Assessing the impact of a sacral resection on morbidity and survival after extended radical surgery for locally recurrent rectal cancer. Ann Surg. 2013;258:1007-1013. [PMID: 23364701 DOI: 10.1097/sla.0b013e318283a5b6]

The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases

Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.

The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer

OBJECTIVE

To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer.

BACKGROUND

Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control.

METHODS

Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease.

RESULTS

Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes.

CONCLUSIONS

R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival

BACKGROUND

The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure.

OBJECTIVE

The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer.

DATA SOURCES

A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations.

STUDY SELECTION

Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma.

MAIN OUTCOME MEASURE

Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured.

RESULTS

A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection.

LIMITATION

The studies assessed by this review were retrospective case series and thus are subject to significant bias.

CONCLUSION

Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.

Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer

BACKGROUND

The main predictor of long-term survival in patients with recurrent rectal cancer is surgical resection with a clear resection margin. MRI plays a role in patient selection and surgical planning.

OBJECTIVE

This study aimed to validate MRI in determining pelvic involvement by comparing MRI to histological outcomes, to assess the effect of MRI on surgical planning by comparing MRI findings with the surgical procedure, and to compare MRI anatomical involvement with resection outcome to assess if MRI can predict a clear resection margin.

DESIGN

Retrospective study reviewing prepelvic exenteration MRI and correlating organ, involving an MRI with pathological involvement and surgical outcomes.

SETTINGS

Single quaternary referral center with a special interest in pelvic exenteration.

PATIENTS

The patients included 40 men and 22 women with median age of 60 years who had locally recurrent rectal cancer.

MAIN OUTCOME MEASURES

The accuracy of MRI as measured using sensitivity and specificity by correlating MRI involvement with pathological involvement was the primary outcome measured.

RESULTS

Recurrence in the anterior and central compartments was identified with accuracy on MRI and was likely to be associated with clear resection margins. MRI was less accurate at determining pelvic sidewall involvement. Lateral recurrence, high sacral, and nerve involvement were more likely to be associated with a positive resection margin. Sensitivity and specificity for pelvic sidewall structures was 46% and 91%. Involvement of nerve roots (60%-69%) and the upper sacrum (80%) on MRI was more likely to predict a positive resection margin than involvement of major pelvic viscera (22%).

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

MRI findings can be used to help predict resection margin. Prospective work with MRI interpretation and close correlation and involvement by pathologists is needed to address imaging and surgical limitations at the pelvic sidewall and high posterior margin.

Abdominosacral resection for locally recurring rectal cancer

AIM

To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.

METHODS

A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.

RESULTS

At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.

CONCLUSION

Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Triangle of Marcille: the anatomical gateway to lateral pelvic exenteration

BACKGROUND

To perform more radical surgery for complex pelvic malignancies and recurrent colorectal cancer, the surgeon must increasingly operate outside the conventional anatomical planes. Published in 1963 the 'Triangle of Marcille' (lumbosacral triangle) remained primarily of intellectual interest being found lateral to the traditional operating field. However, with the advancement of complex colorectal and gynaecological surgery it now provides a schema to assist surgeons in becoming acquainted with a complex and poorly understood anatomical region. Additionally, it prepares the surgeon for the extent of lateral dissection required to achieve the 'holy grail' for oncological surgery in pelvic malignancy, the complete resection (R0).

METHODS

To prosect a preserved cadaver in order to demonstrate, in vivo, the contents and borders of the Triangle of Marcille for the purposes of teaching surgeons and future surgeons.

RESULTS

The Triangle of Marcille is both described and demonstrated in vivo, illustrated with diagrams and photographs. The importance of this region to the surgical management of complex colorectal and gynaecological surgery is discussed.

CONCLUSION

The Triangle of Marcille is a vital anatomical region for advanced pelvic surgery, particularly in the current era of pelvic exenteration, and especially for those that include the lateral pelvic compartment.

Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer

INTRODUCTION

Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist.

OBJECTIVE

This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration.

DESIGN

A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period.

SETTINGS

This study was conducted at a tertiary level exenteration unit.

MAIN OUTCOME MEASURES

Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality.

RESULTS

Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6-15) hours, and median blood loss was 2971 (range, 300-8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4-12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common.

LIMITATIONS

This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample.

CONCLUSION

Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.

Carbon-Ion Radiation Therapy for Pelvic Recurrence of Rectal Cancer

PURPOSE

Investigation of the treatment potential of carbon-ion radiation therapy in pelvic recurrence of rectal cancer.

