Seven cases of pelvic exenteration combined with sacral resection for locally recurrent rectal cancer

[Sacral resection in surgical treatment of locally advanced primary and recurrent rectal and anal cancer: short-term outcomes]

AIM

To assess safety of rectum removal with distal sacral resection.

MATERIAL AND METHODS

The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures.

RESULTS AND DISCUSSION

Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р<0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases.

CONCLUSION

Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.

Extended sacropelvic resection for locally recurrent rectal cancer: can it be done safely and with good oncologic outcomes?

BACKGROUND

A multimodality approach to patients with locally recurrent rectal cancer that includes surgery is associated with a significant survival advantage when tumor-free margins are achieved. Patients with advanced tumors will require extended sacropelvic resection to optimize oncologic outcomes.

OBJECTIVE

The aim of this study was to assess the safety, feasibility, and oncologic outcomes of extended sacropelvic resection for locally recurrent rectal cancer at our institution.

DESIGN

A retrospective review identified 406 patients who had surgery for locally recurrent rectal cancer between 1997 and 2007. From this group, all patients who underwent a curative-intent sacropelvic resection were analyzed.

SETTINGS

This investigation was conducted at an academic tertiary referral center.

PATIENTS

Thirty patients (24 male) were identified. Median age was 59 years (range, 25-84). Operations were performed for a first local recurrence (n = 24), a second recurrence (n = 5) and for a third recurrence (n = 1).

INTERVENTIONS

Twenty-six patients underwent neoadjuvant radiation, and 20 received intraoperative radiation therapy. All patients underwent extended sacropelvic resection.

MAIN OUTCOME MEASURES

The primary outcomes measured were early (<30 days) and late (>30 days) surgical complications. Overall and disease-free survivals were estimated by using the Kaplan-Meier technique.

RESULTS

Margin-negative resection was achieved in 93%. The most proximal level of spinal transection was the fourth lumbar space, and 4 patients underwent lower extremity amputation. There was no mortality, and early morbidity was seen in 76%. Median follow-up was 2.7 years (range, 2 months to 10.8 years). Overall survival at 2 and 5 years was 86% and 46%. Disease-free survival at 2 and 5 years was 79% and 43%.

LIMITATIONS

This study was limited by its retrospective nature and the limited number of patients.

CONCLUSIONS

We found extended sacropelvic resection for locally recurrent rectal cancer to be feasible and safe with overall and disease-free survival rates in comparison with survival rates seen in patients undergoing nonsacropelvic resections for locally recurrent rectal cancer.

Prevention of severe pelvic abscess formation following extended radical surgery for locally recurrent rectal cancer

BACKGROUND

For treatment of locally recurrent rectal cancer (LRRC), extended radical surgery is sometimes required to obtain a negative margin. Such surgery is often associated with severe postoperative pelvic abscess (PA) formation. The aim of this study was to determine the effects of reconstructive surgery using a large rectus abdominis myocutaneous (RAM) flap and anal preservation surgery on the incidence of severe PA.

METHOD

Between February 1998 and June 2008, 44 patients underwent extended surgery for LRRC. Patients were divided into the pre-2004 group (n = 15) and the post-2004 group (n = 29). To reduce the risk of infections, we modified the surgical approach after 2004 to include a larger volume of RAM flap (modified RAM flap) and implemented anal preservation surgery.

RESULTS

The overall incidence of severe PA was significantly lower in the post-2004 group [6 of 29 (21%)] than the pre-2004 group [9 of 15 (60%), P = 0.017]. The incidence of severe PA was lower in the anal preservation group [1 of 12 (8.3%)] compared with those who did not undergo such surgery [14 of 32 (44%), P = 0.035]. Modified RAM flap reduced the incidence of severe PA, albeit insignificantly (pre-2004 group: 57%, post-2004 group: 23%). All three patients who underwent anal preservation and modified RAM flap reconstruction did not develop severe PA. Multiple logistic analysis identified no anal preservation (Odds ratio [OR] = 10.6) and performing of sacrectomy (OR = 20.0) as risk factors for severe PA.

CONCLUSION

Anal preservation surgery is an effective measure against the development of severe PA after radical resection of LRRC.

