Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. Br J Surg. 2018;105:650-657. [PMID: 29529336 DOI: 10.1002/bjs.10734]

R0 Resection Rates in Minimally Invasive Versus Open Pelvic Exenteration for Colorectal Malignancies: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Pelvic exenteration is a curative option for select patients with locally invasive or recurrent colorectal cancer. Achieving clear margins (R0 resection) is critical for optimal oncological outcomes and quality of life. Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, offers advantages in visualisation and precision, but its feasibility is debated given data limitations. This meta-analysis compares outcomes of MIS with open pelvic exenteration for colorectal cancer.

METHODS

A systematic review and meta-analysis were conducted with studies comparing MIS to open approaches for pelvic exenteration in colorectal cancer included. The primary outcome was R0 resection rate, with secondary outcomes encompassing operative, postoperative, and oncological results.

RESULTS

Seven retrospective studies were analysed, including a total of 564 patients. Meta-analysis showed no significant difference in R0 resection rates between MIS and open approaches (RR = 0.74, 95% CI: 0.36, 1.51, p = 0.41) with low heterogeneity (I2 = 19%). MIS had similar lymph node harvest, operative time, and postoperative complications but demonstrated significantly reduced intraoperative blood loss, shorter length of stay, and improved 3-year overall and disease-free survival rates.

CONCLUSIONS

MIS achieves comparable R0 resection rates to open surgery in pelvic exenteration for colorectal cancer, with advantages in recovery and survival outcomes. Current evidence is limited by retrospective studies with selection bias requiring future standardised prospective trials.

Short- and long-term outcomes of minimally invasive vs. open pelvic exenteration in rectal tumours: a focused meta-analysis

PURPOSE

Pelvic exenteration (PE) is a complex surgical procedure used to treat patients with recurrent or locally advanced rectal cancer (LARC) as a final recourse. Thus, minimally invasive surgery (MIS) has emerged as an alternative to the traditional open PE as it may reduce surgical trauma and improve recovery. This meta-analysis compared the clinical outcomes between MIS and open PE in patients with LARC.

METHODS

A systematic review and meta-analysis were conducted following PRISMA and AMSTAR guidelines. Six retrospective studies comprising 368 patients (179 MIS patients; 189 open patients) were included. Data on operative parameters along with short-term and long-term outcomes, including the 3-year overall (OS) and disease-free survival (DFS), were extracted. Risk ratios (RRs) and odds ratios (ORs) were calculated for binary outcomes, while standardised mean differences (SMDs) were calculated for continuous outcomes. All measures were reported with 95% confidence intervals (CIs) using random-effects models.

RESULTS

MIS was associated with significantly reduced blood loss (standardised mean difference (SMD), - 1.57; 95% CI, - 2.27 to - 0.88; p < 0.00001), shorter hospital stays (SMD, - 6.46; 95% CI, - 12.21 to - 0.71; p = 0.03), and quicker diet resumption (SMD: - 0.79; 95% CI, - 1.36 to - 0.21; p = 0.008) than open PE. MIS was associated with a borderline reduction in total complications (OR, 0.45; 95% CI, 0.20-1.00; p = 0.05) and lower rates of abdominal wound complications (OR, 0.22; 95% CI, 0.11 to 0.45; p < 0.0001). No significant differences were observed in R0 resection rates, major complications, or mortality. For long-term outcomes, MIS demonstrated significantly improved 3-year OS (RR, 1.19; 95% CI, 1.01 to 1.41; p = 0.04), whereas 3-year DFS showed no significant difference (RR, 1.02; 95% CI, 0.79 to 1.41; p = 0.87).

CONCLUSION

MIS offers significant short-term advantages over open PE, including reduced blood loss, faster recovery, and fewer complications while demonstrating improved 3-year OS. These findings support MIS PE as a safe, effective, and viable option for patients with recurrent or LARC.

Oncological and functional outcomes after sacrectomy for colorectal cancer: A systematic review

AIM

Worldwide, of all cancers, colorectal cancer has the fourth highest rate of mortality. Curative treatment for locally advanced or recurrent rectal cancer can require extended resections with sacrectomy, but this sugery can have major consequences for patients. The aim of this study was to investigate the oncological and functional outcomes after sacrectomy in patients with colorectal cancer.

METHOD

The protocol was registered in (PROSPERO), the international prospective register of systematic reviews. PubMed, Embase, The Cochrane Library, Scopus and Google Scholar were searched using a predetermined search strategy. Article selection, quality of evidence [Grading of Recommendation, Assessment, Development and Evaluation (GRADE)] and risk of bias [The Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I)] were assessed by two independent reviewers. Studies reporting on sacrectomy for colorectal cancer were included. Oncological and functional outcomes after sacrectomy for colorectal cancer were the primary outcomes.

RESULTS

Forty-six articles with 1687 patients (1115 men; 506 women) were included. Median follow-up was 31.4 months. Mean 30-day mortality was 1.1%. After R0 resection, overall survival was achieved in 86.2%, 68.0% and 42.1% patients, and disease-free survival was achieved in 75.0%, 51.0% and 43.0% patients, respectively, after 1, 3 and 5 years. Survival rates were lower after R1 or R2 resection. Most patients reported elimination of or significantly reduced pain after surgery, and 82.2% were able to walk independently, without the use of assistive devices. More patients were dependent on walking-assist devices after high sacrectomy than after low sacrectomy. The most commonly reported bowel dysfunctions were bowel obstruction (22.3%) and fistula (4.6%). Bladder dysfunction was mainly reported as incontinence (8.3%) and neurogenic bladder (23.3%). No study included quality of life as an outcome.

CONCLUSIONS

The mortality was limited, and the morbidity rates were in concordance with published literature. The results suggest that R0 resection has higher survival rates than R1/R2 resections. Both short- and long-term functional outcomes could have major impact on a patient's quality of life. Heterogeneity was high, and neither comparative analyses nor meta-analysis could be performed.

Patterns of Care and Oncologic Outcomes after Pelvic Exenteration for Locally Advanced Rectal Cancer in the United States

BACKGROUND

Pelvic exenterations (PEs) are technically demanding procedures performed with curative intent for advanced malignancies to improve patient survival while balancing morbidity and functional outcomes. The majority of United States (US) data regarding PE for rectal cancers originate from single-center series.

OBJECTIVE

We aimed to investigate patterns of care and oncologic outcomes for primary rectal cancer patients undergoing PE in a national registry.

METHODS

The National Cancer Database (2004-2019) was queried for adults with a pT4 rectal adenocarcinoma. Logistic regression identified factors associated with positive margins. Multivariable Cox regression estimated treatment effects on overall survival (OS).

RESULTS

Of 673 patients (73% <65 years of age, 39% male, 82% White), median follow-up was 39 months. The majority received neoadjuvant chemotherapy (76%) and radiation (75%), while adjuvant chemotherapy (37%) and radiation (13%) were less common. Twenty-four percent had positive margins (R1 = 98, R2 = 11, R + NOS = 48). Univariable analysis demonstrated that only nodal involvement was associated with higher positive margin rates (odds ratio 1.75, 95% confidence interval [CI] 1.22-2.51). Five-year OS for R0 and R+ resections were 55% and 33%, respectively. On multivariable analysis, age <65 years (hazard ratio [HR] 0.73, 95% CI 0.53-0.99) and adjuvant chemotherapy (HR 0.62, 95% CI 0.47-0.82) were associated with improved OS, while N+ status (HR 2.13, 95% CI 1.67-2.70) and positive margins (HR 1.82, 95% CI 1.41-2.35) portended worse prognosis. No significant associations were observed between outcomes and institutional volume.

CONCLUSION

One in four US patients undergoing PE for locally advanced rectal cancer had an R+ resection regardless of center volume. Quality of surgical resection to achieve negative margins remains the most relevant prognostic factor.