METHODS AND MATERIALS

A phase 1/2 dose escalation study was performed. One hundred eighty patients (186 lesions) with locally recurrent rectal cancer were treated with carbon-ion radiation therapy (CIRT) (phase 1/2: 37 and 143 patients, respectively). The relapse locations were 71 in the presacral region, 82 in the pelvic sidewalls, 28 in the perineum, and 5 near the colorectal anastomosis. A 16-fraction in 4 weeks dose regimen was used, with total dose ranging from 67.2 to 73.6 Gy(RBE); RBE-weighted absorbed dose: 4.2 to 4.6 Gy(RBE)/fraction.

RESULTS

During phase 1, the highest total dose, 73.6 Gy(RBE), resulted in no grade >3 acute reactions in the 13 patients treated at that dose. Dose escalation was halted at this level, and this dose was used for phase 2, with no other grade >3 acute reactions observed. At 5 years, the local control and survival rates at 73.6 Gy(RBE) were 88% (95% confidence interval [CI], 80%-93%) and 59% (95% CI, 50%-68%), respectively.

CONCLUSION

Carbon-ion radiation therapy may be a safe and effective treatment option for locally recurrent rectal cancer and may serve as an alternative to surgery.

High subcortical sacrectomy: a novel approach to facilitate complete resection of locally advanced and recurrent rectal cancer with high (S1-S2) sacral extension

AIM

R0 resection of locally advanced or recurrent rectal cancer is the key determinant of outcome. Disease extension high on the sacrum has been considered a contraindication to surgery because of associated morbidity and difficulty in achieving complete pathological resection. Total sacrectomy has a high morbidity with poor function.

METHOD

We describe a novel technique of high subcortical sacrectomy (HiSS) to facilitate complete resection of disease extending to the upper sacrum at S1 and S2 to avoid high or total sacrectomy or a nonoperative approach to management. Details of patient demographics, radiology, operative details, postoperative histology, length of hospital stay and complications were entered into a prospectively maintained electronic patient database. All patients had had preoperative chemoradiotherapy.

RESULTS

During 2013-2014, five patients, including three with advanced primary cancer and two with recurrent rectal cancer, underwent excision using this approach. All patients had an R0 resection. Four patients had a minor postoperative complication (Clavien-Dindo Grades I and II) and one had a major complication (Clavien-Dindo Grade IIIb). There was no mortality at 90 days, and four patients were disease free at a median of 18 months.

CONCLUSION

Patients with locally advanced and recurrent rectal cancer involving the upper sacrum may be rendered suitable for potentially curative radical resection with a modified approach to sacral resection. This pilot series suggests that this novel technique results in a high rate of complete pathological resection with acceptable morbidity in patients for whom the alternatives would have been an incomplete resection, a total sacrectomy or nonoperative management.

Factors associated with the location of local rectal cancer recurrence and predictors of survival

PURPOSE

The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC.

METHODS

Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980-2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database.

RESULTS

One hundred and fifty-seven patients were identified with a mean follow-up 59.8 ± 50.1 months and time to LRRC of 31.7 ± 30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P = 0.019) and lateral (P = 0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P = 0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2-8.4; P < 0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3-2.7, P < 0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1-2.1; P = 0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2-2.7; P = 0.008) were associated with reduced LRRC 5-year survival.

CONCLUSIONS

The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration

BACKGROUND

Malignant infiltration of the pubic bone traditionally is considered inoperable. Consequently, there is little published on surgical approaches to resection of the anterior pelvic bone. En bloc partial or complete pubic bone excision can be performed depending on the degree of involvement.

OBJECTIVE

This article describes our surgical approach of pelvic exenteration with en bloc composite pubic bone excision.

DESIGN

The surgical technique describes 2 distinct aspects of the surgery, first, a perineal as opposed to abdominal transection of the urethra, and, second, varying extents of en bloc pubic bone excision.

SETTINGS

This study was conducted at a tertiary care hospital.

MAIN OUTCOME MEASURES

Pelvic tumors infiltrating the pubic bone require radical en bloc composite bone resection to achieve an R0 margin that should translate to longer-term survival versus nonoperative treatments.

RESULTS

Results of our study are currently under review.

CONCLUSIONS

As the magnitude of pelvic exenteration surgery continues to evolve for all compartments of the pelvis, malignant infiltration of the anterior pelvic bone should not be considered a contraindication to surgery.

