Internal hemipelvectomy in the treatment of recurrent carcinoma of the colon: report of a case

Surgery of resectable local recurrence following colorectal cancer: Compartmental surgery improves local control

BACKGROUND

This study aims to identify prognostic factors and define the best extent of surgery for optimizing treatment of local recurrence (LR) following colorectal cancer (CRC).

METHODS

An institutional database of consecutive patients who underwent radical resection (R0/R1) of LR following CRC was analyzed prospectively from 2010 to 2021 at one tertiary cancer center.

RESULTS

In this study, 75 patients were included with LR following CRC and analyzed. Patients were categorized as compartmental resections (CompRe) (n = 47) if all adjacent organs were systematically removed, with or without tumor involvement, or noncompartmental resections (NoCompRe) (n = 28) if only contiguously involved organs were resected. NoCompRe were mainly related to contact between major vessels or bone and the tumor, with only 8/19 (42.1%) resections. Five-year overall survival and locoregional-free survival were 37.5% and 38.8% respectively. Local control was better in the CompRe than the NocompRe group (61.4% vs. 11%; p < 0.01). CompRe (hazard ratio: 2.34 [1.16-4.68]; p = 0.017) and absence of peritoneal metastasis (3.05 [1.03-9.02]; p = 0.044) were the two factors associated with decreased abdominal recurrences in multivariate analysis.

CONCLUSION

Complete compartmental surgery is safe and improves local control. Optimal LR resection needs to remove all contiguous organs, with or without tumor involvement.

Locally advanced rectal cancer: management challenges

Between 5% and 10% of patients with rectal cancer present with locally advanced rectal cancer (LARC), and 10% of rectal cancers recur after surgery, of which half are limited to locoregional disease only (locally recurrent rectal cancer). Exenterative surgery offers the best long-term outcomes for patients with LARC and locally recurrent rectal cancer so long as a complete (R0) resection is achieved. Accurate preoperative multimodal staging is crucial in assessing the potential operability of advanced rectal tumors, and resectability may be enhanced with neoadjuvant therapies. Unfortunately, surgical options are limited when the tumor involves the lateral pelvic sidewall or high sacrum due to the technical challenges of achieving histological clearance, and must be balanced against the high morbidity associated with resection of the bony pelvis and significant lymphovascular structures. This group of patients is usually treated palliatively and subsequently survival is poor, which has led surgeons to seek innovative new solutions, as well as revisit previously discarded radical approaches. A small number of centers are pioneering new techniques for resection of beyond-total mesorectal excision tumors, including en bloc resections of the sciatic notch and composite resections of the first two sacral vertebrae. Despite limited experience, these new techniques offer the potential for radical treatment of previously inoperable tumors. This narrative review sets out the challenges facing the management of LARCs and discusses evolving management options.

A rare presentation of locally re-recurrent colon cancer involving the iliac bone and a review of the literature

Colorectal cancer is a leading cause of cancer death in the USA. While locally advanced rectal cancer involving bone has been described extensively, colon cancer locally involving bone has only been described, to our knowledge, in a single case report. In this case report, we describe the presentation and treatment of locally advanced re-recurrent colon cancer involving the iliac bone. We also discuss the available literature on treatment for recurrent and re-recurrent colorectal cancer.

Pelvic exenteration for rectal cancer: a systematic review

BACKGROUND

Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer.

OBJECTIVE

This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration.

DATA SOURCES

A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified.

STUDY SELECTION

Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination.

MAIN OUTCOME MEASURES

Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates.

RESULTS

A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer.

LIMITATIONS

Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported.

CONCLUSIONS

Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.

Extended external hemipelvectomy for sigmoid adenocarcinoma treatment

Surgery is the most effective way of treating a locally advanced colorectal carcinoma and an extended en bloc resection is necessary to achieve the best overall survival rate. In this rare case, a multi-visceral resection was performed along with the entire lower left limb and left iliac bone for a sigmoid carcinoma. The T4N0M0 (B3) tumor involved the left iliac vessels, left pelvic wall, small bowel and both rectus muscles, besides presenting with a skin fistula. A Hartmann colostomy was also performed. Chemotherapy was interrupted because of toxicity. The patient is free of disease after 38 months. There are very few cases that describe an extended hemipelvectomy as part of a colorectal carcinoma treatment.

Composite pelvic exenteration: is it worthwhile?

BACKGROUND

In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis.

METHODS

Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3.

RESULTS

Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively.

CONCLUSIONS

Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.