Liver resection for colorectal metastases is safe and effective therapy and currently represents the only potentially curative therapy for metastatic colorectal cancer. The only absolute contraindication to resection is extrahepatic disease. A randomized trial to examine efficacy of surgical resection cannot ethically be performed. Liver resection should be considered standard therapy for all fit patients with colorectal metastases isolated to the liver.

Treatment of locally advanced rectal cancer with preoperative CMT followed by TME can provide for a durable 10-year OS of 58% and RFS of 62%. Patients who achieve a >95% response to preoperative CMT have an improved long-term oncologic outcome, a novel finding that deserves further study.

Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.

The use of preoperative chemoradiation results in increased operative time, blood loss, and pelvic abscess formation but does not increase the rate of anastomotic leaks or the length of hospital stay after low anterior resection for rectal cancer. The 5-year actuarial overall survival rate for patients undergoing curative resection exceeded 80%, with a local recurrence rate of 10%.

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Patterns of local and distant recurrences following resections for rectal cancer provide clinical perspective for multidisciplinary prevention and follow‐up programs. From 1968 to 1976 at Memorial Hospital, 412 patients with potentially curable rectal cancer were treated by anterior (AR) or abdominoperineal (APR) resections. First sites of recurrences were categorized as pelvis, liver, distant viscera, and intraabdominal/ retroperitoneal sites. Pelvic recurrences were further evaluated according to the location of the tumor, type of resection, and stage of disease. Among the 412 cases, 182 (44.2%) patients developed recurrence, of which 105 (57.6%) were pelvic. Pelvic recurrence was the predominating site either alone (55 of 103) or with concomitant extra‐pelvic sites (50/79). In instances of single‐site first recurrence, pelvic failure was recognized earliest at 19.1 months, which was significantly earlier than single‐distant visceral sites at 34.9 months. Pelvic recurrence was selectively related to various categories of the Dukes and modified Dukes staging systems. Dukes stage significantly predicted pelvic recurrence rates for Dukes A versus B. Astler‐Coller stages of B2 and C1 were associated with significantly lower rates of pelvic recurrence (29.7% and 22.1%, respectively) than C2 cancers. The incidence of pelvic recurrence was significantly increased for low and mid rectal cancers as compared with cancers at or above 12 cm. The type of resection utilized (APR versus AR) was associated with no difference in the rate of pelvic recurrence, except for the few patients in whom AR was performed for low rectal Dukes C cancers. Patients with pelvic recurrence had an ultimate disease‐free survival of only 3.8% as compared with patients with no pelvic recurrence of whom 77% remained alive without disease or went on to die of other causes. The timing and predominance of pelvic failure in rectal cancer with its own treatment‐related morbidity and overall dismal survival outcome justifies organized multidisciplinary efforts to prevent such failure and prospective trials of comprehensive follow‐up programs to evaluate improved cure rates or palliation. Cancer 53:1354‐1362, 1984.

Salvage surgery for locoregional recurrence colon cancer is appropriate for select patients. Complete resection is critical to long-term survival and is associated with a single site of recurrence, perianastomotic disease, low presalvage carcinembryonic antigen level, and absence of distant disease.

Total mesorectal excision with autonomic nerve preservation for rectal cancer is based on the anatomy of the mesorectum and of the pelvic autonomic nerves. Cadaver dissections were performed to describe the relationship between these structures. Between the rectum and the sacrum a retrorectal space can be developed, lined anteriorly by the visceral leaf and posteriorly by the parietal leaf of the pelvic fascia. The hypogastric nerve runs anterior to the visceral fascia, from the sacral promontory in a laterocaudad direction. The splanchnic sacral nerves originate from the sacral foramina, posterior to the parietal fascia, and run caudad, laterally and anteriorly. After piercing the parietal layer of the pelvic fascia, approximately 4 cm from the midline, the sacral nerves run between a double layer of the visceral part of the pelvic fascia. The relationship between the hypogastric nerves, the splanchnic nerves and the pelvic fascia was comparable in all six specimens examined.