Yokoyama Yasuyuki, Uehara Kay, Yamada Takeshi, Monkhonsupphawan Aitsariya, Shinji Seiichi, Matsuda Akihisa, Takahashi Goro, Riansuwan Woramin, Yoshida Hiroshi
Department of Gastroenterological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan.
Department of Surgery, Siriraj Hospital, Mahidol University, Wanglang Road Bangkoknoi, Bangkok 10700, Thailand.
Jpn J Clin Oncol. 2025 Aug 7. doi: 10.1093/jjco/hyaf127.
Locally recurrent rectal cancer (LRRC) remains one of the most challenging problems in the rectal cancer management, despite advances in multimodal treatments. R0 resection remains the cornerstone of curative therapy and the most critical prognostic factor. However, achieving R0 resection is technically demanding, with outcomes heavily influenced by tumor location, institutional expertise, and careful patient selection. This narrative review summarizes current surgical strategies for LRRC, emphasizing the importance of accurate anatomical classification, multidisciplinary collaboration, and individualized planning. Extended resections-including bony pelvis, pelvic sidewall, and vascular dissections-have expanded surgical indications but require specialized expertise and carry risks of functional impairment. Minimally invasive approaches, such as laparoscopic or robotic pelvic exenteration, may offer potential advantages in selected cases but remain technically challenging. Carbon ion radiotherapy, which demonstrates superior local control compared to conventional radiotherapy, is expected to be a promising treatment for unresectable LRRCs. Its future role as an alternative or perioperative treatment for resectable or borderline cases is under investigation. Preoperative chemoradiotherapy may play an important role in radiation-naïve patients, while re-irradiation strategies remain controversial for previously irradiated cases. In patients with resectable distant metastases, aggressive combined surgical approaches may be pursued if curative resection is feasible. Ultimately, shared decision-making with patients is essential for optimal management of LRRC, based on a highly individualized, evidence-based approach that balances oncological prognosis and postoperative quality of life.
尽管多模式治疗取得了进展，但局部复发性直肠癌（LRRC）仍然是直肠癌治疗中最具挑战性的问题之一。R0切除仍然是根治性治疗的基石和最关键的预后因素。然而，实现R0切除在技术上要求很高，其结果受到肿瘤位置、机构专业知识和仔细的患者选择的严重影响。这篇叙述性综述总结了LRRC目前的手术策略，强调了准确的解剖学分类、多学科协作和个体化规划的重要性。扩大切除术，包括骨盆、盆腔侧壁和血管解剖，扩大了手术适应症，但需要专业知识，并且存在功能受损的风险。微创方法，如腹腔镜或机器人盆腔脏器切除术，在某些病例中可能具有潜在优势，但在技术上仍然具有挑战性。碳离子放疗与传统放疗相比显示出更好的局部控制效果，有望成为不可切除LRRC的一种有前景的治疗方法。其作为可切除或临界病例的替代或围手术期治疗的未来作用正在研究中。术前放化疗可能在未接受过放疗的患者中发挥重要作用，而再次放疗策略在既往接受过放疗的病例中仍存在争议。对于有可切除远处转移的患者，如果可行根治性切除，可以采用积极的联合手术方法。最终，基于高度个体化、循证的方法，在平衡肿瘤预后和术后生活质量的基础上，与患者共同决策对于LRRC的最佳管理至关重要。