Preliminary results of phase I trial of oral uracil/tegafur (UFT), leucovorin plus irinotecan and radiation therapy for patients with locally recurrent rectal cancer

BACKGROUND

Surgical attempts for locally recurrent rectal cancer often fail due to local re-recurrence and distant metastasis. Preoperative chemoradiation may enhance better local control and survival. The aim of this study was to assess the safety of oral uracil and tegafur (UFT) plus leucovorin (LV), and irinotecan combined with radiation and determine the maximum-tolerated dose (MTD) and dose limiting toxicity (DLT) of the triple drug regimen.

PATIENTS AND METHODS

Patients with locally recurrent rectal cancer received escalating doses of irinotecan on days 1, 8, 15, and 22 (starting at 30 mg/m2, with 10 mg increments between consecutive cohorts) and fixed doses of UFT (300 mg/m2) plus LV (75 mg/day) on days 3 to 7, 10 to 14, 17 to 21, and 24 to 28. Radiation was given 5 days per week totaling 40 to 50 Gy (2Gy/day).

RESULTS

Six patients were treated at the starting dose, and 2 received the full scheduled chemoradiotherapy. The other 4 patients had grade 3 diarrhea and diarrhea was the DLT. One patient had partial response and he had subsequently radical surgical resection. Median progression free survival for local recurrence was 320 days.

CONCLUSION

Irinotecan plus UFT/LV with concomitant radiotherapy in patients with locally recurrent rectal cancer was not feasible due to diarrhea in this setting. Modification of the treatment is needed.

Results of an aggressive approach to resection of locally recurrent rectal cancer

BACKGROUND

The value of resection for locally recurrent rectal cancer (LRRC) remains controversial. We analyzed outcomes of an aggressive approach to resection of LRRC.

METHODS

We conducted a retrospective chart review of 52 consecutive patients who underwent resection of LRRC from September 1997 through August 2005. Overall and disease-free survival (OS, DFS) curves were constructed by the Kaplan-Meier method, and compared by log-rank analysis. Median follow-up time was 29 months (range 3-72).

RESULTS

Thirty-one patients (60%) were male. Median age was 60 years (range 36-88). Forty-six of the 52 patients were resected with curative intent, while 6 had known distant metastases at the time of resection. All 52 patients underwent grossly complete resection of local disease, and 41 (79%) had microscopically clear resection margins. An en bloc sacrectomy was performed in 28 (54%) patients. Postoperative mortality was nil; significant complications developed in 42% of patients. The complication rate was higher in patients with sacrectomy than without (50 vs. 33%, P = 0.017, Chi square). For the entire cohort of 52 patients, median OS and DFS were 40 and 24 months, respectively. Survival was equivalent in patients with and without sacrectomy. In the 46 patients who had resection with curative intent, 4-year OS was 48%. Median OS in the six patients with distant metastases at the time of resection was 21 months. OS was predicted by the presence of metastases (P = 0.01), and margin status (P < 0.0001). DFS was predicted by margin status (P = 0.0001).

CONCLUSIONS

In this series of patients who underwent resection of LRRC, microscopic margin status was the most significant predictor of OS and DFS. Requirement for en bloc sacrectomy was not associated with inferior survival. Carefully selected patients with distant metastases may benefit from resection of LRRC.

Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns

BACKGROUND

Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns.

METHODS

Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted.

RESULTS

Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8-28]), a local disease-free interval of <12 months (4.2 [1.8-9.8]), and pain radiating to the buttock or further (4.2 [1.6-11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4-40]). Of the patients with recurrence, 56% had failures confined locally or to the lung.

CONCLUSIONS

ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease-free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.

Treatment Strategy for Locally Recurrent Rectal Cancer

Despite radical surgery, up to 33% of patients with rectal cancer will develop locoregional relapse. The management of these patients is particularly challenging. Surgery is the mainstay of treatment for those with a mobile recurrence. However, the majority of patients develop recurrence involving the pelvic wall. In these patients, multimodality therapy including radical surgery and intraoperative radiotherapy have been reported with 5-year survival of up to 31% and local control rates of 50-71%. The most important factor for obtaining long-term local control and survival is R0 resection. Extended surgery such as abdomino-sacral resection has not been popular because of 5-year survival rates of 16-31%, and significant postoperative morbidity. Re-recurrence following surgery occurs locally and in the lung, and remains a significant problem. In surgical treatment for local recurrence, surgeon-related factors are crucial. A staging system using degree of fixation and other prognostic factors should be developed so that appropriate treatment modalities are applied to each case.

Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis

PURPOSE

This study evaluates the effectiveness of total pelvic exenteration with distal sacrectomy for fixed recurrent tumor that developed from primary rectal cancer.

METHODS

We investigated surgical indications, techniques to minimize blood loss and reduce complications, and oncological outcomes in 57 patients who underwent total pelvic exenteration with distal sacrectomy between 1983 and 2001.

RESULTS

Forty-eight patients (84 percent) had negative margins. A comparison between two periods (1983-1992 and 1993-2001) showed that mean blood loss decreased from 4,229 to 2,500 ml (P = 0.002), indicating a favorable learning curve in minimizing blood loss. Two hospital deaths were observed in the earlier period and none in the later period. The most common sacral amputation level was the S3 superior margin, followed by the S4 inferior margin and the S2 inferior margin. The most frequent complication was sacral wound dehiscence in 51 percent, followed by pelvic sepsis in 39 percent. The incidence of pelvic sepsis in the later period was significantly decreased to 23 percent, compared with 72 percent in the earlier period (P = 0.046). Multivariate analysis showed that negative margins and negative carcinoembryonic antigen predicted improved survival. In 48 patients with negative margins, three-year and five-year disease-specific survival rates were 62 percent and 42 percent, respectively.

CONCLUSION

Strict patient selection makes total pelvic exenteration with distal sacrectomy a feasible radical approach for fixed recurrent tumor. Careful performance of this surgical procedure along with the proper steps to decrease blood loss should achieve a favorable learning curve and low rate of surgical complications.

Pain and quality of life after treatment in patients with locally recurrent rectal cancer

PURPOSE

Because survival in patients with locally recurrent rectal cancer (LRRC) is limited, pain control and quality of life (QOL) are important parameters. The purpose of this study was to assess the prevalence of posttreatment pain and QOL of patients with LRRC treated with nonsurgical palliation or resection and identify predictors of poor outcome.

PATIENTS AND METHODS

Posttreatment pain severity and QOL were prospectively assessed in 45 patients with LRRC using the Brief Pain Inventory and Functional Assessment of Cancer Therapy-Colorectal questionnaire.

RESULTS

Fifteen patients received nonsurgical palliation, and 30 patients underwent resection of their pelvic tumors. There was a significant association between higher posttreatment pain scores and worse QOL (P <.001). Patients treated with nonsurgical palliation reported moderate to severe pain beyond the third month of treatment. Resected patients reported comparable levels of pain during the first 3 postoperative years, particularly after bony resections; long-term survivors (beyond 3 years), however, reported minimal pain and good QOL. Female sex, pelvic/sciatic pain at presentation, total pelvic exenteration, and bony resection were associated with higher rates of moderate to severe posttreatment pain (P =.04, P <.001, P =.04, and P =.02, respectively). Pain at presentation was an independent predictor of posttreatment pain (odds ratio, 7.4 [95% confidence interval, 1.8 to 30.3]; P =.006).

CONCLUSION

Patients with LRRC treated with nonsurgical palliation or resection experience significant levels of pain after treatment. Close posttreatment pain monitoring is warranted in patients presenting with pelvic pain, and more aggressive pain management strategies may improve posttreatment QOL.

Abdominosacral resection for primary irresectable and locally recurrent rectal cancer

PURPOSE

The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation.

METHODS

Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection.

RESULTS

Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002).