Urological complications following pelvic exenteration are comparable to those following radical cystectomy

INTRODUCTION

Radical cystectomy and urinary diversion is required for both primary muscle-invasive bladder cancer and in the setting of pelvic exenteration for advanced malignancy of pelvic organs. Acute and chronic complications following radical cystectomy can be a significant cause of morbidity. We compared the rates of urological complications following these two procedures at our tertiary referral centre.

METHODS

Patients who underwent radical cystectomy and urinary diversion either alone or as part of pelvic exenteration between June 2017 and April 2024 at our hospital were included. Short and long-term post-operative urological complications were collected, and data for patients who underwent PE were collected prospectively as part of a larger database.

RESULTS

One hundred eleven patients underwent cystectomy: 44 as part of pelvic exenteration (PE), 67 cystectomy alone. Post-operative urological complications occurred in 45% of patients undergoing PE and 42% undergoing cystectomy alone (P = 0.703). Urosepsis was the most frequent complication in both cohorts, occurring in 27% and 24% of patients who underwent PE and cystectomy alone respectively. Return to theatre was required in 9% of PE patients and 7% of non-PE patients. ASA status was predictive of complication development in the non-PE cohort, no factors analysed were predictive in the PE cohort.

CONCLUSIONS

In this cohort, the rate of urological complications and return to the theatre following radical cystectomy and urinary diversion were comparable among those undergoing PE and cystectomy alone. No individual factor was identified that was predictive of post-operative complications.

Early failure following pelvic exenteration: Who are the bad actors?

BACKGROUND

Pelvic exenteration for locally advanced (LARC) or recurrent rectal cancer (LRRC) is technically challenging with considerable morbidity for the patient. Though surgery can confer long-term survival in selected patients, early failure, defined as recurrence with one year, represents a major issue as both survival and quality of life are severely impacted. This study aims to highlight the "bad actors" associated with early failure.

METHODS

A retrospective study of patients who underwent exenteration for LARC & LRRC in a quaternary referral unit was performed. Specifically, characteristics of patients with early recurrence were identified and compared to those who recurred after one year.

RESULTS

159 and 85 patients underwent pelvic exenteration for LARC and LRRC, respectively. Of these, there were 61 (38.3 %) recurrences in the LARC and 74 (87.1 %) LRRC cohorts. For LARC, 18 patients had an early failure. Expectantly, these patients had a higher proportion of positive margins (R1) (50 % vs. 21 % in the remaining 141 patients, ∗p = 0.04). Interestingly, early failure was also associated with more genetic mutations (33 % vs. 22 %), extramural venous invasion (32 % vs. 24 %), lymphovascular invasion (38 % vs. 22 %), and other adverse histopathological features including poor-differentiation, signet-ring and/or mucinous disease (38 % vs. 21 %). Median and 3-year overall survival (OS) in the early failure group compared to the rest of the cohort was 96 months versus 30 months and 35 % versus 73 %, respectively (∗p = 0.003). There were 18 early failures in the LRRC cohort. Similarly, there were more patients with positive margins in the early failure group (55 % versus 39 %, ∗p = 0.02). The early failure group was also associated with extramural venous invasion (38 % versus 23 %) and adverse histopathological features (55 % versus 28 %). Median and 3-year overall survival (OS) in the early failure group compared to the non-early-failure group was 15 versus 0 months and 17 % versus 68 % respectively (∗p=<0.001).

CONCLUSION

Tailoring treatment strategies according to tumour characteristics is increasingly important in the management of advanced rectal cancer. Multicentre data is needed to validate these findings and would have a profound impact to patient counselling and outcome expectations.

Lumbosacral Plexopathy After Carbon-ion Radiation Therapy for Postoperative Pelvic Recurrence of Rectal Cancer: Subanalysis of a Prospective Observational Study (GUNMA 0801)

Purpose

Data are lacking on the risk factors for radiation-induced lumbosacral plexopathy (RILSP) after carbon-ion radiation therapy (CIRT) for pelvic tumors, such as postoperative recurrence of rectal cancer. We investigated the incidence of RILSP and the associated dosimetric parameters using data from a prospective study of CIRT for postoperative pelvic recurrence of rectal cancer (GUNMA 0801).

Methods and Materials

The GUNMA 0801 study included 28 patients, of which we analyzed 20 without lumbosacral plexopathy prior to CIRT. The total dose of CIRT was 73.6 Gy (relative biological effectiveness [RBE]) in 16 fractions. The incidence of RILSP and parameters of the dose-volume histogram were evaluated for the lumbosacral plexuses. RILSP was graded according to the Common Terminology Criteria for Adverse Events version 4.0.

Results

Median follow-up was 24 months. The incidence of all RILSP (grades 1 and 2) and grade 2 RILSP was 22.5% (9/40) and 10% (4/40) of 40 lumbosacral plexuses in 20 patients, respectively, and no grade ≥ 3 toxicity was observed. Throughout the dose range, the volumes of the irradiated lumbosacral plexuses were significantly higher in patients with RILSP than in patients without RILSP (P < .001 for Dmax, D0.5 cm3 - D2 cm3, V20 Gy(RBE) - V70 Gy(RBE)). D2 cm3 and V50 Gy(RBE) were considered useful for receiver operating characteristic analysis. Cutoff values for RILSP were 73.82 Gy(RBE) and 33.2% for D2 cm3 and V50 Gy(RBE), respectively.

Conclusions

We demonstrated the incidence and predictive dosimetric parameters for RILSP after CIRT and showed that D2 cm3 ≥ 73.82 Gy(RBE) and V50 Gy(RBE) = 33.2% are cutoff values for predicting RILSP. These results would improve treatment plans using CIRT for patients with pelvic recurrences of rectal cancer.

A Scoping Review of the Implications and Applications of Body Composition Assessment in Locally Advanced and Locally Recurrent Rectal Cancer

Background: A strong body of evidence exists demonstrating deleterious relationships between abnormal body composition (BC) and outcomes in non-complex colorectal cancer. Complex rectal cancer (RC) includes locally advanced and locally recurrent tumours. This scoping review aims to summarise the current evidence examining BC in complex RC. Methods: A literature search was performed on Ovid MEDLINE, EMBASE, and Cochrane databases. Original studies examining BC in adult patients with complex RC were included. Two authors undertook screening and full-text reviews. Results: Thirty-five studies were included. Muscle quantity was the most commonly studied BC metric, with sarcopenia appearing to predict mortality, recurrence, neoadjuvant therapy outcomes, and postoperative complications. In particular, 10 studies examined relationships between BC and neoadjuvant therapy response, with six showing a significant association with sarcopenia. Only one study examined interventions for improving BC in patients with complex RC, and only one study specifically examined patients undergoing pelvic exenteration. Marked variation was also observed in terms of how BC was quantified, both in terms of anatomical location and how cut-off values were defined. Conclusions: Sarcopenia appears to predict mortality and recurrence in complex RC. An opportunity exists for a meta-analysis examining poorer BC and neoadjuvant therapy outcomes. There is a paucity of studies examining interventions for poor BC. Further research examining BC specifically in patients undergoing pelvic exenteration surgery is also lacking. Pitfalls identified include variances in how BC is measured on computed tomography and whether external cut-off values for muscle and adipose tissue are appropriate for a particular study population.

Clinical calculator based on clinicopathological characteristics predicts local recurrence and overall survival following radical resection of stage II-III colorectal cancer

PURPOSE

This study aimed to analyze the risk factors and survival prognosis of local recurrence in stage II-III colorectal cancer (CRC) and develop a clinical risk calculator and nomograms to predict local recurrence and survival in treated patients.