Development of a conceptual framework of health-related quality of life in locally recurrent rectal cancer

AIM

The surgical management of locally recurrent rectal cancer (LRRC) has become widely accepted to afford cure and improve quality of life in this subset of patients. Thus far, traditional surgical and oncological markers have been used to highlight the success of surgical intervention. The use of patient-reported outcomes, specifically health-related quality of life (HRQoL), is sparse in these patients. This may be in part due to the lack of well-designed, validated instruments. This study identifies HRQoL issues relevant to patients undergoing surgery for LRRC, with the aim of developing a conceptual framework of HRQoL specific to LRRC to enable measurement of patient-reported outcomes in this cohort of patients.

METHOD

Qualitative focus groups were undertaken at two institutions to identify relevant HRQoL themes. The principles of thematic content analysis were used to analysis data. NViVo10 was used to analyse data.

RESULTS

Twenty-one patients participated in six consecutive focus groups. Two patterns of themes emerged related to HRQoL and healthcare service delivery and utilization. Identified themes related to HRQoL included symptoms, sexual function, psychological impact, role and social functioning and future perspective. Under healthcare service and delivery and utilization the subdomain of disease management, treatment expectations and healthcare professionals were identified.

CONCLUSION

This is the first qualitative study undertaken exclusively in patients with LRRC to ascertain relevant HRQoL outcomes. The impact of LRRC on patients is wide-ranging and extends beyond traditional HRQoL outcomes. The study operationalizes the identified outcomes into a conceptual framework, which will provide the basis for the development of a LRRC-specific patient-reported outcome measure.

Lateral pelvic compartment excision during pelvic exenteration

BACKGROUND

Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment.

METHODS

Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review.

RESULTS

Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage.

CONCLUSION

The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.

Systematic review of health-related quality of life issues in locally recurrent rectal cancer

The standardization of surgical techniques supplemented with appropriate neoadjuvant chemoradiation has led to the decline in local recurrence rates of rectal cancer (LRRC) from 25-50% to 5-10%. The outcomes reported for surgical intervention in LRRC is encouraging, however, a number of controversies exist especially in the ultra-advanced and palliative setting. Incorporating health-related quality of life (HRQoL) outcomes in this field could supplement traditional clinical endpoints in assessing the effectiveness of surgical intervention in this cohort. This review aimed to identify the HRQOL themes that might be relevant to patients with LRRC. A systematic review was undertaken to identify all studies reporting HRQoL in LRRC. Each study was evaluated with regards to its design and statistical methodology. A meta-synthesis of qualitative and quantitative studies was undertaken to identify relevant HRQoL themes. A total of 14 studies were identified, with 501 patients, with 80% of patients undergoing surgery. HRQoL was the primary endpoint in eight studies. Eight themes were identified: physical, psychological and social impact, symptoms, financial and occupational impact, relationships with others, communication with healthcare professionals and sexual function. The impact on HRQoL is multifactorial and wide ranging, with a number of issues identified that are not included in current measures. These issues must be incorporated into the assessment of HRQoL in LRRC through the development of a validated, disease-specific tool.

Aggressive surgical treatment with bony pelvic resection for locally recurrent rectal cancer

BACKGROUND

In the current era of total mesorectal excision, local relapse remains a main cause of recurrence. Although standard treatment for locally recurrent rectal cancer (LRRC) has not been established, R0 resection represents the only potentially curative treatment. However, extended surgery accompanying bony pelvic resection is technically demanding and is still challenging.

METHODS

Studied were 35 patients with LRRC who underwent combined resection of bony pelvis between August 2006 and October 2013. Safety and prognostic factors for survival were analyzed. Median follow-up was 33 months.

RESULTS

Sacrectomy was performed in 32 patients and 3 patients underwent combined resection of the pubis and ischium. The dominant operative procedure was total pelvic exenteration in 30 (86%) patients. R0 resection was achieved in 27 (77%) patients. No patients died. Pelvic sepsis was the most frequent complication (40%). Recurrence developed in 20 (57%), with the lung the most frequent site (10 patients). Three-year local relapse-free survival (LRFS) and disease-free survival (DFS) were 72.1% and 32.7%, respectively. On multivariate analysis, R1 resection was the only independent risk factor for local recurrence (p = 0.010), and concomitant liver metastasis and initial non sphincter-preserving surgery were independent predictors of worse DFS (p = 0.008 and p = 0.042, respectively).

CONCLUSIONS

Aggressive surgical treatment combined with bony resection for carefully selected patients with LRRC was safe with a high rate of R0 resection and favorable LRFS. However, DFS was not satisfactory even after R0 resection and the main cause was lung metastasis. Preventing distant recurrence might be a key to improve survival.

