Composite pelvic exenteration: is it worthwhile?

Prerequisites to improve surgical cytoreduction in FIGO stage III/IV epithelial ovarian cancer and subsequent clinical ramifications

BACKGROUND

No residual disease (CC 0) following cytoreductive surgery is pivotal for the prognosis of women with advanced stage epithelial ovarian cancer (EOC). Improving CC 0 resection rates without increasing morbidity and no delay in subsequent chemotherapy favors a better outcome in these women. Prerequisites to facilitate this surgical paradigm shift and subsequent ramifications need to be addressed. This quality improvement study assessed 559 women with advanced EOC who had cytoreductive surgery between January 2014 and December 2019 in our tertiary referral centre. Following implementation of the Enhanced Recovery After Surgery (ERAS) pathway and prehabilitation protocols, the surgical management paradigm in advanced EOC patients shifted towards maximal surgical effort cytoreduction in 2016. Surgical outcome parameters before, during, and after this paradigm shift were compared. The primary outcome measure was residual disease (RD). The secondary outcome parameters were postoperative morbidity, operative time (OT), length of stay (LOS) and progression-free-survival (PFS).

RESULTS

R0 resection rate in patients with advanced EOC increased from 57.3% to 74.4% after the paradigm shift in surgical management whilst peri-operative morbidity and delays in adjuvant chemotherapy were unchanged. The mean OT increased from 133 + 55 min to 197 + 85 min, and postoperative high dependency/intensive care unit (HDU/ICU) admissions increased from 8.1% to 33.1%. The subsequent mean LOS increased from 7.0 + 2.6 to 8.4 + 4.9 days. The median PFS was 33 months. There was no difference for PFS in the three time frames but a trend towards improvement was observed.

CONCLUSIONS

Improved CC 0 surgical cytoreduction rates without compromising morbidity in advanced EOC is achievable owing to the right conditions. Maximal effort cytoreductive surgery should solely be carried out in high output tertiary referral centres due to the associated substantial prerequisites and ramifications.

Quality of life after extended pelvic exenterations

BACKGROUND

The aim of the study was to compare health-related quality of life (QoL) and oncological outcome between gynaecological cancer patients undergoing pelvic exenteration (PE) and extended pelvic exenteration (EPE). EPEs were defined as extensive procedures including, in addition to standard PE extent, the resection of internal, external, or common iliac vessels; pelvic side-wall muscles; large pelvic nerves (sciatic or femoral); and/or pelvic bones.

METHODS

Data from 74 patients who underwent PE (42) or EPE (32) between 2004 and 2019 at a single tertiary gynae-oncology centre in Prague were analysed. QoL assessment was performed using EORTC QLQ-C30, EORTC CX-24, and QOLPEX questionnaires specifically developed for patients after (E)PE.

RESULTS

No significant differences in survival were observed between the groups (P > 0.999), with median overall and disease-specific survival in the whole cohort of 45 and 49 months, respectively. Thirty-one survivors participated in the QoL surveys (20 PE, 11 EPE). No significant differences were observed in global health status (P = 0.951) or in any of the functional scales. The groups were not differing in therapy satisfaction (P = 0.502), and both expressed similar, high willingness to undergo treatment again if they were to decide again (P = 0.317).

CONCLUSIONS

EPEs had post-treatment QoL and oncological outcome comparable to traditional PE. These procedures offer a potentially curative treatment option for patients with persistent or recurrent pelvic tumour invading into pelvic wall structures without further compromise of patients´ QoL.

The Uncertain Benefit of Adjuvant Chemotherapy in Advanced Low-Grade Serous Ovarian Cancer and the Pivotal Role of Surgical Cytoreduction

