa. RESULTS: On multivariable analysis, baseline mrTD/mrEMVI (extramural venous invasion) status was the only significant MRI factor for adverse survival [hazard ratio (HR) 2.36 (1.54-3.61] for overall survival, 2.37 (1.47-3.80) for disease-free survival (both P < 0.001), superseding T and N categories. mrLNMs were associated with good prognosis (HR 0.50 (0.31-0.80) P = 0.004 for overall survival, 0.60 (0.40-0.90) P = 0.014 for disease-free survival). On multivariable analysis, mrTDs/mrEMVI were strongly associated with distant recurrence (HR 6.53 (2.52-16.91) P ≤ 0.001) whereas T and N category were not. In a subgroup analysis of posttreatment MRIs in postchemoradiotherapy patients, mrTD/mrEMVI status was again the only significant prognostic factor; furthermore those who showed a good treatment response had a prognosis similar to patients who were negative at baseline. Inter-observer agreement for detection of mrTDs was k0.77 and k0.83. CONCLUSIONS: Current MRI staging predicting T and N status does not adequately predict prognosis. Positive mrTD/mrEMVI status has greater prognostic accuracy and would be superior in determining treatment and follow-up protocols. Chemoradiotherapy may be a highly effective treatment strategy in mrTD/mrEMVI positive patients.