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

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.

Reported outcomes following cytoreductive surgery for colorectal peritoneal metastases: A systematic review to inform evidence-based practice and international consensus

AIM

Cytoreductive surgery provides a chance for long-term survival and cure in selected patients with colorectal peritoneal metastases. As clinical and academic interest in this field increases, heterogeneity in outcome reporting hinders the valid and meaningful synthesis of data into high-quality meta-analyses. The aim of this systemic review was to investigate variability in outcome reporting following cytoreductive surgery with or without intraperitoneal chemotherapy for colorectal peritoneal metastases.

METHOD

Five electronic databases [MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL)] were interrogated from 2000 to October 2023 to identify all reported outcomes in the current literature. Extracted outcomes were catalogued and reviewed by a multidisciplinary working group into standardized terms and domains.

RESULTS

A total of 294 studies, from 5112 screened, were included for analysis. We extracted 2903 outcomes verbatim from included studies and catalogued them into 85 standardized outcomes across seven outcome domains. The most frequently reported domains were survival, in 274 (93%) studies, and pathological outcomes, in 232 (79%) studies. Outcomes pertaining to function and life impact were only reported in seven (2%) studies. Reported outcomes were only defined in 35% of cases, and significant variability existed between definitions.

CONCLUSION

This systematic review highlights the heterogeneity of outcome measurement and reporting following cytoreductive surgery for colorectal peritoneal metastases. Patient-reported outcomes are relatively underrepresented in the current literature. The results of this review will inform an international collaborative effort to create a core outcome set to address these issues.

A matter of survival-patients' and carers' perspectives on the decision to undergo pelvic exenteration surgery for locally advanced and recurrent rectal cancer

AIM

Pelvic exenteration is the only potentially curative treatment for patients with locally advanced or recurrent rectal cancer. This study aimed to investigate how patients decide to undergo such radical surgery.

METHOD

This qualitative study employed an exploratory interpretive design informed by hermeneutic philosophy. During semi-structured interviews, individuals who had undergone pelvic exenteration at a specialised centre and their carers were asked to reflect on the decision-making process around surgery.

RESULTS

Thirty-eight interviews were conducted with 39 participants (34 patients and five carers). Four themes were identified. There really wasn't a choice-participants indicated that long-term survival was their absolute priority, with many feeling that there was no alternative. Only one participant expressed decision regret due to the consequences of surgery. Grappling with the magnitude of surgery-despite extensive preoperative education and counselling, the enormity of the surgery and recovery experience was incomprehensible to participants until they were 'in it', with many surprised by a slow and protracted recovery. A spectrum of psychological states and support needs-participants reflected on their psychological state prior to surgery, identifying family or professional pre-surgery counselling as sources of support. Understanding life after surgery-although most participants were willing to accept anything in order to survive, many identified the impact on bodily functions, body image and overall quality of life as important.

CONCLUSIONS

Long-term survival was the principal factor influencing the decision to undergo pelvic exenteration. Individualised preoperative counselling may improve patient preparedness for the consequences of surgery.

Open versus robotic-assisted techniques for multivisceral pelvic resections of locally advanced or recurrent colorectal and anal cancers: short-term outcomes from a single centre

BACKGROUND

Pelvic exenterations are now established as a standard of care for locally advanced and recurrent rectal cancer. Traditionally, these radical and complex operations have been performed via an open approach, but with the increasing expertise in robotic-assisted surgery (RAS), there is scope to perform such cases robotically. This study compares outcomes from open and RAS pelvic exenterations.

METHODS

This retrospective observational study includes all pelvic exenterations for locally advanced or recurrent colorectal cancers performed in a single centre between September 2018 and September 2023. Cases were grouped into open or RAS surgery and classified in terms of operative extent and complexity. The primary outcome was resection margin status. Secondary outcomes were postoperative morbidity, length of stay and blood loss.

RESULTS

Thirty-three patients were included. Nineteen (57.6%) cases utilised an open technique, and 14 (42.4%) used RAS. Patient characteristics and operative complexity were equivalent between groups. R0 rate (63.1% vs 71.4%, p = 0.719), median haemoglobin drop (19 (11-30) g/L vs 13 (5-26) g/L, p = 0.208) and postoperative morbidity (18/19 (94.7%) vs 9/14 (64.3%), p = 0.062) were equivalent. Length of stay (16.0 days (8-25) vs 9.5 days (6-16), p = 0.047) was shorter in the RAS group.

CONCLUSIONS

Short-term surgical and histopathological outcomes are equivalent in this small cohort of patients. This study suggests that RAS may be a safe and effective method for performing pelvic exenterations for colorectal malignancies. Larger-scale and robustly designed prospective studies are required to confirm these preliminary findings and report on long-term oncological outcomes.