In our center, adjuvant chemotherapy is routinely offered in high-grade serous ovarian cancer (HGSOC) patients but less commonly as a standard treatment in low-grade serous ovarian cancer (LGSOC) patients. This study evaluates the efficacy of this paradigm by analysing survival outcomes and by comparing the influence of different clinical and surgical characteristics between women with advanced LGSOC (n = 37) and advanced HGSOC (n = 300). Multivariate analysis was used to identify independent prognostic features for survival in LGSOC and HGSOC. Adjuvant chemotherapy was given in 99.7% of HGSOC patients versus in 27% of LGSOC (p < 0.0001). The LGSOC patients had greater surgical complexity scores (p < 0.0001), more frequent postoperative ICU/HDU admissions (p = 0.0002), and higher peri-/post-operative morbidity (p < 0.0001) compared to the HGSOC patients. The 5-year OS and progression-free survival (PFS) was 30% and 13% for HGSOC versus 57% and 21.6% for LGSOC, p = 0.016 and p = 0.044, respectively. Surgical complexity (HR 5.3, 95%CI 1.2-22.8, p = 0.024) and complete cytoreduction (HR 62.4, 95% CI 6.8-567.9, p < 0.001) were independent prognostic features for OS in LGSOC. This study demonstrates no clear significant survival advantage of chemotherapy in LGSOC. It highlights the substantial survival benefit of dynamic multi-visceral surgery to achieve complete cytoreduction as the primary treatment for LGSOC patients.

Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer

BACKGROUND

Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer.

METHODS

This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis.

RESULTS

A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively.

CONCLUSION

There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.

En Bloc Resection with Partial Sacrectomy Helps to Achieve R0 Resection in Locally Advanced Rectal Cancer, Experience from a Tertiary Cancer Center

Partial sacrectomy is a radical procedure that benefits a select group of patients with locally advanced primary or recurrent rectal cancer with posterior extension and carries potential for significant morbidity. This study was done to evaluate the morbidity and oncological outcome of patients who underwent partial sacral resection for rectal cancer in a tertiary cancer center. Seventeen patients underwent partial sacrectomy during the period from 2011 to 2015. Eleven patients had primary and six had recurrent rectal cancer. All patients were evaluated with MRI pelvis and metastatic evaluation with CT scan of the chest and abdomen and PET scan in patients with recurrent cancer. All patients had resection below the level of S2/S3 junction or lower. Three patients were females and the remaining were males. Median age was 56 years. Overall morbidity was 76% and most common morbidity was wound related. The mean estimated relapse-free survival (RFS) for patients treated for primary rectal cancer was 20.3 months (95% confidence interval (CI), 12.8-27.9) and the mean estimated overall survival (OS) 23.9 months. Estimated mean RFS for patients who were operated for recurrent rectal cancer was 25.6 months (95% CI, 17.7-33.5) and the median RFS was yet to reach. Estimated mean OS was 29.7 months (95% CI, 15.5-43.8) and the median OS was 39.6 months. Partial sacrectomy below the level of S2/S3 junction is a safe approach to facilitate en bloc resection of locally advanced primary and recurrent rectal cancer extending posteriorly with loss of plane with sacrum. In selected patients, this approach can improve survival at the cost of high morbidity.

Marital status and survival in patients with rectal cancer: A population-based STROBE cohort study

To examine the impact of marital status on overall survival (OS) and rectal cancer-specific survival (RCSS) for aged patients.We used the Surveillance, Epidemiology and End Results database to identify aged patients (>65 years) with early stage rectal cancer (RC) (T1-T4, N0, M0) in the United States from 2004 to 2010. Propensity score matching was conducted to avoid potential confounding factors with ratio at 1:1. We used Kaplan-Meier to compare OS and RCSS between the married patients and the unmarried, respectively. We used cox proportion hazard regressions to obtain hazard rates for OS, and proportional subdistribution hazard model was performed to calculate hazard rates for RCSS.Totally, 5196 patients were included. The married (2598 [50%]) aged patients had better crude 5-year overall survival rate (64.2% vs 57.3%, P < .001) and higher crude 5-year cancer-specific survival rate (80% vs 75.9%, P < .001) than the unmarried (2598 (50%)), respectively. In multivariate analyses, married patients had significantly lower overall death than unmarried patients (HR = 0.77, 95% CI = 0.71-0.83, P < .001), while aged married patients had no cancer-specific survival benefit versus the unmarried aged patients (HR = 0.92, 95% CI = 0.81-1.04, P = .17).Among old population, married patients with early stage RC had better OS than the unmarried, while current evidence showed that marital status might have no protective effect on cancer-specific survival.

Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer

BACKGROUND

Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single-centre series. This study analysed data from an international collaboration to determine robust parameters that could inform clinical decision-making.

METHODS

Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed.

RESULTS

Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty-one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P < 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three-year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P < 0·001). Node-positive patients had a shorter median overall survival than those with node-negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long-term survival.

