Objective:

To evaluate the prognostic value of initial recurrence patterns on post-recurrence survival (PRS) and examine clinicopathological factors associated with recurrence-free survival (RFS) in patients with locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy and surgery.

Approach:

• Data Analysis: RFS was analyzed using the Kaplan–Meier method and Cox proportional hazards regression models; PRS was similarly analyzed based on initial recurrence patterns.

Key Findings:

• 347 patients remained recurrence-free, 28 had preoperative metastasis, and 62 developed postoperative recurrence.
• Pathological tumor deposit positivity and ypTNM stage II–III were associated with shorter RFS.
• Complex recurrence was associated with poorer PRS compared to isolated lung metastasis, which had the most favorable outcome.

Interpretation:

Initial postoperative recurrence pattern is independently associated with PRS in LARC patients following NCRT and surgery, with isolated lung metastasis indicating better outcomes and complex recurrence indicating poorer prognosis.

Limitations:

• Retrospective design may introduce selection bias.
• Single-center data may limit generalizability.

Conclusion:

The study highlights the prognostic significance of initial recurrence patterns and clinicopathological factors in LARC, potentially aiding in postoperative risk stratification and surveillance.