Management of Locoregional Recurrence of Rectal Cancer After Surgery Using Radiofrequency Ablation
Abstract: The primary mode of treatment for rectal carcinoma is resection. Despite radical surgery, 10% to 25% of patients develop local recurrence, the majority of which involve pelvic sidewall or surrounding organs. Radiofrequency ablation has been reported as a promising treatment option in this group of patients. We present a case of locoregional recurrence of rectal cancer post surgery. Radiofrequency ablation of the lesion was performed. No peri- or postprocedural complications were seen. Carcinoembryonic antigen levels dropped post procedure without any concurrent therapy. No evidence of local residual disease or recurrence was seen on imaging up to 68 months follow-up. Radiofrequency ablation should be considered as an option in patients who have received prior treatment for rectal cancer presenting with local site pelvic recurrence.
Key words: rectal cancer, locoregional recurrence, recurrence, radiofrequency ablation, nonsurgical treatment
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The primary mode of treatment for rectal carcinoma is resection. Despite radical surgery, 10% to 25% of patients will develop local recurrence. Surgery is also the mainstay in the management of recurrence. However, the majority of patients develop recurrence involving pelvic sidewall or the surrounding organs, which poses a major therapeutic challenge. Repeat surgery is challenging due to scarring related to previous surgery and chemoradiation. Radiofrequency ablation (RFA) has been reported as a promising treatment option in this group of patients and can be performed with curative or a palliative intent.1,2,3 We present a case of rectal cancer with local recurrence successfully treated with RFA.
Case Report
A 70-year-old male presented with rectal carcinoma which had been excised via low anterior resection with coloanal anastomosis, chemotherapy, and radiotherapy in May 2005. At 12 months follow-up, the patient had elevated carcinoembryonic antigen (CEA) and recurrence at the anastomotic site due to which abdominoperineal resection and end colostomy was performed, followed by chemoradiation. Surgery was challenging as the site was scarred due to the prior radiation and the tumor circumferentially involved the anastomotic site.
Follow-up PET CT 6 months later showed an ill-defined soft tissue density in the rectal 
fossa showing high FDG activity (SUV=5), with no invasion of pelvic sidewalls. The CEA went up to 33.9, at which point chemotherapy was initiated. The patient had good response to chemotherapy with CEA dropping to 1.73 at 4-month follow-up. However, a few months later, CEA went up to again to 29.8. A CT scan was performed that showed a recurrent lesion measuring 30 mm x 30 mm (Figure 1). The patient was considered a poor surgical candidate due to the 2 prior surgeries and radiation. The patient was referred to interventional radiology for RFA.
A CT scan was performed to plan the procedure and confirm lack of major critical structures around the lesion. Under continuous CT scan monitoring (Figure 2), using the StarBurst XL RFA device (AngioDynamics) the probe was advanced into the lesion and 
deployed sequentially up to 4 cm and ablation performed according to protocol. The probe was then removed while ablating the tract. CT scan was repeated which showed no procedure related complications. The patient tolerated the procedure well.
Follow-up PET scans (Figure 3) performed at 6-month intervals for 1 year followed by yearly scans showed a residual soft tissue mass with no metabolic activity at the site of prior recurrence at 4-year follow-up. The CEA levels were down from 29.8 preprocedure to 8.5 at 6 months follow-up. The CEA levels however started rising after that, presumably due to a new lung nodule. Post right thoracotomy for the lung nodule, CEA levels dropped again, convincing us that new 
disease in the lung was probably responsible for the elevated CEA, rather than residual or recurrent disease in the perirectal region.
During the last 3 years, he has had multiple new recurrences in his lungs and episodes of elevated CEA, which have been treated with chemotherapy. At follow-up in June 2015, his PET CT showed no hypermetabolic activity in the stable soft tissue in the presacral region. The lung nodules were also not hypermetabolic. Figure 4 shows a timeline of the patient’s treatment.
Discussion
Most locoregional recurrences following surgery for rectal cancer involve the pelvic wall, 
wherein multimodality therapy including surgery, radiotherapy, and chemotherapy has poor results with increased morbidity. Radiofrequency ablation appears to have evolved as an option in this group of patients.1-3 In the past few years, several studies have reported the use of RFA in treatment of pelvic recurrence from rectal cancer, both for palliative and possibly curative treatment. Ohhigashi et al reported the largest series, in which RFA was performed in 14 recurrent pelvic lesions in 10 patients, post resection of rectal carcinoma. The ablation was aimed at curative treatment in 4 patients (solitary lesions <4 cm) and palliative, mainly for pain control, in 6 patients (10 recurrent lesions >4 cm).They concluded that RFA was a good option in treatment of recurrences and that complete tumor ablation is important for curative as well as palliative cases. They proposed that adequate ablation depended on tumor site, infiltration, and the size of the tumor, with more complete ablation possible in tumors less than 4 cm. Complications like abscesses, bleeding, and neuralgia were seen in the larger lesions.4
In another series by Belfiore et al, palliative CT-guided RFA was used in 14 patients with recurrent rectal adenocarcinoma. In contrast to the series by Ohhigashi et al, encouraging pain palliation was obtained despite producing an ablated area of only 75% of the index tumor.5
Our case shows a locoregional recurrence measuring <4 cm, successfully treated by RFA with no peri- or postprocedural complications. The CEA levels also dropped significantly up to 6 months post procedure, during which time the patient had not received any other form of treatment. There was no imaging evidence of local residual disease or recurrence up to 68 months follow-up.
Radiofrequency ablation should be considered as an option in patients who have received prior treatment for rectal cancer and are presenting with local site pelvic recurrence. Attention to specific complications of thermal injury to surrounding vital organs in the rectal region is of paramount importance. More trials should be performed to evaluate the efficacy, safety, and long-term follow-up to evaluate impact on survival in these patients. Awareness on the part of the surgical oncologist and interventional radiologist is the key in offering RFA as a treatment option in recurrent rectal cancer.
References
- Chau I, Allen MJ, Cunningham D, et al. The value of routine serum carcinoembryonic antigen measurement and computed tomography in the surveillance of patients after adjuvant chemotherapy for colorectal cancer. J Clin Oncol. 2004;22(8):1420-1429.
- Green SH, Khatri VP, McGahan JP. Radiofrequency ablation as salvage therapy for unresectable locally recurrent rectal cancer. J Vasc Interv Radiol. 2008 ;19(3):454-458.
- Moriya Y. Treatment strategy for locally recurrent rectal cancer. Jpn J Clin Oncol. 2006;36(3):127-131.
- Ohhigashi S, Watanabe F. Radiofrequency ablation is useful for selected cases of pelvic recurrence of rectal carcinoma. Tech Coloproctol. 2003;7(3):186-191.
- Belfiore G, Tedeschi E, Ronza FM, et al. CT-guided radiofrequency ablation in the treatment of recurrent rectal cancer. AJR Am J Roentgenol. 2009;192(1):137-141.
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Editor’s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Bhatia reports honoraria from AngioDynamics. The remaining authors report no disclosures related to the content herein. The authors report that patient consent was given. Human and animal rights approval was not applicable in this case.
Manuscript received March 28, 2015; manuscript accepted April 1, 2015.
Address for correspondence: Shivank S. Bhatia, Department of Radiology, Suite D300B, 1201 NW 16th St. Miami, FL 33125. Email: sbhatia1@med.miami.edu
Suggested citation: Bhatia SS, Pereira K, Spector S. Management of loco-regional recurrence of rectal cancer after surgery using radiofrequency ablation. Intervent Oncol 360. 2015;3(7):E73-E77.