METHODS

Patients who underwent radical surgery between January 2009 and December 2019 at the China National Cancer Center were included. Multivariate nomograms and a clinical risk calculator based on Cox regression were developed. Discrimination was measured with an area under curve (AUC) and variability in individual predictions was assessed with calibration curves. We stratified patients into different risk groups according to the established model to predict their prognosis and guide clinical practice.

RESULTS

The clinical risk calculator incorporated six variables: tumor thrombus, perineural invasion, tumor grade, pathology T-stage, pathology N-stage, and whether more than 12 lymph nodes were harvested. Our clinical risk calculator provided good discrimination, with AUC values of local recurrence-free survival (LRFS) (0.764) and overall survival (OS) (0.815) in the training cohort and LRFS (0.740) and OS (0.730) in the test cohort. Calibration plots illustrated excellent agreement between the clinical risk calculator predictions and actual observations for 3- and 5-year LRFS and OS. Recurrence risk-stratified analysis showed that low-risk patients were more likely to undergo salvage radical surgery when recurrent disease existed.

CONCLUSION

The clinical calculator can better account for tumor and patient heterogeneity, providing a more individualized outcome prognostication. The model is expected to aid in treatment planning, such as resectability evaluation, and it can be used in postoperative surveillance (https://oldcoloncancer.shinyapps.io/dynnomapp/).

Therapeutic Management of Locally Advanced Rectal Cancer: Existing and Prospective Approaches

Rectal cancer (RC) presents significant challenges in diagnosis and treatment, with increasing incidence among younger populations. Treatment approaches, particularly for locally advanced rectal cancer (LARC), have evolved, notably with the introduction of total neoadjuvant therapy (TNT). TNT combines neoadjuvant chemotherapy and chemoradiotherapy before surgery, improving overall survival and reducing both metastasis and local recurrence rates compared to traditional methods, while enabling more patients to complete the full oncological treatment. Clinical trials, such as RAPIDO, OPRA, and PRODIGE 23, have demonstrated the effectiveness of TNT in tumor downstaging and complete pathological responses, offering better outcomes for patients; however, debates persist regarding the role of neoadjuvant radiotherapy, with novel strategies exploring its omission in specific cases to reduce toxicity and enhance quality of life. In addition, organ preservation strategies, such as the watch-and-wait (WW) approach, have emerged as viable options for patients with a complete response to neoadjuvant therapy. Future directions point towards personalized treatment plans incorporating radiogenomics and the integration of artificial intelligence into diagnostics to optimize patient outcomes. This review aims to synthesize current treatment strategies and ongoing advancements in rectal cancer management, providing insights into potential future innovations.

Short- and Intermediate-Term Morbidity Following Total Pelvic Exenteration in Colorectal Cancer

INTRODUCTION

Total pelvic exenteration (TPE) for clinical T4b colorectal cancer (CRC) is associated with significant morbidity. Short (0-30 days)- and intermediate (31-90 days)-term temporal analysis of complication onset is not well described, yet needed, to better counsel patients considering TPE.

METHODS

A retrospective cohort study of consecutive patients with primary or recurrent clinical T4b pelvic CRC undergoing open TPE between 2014 and 2023 was conducted. Clinicopathologic variables were collected for each patient. Postoperative morbidity was classified according to the Clavien-Dindo (CD) grade system and stratified by time of onset within 90 days of surgery. Pearson's Chi-square test, Fisher's Exact test, and the Mann-Whitney U test were used to compare primary vs recurrent patient groups, and logistic regression assessed predictors of postoperative morbidity. Statistical analysis was performed using R with two-sided significance set at <0.05.

RESULTS

Twenty-seven patients were identified of which 24 (88.9%) were male with a median age of 60.4 years (interquartile range [IQR]: 56.3-70.5). Seventeen (63.0%) patients had primary disease and 10 (37.0%) had recurrent CRC. Twenty-three (85.2%) patients experienced at least one complication within 90 days of surgery, but no mortality was observed. Ten (37.0%) patients experienced a CD ≥ 3 event, of which 40% took place beyond 30 days. The most common complication overall was anemia requiring transfusion, while the most common major complication was pelvic abscess. No clinicopathologic variables analyzed were predictive of major postoperative complication within 90 days of TPE.

CONCLUSION

TPE for clinical T4b CRC carries a high risk of postoperative morbidity in both the short- and intermediate-term after surgery, with a significant proportion of complications occurring after 30 days. Given the magnitude of operation, an extended recovery with high risk for complications is common. Although a single-center series, this annotated postoperative complication profile may assist patients and clinicians when reviewing informed consent for TPE.

Ten-year survival and pattern of recurrence in patients with locally recurrent rectal or sigmoid cancer undergoing resection

AIM

The aim of this work is to report actual overall survival (AOS) at 5 and 10 years after multimodal treatment for locally recurrent rectal or sigmoid cancer (LRRC) and the importance of local re-recurrence (reLRRC) and distant metastases for AOS.

METHOD

All patients resected for LRRC at a single centre between years 1990 and 2007 were included. Resections were based on images taken after neoadjuvant treatment. Patients were prospectively followed up for 5 years. After a minimum of 10 years, the records of referring hospitals were analysed.

RESULTS

A total of 224 patients underwent resection. At 5 and 10 years 33% and 17%, respectively, had survived. Median survival was 38 months [interquartile range (IQR) 62 months]. Patients with complete resections had 5- and 10-year survival of 56% and 28%, respectively, versus 22% and 11% for those with microscopic remaining tumour; none with macroscopic remains survived beyond 4 years. Median survival was 71 months (IQR 106 months), 33 months (IQR 35 months) and 15 months (IQR 17 months), respectively. With a median survival of 123 months (IQR 80 months), the 54 patients without recurrence had 5- and 10-year survival of 69% and 59%, respectively. The independent predictor of survival was R-stage. Of the 197 patients who had radical resection, 83 developed reLRRC and 108 distant metastases. ReLRRC appeared at a median of 18 months (IQR 21 months) and distant metastases at 12 months (IQR 21 months). Lung metastases were the most common form of distant disease.

CONCLUSION

More than 5 years postoperatively the mortality from cancer was substantial. Most metastases appeared not to be secondary to reLRRC. Planning surgery from pretreatment images might reduce reLRRC.

Advances in beyond total mesorectal excision surgery: Behind the scenes

The management of locally advanced rectal cancer involving adjacent organs and extending beyond the surgical planes of total mesorectal excision has evolved over the past few decades both in terms of the effectiveness of preoperative treatments and surgical innovation. The use of a robotic platform is increasing, even in complex surgery such as pelvic exenteration together with the advantages of minimally invasive procedures. However, satisfactory surgical, oncological, and functional outcomes are achieved not only minimizing the impact of a demolitive surgery but also when a multidisciplinary specialized team focuses on experienced surgeons, mandatory rules of surgical oncology, appropriate medical treatments, accurate preoperative planning, and an acceptable quality of life.

Current Management of Locally Recurrent Rectal Cancer

Locally recurrent rectal cancer (LRRC), which occurs in 6-12% of patients previously treated with surgery, with or without pre-operative chemoradiation therapy, represents a complex and heterogeneous disease profoundly affecting the patient's quality of life (QoL) and long-term survival. Its management usually requires a multidisciplinary approach, to evaluate the several aspects of a LRRC, such as resectability or the best approach to reduce symptoms. Surgical treatment is more complex and usually needs high-volume centers to obtain a higher rate of radical (R0) resections and to reduce the rate of postoperative complications. Multiple factors related to the patient, to the primary tumor, and to the surgery for the primary tumor contribute to the development of local recurrence. Accurate pre-treatment staging of the recurrence is essential, and several classification systems are currently used for this purpose. Achieving an R0 resection through radical surgery remains the most critical factor for a favorable oncologic outcome, although both chemotherapy and radiotherapy play a significant role in facilitating this goal. If a R0 resection of a LRRC is not feasible, palliative treatment is mandatory to reduce the LRRC-related symptoms, especially pain, minimizing the effect of the recurrence on the QoL of the patients. The aim of this manuscript is to provide a comprehensive narrative review of the literature regarding the management of LRRC.