CONCLUSION

The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

Locally recurrent rectal cancer: role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence

Locally recurrent cancer of the rectum has been under-recognized as a complication, although it affects up to 40% of patients treated with surgery alone. Even in the best centers, rates average 25%. While radiotherapy may reduce recurrence, it is now apparent that total mesorectal excision is the most effective modality, with rates as low as 5%. The dramatic decrease in local recurrence can also be linked to increased survival in prospective studies, an effect more significant than any adjuvant therapy. The options, however, for patients with locally recurrent cancer are limited. Fifteen percent of patients with this complication die without systemic spread. Salvage by surgery offers potential cure. Other than anastomotic recurrences that can be locally resected, the best approach for long-term survival is an extensive surgical procedure requiring en bloc removal of adjacent organs and pelvic structures-so-called composite resection. With careful selection, 30% 5-year survival can be achieved and palliation is considerable, with 50% long-term local control. Intraoperative radiotherapy and brachytherapy, and/or preoperative chemoradiation may provide better results in future. Newer techniques of coloanal anastomosis, improved urinary diversion, and myocutaneous flaps for perineal reconstruction radically reduce the morbidity of these procedures. The approach to recurrent rectal cancer requires a sophisticated multidisciplinary team to obtain optimum results.

Reresection for local recurrence of rectal cancer

Local recurrence is one of the major reasons that rectal cancer surgery is unsuccessful. The aim of this study was to investigate the surgical characteristics of patients undergoing reresection for local recurrence of rectal cancer. A total of nine patients were enrolled in this study, six of whom underwent total pelvic exenteration, one, posterior exenteration, one, abdominoperineal resection with sacral resection, and one, lymph node dissection alone. The mean operative time was 8 h 15 min, and the mean operative blood loss was 2 325 ml. Although major postoperative complications occurred in four patients (44%), there were no postoperative or hospital deaths. Lateral lymph node metastasis was detected in all four patients whose lateral lymph nodes were dissected or extirpated at the reresection. Two patients survived for more than 5 years without rerecurrence, and the cumulative 5-year survival rate was 26%. The para-aortic lymph nodes were the most common site of first rerecurrence. The results of this study indicate that patients who undergo reresection for local recurrence of rectal cancer are at high risk of devel-oping lateral or para-aortic nodal metastasis. Nevertheless, reresection may be a therapeutic option for the local recurrence of rectal cancer.

Pelvic exenteration for carcinoma of the colon and rectum

Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation.

[Total pelvic exenteration and rectal cancer. Apropos of 20 cases]

STUDY AIM

The report of a series of 20 patients with the aim of trying to specify the implications of pelvic exenteration for rectal cancer.

PATIENTS AND METHODS

From 1986 to 1996, 20 total pelvic exenterations were performed for rectal adenocarcinoma. This retrospective study included locally extended carcinomas (n = 10), and recurrences (n = 10) after anterior resection (n = 7), and after abdominoperineal resection (n = 3). The subjects included 13 men and seven women with a mean age of 54 years (34-74 years). Complaints were major and serious: pain (n = 20), rectal syndrome (n = 17), recto-vesical fistula (n = 5) recto-vaginal fistula (n = 5), urinary infection (n = 13), and hematuria (n = 6). Preoperative radiotherapy was performed in 11 patients and preoperative radio chemotherapy in six. The surgical procedure included a total pelvic exenteration with perinectomy in 12 patients, and a total pelvic exenteration with preservation of levator ani and perineum in eight, associated in two cases with a partial resection of the sacrum, and in two other cases with partial hepatectomy for a single liver metastasis. Urinary diversion was a trans ileal ureterostomy in 17 patients and a direct double ureterostomy in three.

RESULTS

The mean duration of surgery was 6 h. The mean preoperative blood loss was 1,200 L. Nine patients received blood transfusion. There was no postoperative mortality but in contrast, the morbidity rate was high with mainly urinary and digestive complications, pelvic sepsis and thromboembolic complications. After pathological examination, tumoral resections were classified R0 in 19 cases, and R1 in one. All tumors were T4 with tumoral invasion of the bladder (n = 15), prostate (n = 6), seminal vesicles (n = 4), ureter (n = 3), vagina (n = 7), urethra (n = 1), and sacrum (n = 1). Lymph node involvement was present in four patients. The 3 and 5 year actuarial survival rate was respectively 47 and 18%. Thirteen patients died of their cancer, nine from metastases, and four from local recurrence with a mean survival of 29 and 32 months respectively. Seven patients were alive at the time of this study, six without actual recurrence.

