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