Regional therapy of rectal cancer

Histopathologic examinations of resected specimens have revealed that the development of local recurrence after rectal surgery for cancer is related to the resection margin of the mesorectum. The incidence rate of local pelvic recurrence after standard “curative” surgery for rectal cancer varies widely. The treatment of local recurrence remains a challenge. Extensive resection (abdominal sacral resection with or without pelvic exenteration) gives the best chance of survival. For patients with unresectable recurrent rectal cancer, neither intravenous systemic chemotherapy nor intraarterial chemotherapy achieve desirable results in terms of pain control and tumor response. To improve clinical response, several methods of regional chemotherapy delivery have been suggested. One of these is regional pelvic perfusion. In our study, hypoxic pelvic perfusion has been proposed as palliative treatment in patients with unresectable locally recurrent rectal cancer who are nonresponders or who have disease progression after the standard modalities. The median survival time (12.2 mo) registered after one course of hypoxic pelvic perfusion is comparable to that obtained by irradiation or reirradiation in non-pretreated patients. Considering the vascular damage following radiotherapy, a different sequence in the multimodular treatment of unresectable recurrent rectal cancer could be more useful. Further studies are necessary to establish whether hypoxic pelvic perfusion improves the quality of life and survival of these patients if administered before radiotherapy with or without concomitant systemic chemotherapy. In conclusion, hypoxic pelvic perfusion is a good palliative treatment for patients with unresectable locally recurrent rectal cancer, but it should be considered as a link of a chain in a multimodular approach.