1
|
Sorrentino L, Colletti G, Belli F, Gronchi A. Extraperitoneal lateral pelvic sidewall excision: a novel rectal-sparing approach for lateral locally recurrent rectal cancer. Updates Surg 2024; 76:1109-1113. [PMID: 38582795 DOI: 10.1007/s13304-024-01834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 03/15/2024] [Indexed: 04/08/2024]
Abstract
Locally recurrent rectal cancer (LRRC) involving the lateral pelvic sidewall requires a complex approach to maximize the likelihood of R0 resection, which is the only predictor of survival. The purpose of this report is to describe a novel technique to resect a localized lateral pelvic sidewall LRRC. A 63-year-old male patient was referred for a 15-mm LRRC near the right internal iliac vessels. Endoscopic ultrasound and magnetic resonance imaging excluded any involvement of the pelvic colon or residual rectum. A combined extraperitoneal antero-lateral approach and gluteal access were used to optimize vascular control on the internal iliac vessels, to promptly identify the ureter and to achieve a better posterior exposition of the sciatic notch. This technique allowed a controlled and tailored resection of pelvic sidewall without entering into the abdominal cavity. The postoperative course was uneventful. The pathologic report confirmed clear margins (R0), with one involving obturator lymph node. At 3 months, the patient is alive and free from local re-relapse. A right lung metastasis has occurred, and it was treated by stereotactic radiotherapy. The present report proposes a novel extraperitoneal pelvic sidewall excision to resect lateral LRRC with a colorectal-sparing approach, thus minimizing the risk of exenterative surgery-related complications. A proper selection of patients is mandatory, as the proposed technique could not be generalized as the standard of care in all lateral LRRCs.
Collapse
Affiliation(s)
- Luca Sorrentino
- Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Gaia Colletti
- Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Filiberto Belli
- Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Alessandro Gronchi
- Sarcoma Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| |
Collapse
|
2
|
Gao Z, Gu J. Surgical treatment of locally recurrent rectal cancer: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1026. [PMID: 34277826 PMCID: PMC8267292 DOI: 10.21037/atm-21-2298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
Objective To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC). Background LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life. Methods We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020. Conclusions LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.
Collapse
Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China.,Department of Gastrointestinal Surgery III, Peking University Cancer Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
| |
Collapse
|
3
|
Sorrentino L, Belli F, Guaglio M, Daveri E, Cosimelli M. Prediction of R0/R+ surgery by different classifications for locally recurrent rectal cancer. Updates Surg 2021; 73:539-545. [PMID: 33555570 DOI: 10.1007/s13304-020-00941-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
A widely adopted classification system for locally recurrent rectal cancer (LRRC) is currently missing, and the indication for surgery is not standardized. To evaluate all the published classification systems in a large monocentric cohort of LRRC patients, assessing their capability to predict a radical (R0) resection. A total of 152 consecutive LRRC patients treated at the National Cancer Institute of Milan (NCIM) from 2009 to 2017 were classified according to Pilipshen, Mayo Clinic, Memorial Sloan-Kettering Cancer Center (MSKCC), Wanebo, Yamada, Boyle, Dutch TME Trial, Royal Marsden and National Cancer Institute of Milan (NCIM) classification systems. Central location of LRRC was significantly predictive of R0 resection across all classification systems. R + resection was predicted by the "anterior" category of MSKCC (OR 2.66, p = 0.007), the "S2b" (OR 3.50, p = 0.04) and the "S3" (OR 2.70, p = 0.01) categories of NCIM, "pelvic disease through anastomosis" of Pilipshen (OR 2.89, p = 0.002), "fixed at 2 sites" of Mayo Clinic (OR 2.68, p = 0.019), and "TR4" of Wanebo (OR 3.39, p = 0.002). The NCIM was the most predictive classification for R0 surgery. The NCIM classification seems to be superior among the others in predicting R0 surgery. Generally, lateral invasive and high sacral invasive relapses are associated with reduced probability of R0 surgery and unfavorable outcomes.
Collapse
Affiliation(s)
- Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Elena Daveri
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| |
Collapse
|
4
|
Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg 2019; 269:315-321. [PMID: 28938268 DOI: 10.1097/sla.0000000000002528] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of the study was to analyze data from an international collaboration, and ascertain prognostic indicators that inform clinical decision-making and practices regarding the role of pelvic exenteration for locally advanced primary rectal cancer (LARC). BACKGROUND With improved national screening programs fewer patients present with LARC. Despite this, select cohorts of patients require pelvic exenteration. To date, the majority of outcome data are from single-center series. METHODS Anonymized data from 14 countries on patients who had pelvic exenteration for LARC between 2004 and 2014 were accumulated. The primary endpoint was overall survival. The impact of resection margin, nodal status, bone resection, and use of neoadjuvant therapy (before exenteration) on survival was evaluated using multivariable analysis. RESULTS Of 1291 patients, 778 (60.3%) were male with a median (range) age of 63 (18-90) years; 78.1% received neoadjuvant therapy. Bone resection en bloc was performed in 8.2% of patients (n = 106), and 22.6% (n = 292) had resection combined with flap reconstruction. Negative resection margin (R0 resection) was achieved in 79.9%. The 30-day postoperative mortality was 1.5%.The median overall survival following R0, R1, and R2 resection was 43, 21, and 10 months (P < 0.001) with a 3-year survival of 56.4%, 29.6%, and 8.1%, respectively (P < 0.001); 37.8% of patients experienced one or more major complication. Neoadjuvant therapy increased the risk of 30-day morbidity (P < 0.012). Multivariable analysis identified resection margin and nodal status as significant determinants of overall survival (other than advanced age). CONCLUSIONS Attainment of negative resection margins (R0) is the key to survival. Neoadjuvant therapy may improve survival; however, it does so at the increased risk of postoperative morbidity.
Collapse
|
5
|
Kulu Y, Mehrabi A, Khajeh E, Klose J, Greenwood J, Hackert T, Büchler MW, Ulrich A. Promising Long-Term Outcomes After Pelvic Exenteration. Ann Surg Oncol 2018; 26:1340-1349. [PMID: 30519763 DOI: 10.1245/s10434-018-07090-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting. METHODS This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses. RESULTS The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor. CONCLUSIONS Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.
Collapse
Affiliation(s)
- Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Klose
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johanna Greenwood
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany
| |
Collapse
|
6
|
The Evolution of Pelvic Exenteration Practice at a Single Center: Lessons Learned from over 500 Cases. Dis Colon Rectum 2017; 60:627-635. [PMID: 28481857 DOI: 10.1097/dcr.0000000000000825] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
Collapse
|
7
|
Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer. Dis Colon Rectum 2017; 60:144-151. [PMID: 28059910 DOI: 10.1097/dcr.0000000000000766] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
Collapse
|
8
|
Quyn A, Austin K, Young J, Badgery-Parker T, Masya L, Roberts R, Solomon M. Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:823-8. [DOI: 10.1016/j.ejso.2016.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/22/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
|