CONCLUSIONS

In spite of its aggressive aspect, total pelvic exenteration seems justified in rectal carcinoma when extended to the urinary tract, when it causes major functional disorders, when there are no detectable metastases, and when the tumor has no posterior or lateral fixation. Local tumoral evolution can usually be controlled by pelvic exenteration but prolongation of survival is not demonstrated.

Surgical treatment of locally recurrent rectal carcinoma

PURPOSE

This study was performed to analyze the outcomes of patients with local (pelvic) recurrence (following radical surgery for rectal cancer) who subsequently underwent a new operation.

METHODS

Forty-five patients (19 percent of 213 local recurrences) were explored surgically because the disease was deemed to be confined to the pelvis with a limited extension and, therefore, amenable to surgical cure.

RESULTS

Only 21 of the 45 patients who underwent surgical exploration had an oncologically radical operation (R0). In the remaining 24 patients, either a simple exploration or palliation or a nonradical procedure (R1-R2) was performed. In the R0 group, there was a 19 percent five-year survival rate vs. a 0 percent rate in the R1-R2 group (median survival, 4 months). Site of recurrence (anastomosis vs. other sites) was statistically associated with a higher chance of long-term survival for those who underwent an R0 operation.

CONCLUSIONS

The prognosis of locally recurrent rectal cancer is dismal; less than 10 percent of all patients who underwent surgical treatment benefit from reoperation with an overall survival for five years. On the basis of these results, we no longer consider the surgical approach as the primary option for treating locally recurrent rectal cancer.

The need for a multidisciplinary approach in the treatment of advanced colorectal cancer: a critical review from a medical oncologist and surgeon

Over the last 10 years important advances have been made in the treatment of patients with advanced colorectal cancer, particularly with surgery either alone or in combination with radiotherapy. Furthermore, despite early scepticism, several chemotherapy studies have now reported significant clinical benefits with 5-FU-based regimens and promising results have also been reported with newer agents such as raltitrexed and irinotecan. Taken together these advances now enable a significant proportion of patients to undergo treatment which will improve their quality of life, prolong survival and even result in cure in certain cases. Patients with advanced colorectal cancer can only benefit from these important advances, however, if a truly multidisciplinary approach to patient care is adopted which requires integration of the roles of the surgeon, medical oncologist and radiotherapist.

Surgical management of locally recurrent rectal cancer

The surgical management of locally recurrent rectal cancer may involve major procedures and is not for the faint-hearted. Nevertheless, such treatment is preferable to chemotherapy and radiotherapy; the latter will fail over a period of months during which the patient is likely to experience intractable pain. Radical surgery offers good palliation and a better quality of life. Survival is prolonged by such operations which may be curative in up to one-third of patients. Nevertheless, surgeons must be realistic in their assessment of and discussions with patients.

Intraoperative radiation therapy for locally advanced recurrent rectal or rectosigmoid cancer

Recurrent rectal or rectosigmoid cancer is a difficult therapeutic problem. A treatment program of external beam irradiation, surgery, and intraoperative irradiation has been used for 41 patients. The 5-year actuarial local control and disease-free survival of all 41 patients was 30% and 16%, respectively. Subset analysis demonstrated differences in outcome by extent of surgical resection. The 5-year actuarial local control and disease-free survival of 27 patients undergoing complete resection was 47% and 21%, respectively. By contrast, the outcome of 14 patients undergoing partial resection was poor, with a 5-year actuarial local control and survival of 21% and 7%, respectively. Late complications included soft tissue or peripheral nerve injury, with many of these resolving within 4-18 months. Local control and disease-free survival rates are favorable in comparison with the results achieved by aggressive surgery. Patients who achieve a gross total resection at intraoperative irradiation have a markedly better prognosis than that of patients with residual gross disease.

Pelvic resection of recurrent rectal cancer

OBJECTIVE

The authors describe their experience with pelvic resection of recurrent rectal cancer with emphasis on patient selection for curative intent based on known tumor risk factors.

