Indications and Outcome of Pelvic Exenteration for Locally
Advanced Primary and Recurrent Rectal Cancer
Aneel Bhangu, MBChB, MRCS, S. Mohammed Ali, MBBS, MRCS, Gina Brown, MBBS, FRCR,R. John Nicholls, MChir, FRCS, and Paris Tekkis, MD, FRCS
Annals of Surgery February 2014 Objective Compare the outcome of pelvis exenteration in patients with LAP and RRC in a high volume tertiary referral center Identify risks and benefits of pelvic exenteration for advanced rectal cancer in a multidisciplinary environment Background 1.23 new cases of RC in 2008 40,000 new cases in USA 14,000 in UK: 33% locally advanced (T4) Total mesorectal excision with neoadjuvant radiotherapy: margin negative rates of 90% and local recurrence rates between 6-10% 6% will breach the mesorectal plane Resectable RRC R0 rates: 37-57% Multivisceral exenterative surgical resection offers the best chance of cure for LAP and RRC Methods Prospectively maintained database of Royal Marsden Hospital Patients undergoing surgery for LAP and RRC from Jan 2006 to Dec 2011 Noncolorectal and benign retrorectal tumors were excluded Performed by a colorectal team and supported by surgical oncology, spinal orthopedics, urology, gynecology and plastic surgery Staging and Neoadjuvant Therapy Clinical examination, endoscopy, MRI, CT scan and PET scan Organ specific resection: likelihood of involvement, need for surgical access, risks and patient discussion Radiotherapy naive patients were offered a long-course chemoradiotherapy, others were given a booster Patients with multifocal disease, distant metastases were treated medically Some patients proceeded directly to surgery if anatomically identified R0 resection planes on MRI Restaging was done after 6-8 weeks and surgery after 6 weeks of last radiological staging test Endpoints Primary: 3 year disease free survival Seconday: 3 year overall survival, 3 year local recurrence free survival, resection margins and perioperative adverse effects Defenitions RRC: Locally recurrent, new sites of tumor in pelvis after previous surgery LAP: Needing resection beyond mesorectum to achieve R0 (MRI) Margins: R0 -ve within 1mm, R1 +ve within 1mm, R2 invading margin Adverse: Intraoperative, major within 30 days, minor within 30 days, long term beyond 3 months DFS: Date of surgery to pelvic recurrence, distant disease or death OS: Date of surgery to death LRFS: Date of surgery to pelvic recurrence or death Results 272 rectal cancer resections: 172 for nonadvanced and 100 pelvic exenterations (55 LAP and 45 RRC) Median age 60, 70% men 45 RRC patients: 32 anterior resections, 5 abdominoperineal resections, 3 exenterations, 2 local excisions and 1 Hartman. 33% took radiotherapy Neoadjuvant therapy: 70 chemoradiotherapy, 5 radiotherapy, omitted in 22% of LAP (12/55) and 29% of RRC (13/45) Surgery Most patients (49%) required resection of 2 compartments, 1 required resection of 4 Anterior compartment: 65% (36/55) in LAP and 33% (15/45) in RRC Posterior compartment: 15% (8/55) in LAP and 53% (24/45) in RRC Sacrectomy: 49% in RRC and 15% in LAP, 70% were for RRC Inferior compartment: 27 patients, 19 required extralevator abdominoperineal resection ( 14 LAP and 5 RRC) with en bloc removal of coccyx Cystectomy: 40% (22/55) in LAP and 31% (14/45) in RRC Bowel reanastamosis: 32% Perineal reconstruction: 55%, 96% (53/55) flap Associated procedures: 4 in LAP (3 syn hepatectomies, 1 syn para- aortic lymphadenectomy) 3 in RRC (1 staged hepatectomy, 1 syn RF ablation, 1 staged lung lobectomy) Short Term Outcome No 30 day or inhospital mortality Mean blood loss 2048 ml: 1689 LAP 2444 RRC P=0.135 Median duration of surgery 8.4 hrs, median stay in hospital 21 days (similar) Sacrectomy: longer duration, longer stay, higher blood loss Cystectomy: longer duration Perineal flap: longer mean operating time and mean length of stay Resection Margin and Pathological Outcome R0 78%, R1 15%, R2 7% R0: 91% (50/55) in LAP, 62% (28/45) in RRC R1: 5% in LAP, 27% in RRC R2: 4% in LAP, 11% in RRC Most of +ve margin were on pelvic sidewall (10) Pathological complete response: 3 in LAP, 4 in RRC Organ Specific Exenteration Based on preoperative MRI: 63.9% of cystectomies, 73.9% of prostatectomies, and all sacrectomies Tumor regression by histology: 30% of cystectomies, 41% of prostatectomies and 26% of sacrectomies Adverse Events 53% suffered at least one event: 49% in LAP and 58% in RRC 98 separate events: 10 intraoperative, 28 30- day major, 38 30-day minor and 21 long term Intraoperative: 7 bleeding more than 5L,1 bleeding more than 17L, 1 ventricular fibrillation and 1 sciatic nerve injury Disease Free Survival R0 67%, R1 49%, R2 0% 70% for LAP and 50% for RRC R0: 76% for LAP and 57% for RRC Positive margin status and positive node staging were significant predictors for reduced DFS on multivariate Cox regression analysis Overall Survival R0 82%, R1 55%, R2 0% 78% in LAP 65% in RRC R0: 85% in LAP vs 79% in RRC Positive margin status and positive node staging were significant predictors of reduced OS Local Recurrence Free Survival R0 85%, R1 46% 84% in LAP and 72% in RRC R0: 86% in LAP and 84% in RRC Only positive margin status was a significant predictor of a reduced LRFS Conclusion The key prognostic indicator for outcome from pelvis exenteration for LAP and RRC is resection margin status More important than wether the tumor is primary or recurrent Patients with RRC are at a higher risk for positive margins Long term survival for both LAP and RRC can be achieved with pelvic exenteration although morbidity could be high Survival after R0 resection is excellent and exenteration should be offered where resection beyond TME planes is required Thorough preoperative planning and high quality surgery are required to maximize the chances of R0 resection