Abstract
Before TME was described by William Heald, most recurrences of rectal cancer were anastomotic, or centropelvic and anterior, probably related to incomplete resection of mesorectal fatty tissue. Nowadays, since the use of combined treatments, lateral and posterior forms appear more often. However, a pelvic CT scan study of 100 patients with recurrence after TME for rectal adenocarcinoma showed that mesorectal residua can be detected in up to 50% of cases; underscoring the fact that suboptimal proctectomy was still being performed in the era of TME.
Many studies have shown that surgery is beneficial for LR but these studies combined extra- and intraluminal recurrences including isolated anastomotic line recurrence after resection with sphincter preservation, where treatment gives much better carcinologic results (iterative anterior resection and colo anal anastomosis or APR) compared with extraluminal recurrence.
When recurrence occurs with an extraluminal component, the different planes of dissection such as the mesorectum and fascia recti, normally well individualizable, have completely disappeared, leading to tumor cell dissemination in a non-anatomical plane, and rendering dissection delicate if not impossible. When dissemination is no longer limited by the fascia, the number of recurrence loci increases within the pelvis and consequently, the number of organs and structures involved as well. The number of invaded pelvic sites appears to be a predictive factor for overall and disease-free survival and the presence of at least two pelvic fixation points (anterior, posterior or lateral) represents a pejorative prognostic factor.