CONCLUSION

Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.

Population-based study of factors predicting treatment intention in patients with locally recurrent rectal cancer

Background

Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC.

Methods

Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed.

Results

A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44).

Conclusion

Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.

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.

Surgery for recurrent rectal cancer: higher and wider?

AIM

There has been a steady increase in the number of centres that carry out resection of locally recurrent rectal cancer (LRRC). The aim of this review was to highlight the present management and suggest technical strategies that may improve survival and quality of life.

METHOD

The review identified relevant studies from an electronic search of MEDLINE and PubMed databases between 1980 and 2011. References in published articles were also reviewed.

RESULTS

Surgical intervention offers the best hope to control LRRC but the proportion of patients offered this remains small. Certain contraindications previously considered to be absolute should now be thought of as relative.

CONCLUSION

Awareness of the surgical options and a willingness to consider more aggressive options may result in more patients being considered for potentially curative resection.

Outcome of surgical resection of second-time locally recurrent rectal cancer

BACKGROUND

Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer.

METHODS

Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences.

RESULTS

Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection).

CONCLUSION

Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.

Locally advanced colorectal cancer: results of surgical treatment and prognostic factors

OBJECTIVES

To evaluate the incidence surgical results and prognostic factors of locally advanced colorectal cancer.

METHODS

Cohort study including 679 colorectal cancer patients treated from 1997 to 2007. Clinical, surgical and histological data were analyzed.

RESULTS

Ninety patients (females 61%; median age 59 years) were treated for locally advanced carcinomas (13.2%), either in the colon (66%) or rectum (34%). Extended resections most commonly involved the small bowel (19.8%), bladder (16.4%), uterus (12.9%) and ovaries (11.2%). Postoperative morbidity and mortality occurred in 23 (25.6%) and 3 (3.3%) patients, respectively. Survival and recurrence analysis among 76 R0 (84.4%) procedures revealed a 60% 5-year survival and 34% local recurrence rates. Survival curves demonstrated reduced rates for rectal location (45% vs 65%), tumor depth (50% for T4 vs 75% for T3), vascular/ lymphatic/perineural invasion (35% vs 80%) and lymph node metastasis (35% vs 80%).

CONCLUSIONS

Locally advanced carcinomas were found in 13.2% of patients. Survival rates were negatively affected by rectal location and adverse histological features. Number of involved organs and neoplastic adhesions did not influenced chances of survival. A radical R0 extended resection was achieved in a high proportion of cases, resulting in a 60% cancer-free survival under acceptable operative risks.

Management of locally advanced primary and recurrent rectal cancer

Treatment for patients with locally advanced and recurrent rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Adequate preoperative imaging of the pelvis is therefore important to identify those patients who are candidates for multimodality treatment, including preoperative chemoradiation protocols, intraoperative radiotherapy, and extended surgical resections. Much effort should be made to select patients with these advanced tumors for treatment in specialized referral centers. This has been shown to reduce morbidity and mortality and improve long-term survival rates. In this article, we review the best treatment options for patients with locally advanced and recurrent rectal cancer. We also emphasize the necessity of a multidisciplinary team, including a radiologist, radiation oncologist, urologist, surgical oncologist, plastic surgeon, and gynecologist in the diagnosis and treatment of patients with these pelvic tumors.

Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement

PURPOSE

Lateral pelvic recurrence is considered a poor prognostic variable and a relative contraindication to surgery because of the difficulty in achieving clear margins. The aim of this study was to outline our surgical approach to lateral pelvic sidewall involvement and assess the oncologic and long-term outcomes.

METHODS

A retrospective review of a prospective database was performed. Patient demographics, cancer and operative details, intent, margins, lymph node status, rerecurrence at resection site, follow-up, living and death details were assessed.

RESULTS

En bloc lateral pelvic wall dissection and vascular resection with pelvic exenteration was performed in 36 patients of 107 exenterations. All patients underwent surgery with curative intent. Negative margins were achieved in 19 patients (53%). Ten patients (28%) developed recurrence at the site of resection compared with 26 patients (72%) who remained disease free at the site of surgery. Sixteen patients (46%) are disease-free with the average disease-free interval of 30 months. Twenty-five patients (69%) are alive with a mean follow-up of 19 months. No mortalities occurred in this cohort of patients.

