Purpose: Locally recurrent rectal cancer occurs in 10-30% of patients following primary resection and extra pelvic metastases occur in an additional 30-40%, some of which are resectable. The ability to achieve an RO resection of recurrence is governed by stage and biology of the disease which is the subject of this review. Method: Patients with recurrent rectal cancer (1990-2005) were staged as follows: TR local recurrence at primary site, TR1-invasion of mucosa, TR2-submucosal invasion into muscularis propria, TR3-full thickness penetration into peri-rectal tissue, TR4 (locally extensive) penetrates soft tissue or adjacent organ, TR5-invades bone, ligaments of pelvis. TanyNanyM1-distant mets, (visceral sites). All patients had been irradiated either prior to or after having recurrence (45-50Gy), usually with sensitizing chemotherapy. Patient Data: 156 patients were reviewed for recurrent recto-sigmoid cancer, 123 with rectal cancer and 32 with rectosigmoid cancer. All had adjuvant neoadjuvant chemo radiation or if not were give chemo radiation prior to salvage surgery. Patient treatment groups included palliative therapy in 58 pts: no surgery (chemo/radiation only 22 pts), palliative surgery-resection/bypass (13 pts)/ pelvic perfusion (23 pts) and resectional surgery with curative intent (98 pts). The latter included salvage by anterior resection/abdominal perineal resection +/- exenterations (34 pts) and abdominal sacral resection +/- exenterations in 58 pts. Distant disease was identified in 16 potentially resectable patients with liver (9), Lung (4) & Brain (3) metastases; all had resection with curative intent. Conclusions: Tumor stage directed RO resection of locally recurrent rectal cancer can achieve long term survival in approximately 30% of patients and mimics the well established resectional results of patients with liver metastases.

Primary Resection Rectal Cancer	Stage of Recurrence	REsection of Recurrence w/ curative intent	Patients	Survival Med mos	5yr KM
Local Excision (Rectal Cancer)	Tr1-2	AR/APR	5	29	30%
Rectosigmoid Resect (Mid-distal Cancer)	TR3	AR/APR Segmental	12	38	30%
Anterior Resection (Mid-low Rectum)	TR4 TR5	APR ASR*	17 30	35 31	20% 35%
Abdominal perineal (Mid-low Rectum)	TR5	ASR*	28	34	20%
Anterior resect/APR	TanyNanyM1 (distant mets)	Liver Lung Brain	9 4 316	263532	38%

Palliative Group	Stage	58 Pts	Survival(median)	5yr KM
Post AR/APR No Surgery (chemo/radiation)	TR5	22	12 mos	5%
Post AR/APR Exploration/Resection/Bypass	TR5	13	11 mos	8%
Post AR/APR Pelvic Perfusion (pain/mass)	TR5	23	8 mos	0%