Colorectal cancer recurrence and recurrent pelvic tumors

Why the tumor comes back

Recurrence is the return of the disease after treatment that was considered radical. It can be local (locoregional), distant or combined:

• local — in the area of the operation: in the pelvis after rectal surgery, including at the anastomosis; after colon surgery — at the anastomosis, in the mesentery or in the retroperitoneum;
• distant — most often in the liver, lungs or peritoneum; these situations are treated by different rules, some of them surgically too.

The risk of local recurrence is higher if the tumor was locally advanced, if it reached the circumferential resection margin, if it could not be removed completely at the first operation (tumor cells at the resection margin under the microscope — R1, or part of the tumor visibly left behind — R2), if the integrity of the anatomical envelopes of the bowel was not preserved, if the tumor perforated, and after emergency operations. Yet recurrence is possible even after flawlessly performed treatment.

A separate group are patients after incomplete (R1/R2) resections, when the operative report already shows that the tumor was not removed completely. For them, after restaging, the multidisciplinary team decides whether repeat surgery is possible — straight away, not years later.

Symptoms

Recurrence is often found before any complaints — from a rising CEA or on follow-up CT or MRI. When there are symptoms, the most common are:

• pain in the pelvis, perineum or sacrum; pain radiating to the leg may indicate nerve involvement — this is clarified on MRI;
• blood or mucus from the rectum or vagina;
• bowel obstruction;
• urinary problems, leg swelling;
• fistulas — abnormal passages between the bowel, bladder, vagina or skin.

Any new pelvic pain after rectal surgery is a reason for an unscheduled examination, not just for pain relief.

Tests needed before a decision

• High-quality pelvic MRI — the key examination: it shows which organs, fascia, bones, vessels and nerves the tumor reaches and allows the extent of resection to be planned.
• Contrast-enhanced CT of the chest, abdomen and pelvis — to rule out distant metastases or to assess whether they can be removed.
• PET-CT — used selectively: when MRI and CT cannot clearly tell recurrence from scar tissue or hidden spread is suspected.
• Biopsy — guided by CT, ultrasound or endoscopy; tissue confirmation is sought before treatment starts, and if a sample cannot be taken safely, the decision is made from all the findings and how they change over time.
• Records of previous treatment — the operative report, the histology report with resection margins, radiotherapy doses and fields: they determine what is possible now.

Kidney function and the patency of the ureters are also checked: a pelvic recurrence can compress them.

When repeat surgery is possible

The decisive condition is the possibility of removing the tumor completely, with clear margins (R0). This is the most important factor for the result of repeat surgery. So the pelvic compartments and the specific structures involved are assessed:

• central compartment — recurrence at the anastomosis or in the center of the pelvis — repeat bowel resection with or without an anastomosis;
• anterior compartment — growth into the bladder, uterus, vagina, prostate: they are removed en bloc with the tumor, completely or partially;
• ureteric involvement — removal of the affected segment with restoration of urine drainage;
• posterior and lateral compartments — growth into the sacrum, the pelvic side walls, major vessels: such involvement is not always unresectable, but whether it can be removed depends on the level and extent of involvement, and the decision is made individually together with specialists from related fields.

A radical operation that leaves tumor behind is usually not worthwhile: it carries all the risks without the expected benefit. So if everything cannot be removed, it is more honest to say so before surgery and discuss other treatment; symptom-relieving procedures — for example, a stoma for obstruction — are considered separately.

Recurrence combined with liver metastases does not always rule out surgery: if all lesions can be removed, treatment is planned in stages. More on the page colorectal liver metastases.

If surgery is not possible right away

• the tumor cannot be removed with clear margins — chemotherapy first and, where possible, radiotherapy or chemoradiotherapy, including re-irradiation in selected patients after analysis of previous radiotherapy plans; after a follow-up MRI the question of surgery is revisited;
• there are distant metastases that cannot be removed yet — systemic therapy with reassessment after several cycles;
• complications — bowel obstruction, compression of the ureters, bleeding: they are dealt with first (a stoma, ureteric stents or a nephrostomy) to keep further treatment possible;
• pain — pain relief is set up properly without waiting for the decision on surgery.

A refusal of repeat surgery given without high-quality pelvic MRI or without review by a specialized team that performs such operations is a reason to get another opinion.

How the operation is performed

Repeat pelvic operations are performed in tissue changed by the previous operation and often by radiation, so the boundaries of organs and tumor are hard to distinguish. During surgery scar and tumor cannot be reliably told apart by eye, so organs and structures suspected of involvement whose removal is needed for clear margins are removed en bloc, without cutting through the tumor. The extent is planned in advance on MRI and confirmed during the operation.

Depending on the spread, a section of bowel, part or all of the bladder, the uterus, the vaginal wall or a segment of ureter are removed together with the recurrence. Radical en bloc removal of several pelvic organs is called pelvic exenteration; its type is defined by which compartments are removed. It is planned together with urologists, gynecologists and, when needed, other specialists: restoring urine drainage and closing the tissue defect are part of the same operation.

Repeat operations after colon surgery — removal of a recurrence in the mesentery, retroperitoneum or abdominal wall — may also require resection of adjacent organs.

The approach is chosen individually: in complex repeat resections open surgery predominates, and a minimally invasive approach is possible in selected cases.

Recovery after surgery

Recovery after repeat pelvic surgery takes longer than after the first operation, and the risk of complications is higher — especially wound problems in an irradiated area. The first days may be spent in the intensive care unit. Care follows enhanced recovery after surgery (ERAS) principles: early mobilization, nutrition, controlled pain relief, but the pace is set individually.

After such operations a permanent bowel stoma is needed more often, and when the bladder is removed, another route for urine drainage is needed as well; the type of stoma and of urinary diversion is decided individually. Preparation starts before surgery: patients are shown how to care for a stoma and the right supplies are chosen. Functional recovery varies considerably between patients, and what to expect is discussed in advance.

Follow-up after treatment

The follow-up plan after radical removal of a recurrence is individual — based on the risk, previous treatment and the possibility of further therapy: CEA, CT of the chest, abdomen and pelvis, pelvic MRI and PET-CT when indicated. The schedule is set by the doctor; examinations are most frequent in the first years.

Whether chemotherapy is needed after surgery is decided from the histology report, the extent of the disease, the molecular profile of the tumor, previous treatment and the patient's condition. The regimen is set by the medical oncologist together with the surgeon.

What to bring to the consultation

• pelvic MRI, CT and PET-CT discs — both current ones and those made before the first operation, for comparison;
• the report of the previous operation and the histology report with resection margins;
• the radiotherapy summary: dates, doses, treated areas;
• chemotherapy regimens with the number of cycles and how you tolerated them;
• CEA results over time and recent blood tests, including kidney function.

If some documents are missing, that is no reason to postpone the consultation — some of the tests can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.