CONCLUSION

Despite the complexity of this technique, it is safe and feasible. Careful preoperative radiologic assessment and a multidisciplinary approach are paramount to achieving clear margins.

Current developments for pelvic exenteration in gynecologic oncology

PURPOSE OF REVIEW

The present review aims to update new techniques of pelvic exenteration including minimal invasive surgery, and discuss other aspects of this radical surgery, including worldwide differences.

RECENT FINDINGS

Major advances are made since the first description of pelvic exenteration and the operation is still under evolution. Explorative laparoscopy prior to exenteration is a valuable alternative to laparotomy to elect candidates for pelvic exenteration. There are considerable differences with respect to indications, contraindications, preoperative staging and adjuvant therapy after exenteration in different countries. Advances in laparoscopic instruments also led to the laparoscopic exenteration. The main limiting step of the operation is urinary diversion. New techniques of laparoscopic-assisted and robotic-assisted techniques of urinary diversion have been reported that decrease the operation time. Vascularized muscle flaps are preferred by many surgeons to fill the empty pelvis and provide an acceptable vaginal reconstruction. J-pouch seems to be a safer technique than end-to-end coloanal anastomosis for bowel reconstruction. Developments in the bioengineering tissue for pelvic reconstruction are required.

SUMMARY

Laparoscopy has the advantages of decreased blood loss, improved convalescence, lower incidence of wound infection and incisional hernia, short recovery periods, rapid return of bowel function, better pain control and improved cosmetics compared with laparotomy for pelvic exenteration. Magnification and improved visualization permits en-bloc dissection of tumor and good anastomosis technique. New techniques of urinary diversion, orthotopic neobladder and coloanal are promising.

Fatal vascular injury as a result of operations: experience of two surgery-related autopsies

We experienced two autopsy cases of unexpected death during surgical operation. Case 1 was a 60-year-old male. Salvage esophagectomy was performed from the right side of the thrax. After dissection of the lymph node, blood pressure decreased suddenly. Emergency thoracotomy was done for diffuse hemothorax in the left thoracic cavity. The patient died despite aggressive hemostasis. Autopsy findings revealed that the operator dissected the left subclavian artery instead of the lymph nodes. Case 2 was a 60-year-old male with advanced thyroid cancer with pelvic metastasis. Surgical removal of the sacrum was attempted for pain relief. The operation was interrupted because of massive hemorrhage from the iliac veins. After the operation, the patient's left leg quickly became necrotic. Despite the bypass grafting from the right to the left femoral artery, the patient died of reperfusion injury. Autopsy revealed ligation of the left common iliac artery along with the accompanying vein. The leg necrosis was thought to have resulted from the vascular ligation. In these two cases, the demonstration and elucidation of the causes of deaths were required with medicolegal autopsies. However, it proved difficult to visualize the operated vessels in detail. In autopsy investigations related to surgical operations, detailed information of the clinical course is valuable and should be provided by the operators themselves, as well as being obtained from clinical charts.

Comparison of immediate surgical outcomes between posterior pelvic exenteration and standard resection for primary rectal cancer: A matched case-control study

AIM: To determine the immediate surgical outcome and recovery of bowel function following posterior pelvic exenteration (PPE) for primary rectal cancer with suspected local invasion to the female internal reproductive organs, in comparison with a case-control series of standard resection for primary rectal cancer.

METHODS: We analyzed 10 consecutive female patients undergoing PPE for the aforementioned indication between December 2003 and May 2006 in a single institution. Data were prospectively collected during hospitalization, including patient demographics, tumor- and operation-related variables and early surgical outcomes. These patients were compared with a group of female patients, matched for age, co-morbidity and location of tumor, who underwent standard resection for primary rectal cancer in the same period (non PPE group).

RESULTS: In the PPE group, pathological reports showed direct invasion of the reproductive organs in 4 cases and an involvement of lymph nodes in 7 cases. A sphincter-saving operation was performed in each case. Operative time was longer (274 min vs 157 min, P < 0.001) and blood loss was greater (769 mL vs 203 mL, P = 0.008) in the PPE group. Time to first bowel movement, time to first defecation, time to resumption of normal diet, and hospital stay were not significantly different between the two groups. Postoperative complication rates were also similar.