Patient-Reported Outcomes in Chinese Patients with Locally Advanced or Recurrent Colorectal Cancer After Pelvic Exenteration

BACKGROUND

Pelvic exenteration (PE) is often the only curative treatment option for selected locally advanced and locally recurrent colorectal cancer associated with significant morbidity. Open and laparoscopic approaches were accepted for this procedure.

OBJECTIVE

This study aimed to examine the Chinese patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after PE.

METHODS

A total of 122 enrolled participants were asked to complete PROs at baseline and 1, 3, 6, 9 and 12 months after PE. PROs included seven symptoms from the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). The HRQoL was assessed using the Functional Assessment of Cancer Therapy-Colorectal (FACT-C).

RESULTS

The overall postoperative complication rate was 41.0%. Patients experienced lower physical and functional well-being and FACT-C 1 month after surgery, then gradually recovered. The FACT-C score returned to baseline 9 months after surgery. Social and emotional well-being did not show signs of recovery until 6 months after the surgical procedure, and did not fully return to baseline until 12 months post-surgery. Symptom rates of insomnia, anxiety, discouragement, and sadness (composite score >0) did not improve significantly from baseline until 12 months after surgery.

CONCLUSIONS

PE is a feasible treatment choice for locally advanced primary and recurrent colorectal cancer. Social, psychological, and emotional recovery in the Chinese population after PE tends to be slower compared with the physical condition.

Serving Queensland: reflecting on geographical access to the pelvic exenteration service in Queensland

BACKGROUND

Pelvic exenteration for rectal cancer involves a radical multi-visceral resection to improve complete surgical clearance, and access is limited within Queensland.

METHODS

A retrospective review of a prospective database of the referrals to the pelvic exenteration service in the Royal Brisbane and Women's Hospital from 2009 to2023. Geographic, as well as clinical and demographic information was collected.

RESULTS

One hundred and seventy six patients were referred to the pelvic exenterations service. In total 93 patients were referred from a major city, 52 from inner regional areas, and 31 from outer regional or remote areas. One hundred and three referred patients (58.5%) proceeded to surgery, significantly more of whom were referred from a major city (P < 0.001). Of the patients referred from outer regional, inner regional, and major cities, a similar proportion of patients proceeded to surgery (55%, 52%, and 63.4%). Patients not proceeding to surgery in major cities and inner regional areas were most commonly unfit to proceed, whereas in outer regional areas most patients decided against surgery (61.5%). In the 14-year period, overall referrals increased, with inner regional referrals increasing the most over time. Overall survival was not significantly impacted by remoteness.

CONCLUSION

Awareness of the pelvic exenteration service in regional Queensland may have resulted in less referrals to the service. It is important to confirm a broad-reaching service to optimize patient care.

Current perioperative care in patients undergoing a beyond total mesorectal excision procedure for rectal cancer: What are the differences with the colorectal enhanced recovery after surgery protocol?

AIM

Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS-related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol.

METHOD

This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS-related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients.

RESULTS

Seven studies reported on ERAS-related outcomes in patients undergoing bTME. Median length of hospital stay was 9-19 days, median stay in the intensive care unit was 2-4 days and 30-day postoperative major complication rates were 22.6%-61.3%. Seventy-five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization.

CONCLUSION

Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS-related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC.

A patient-designed integrative oncology intervention for stage IV locally recurrent rectal cancer: A case report

INTRODUCTION

Stage IV colorectal cancer is a highly challenging condition to treat, with 5-year survival rates of 13% in Australia, improving to 40% for those patients with locally recurrent rectal cancer who are suitable for total neoadjuvant therapy and pelvic exenterative surgery. This study reports a unique case of a patient with Stage IV locally recurrent rectal cancer (LRRC), who designed and implemented a holistic integrative oncology intervention.

CASE PRESENTATION

The patient was 59-years-old when diagnosed with Stage IV locally recurrent rectal cancer, and referred to a highly specialised centre for colorectal cancer care at a tertiary teaching hospital in Sydney, Australia. Treatment included chemo/radiotherapy, liver resection and posterior pelvic exenteration surgery. The patient's background as a health researcher and clinician optimised her ability to design and implement an integrative oncology model of care, including yoga, mindfulness, Buddhist meditation and study, social connection, exercise, psychotherapeutic and nutritional support. This paper describes these mind-body practices and lifestyle modifications and outlines her experiences and outcomes at each stage of her extensive and radical treatment.

CONCLUSION

This case provides a unique perspective into how the integration of mind-body practices and lifestyle modifications with conventional treatment can support those living with colorectal cancer.

Pelvic Exenteration in Advanced, Recurrent or Synchronous Cancers-Last Resort or Therapeutic Option?

First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. Methods: For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology "Prof. Dr. Al. Trestioreanu" in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. Results: The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Conclusions: Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits.

Impact of Intraoperative Decision-Making on Pathological Margin Status in Patients Undergoing Pelvic Exenteration for Locally Recurrent Rectal Cancer

BACKGROUND

A key component of preoperative preparation for pelvic exenteration surgery is the development of an operative plan in a multidisciplinary setting based on the extent of local tumor invasion on preoperative imaging. Changes to the extent of resection or operative plan may occur intraoperatively based on intraoperative findings.

OBJECTIVE

To report the frequency and extent of intraoperative deviation from the planned extent of resection during pelvic exenteration for locally recurrent rectal cancer and determine whether this resulted in a more or less radical resection.

DESIGN

Retrospective observational study.

SETTINGS

A high-volume pelvic exenteration center.

PATIENTS

Patients who underwent pelvic exenteration for locally recurrent rectal cancer between January 2015 and December 2020.

MAIN OUTCOME MEASURES

Frequency and extent of intraoperative deviation from the planned extent of resection, R0 resection rate.

RESULTS

One hundred thirty-six patients underwent pelvic exenteration for locally recurrent rectal cancer, of whom 110 (81%) had R0 resection margins. Twelve patients were excluded because of missing information, and 49 patients (40%) had a change to the operative plan. Operative changes were major in 30 patients (61%), more radical in 40 patients (82%), and margin relevant in 24 patients (49%). In patients in whom there was a change to the operative plan and R0 resection was achieved, the median distance to a relevant margin was 2.5 mm (range, 0.1-10 mm). Of 8 patients with a change in operative plan and R1 resection, 3 were margin relevant, of whom all were considered major, and 2 were more radical and 1 was less radical.

LIMITATIONS

Generalizability outside of specialist units may be limited.

CONCLUSIONS

Intraoperative changes to the planned extent of resection occur commonly and most often result in an unanticipated major or more radical resection. Such changes may contribute to high rates of R0 resection margins in specialist pelvic exenteration units that use an ultraradical approach in these patients. See Video Abstract .

