ASCRS Ch32 - Locally Recurrent Rectal Cancer

Chapter 32 of the ASCRS Textbook of Colon and Rectal Surgery, 4th edition (Solomon MJ). Book pp. 561–575. Thirty-second chapter overall — the textbook's dedicated treatment of locally recurrent rectal cancer (LRRC) and pelvic exenteration, distinct from Chapter 29's proctectomy-for-primary- rectal-cancer content and Chapter 31's distant-metastasis content.

Textbook reference chapter — not primary literature; individual cited series/collaboratives (the PelvEx Collaborative's 1184-patient pooled dataset, the author's own-unit series of 200+ exenterations) are named and their headline results reported, but none are independently ingested from primary publications.

Key content

• Framing: pelvic exenteration for LRRC is argued to be fundamentally a different operation than exenteration for advanced primary rectal cancer (T4) — LRRC develops in extra-mesorectal planes (pelvic floor muscles, presacral fascia, lateral compartment incl. iliac vessels/piriformis/deeper neurovascular structures) that a "TME surgeon" doesn't routinely operate in, whereas primary T4 disease breaches the mesorectal fascia into surrounding compartments more centrally. R0 resection rates for LRRC have climbed from <50% (mid-2000s) to ~70% (current) at specialized centers, with 49% requiring total cystectomy, 58% sacrectomy, and 73% lateral-compartment involvement in the author's own >200-case series.
• Anatomical classification: five pelvic compartments (central/axial, bilateral lateral, posterior, anterior), each supra- or infralevator — Fig. 32.1. No LRRC classification system has been universally adopted; the author's unit's current system centers on the pelvic floor and its bony attachments.
• Patient selection and treatment planning: PET-CT + MRI as the imaging mainstay (MRI positive/ negative predictive value 100%/89% for LRRC diagnosis); dedicated MDT assessment (referral-pattern data showing the MDT changes resectability determination in ~30% of cases); an evolving definition of "resectable" LRRC (lateral-compartment/iliac-vessel involvement no longer an absolute contraindication — R0 rates in the lateral compartment have risen from 21% (2008) to 69% (current) at the author's unit); metastatic disease present in up to 40% at LRRC diagnosis (synchronous metastasectomy generally avoided; liver/lung surgery before exenteration given longer post- exenteration recovery); neoadjuvant long-course chemoradiotherapy recommended for patients who didn't receive it for their primary tumor.
• Technical considerations: three-phase framework (dissection, resection, reconstruction) and a "6 C philosophy" (coherent plan, clear exposure, control [proximal/distal], circumnavigate the tumor, constantly reassess, calm). Positioning (modified Lloyd-Davies), preparation (dual-consultant colorectal staffing, urological/orthopedic/plastic/vascular input, stoma marking for VRAM flap contingency), exploration, central/anterior/lateral/posterior compartment-specific technique (composite pubic bone resection, interlabial radical vaginectomy technique, en bloc iliac vascular resection, sciatic nerve resection, abdomino-lithotomy vs. prone jackknife sacrectomy approach by amputation level), reconstruction (urinary conduit options — Fig. 32.14 — and Boari flap ureterocystostomy), postoperative management (ICU admission, TPN, urinary-conduit creatinine monitoring for leak detection).
• Outcomes: PelvEx Collaborative pooled data (1184 patients) — median LOS 15 days, major complication/reintervention rates 32%/10%, R0 resection 55% (58% in a separate systematic review), 5-year OS 40–50% with clear margins. ~55% of radical-salvage patients develop disease recurrence (14–21% local, more systemic/distant). No data on neoadjuvant chemotherapy specifically for LRRC, though it may be considered to reduce systemic-failure risk.

Wiki integration

Backs a new procedure page, Pelvic Exenteration for Locally Recurrent Rectal Cancer — the wiki's first dedicated treatment of LRRC-specific exenteration technique. Cross-linked into (not duplicating) Total Mesorectal Excision (TME) & Sphincter-Sparing Resection's existing brief exenteration mention (sourced from Ch29, about primary T4 rectal cancer exenteration — a related but distinct clinical scenario from recurrent-disease exenteration).