CONCLUSION: PPE for rectal cancer was associated with longer operative time and increased blood loss, but did not compromise immediate surgical outcomes and postoperative bowel function compared to standard rectal resection.

Reirradiation, surgery and IORT for recurrent rectal cancer in previously irradiated patients

A total of 11 patients with recurrent rectal cancer who had been previously irradiated were treated with preoperative reirradiation (median dose 30Gy), surgery and IORT. This treatment was related with high morbidity, a short pain-free survival (5 months) and poor local control (27% after 3 years), although some patients have long-term distant control and survival.

A exenteração pélvica para o câncer de reto: avaliação dos fatores prognósticos de sobrevida em 27 pacientes operados

OBJETIVO: Identificar os fatores prognósticos de sobrevida dos pacientes submetidos à exenteração pélvica no tratamento curativo do câncer de reto (no Estádio T4 e na recidiva pélvica isolada). MÉTODOS: Os dados completos de 27 pacientes submetidos a esse tipo de operação por adenocarcinoma de reto entre Janeiro de 1996 a Junho de 2006 foram avaliados. Foram estudados diversos fatores prognósticos epidemiológicos, cirúrgicos e histológicos por meio de análise multivariada. RESULTADOS: A mortalidade pós-operatória foi de 7 % (n=2) enquanto a morbidade global foi de 55 % (n=15). A média de sobrevida global foi de 38 meses. A sobrevida global foi maior nos tumores T4 do que nas recidivas pélvicas (47 X 26 meses). Somente o comprometimento linfonodal (N+) foi fator prognóstico negativo na análise multivariada. CONCLUSÃO: A exenteração pélvica para o tratamento do câncer de reto apresenta alta morbidade e considerável mortalidade. Deve ser indicada nos tumores T4, principalmente quando não há disseminação linfonodal.

Extended pelvic resections for recurrent uterine and cervical cancer: out-of-the-box surgery

Patients with recurrent uterine and cervical cancer have poor prognoses. The objective of this study was to analyze the outcomes of patients with recurrent uterine and cervical cancer who had undergone attempted curative resection of pelvic bone, sidewall muscle, major blood vessels, and/or nerves. We reviewed the records of all 14 patients with recurrent uterine and cervical cancer who had extended pelvic resections at our institution between June 2000 and November 2006. Primary sites of disease were the uterus (11 patients) and cervix (3 patients). Tumor histology was as follows: adenocarcinoma, seven; squamous cell carcinoma, three; leiomyosarcoma, three; and adenosarcoma, one. Previous treatment included hysterectomy, 11; pelvic radiation, 9; chemotherapy, 9; and total pelvic exenteration, 2. Extended pelvic resections included removal of pelvic sidewall muscle, five; bone, five; common and/or external iliac vessel, five; femoral nerve, two; lumbosacral nerve root, one; and obturator nerve, one. Other procedures included total pelvic exenteration, three; posterior exenteration, two; and anterior exenteration, one. Complete resection with negative margins was obtained in 11 (78%) of 14 patients. Seven patients (50%) received high-dose rate intraoperative radiation therapy. Reconstructive procedures included continent or incontinent urinary diversion, four; femoral-femoral arterial bypass, two; myocutaneous flap, two; and urinary ileal interposition, one. Median total operating time was 628 min (range, 345-935 min) and median estimated blood loss was 900 mL (range, 300-16,000 mL). Seven patients (50%) had one or more major complication(s), including pelvic abscess, three; colonic fistula, two; massive intraoperative hemorrhage, one; postoperative bladder perforation, one; thrombosed femoral-femoral graft, one; and disruption of appendicocutaneous urinary anastomosis, one. At a median follow-up of 26 months (range, 5-84 months), ten patients (71%) are alive and four patients (29%) have died of disease at 8, 13, 33, and 42 months postoperatively.

Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence

OBJECTIVE

The current optimal management of locally advanced rectal cancer has evolved from surgical excision followed by postoperative therapy in patients with involved margins, to an increasing use of a preoperative strategy to 'down-stage and/or down-size' the tumour. This treatment strategy is based on the relationship of the tumour to the mesorectal fascia, the optimal surgical circumferential resection margin that can be achieved by total mesorectal excision. We have reviewed the recent evidence for this strategy.