IMPACTO DE LA TOMA DE DECISIONES INTRAOPERATORIA SOBRE EL ESTADO DEL MARGEN PATOLGICO EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR RECURRENCIA LOCAL EN CNCER DE RECTO

ANTECEDENTES:Un componente clave de la preparación preoperatoria para exenteración pélvica es el desarrollo de un plan quirúrgico en un entorno multidisciplinario, basado en el grado de invasión tumoral local en las imágenes preoperatorias. Es posible que se produzcan cambios intraoperatorios en la extensión de la resección o en el plan quirúrgico según los hallazgos intraoperatorios.OBJETIVO:Informar la frecuencia y la extensión de la desviación intraoperatoria de la extensión planificada de la resección durante la exenteración pélvica para el cáncer de recto localmente recurrente, y si esto resultó en una resección más o menos radical.DISEÑO:Estudio observacional retrospectivo.ESCENARIO:Un centro de exenteración pélvica de alto volumen.PACIENTES:Pacientes sometidos a exenteración pélvica por cáncer de recto localmente recurrente entre enero de 2015 y diciembre de 2020.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia y extensión de desviación intraoperatoria de la extensión planeada de resección, tasa de resección R0.RESULTADOS:136 pacientes fueron sometidos a exenteración pélvica por cáncer de recto localmente recurrente, de los cuales 110 (81%) tuvieron márgenes de resección R0. 12 pacientes fueron excluidos por falta de información y 49 pacientes (40%) tuvieron un cambio en el plan quirúrgico. Los cambios operatorios fueron mayores en 30 pacientes (61%), más radicales en 40 pacientes (82%) y con relevancia sobre márgenes en 24 pacientes (49%). En los pacientes en los que hubo un cambio en el plan quirúrgico y se logró la resección R0, la distancia mediana hasta un margen relevante fue de 2.5 mm (rango 0.1-10 mm). De ocho pacientes con un cambio en el plan quirúrgico y resección R1, tres tuvieron relevancia sobre márgenes de los cuales todos se consideraron mayores, dos fueron más radicales y uno fue menos radical.LIMITACIONES:La generalización fuera de las unidades especializadas puede ser limitada.CONCLUSIONES:Los cambios intraoperatorios en la extensión planificada de la resección ocurren comúnmente y con mayor frecuencia resultan en una resección mayor imprevista y más radical. Dichos cambios pueden contribuir a altas tasas de márgenes de resección R0 en unidades especializadas en EP que emplean un enfoque ultrarradical en estos pacientes. (Traducción-Dr. Jorge Silva Velazco ).

Minimally invasive pelvic exenteration for primary or recurrent locally advanced rectal cancer: A glimpse into the future

Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer (LARC) for many years. Their main objectives are to increase the overall survival and quality of life of the patients and to mitigate postoperative complications. Currently, pelvic exenteration (PE) with or without neoadjuvant treatment is a curative treatment when negative resection margins are achieved. The traditional open approach has been favored by many surgeons. However, the technological advancements in minimally invasive surgery have radically changed the surgical options. Recent studies have demonstrated promising results in postoperative complications and oncological outcomes after robotic or laparoscopic PE. A recent retrospective study entitled "Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review" was published in the World Journal of Gastrointestinal Surgery. As we read this article with great interest, we decided to delve into the latest data regarding the benefits and risks of minimally invasive PE for LARC. Currently, the small number of suitable patients, limited surgeon experience, and steep learning curve are hindering the establishment of minimally invasive PE.

Outcomes Following Treatment of Pelvic Exenteration for Rectal Cancer in a Tertiary Care Center

Pelvic exenteration is potentially curative for operable locally advanced primary and locally recurrent rectal cancers. R0 resection is associated with higher survival. This procedure is associated with low mortality rates but high postoperative morbidity proportional to the extent of resection. This study was done to find out the survival outcome and morbidity associated with this procedure and to determine prognostic factors associated with postoperative outcomes. Seventy-three patients with rectal cancer underwent pelvic exenteration between January 2009 and December 2020. Sixty-six patients had locally advanced rectal cancer and 7 patients had recurrent cancer. All patients with primary tumors were evaluated with MRI pelvis and CT scan of the chest and abdomen while patients with recurrence were evaluated with a PET scan. The median follow-up duration was 39 months. The majority of patients were in the age group 40-69 years. Thirty patients were males and 43 were females. The 30-day postoperative major morbidity was reported in 28 patients (38.4%). The most common morbidity was wound dehiscence. The mean overall survival (OS) was 110.6 months (95% CI, 97.5-123.7) and mean disease free survival (DFS) was 85 months (95% CI, 71.0-100.4). R0 resection was associated with favorable overall survival. Tailored exenterations were associated with low morbidity. En bloc partial sacrectomy helped achieve R0 resection in patients who underwent the procedure. Extended resections yielded high R0 resection rates with favorable survival (65 months) but were associated with high morbidity. These procedures shall be best practiced in high-volume institutes of expertise.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01918-w.

Outcomes Following Pelvic Exenteration for Locally Recurrent Rectal Cancer With and Without En Bloc Sacrectomy

BACKGROUND

Extended radical resection is often the only chance of cure for locally recurrent rectal cancer. Recurrence in the posterior compartment often necessitates en bloc sacrectomy as part of pelvic exenteration to obtain clear resection margins and provide survival benefit.

OBJECTIVE

To compare oncological outcomes, morbidity, and quality-of-life outcomes following pelvic exenteration with and without en bloc sacrectomy for recurrent rectal cancer.

DESIGN

Comparative cohort study with retrospective analysis of prospectively collected data.

SETTING

This study was conducted at a high-volume pelvic exenteration center.

PATIENTS

Patients who underwent pelvic exenteration for locally recurrent rectal cancer between 1994 and 2022.

MAIN OUTCOME MEASURES

Overall survival, postoperative morbidity, R0 resection margin, and quality-of-life outcomes.

RESULTS

Of 965 patients, 305 (31.6%) underwent pelvic exenteration for locally recurrent rectal cancer. Among these patients, 64.3% were men and the median age was 62 years (range, 29-86). One hundred eighty-five patients (60.7%) underwent en bloc sacrectomy, 65 (35.1%) underwent high transection, and 119 (64.3%) had sacrectomy below S2. R0 resection was achieved in 80% of patients with sacrectomy and 72.5% of patients without sacrectomy. Sacrectomy patients experienced more postoperative complications without increased mortality. The median overall survival was 52 months; median survival was 47 months with sacrectomy and 73 months without ( p  = 0.059). Quality-of-life scores were not significantly different across physical component ( p  = 0.346), mental component ( p  = 0.787), or Functional Assessment of Cancer Therapy-Colorectal ( p  = 0.679) scores at 24-month follow-up.

LIMITATIONS

The generalizability of these findings may be limited outside of subspecialist exenteration units. Selection bias exists in a retrospective analysis.

CONCLUSIONS

Patients undergoing pelvic exenteration with and without en bloc sacrectomy for locally recurrent rectal cancer experience similar rates of R0 resection, survival, and quality-of-life outcomes. As R0 remains the most important predictor of survival, the requirement of sacral resection should prompt referral to a subspecialist center that performs sacrectomy routinely. See Video Abstract .

