Colorectal Cancer Multidisciplinary Unit, Donostia Hospital, University of the Basque Country, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, 20010 San Sebastian, Spain.
World J Gastroenterol. 2011 Apr 7;17(13):1674-84. doi: 10.3748/wjg.v17.i13.1674.
Improvements in surgery and the application of combined approaches to fight rectal cancer have succeeded in reducing the local recurrence (LR) rate and when there is LR it tends to appear later and less often in isolation. Moreover, a subtle change in the distribution of LRs with respect to the pelvis has been observed. In general terms, prior to total mesorectal excision the most common LRs were central types (perianastomotic and anterior) while lateral and posterior forms (presacral) have become more common since the growth in the use of combined treatments. No differences have been reported in the current pattern of LRs as a function of the type of approach used, that is, neo-adjuvant therapies (short-term or long-course radiotherapy, or chemoradiotherapy versus extended lymphadenectomy, though there is a trend towards posterior or presacral LR in patients in the Western world and lateral LR in Asia. Nevertheless, both may arise from the same mechanism. Moreover, as well as the mode of treatment, the type of LR is related to the height of the initial tumor. Nowadays most LRs are related to the advanced nature of the disease. Involvement of the circumferential radial margin and spillage of residual tumor cells from lymphatic leakage in the pelvic side wall are two plausible mechanisms for the genesis of LR. The patterns of pelvic recurrence itself (pelvic subsites) also have important implications for prognosis and are related to the potential success of salvage curative approach. The re-operability for cure and prognosis are generally better for anastomotic and anterior types than for presacral and lateral recurrences. Overall survival after LR diagnosis is lower with radio or chemoradiotherapy plus optimal surgery approaches, compared to optimal surgery alone.
手术技术的改进和综合治疗方法的应用已经成功降低了直肠癌的局部复发率（LR），而且当出现局部复发时，往往更晚且更孤立。此外，LR 在骨盆内的分布也发生了微妙的变化。一般来说，在全直肠系膜切除之前，最常见的 LR 是中央型（吻合口和前位），而自从综合治疗应用增加以来，侧位和后位（骶前）的形式变得更为常见。目前，LR 的模式与所采用的治疗方法类型无关，无论是新辅助治疗（短期或长程放疗、或放化疗与扩大淋巴结清扫术相比），尽管在西方世界，LR 有向后或骶前的趋势，而在亚洲则有向侧位的趋势。然而，这两种趋势可能来自于相同的机制。此外，除了治疗方式外，LR 的类型也与肿瘤的初始位置有关。现在，大多数 LR 与疾病的晚期有关。肿瘤的环周切缘受累和淋巴结漏出的残余肿瘤细胞在骨盆侧壁的外溢是 LR 发生的两种可能机制。LR 本身的骨盆复发模式（骨盆亚区）对预后也有重要影响，与挽救性治愈方法的潜在成功有关。对于吻合口和前位类型的 LR，治愈和预后的再次手术可操作性通常优于骶前和侧位 LR。与单独采用最佳手术方法相比，LR 诊断后的总生存率在接受放疗或放化疗加最佳手术方法治疗的患者中较低。