METHOD

An electronic literature search using PubMed identified articles on the subject of rectal cancer between January 2000 and December 2005. The search was limited to English language publications with secondary references obtained from key articles. Articles published in high impact factor journals formed the basis of the review, together with articles related to national programmes on the management of rectal cancer. This does lead to a selection bias, particularly as the articles identified had a European bias.

CONCLUSION

The UK NHS Cancer Plan has outlined the basis for the multidisciplinary team (MDT) management of rectal cancer. Advances in preoperative assessment through accurate staging and the recognition of the importance of the relationship of the tumour to the mesorectal fascia has allowed the selection of patients for a preoperative strategy to down-size/down-stage the tumour if this fascial layer is involved or threatened. Improvements in the quality of surgical resection through the acceptance of the principle of total mesorectal excision have ensured that optimal surgery remains the cornerstone to successful treatment. Further refinements of the MDT process strive to improve outcome. Accurate radiological staging, optimal surgery and detailed histopathological assessment together with consideration of a preoperative neoadjuvant strategy should now form the basis for current treatment and future research in rectal cancer.

Extended abdominoperineal resection in women: the Barbadian experience

BACKGROUND AND OBJECTIVES

We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters.

METHODS

Eighteen female patients (mean age: 62.9 years; range: 44-81 years) with a median follow-up of 14 months (range: 2-36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied.

RESULTS

Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively.

DISCUSSION

Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.

[Results of resection of locally recurrent rectal cancer]

AIMS OF THE STUDY

The treatment of locally recurrent rectal cancer (LRRC) remains a difficult and controversial issue. The aim of this study was to retrospectively assess the results of an univocal attitude associating resection of a priori resectable lesions using visceral excisions as required, without sacral excision, but including intra-operative radiotherapy (IORT).

PATIENTS AND METHODS

Between 1989 and 1999, 32 patients underwent resection for LRRC. Twelve had previously undergone abdomino-perineal excision and 22 had received radiotherapy. Twenty-three patients underwent pelvic exenteration (total in 17, with rectus myocutaneous flap in 18). Twenty-five patients underwent IORT.

RESULTS

Three patients (9.3%) died in the early postoperative period and 11 experienced complications (37%). Resections were considered R0 in 6 patients, R1 in 21 patients and R2 in 5 patients. Five-year survival rates, overall and without disability, were respectively 12%, 12% and 5%. Median survivals, overall and without disability, were respectively 22 and 12 months.

CONCLUSION

Resection of LRRC remains a surgical challenge. It may achieve an average of one-year survival without disability, and hope for a few cures. Improvement of oncologic results might come from a more accurate patient selection.

Mesorectal lymph node involvement and prognostic implications at total pelvic exenteration for gynecologic malignancies

OBJECTIVES

To determine the incidence and prognostic implications of positive mesorectal lymph nodes in patients undergoing total pelvic exenteration for recurrent gynecologic malignancies.

METHODS

We performed a retrospective chart review of all patients who had undergone total pelvic exenteration for a gynecologic malignancy between July 1992 and December 2003. Patient charts were reviewed for information regarding demographics, site of cancer, histology, pathology report, and time to recurrence.

RESULTS

Fifty-eight women had undergone total pelvic exenteration for recurrent gynecologic malignancies during the study period and 57 were available for analysis. Primary cancer site was as follows: cervix, 37 (65%); vagina, 8 (14%); vulva, 5 (9%); and uterine corpus, 7 (12%). In 30 patients (53%), the mesorectal lymph node status was pathologically evaluated. Of these 30 patients, 3 (10%) had positive mesorectal lymph nodes at the time of total pelvic exenteration. All 3 patients had rectal wall involvement (rectal submucosa, 2; rectal mucosa, 1), and all 3 patients recurred within 4 months of pelvic exenteration. The median time to recurrence after surgery was 2.4 months in those patients with positive mesorectal lymph nodes compared with 7.3 months in those with negative mesorectal lymph nodes (P = 0.005). When individually adjusted for other prognostic variables, such as margin status, tumor grade, lymphovascular space involvement, primary cancer site, and histologic type, a finding of positive mesorectal lymph nodes was associated with a shorter time to recurrence of disease (all P < 0.05).

CONCLUSIONS

Mesorectal lymph node involvement is a common finding at total pelvic exenteration, particularly in patients with rectal wall involvement. Patients with positive mesorectal lymph nodes appear to have a worse outcome with a shorter time to recurrence of disease.