SUMMARY BACKGROUND DATA

Pelvic recurrence is a formidable problem in 30% of patients who have undergone a curative resection of primary rectal cancer. Although radiation can reduce the development of local recurrence and can provide palliation to many patients with localized disease, it is not curative. The authors and others have used the technique of abdominal sacral resection (ABSR) with or without pelvic exenteration to resect pelvic recurrence and its musculoskeletal extensions in selected patients with satisfactory long-term survival.

METHODS

The technique of ABSR with or without pelvic exenteration or resection of pelvic viscera, which the authors have described previously, was used in 53 patients with recurrent rectal cancer--47 patients for curative intent and 6 for palliation. Previous surgeries were abdominal perineal resections (APRs) in 26 patients, anterior resections in 19 patients, and other procedures in 2 patients; original primary Dukes' stage was B in 52% and C in 48%. Almost all patients had been irradiated previously, generally in the 4000 to 5900 cGy range. Preoperative carcinoembryonic antigen (CEA) levels (before ABSR) were elevated (> 5 ng/mL) in 54%.

RESULTS

Postoperative morbidity was encountered in most patients. Mortality was 8.5% in the curative group. Long-term survival for 4 years was achieved in 14 of 43 patients (33%), and 10 patients were alive with an acceptable quality of life after 5 years. Patients who had previous anterior resections or whose preoperative CEA levels were less than 10 ng/mL had a survival rate of approximately 45%, whereas patients with previous APRs and preoperative CEA levels greater than 10 ng/mL had a survival rate of only 15% to 18%. Patients with bone marrow invasion, positive margins, or pelvic node metastases had a median survival of only 10 months.

CONCLUSIONS

Pelvic recurrence of rectal cancer can be resected safely with expectation of long-term survival of 33%. Patient selection based on known risk factors can identify patients most likely to benefit from resection and eliminate those who should be treated for palliation only.

Pelvic exenteration for recurrent colorectal carcinoma: a review

Pelvic recurrence following curative resection for colorectal carcinoma continues to pose a challenge to the oncologist despite current multimodality therapy. Pelvic exenteration with or without sacral resection may provide long-term disease-free survival and a chance of cure for a small subset of patients in whom the recurrent disease is confined to the pelvis and can be resected with "clear" margins. For others with residual disease, exenteration may offer good palliation for the intractable symptoms, but no survival advantage. The clinical decision to perform exenteration with palliative intent must be individualized. This is generally not advised because of the short life expectancy in the face of prolonged convalescence. This technically demanding procedure is associated with significant morbidity, especially in patients with prior pelvic radiation. Current advances in urinary diversion and methods of pelvic reconstruction may significantly reduce these problems. The surgeon's experience and careful patient selection remain the most important determinants of success with this operation.

Pelvic exenteration for recurrent and extensive primary colorectal adenocarcinoma

BACKGROUND

Local failure after curative surgery for colorectal adenocarcinoma remains a major source of morbidity and mortality. This retrospective analysis reviews the authors' experience with pelvic exenteration in the setting of recurrent and locally advanced colorectal cancer.

METHODS

Between 1979 and 1986, 50 pelvic exenterations were performed for recurrent (43) and primary (7) colorectal pelvic malignancies. Of these, 30 patients were operated on with curative intent, whereas 20 underwent operation for palliation of intractable pain, sepsis, fistula, bleeding, or bowel obstruction. Twenty-six patients had received radiation to 4000 cGy or more. Of the recurrent tumors, the median time from primary treatment to exenteration was 39.7 months.

RESULTS

Postoperative mortality included 7 in-hospital deaths (14%): 5 of 20 in the palliative group and 2 of 30 in the curative group. Complications were common (a total of 71 occurrences), but there has been a significant decrease with experience. The median survival was 19 months for the curative group and 10 months for the palliative group, excluding perioperative mortality. The 5-year survival was 6% overall, and 10% for the curative group. Eighty-nine percent of patients in the curative group had significant pain relief (71% complete, 18% partial), whereas 67% of those in the palliative group had complete or partial pain control.

CONCLUSIONS

Long-term survival after pelvic exenteration for recurrent colorectal carcinoma is uncommon (2/43), but sustained palliation and local control can be achieved with acceptable morbidity and mortality in most patients with intractable pelvic symptoms.