RESULTADOS DESPUS DE LA EXENTERACIN PLVICA PARA EL CNCER DE RECTO CON RECURRENCIA LOCAL, CON Y SIN SACRECTOMA EN BLOQUE

ANTECEDENTES:La resección radical ampliada es generalmente la única posibilidad de curación para el cáncer de recto con recurrencia local. La recurrencia en el compartimento posterior generalmente requiere sacrectomía en bloque como parte de la exenteración pélvica para obtener márgenes de resección claros y proporcionar un beneficio de supervivencia.OBJETIVO:Comparar los resultados oncológicos, de morbilidad y de calidad de vida después de la exenteración pélvica con y sin sacrectomía en bloque para el cáncer de recto recurrente.DISEÑO:Estudio de cohorte comparativo con análisis retrospectivo de datos recopilados prospectivamente.AMBIENTE AJUSTE:Estudio realizado en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos sometidos a exenteración pélvica por cáncer de recto con recurrencia local entre 1994 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia general, morbilidad posoperatoria, margen de resección R0 y resultados de calidad de vida.RESULTADOS:305 (31,6%) de 965 pacientes se sometieron a exenteración pélvica por cáncer de recto con recurrencia local. El 64,3% de los pacientes eran hombres con una mediana de edad de 62 años (rango 29-86). 185 pacientes (60,7%) fueron sometidos a sacrectomía en bloque, 65 (35,1%) fueron sometidos a transección alta, 119 (64,3%) tuvieron sacrectomía por debajo de S2. La resección R0 se logró en el 80% de los pacientes con sacrectomía y en el 72,5% sin ella. Los pacientes de sacrectomía experimentaron más complicaciones postoperatorias sin aumento de la mortalidad. La mediana de supervivencia global fue de 52 meses, 47 meses con sacrectomía y 73 meses sin sacrectomía ( p = 0,059). Las puntuaciones de calidad de vida no fueron significativamente diferentes entre las puntuaciones del componente físico ( p = 0,346), componente mental ( p = 0,787) o la evaluación funcional de la terapia contra el cáncer - colorrectal ( p = 0,679) a los 24 meses de seguimiento.LIMITACIONES:La generalización de estos hallazgos puede estar limitada fuera de las unidades de exenteración de subespecialistas. Existe un sesgo de selección en un análisis retrospectivo.CONCLUSIONES:Los pacientes sometidos a exenteración pélvica con y sin sacrectomía en bloque por cáncer de recto con recurrencia local experimentan tasas similares de resección R0, supervivencia y resultados de calidad de vida. Como R0 sigue siendo el predictor más importante de supervivencia, la necesidad de resección sacra debe provocar la derivación a un centro subespecialista que realice sacrectomía de forma rutinaria. (Traducción-Dr. Fidel Ruiz Healy ).

Evaluating postoperative hernia incidence and risk factors following pelvic exenteration

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre.

METHOD

A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination.

RESULTS

A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative.

CONCLUSION

This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts

BACKGROUND

In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time.

METHODS

Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC.

RESULTS

Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013).

CONCLUSION

Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.

The PelvEx Collaborative. Contemporary results from the PelvEx collaborative: improvements in surgical outcomes for locally advanced and recurrent rectal cancer

AIM

The PelvEx Collaborative collates global data on outcomes following exenterative surgery for locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study is to report contemporary data from within the collaborative and benchmark it against previous PelvEx publications.

METHOD

Anonymized data from 45 units that performed pelvic exenteration for LARC or LRRC between 2017 and 2021 were reviewed. The primary endpoints were surgical outcomes, including resection margin status, radicality of surgery, rates of reconstruction and associated morbidity and/or mortality.

RESULTS

Of 2186 patients who underwent an exenteration for either LARC or LRRC, 1386 (63.4%) had LARC and 800 (36.6%) had LRRC. The proportion of males to females was 1232:954. Median age was 62 years (interquartile range 52-71 years) compared with a median age of 63 in both historical LARC and LRRC cohorts. Compared with the original reported PelvEx data (2004-2014), there has been an increase in negative margin (R0) rates from 79.8% to 84.8% and from 55.4% to 71.7% in the LARC and LRRC cohorts, respectively. Bone resection and flap reconstruction rates have increased accordingly in both cohorts (8.2%-19.6% and 22.6%-32% for LARC and 20.3%-41.9% and 17.4%-32.1% in LRRC, respectively). Despite this, major morbidity has not increased.

CONCLUSION

In the modern era, patients undergoing pelvic exenteration for advanced rectal cancer are undergoing more radical surgery and are more likely to achieve a negative resection margin (R0) with no increase in major morbidity.

Urological outcomes following pelvic exenteration for non-urological malignancies

Background

Pelvic exenteration (PE) is a major surgical procedure used as a salvage therapy for patients with locally advanced or recurrent pelvic malignancies. Urinary reconstruction is a major part of PE and is often associated with high rates of post-operative complications. In the current study we evaluate the short and long-term urological outcomes following PE for Colo-Rectal (CR) and gyneco-oncological (GO) malignancies.

Methods

Study included 22 patients who underwent PE for recurrent or locally advanced CR and GO malignancies in our institution between the years 2010-2018. The endpoint was post-operative freedom from urological complications.

Results

Of 22 patients included, 13 (59 %) and 9 (41 %) underwent PE for CR and GO malignancies respectively. The mean age of the patients was 54 years. The median follow-up was 19 months. Seven (78 %) patients with GO malignancy and 11 (85 %) with CR malignancy underwent PE for local recurrence. Hydronephrosis prior to surgery existed in 8 (36.3 %) patients, of which, 5 patients required kidney drainage via nephrostomy tube. Two patients underwent posterior pelvic exenteration (PPE) with bladder preservation whereas the remaining 20 underwent cystectomy with urinary diversion by ileal conduit. Hydronephrosis post PE developed in 13 patients (59 %). eight (36 %) patients needed kidney drainage by nephrostomy tubes post PE, of these, 6 (75 %) had disease recurrence. The 2 years freedom from kidney drainage was 68 %, however the median time for kidney drainage was 0.5 months. The median overall survival was 12.5 months.

Conclusion

The rate of urological complications following PE is relatively high and associated with disease recurrence.

Comparison of urological outcomes and quality of life after pelvic exenteration: partial vs radical cystectomy

OBJECTIVE

To compare perioperative morbidity, functional and quality-of-life (QoL) outcomes in patients with partial cystectomy vs radical cystectomy as part of pelvic exenteration.

PATIENTS AND METHODS

Retrospective analysis of a prospectively maintained database of pelvic exenteration patients (1998-2021) was conducted in a single centre. Study outcomes included postoperative complications, quality-of-life, functional and stoma-related outcomes. The 36-item Short-Form Health Survey Physical and Mental Health Components, Functional Assessment of Cancer Therapy-Colorectal questionnaires and Distress Thermometer were available pre- and postoperatively. QoL outcomes were compared at the various time points. Stoma embarrassment and care scores were compared between patients with a colostomy, urostomy, and both.

RESULTS

Urological complications were similar between both groups, but patients with partial cystectomy experienced less wound-related complications. Overall, 34/81 (42%) partial cystectomy patients reported one or more long-term voiding complication (i.e., incontinence [17 patients], frequency [six], retention [three], high post-voiding residuals [10], permanent suprapubic catheter/indwelling catheter [14], recurrent urinary tract infection [nine], percutaneous nephrostomy [three], progression to urostomy [three]). The QoL improved following surgery in both the partial and radical cystectomy groups, differences between cohorts were not significant. Patients with two stomas reported higher embarrassment scores than patients with one stoma, although this did not result in more difficulties in stoma care.

CONCLUSIONS

Partial cystectomy patients have fewer postoperative wound-related complications than radical cystectomy patients, but often experience long-term voiding issues. The QoL outcomes are similar for both cohorts, with significant improvement following surgery.

Pelvic exenterations combined with cytoreductions for T4 rectal cancers with peritoneal metastasis: a safety analysis

BACKGROUND

Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure.

METHODS

Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed.

RESULTS

Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively.

CONCLUSION

Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.

Trajectories of Quality of Life After Pelvic Exenteration: A Latent Class Growth Analysis

BACKGROUND

Information on the course of quality of life after surgery for advanced cancers within the pelvis is important to guide patient decision-making; however, the current evidence is limited.

OBJECTIVE

To identify quality-of-life trajectory classes and their predictors after pelvic exenteration.

DESIGN

Prospective cohort study.

SETTINGS

Highly specialized quaternary pelvic exenteration referral center.

PATIENTS

Patients undergoing pelvic exenteration due to advanced/recurrent cancers within the pelvis between July 2008 and July 2022.

MAIN OUTCOME MEASURES

Quality-of-life data included the 36-item Short-Form Survey (physical and mental component scores) and the Functional Assessment of Cancer Therapy-Colorectal instruments, which were collected at 11 distinct points from baseline to 5 years postoperatively. Predictors included patient characteristics and surgical outcomes. Latent class analysis was used to identify the likelihood of a better quality-of-life class, and logistic regression models were used to identify predictors of the identified classes.

