Current surgical treatment strategies and ongoing issues for locally recurrent rectal cancer

Locally recurrent rectal cancer (LRRC) remains one of the most challenging problems in the rectal cancer management, despite advances in multimodal treatments. R0 resection remains the cornerstone of curative therapy and the most critical prognostic factor. However, achieving R0 resection is technically demanding, with outcomes heavily influenced by tumor location, institutional expertise, and careful patient selection. This narrative review summarizes current surgical strategies for LRRC, emphasizing the importance of accurate anatomical classification, multidisciplinary collaboration, and individualized planning. Extended resections-including bony pelvis, pelvic sidewall, and vascular dissections-have expanded surgical indications but require specialized expertise and carry risks of functional impairment. Minimally invasive approaches, such as laparoscopic or robotic pelvic exenteration, may offer potential advantages in selected cases but remain technically challenging. Carbon ion radiotherapy, which demonstrates superior local control compared to conventional radiotherapy, is expected to be a promising treatment for unresectable LRRCs. Its future role as an alternative or perioperative treatment for resectable or borderline cases is under investigation. Preoperative chemoradiotherapy may play an important role in radiation-naïve patients, while re-irradiation strategies remain controversial for previously irradiated cases. In patients with resectable distant metastases, aggressive combined surgical approaches may be pursued if curative resection is feasible. Ultimately, shared decision-making with patients is essential for optimal management of LRRC, based on a highly individualized, evidence-based approach that balances oncological prognosis and postoperative quality of life.