Major complications following exenteration in cases of pelvic malignancy: A 10-year experience

AIM: To analyze the major complications after exenteration of gynecological and rectal malignancies.

METHODS: Twenty-two patients with gynecological malignancy and 6 with rectal malignancy underwent pelvic exenteration (PE) between 1996 and 2005. PE was performed for primary malignancy in 71.4% of cases (vulvar cancer in 13, cancer rectal in 5, cervical cancer in 1 and Bartholin’s gland cancer in 1 cases respectively and recurrent malignancy in 28.6% of cases (cervical cancer in 5, ovarian cancer in 1, uterine sarcoma in 1 and rectal cancer in 1 cases respectively). Posterior PE, total PE and anterior PE were most often performed.

RESULTS: Major complications in the operative field involving the urinary tract infection or the wound dehiscence occurred in 12 patients (42.9%). Early complications included massive bleeding from the sacral plexus, adult respiratory distress syndrome (ARDS), thrombophlebitis, acute renal failure, urinary bladder dysfunction, ureter damage, re-operation and pulmonary embolus. Urinary incontinence was observed in 2 women as a late complication. In 1 patient a nephrostomy was performed in 1 patient due to extensive hydronephrosis and 1 patient had complications connected with the gastrointestinal tract. The mortality rate was 7%, of which inter-operative mortality accounted for 3.5%. Major complications often occurred in advanced primary vulvar cancer affecting those with recurrent malignancies.

CONCLUSION: PE is more beneficial to patients with primary vulvar and rectal cancer than to those with recurrent cancer. Knowledge of the inherent complications and morbidity of PE is essential.

Qualitative assessment of patient experiences related to extended pelvic resection for rectal cancer

BACKGROUND

Patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) represent a complex management challenge. While there is potential for cure in a subset of patients, the cost in terms of morbidity can be high. Few descriptions of the physical, psychological, social, and emotional experiences of these patients exist.

METHODS

Face-to-face interviews were completed with ten LARC and LRRC patients treated with multimodal therapy that included surgery. Patient opinions and experiences were explored in depth until information redundancy and common themes were delineated using qualitative research methods. Clinical information was obtained from the database.

RESULTS

Nine of the ten patients were male, seven had LARC, and the median age was 71. Six themes were identified from the patient interviews. Themes reflected patients' highly focused desire to seek wellness and cure, but also revealed misunderstanding of their disease biology, probability of cure, therapeutic options, and treatment morbidity.

CONCLUSIONS

Patient experiences confirm that this is challenging treatment to complete, and that patient understanding of pre-operative information is incomplete. Our findings underscore the need for a multidisciplinary approach when managing this patient population, with emphasis on both supportive care needs and the technically skilled delivery of surgery, chemotherapy, and radiotherapy.

Level-adjusted perioperative risk of sacral amputations

BACKGROUND AND OBJECTIVES

Sacral amputations above the S2 body often involve increased surgical complexity leading to long-term morbidity. The purpose of this study was to determine whether proximal sacral amputations have substantially higher perioperative morbidity compared with more distal sacral amputations.

METHODS

We evaluated the effect of sacral amputation level on perioperative outcomes within 90 days of surgery. Outcome measures included blood loss, intensive care unit (ICU) and hospital stay, hospital cost, and incidence of a major and minor morbidity. Survival analyses were adjusted for the level of resection and histological appearance.

RESULTS

Thirteen proximal and 14 distal resections were performed. In comparing proximal versus distal resections, median estimated blood loss was 4 L versus 1 L (P < 0.001), ICU stay was 4 days versus 0 days (P = 0.012), hospital stay was 19 days versus 8 days (P = 0.001), hospital cost was 28,800 dollars versus 7,500 dollars (P = 0.003), with one or more major complications in 85% versus 29% (P = 0.011). Survival analysis demonstrated that the sacral resection level did not influence survival (P = 0.936), whereas the type of tumor did influence survival (P = 0.012).

CONCLUSION

Tumor resections above S2 demonstrate increased perioperative morbidity, suggesting that proximal osteotomies be reserved for patients with a realistic cure potential.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection

BACKGROUND

Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection.

METHODS

Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy.

RESULTS

Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months).

CONCLUSION

The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.