RESULTS

The study included 565 participants. Two distinct quality-of-life trajectory classes were identified for the Physical Component Score (class 1: high stable and class 2: high decreasing). Three distinct classes were identified for the Mental Component Score (class 1: high increasing, class 2: moderate stable, and class 3: moderate decreasing) and for Functional Assessment of Cancer Therapy-Colorectal total score (class 1: high increasing, class 2: high decreasing, and class 3: low decreasing). Across the 3 quality-of-life domains, overall survival probabilities were also higher in class 1 ( p < 0.0001). Age, repeat exenteration, neoadjuvant therapy, surgical margin, length of operation, and hospital stay were significant predictors of quality-of-life classes.

LIMITATIONS

This study was conducted at a single highly specialized quaternary pelvic exenteration referral center, and findings may not apply to other centers.

CONCLUSIONS

This study demonstrates that quality of life after pelvic exenteration diverges into distinct trajectories, with most patients reporting an optimal course. See Video Abstract .

TRAYECTORIAS EN LA CALIDAD DE VIDA DESPUS DE EXENTERACIN PLVICA ANLISIS DE CRECIMIENTO DE CLASES LATENTES

ANTECEDENTES:La información sobre la evolución en la calidad de vida después de cirugía en cánceres avanzados situados en la pelvis es importante para guiar la toma de decisiones sobre el paciente; sin embargo, la evidencia actual es muy limitada.OBJETIVO:Identificar las clases de trayectorias en la calidad de vida y sus factores pronóstico después de la exenteración pélvica.DISEÑO:Estudio de cohortes prospectivo.AJUSTES:Centro de referencia altamente especializado en la exenteración pélvica cuaternaria.PACIENTES:Todos aquellos sometidos a exenteración pélvica por cáncer avanzados/recurrentes situados en la pelvis entre Julio de 2008 y Julio de 2022.PRINCIPALES MEDIDAS DE RESULTADO:Los datos sobre la calidad de vida incluyeron el Cuestionario de Salud SF-36 (puntuaciones de componentes físicos y mentales) y la evaluación funcional entre la terapia del cáncer/-herramientas colorrectales, recopilados en 11 puntos distintos desde el diagnóstico hasta los 5 años después de la operación.Los predictores incluyeron las características de los pacientes y los resultados quirúrgicos. Se utilizó el análisis de clases latentes para identificar la probabilidad de una mejor calidad de vida y se utilizaron modelos de regresión logística para identificar predictores de las clases identificadas.RESULTADOS:El estudio incluyó a 565 participantes. Se identificaron dos clases distintas de trayectorias de calidad de vida para la puntuación del componente físico (clase 1: alta estable y clase 2: alta decreciente), se identificaron tres clases distintas para la puntuación del componente mental (clase 1: alta creciente; clase 2: moderadamente estable; y clase 3: moderada disminución) y para la evaluación funcional de la terapia contra el cáncer-puntuación total colorrectal (clase 1: aumento alto; clase 2: disminución alta; y clase 3: disminución baja). En los tres dominios de calidad de vida, las probabilidades de supervivencia general también fueron mayores en las clases 1 (p <0,0001). La edad, las exenteraciones pélvicas repetidas, la terapia neoadyuvante, el margen quirúrgico, la duración de la operación y la estadía hospitalaria fueron predictores significativos en las clases de calidad de vida.LIMITACIONES:El presente estudio fué realizado en un único centro de referencia altamente especializado en exenteración pélvica cuaternaria y es posible que los hallazgos no se apliquen a otros centros.CONCLUSIONES:Demostramos con nuestro estudio que la calidad de vida después de la exenteración pélvica diverge en trayectorias distintas, y que la mayoría de los pacientes nos reportaron de una évolución óptima. (Traducción-Dr. Xavier Delgadillo ).

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review

BACKGROUND

Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR.

AIM

To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR.

METHODS

This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05.

RESULTS

A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR.

CONCLUSION

MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations

Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.

Optimization of treatment strategies based on preoperative imaging features and local recurrence areas for locally advanced lower rectal cancer after lateral pelvic lymph node dissection

Purpose

Local recurrence (LR) is the main cause of treatment failure in locally advanced lower rectal cancer (LALRC). This study evaluated the preoperative risk factors for LR in patients with LALRC to improve the therapeutic strategies.

Patients and Methods

LALRC patients who underwent total mesorectal excision (TME) with lateral pelvic lymph node (LPN) dissection (LPND) from January 2012 to December 2019 were reviewed. The log-rank test was used to assess local recurrence-free survival (LRFS), and multivariate Cox regression was used to identify the prognostic risk factors for LRFS. Follow-up imaging data were used to classify LR according to the location.

Results

Overall, 376 patients were enrolled, and 8.8% (n=33) of these patients developed LR after surgery. Multivariate analysis identified positive clinical circumferential resection margin (cCRM) as an independent prognostic factor for LRFS (HR: 4.94; 95% CI, 1.75-13.94; P=0.003). The most common sites for LR were the pelvic plexus and internal iliac area (PIA) (54.5%), followed by the central pelvic area (CPA) (39.4%) and obturator area (OA) (6.1%). Following a subgroup analysis, LR in the OA was not associated with positive cCRM. Patients treated with upfront surgery (n=35, 14.1%) had a lower cCRM positive rate when compared with patients treated with neoadjuvant chemoradiotherapy (nCRT) (n=12, 23.5%). However, the LR rate in the nCRT group was still lower (n=28, 36.4%) than that in the upfront surgery group (n=35, 14.%). Among patients with positive cCRM, the LR rate in patients with nCRT remained low (n=3, 10.7%).

Conclusion

Positive cCRM is an independent risk factor for LR after TME plus LPND in LALRC patients. LPND is effective and adequate for local control within the OA regardless of cCRM status. However, for LALRC patients with positive cCRM, nCRT should be considered before LPND to further reduce LR in the PIA and CPA.

Variation in outcome measurement and reporting in studies of pelvic exenteration for locally advanced and recurrent rectal cancer: a systematic review

AIM

There is increasing research interest in pelvic exenteration for locally advanced and recurrent rectal cancer. Heterogeneity in outcome reporting can prevent meaningful interpretation and valid synthesis of pooled data and meta-analyses. The aim of this study was to assess homogeneity in outcome measures in the current pelvic exenteration literature.

METHOD

MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases were searched from 1990 to 25 April 2023 to identify studies reporting outcomes of pelvic exenteration for locally advanced or recurrent rectal cancer. All reported outcomes were extracted, merged with those of similar meaning and assigned a domain.

RESULTS

Of 4137 abstracts screened, 156 studies met the inclusion criteria. A total of 2765 outcomes were reported, of which 17% were accompanied by a definition. There were 1157 unique outcomes, merged into 84 standardized outcomes and assigned one of seven domains. The most reported domains were complications (147 studies, 94%), survival (127, 81%) and surgical outcomes (123, 79%). Resection margins were reported in 122 studies (78%): the definition of a clear resection margin was not provided in 45 studies (37%), it was unclear in 11 studies (9%) and not specified beyond microscopically 'clear' or 'negative' in 31 (28%). Measurements of 2, 1, 0.5 mm and any healthy tissue were all used to define R0 margins.

CONCLUSION

There is significant heterogeneity in outcome measurement and reporting in the current pelvic exenteration literature, raising concerns about the validity of comparative or collaborative studies between centres and meta-analyses. Coordinated international collaboration is required to define core outcome sets and benchmarks.

Is an uncomplicated postoperative recovery following total pelvic exenteration a more important prognostic factor than achieving R0 in the first 2 years?

AIM

Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously.

METHOD

This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS.

RESULTS

A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years.

CONCLUSIONS

In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.