Sacral resection with pelvic exenteration for advanced primary and recurrent pelvic cancer: a single-institution experience of 100 sacrectomies

BACKGROUND

Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality.

OBJECTIVE

This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution.

DESIGN

This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes.

SETTINGS

Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital.

PATIENTS

One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers.

MAIN OUTCOME MEASURES

This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy.

RESULTS

Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival.

LIMITATIONS

Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors.

CONCLUSIONS

This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.

Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

BACKGROUND

The incidence of rectal cancer recurrence after surgery is 5-45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer.

AIM

To evaluate the surgical and oncological outcome of such treatment.

PATIENTS AND METHODS

Between 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2-3 interface in 10 patients, at S3-4 in 15 patients and S4-5 in 3 patients.

RESULTS

Forty patients, male to female ratio 1.7:1, median age 45 years (range 25-65 years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%.

CONCLUSION

Extended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.

Single-stage anterior high sacrectomy for locally recurrent rectal cancer

STUDY DESIGN

A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC).

OBJECTIVE

To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC.

SUMMARY OF BACKGROUND DATA

High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC.

METHODS

A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival.

RESULTS

Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%).

CONCLUSION

Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes.

LEVEL OF EVIDENCE

N/A.

Sacrectomy via the abdominal approach during pelvic exenteration

BACKGROUND

Sacrectomy is sometimes necessary to achieve negative margins in pelvic exenteration procedures. This is typically done with the patient in the prone position. Some of the limitations of the prone approach include its limited access to the lateral pelvic sidewall structures and suboptimal vascular control in comparison with the access and the vascular control of a combined abdominolithotomy approach.

OBJECTIVE

This article describes a technique for performing a low sacrectomy (below the sacroiliac joint) through a transabdominal approach without the need to turn the patient prone intraoperatively.

PROCEDURE

The procedure involves 2 approaches: abdominal and perineal. The abdominal phase incorporates the complete mobilization of both lateral pelvic sidewalls and their neurovascular bundles to the intended lateral margins. The anterior margin is dependent on the extent of tumor resection necessary and may incorporate the vagina, bladder, prostate, or even part of the pubic bone. The perineal phase involves freeing all the muscular and ligamentous attachments of the posterior sacrum up to the level of S2/3. The sacrectomy is completed by using an osteotome transabdominally. It begins in the midline and extends laterally until the ischial spine and incorporates the sacrospinous through to the sacrotuberous ligaments and the whole pelvic floor.

CONCLUSIONS

Transabdominal low sacrectomy is technically feasible and may be associated with numerous practical advantages in comparison with a low sacrectomy performed with the patient in the prone position for involvement of the lower half of the sacrum.

Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy

BACKGROUND

Pelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient-reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration.

METHODS

Consecutive patients referred for consideration of pelvic exenteration completed clinical and patient-reported outcome assessments at baseline, hospital discharge (exenteration patients only), and 1, 3, 6, 9 and 12 months. Outcomes included cancer-specific quality of life (Functional Assessment of Cancer Therapy - Colorectal; FACT-C), physical and mental health status (Short Form 36 version 2), psychological distress (Distress Thermometer), and pain (study-specific composite) scores. Linear mixed modelling compared trajectories between exenteration and no-exenteration groups.

RESULTS

Among 182 patients, 148 (81.3 per cent) proceeded to exenteration. There were no baseline differences between the two groups. Among patients who had exenteration, the mean FACT-C score at baseline of 93.0 had reduced by 14·4 points at hospital discharge, but increased to 86·7 at 1 month after surgery and continued to improve, returning to baseline by 9 months. For patients in the no-exenteration group, FACT-C scores decreased between baseline and 1 month, increased slowly to 6 months and then began to decline at 9 months. There were few statistically or clinically significant differences in any patient-reported outcomes between the groups.

CONCLUSION

Quality of life and related patient-reported outcomes improve rapidly after pelvic exenteration surgery. For 9 months after surgery, these outcomes are comparable with those of similar do patients who do not have surgery; thereafter, there is a decline in patients who do not have exenteration. Pelvic exenteration can be performed with acceptable quality of life and patient-reported outcomes.

Clinical review: surgical management of locally advanced and recurrent colorectal cancer

AIM

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms 'locally advanced colorectal cancer', 'recurrent colorectal cancer' and 'surgical management' were used.

RESULTS

A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and <5 %, respectively.

CONCLUSION

Multimodal therapy and extended surgery to achieve clear margins offers good prognosis to patients with recurrent and locally advanced colorectal cancers.