Results of surgical treatment of nonhepatic recurrence of colorectal carcinoma

The sites of first recurrence of colorectal cancer include liver (more than 30%), lung and locoregional disease (20-25%), other intraabdominal sites (15-20%), and elsewhere (10%). Isolated locoregional disease accounts for 5-19% of colon recurrences and 7-33% of rectal recurrences. Between 7% and 20% of locally recurrent colorectal cancer can be resected with curative intent. Overall, complete resection of a localized recurrence yields a mean survival of 33-59 months, with long-term survival achieved in 30-50% of patients. Regional recurrence of rectal cancer may require abdominal-sacral resection for adequate margins, with 5-year survival of 18-24%. Early identification (by close monitoring) and accurate staging of recurrence are essential for potentially curative resection. Long-term survival depends on extent of recurrence and completeness of resection. Symptomatic recurrence to the ovaries that requires reoperation occurs in approximately 2% of patients; presentation usually is as part of a diffuse intraabdominal process, and resection is rarely curative. Isolated pulmonary metastases occur in 2-4% of patients experiencing disease recurrence; such tumors are resectable in half of the patients. After the tumors are surgically resected, long-term survival can be expected in 30-40% of patients, with prognosis variably associated with disease-free interval, number and size of lung metastases, and location and stage of the primary tumor. Newer techniques of postoperative monitoring after resection of the primary lesion, more sensitive preoperative and intraoperative staging of recurrences, and the use of intraoperative radiation therapy may increase surgical salvage of recurrent colorectal cancer.

Extended resection for carcinoma of colon and rectum

Although surgery has been the mainstay of treatment for patients with colorectal carcinoma for more than a century, debate continues regarding the appropriate magnitude of operation for optimal survival. Invasion of contiguous organs is a legitimate indication for extended en bloc resection, including pelvic exenteration, in appropriately selected individuals. Extended lymphadenectomy, especially in resections for carcinoma of the rectum, is being reexamined with renewed enthusiasm. Improved perioperative care has permitted performance of more aggressive operative intervention, with improved cure rates for patients with colorectal neoplasms.

Composite resection of posterior pelvic malignancy

Advanced pelvic cancer is a formidable challenge to surgical resection. These tumors commonly invade the bony pelvis, may involve other viscera, and usually have been irradiated previously. The authors are presenting experience with 76 patients who had composite resection of posterior or lateral pelvic malignancy. Fifty-eight patients had secondary cancers involving the musculoskeletal pelvis. This included 47 patients with advanced carcinoma of the rectum (41 curative, 6 palliative), 10 epidermoid cancers of the anorectum (8) or cervix (2), and 1 bladder cancer. Among the 18 patients with primary pelvic tumors were three patients with chordomas, six with bone tumors (osteosarcoma chondrosarcoma, grade III giant cell tumor), and nine with soft tissue tumors. All required major resection of the sacrum or pelvic side walls, and one half had an additional exenterative procedure. The overall mortality rate was 7.9%. Long-term estimated survival was 24% in patients having curative resection of recurrent rectal cancer, and 22.5% in 10 patients with advanced epidermoid cancer. Fifty per cent of patients with primary bone or soft tissue tumors survived from 13 to 88 months. Most patients had reasonable return of function, and were able to return to work or resume their normal previous lifestyle.

Sacral resection for control of pelvic tumors

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.

Is total pelvic exenteration reasonable primary treatment for rectal carcinoma?

Total pelvic exeneration (TPE) is reasonable primary surgical therapy in select patients with large bulky locally invasive rectal cancers that can be removed en bloc. Many do not have either nodal or distant metastasis. Furthermore, TPE can be curative and often is palliative for similar lesions that are recurrent or nonresponsive to radiation therapy. Operative mortality rates should be under 10% and can be under 5% for primary cases. Although improvement in preoperative management and operative technique, especially with urinary conduits and postoperative care is clear, both early and late complications are significant. Unfortunately, preoperative identification of those patients requiring TPE rather than abdominoperineal or low anterior resection remains poor. Furthermore, recent improvements in techniques for pelvic slings to prevent small bowel entrapment and protection from irradiation or myocutaneous flaps to obliterate the massive dead space are not yet clearly established as preventors of either early or later complications.