Five-year outcomes in carbon-ion radiotherapy for postoperative pelvic recurrence of rectal cancer: A prospective clinical trial (GUNMA 0801)

Introduction

Carbon-ion radiotherapy (C-ion RT) is associated with favorable clinical outcomes for the pelvic recurrence of rectal cancer. However, few long-term follow-up studies after C-ion RT have been conducted. Hence, we performed an updated analysis of a prospective clinical trial of C-ion RT for the postoperative pelvic recurrence of rectal cancer.

Materials and methods

The study included 28 patients. Inclusion criteria were patients with confirmed pelvic recurrence of rectal cancer without distant metastasis; those who underwent curative resection of their primary disease and regional lymph nodes without gross or microscopic residual disease; and those who had radiographically measurable tumors. The total dose of C-ion RT for all the patients was 73.6 Gy (relative biological effectiveness) administered in 16 fractions.

Results

The median follow-up duration in all patients and those who survived were 51.2 and 69.2 months, respectively. The follow-up rate at the time of analysis was 96.4%. The 5-year overall survival and local control rates were 50% and 83%, respectively. Four patients had local recurrence, and 17 died of rectal cancer. Regarding late toxicities, two patients developed grade 3 pelvic infection, and nine developed grade 2 peripheral neuropathy.

Conclusion

Our updated analysis of a prospective clinical trial of C-ion RT for postoperative pelvic recurrence of rectal cancer confirmed its long-term efficacy and safety. These results suggest that C-ion RT may be a safe and effective treatment option for the postoperative pelvic recurrence of rectal cancer.

Tata Memorial Centre Evidence Based Management of Colorectal cancer

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.

The double-barrel wet colostomy: An alternative for urinary diversion after pelvic exenteration

AIM

Pelvic exenteration is a radical procedure used to treat locally advanced and/or recurrent pelvic malignancies. Different reconstruction options exist, the most popular being the end colostomy with ileal conduit. The double barrel wet colostomy (DBWC) offers concomitant fecal and urinary diversion through a single stoma, but is infrequently utilized. We aim to review the evidence base of the postoperative complications, long-term oncologic risks and quality of life following creation of a double barrel wet colostomy.

METHODS

A narrative review of the literature was performed evaluating the DBWC. Patient demographics, perioperative complications, operative variables, long terms oncologic outcomes and quality of life data were extracted. Descriptive statistics were used to define the data.

RESULTS

Fourteen articles with a total of 300 patients undergoing DBWC following pelvic exenteration were selected. 41% of malignancies were gastrointestinal in origin while 41.7% were gynecologic and 5.3% genitourinary. 42% of patients experienced at least one complication within in 40 days of surgery, the most common being wound infection (8.7%) and urinary leak (8.3%). There was no evidence of malignancy within the DBWC during long-term surveillance. Quality of life following DBWC is comparable to other reconstructive methods.

CONCLUSION

The DBWC is a well described reconstructive method for urinary and fecal diversion utilizing a single stoma following pelvic exenteration. The short- and long-term outcomes following DBWC are comparable to other reconstructive methods and the quality of life with a DBWC is acceptable. DBWC should remain a readily available option for reconstruction following pelvic exenteration.

Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques

OBJECTIVE

To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes.

BACKGROUND

In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes.

METHODS

A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed.

RESULTS

A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS.

CONCLUSIONS

Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.

TORCH-R trial protocol: hypofractionated radiotherapy combined with chemotherapy and toripalimab for locally recurrent rectal cancer: a prospective, single-arm, two-cohort, phase II trial

For patients with locally recurrent rectal cancer (LRRC), the response rate to chemoradiotherapy is 40%-50%. Additionally, only approximately 40%-50% of patients with recurrent rectal cancer are able to undergo R0 resection. Recent studies in locally advanced rectal cancer (LARC) have shown promising synergistic effects when combining immunotherapy (PD-1/PD-L1 antibodies) with neoadjuvant chemoradiotherapy (nCRT). Therefore, incorporating immunotherapy into the treatment regimen for LRRC patients has the potential to further improve response rates and prognosis. To investigate this, the TORCH-R trial was conducted. This prospective, single-arm, two-cohort, phase II trial focuses on the use of hypofractionated radiotherapy, chemotherapy, and immunotherapy in LRRC patients without or with oligometastases. The trial will include two cohorts: cohort A consists of rectal cancer patients who are treatment-naive for local recurrence, and cohort B includes patients with progressive disease after first-line chemotherapy. Cohort A and cohort B patients will receive 25-40 Gy/5 Fx irradiation or 15-30 Gy/5 Fx reirradiation for pelvic recurrence, respectively. Subsequently, they will undergo 18 weeks of chemotherapy, toripalimab, and stereotactic ablative radiotherapy (SABR) for all metastatic lesions between chemoimmunotherapy cycles. Decisions regarding follow-up of complete response (CR), radical surgery, sustained treatment of non-resection, or exiting the trial are made by a multidisciplinary team (MDT). The primary endpoint of this study is the local objective response rate (ORR). The secondary endpoints include the extrapelvic response rate, duration of response, local recurrence R0 resection rate, progression-free survival (PFS), overall survival (OS), and safety and tolerability. Notably, this trial represents the first clinical exploration of inducing hypofractionated radiotherapy, chemotherapy, and immunotherapy in LRRC patients.

Clinical trial registration

https://clinicaltrials.gov/study/NCT05628038, identifier NCT05628038.

Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence

Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.

Pathological determinants of outcome following resection of locally advanced or locally recurrent rectal cancer

INTRODUCTION

Pathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance.

MATERIALS AND METHODS

A retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS).

RESULTS

388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49-67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC.

CONCLUSIONS

A positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.

Redo Pelvic Surgery and Combined Metastectomy for Locally Recurrent Rectal Cancer with Known Oligometastatic Disease: A Multicentre Review

INTRODUCTION

Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. 'Selective' patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates.

METHODS

A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes.

RESULTS

Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/- 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/- 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5-17.5 months) and 25.9 months (IQR 6.2-39.7 months), respectively.

CONCLUSIONS

Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.

Locally recurrent rectal cancer and distant metastases: is there still a chance ofcure?

INTRODUCTION

Patients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment.

METHODS

Consecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases.

RESULTS

A total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15-2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039).

CONCLUSION

LRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.

Development of a risk prediction tool for patients with locally advanced and recurrent rectal cancer undergoing pelvic exenteration: protocol for a mixed-methods study

INTRODUCTION

Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given the potential morbidity, whether or not PE should be recommended for an individual patient presents a major decisional conflict. This study aims to identify the outcomes of PE for which there is consensus among patients, carers and clinicians regarding their importance in guiding treatment decision-making, and to develop a risk prediction tool which predicts these outcomes.

METHODS AND ANALYSIS

This study will be conducted at a specialist PE centre, and employ a mixed-methods study design, divided into three distinct phases. In phase 1, outcomes of PE will be identified through a comprehensive systematic review of the literature (phase 1a), followed by exploration of the experiences of individuals who have undergone PE for LARRC and their carers (phase 1b, target sample size 10-20 patients and 5-10 carers). In phase 2, a survey of patients, their carers and clinicians will be conducted using Delphi methodology to explore consensus around the outcomes of highest priority and the level of influence each outcome should have on treatment decision-making. In phase 3 a, risk prediction tool will be developed using data from a single PE referral centre (estimated sample size 500 patients) to predict priority outcomes using multivariate modelling, and externally validated using data from an international PE collaboration.

ETHICS AND DISSEMINATION

Ethical approval has been granted for phases 1 and 2 (X22-0422 and 2022/ETH02659) and for maintenance of the database used in phase 3 (X13-0283 and HREC/13/RPAH/504). Informed consent will be obtained from participants in phases 1b and 2; a waiver of consent for secondary use of data in phase 3 will be sought. Study results will be submitted for publication in international and/or national peer reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42022351909.

Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis

INTRODUCTION

Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial.

METHODS

A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted.

RESULTS

11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality.

CONCLUSION

MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.