The management of recurrent pelvic malignancy

Pete Sagar

The General Infirmary at Leeds

England

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Presentation

• PAIN

The problem

• 8-10 000 cases annually of rectal cancer in the UK

• Local pelvic recurrence in 5-15%

Treatment – radiotherapy/chemotherapy

• Good initial palliation

• Long term survivors are rare

• Reserved for end stage disease

Treatment- surgery

• Multimodality therapy

• Team approach essential

• Technical demands

Preoperative assessment

• Biopsy to confirm diagnosis

• CT chest and abdomen

• MRI pelvis

• EUA

• Fitness for operation

The Leeds MDT meeting

Accommodation for relatives

Accommodation for relatives (NHS)

Patterns of pelvic invasion

• Localised type

• Sacral invasion

• Pelvic side wall invasion

Localized type

• Recurrent tumour is localized to the adjacent tissues or connective tissue

Peri-anastomotic recurrence

Perineal recurrence

Mucinous adenocarcinoma

Sacral invasion

• Recurrent tumour invades the lower sacrum (S3, S4, S5) or coccyx

Chordoma with sacral invasion

Sacral invasion- gadolinium enhanced

Lateral invasion

• Recurrent tumour invades pelvic side wall

Pelvic side wall invasion

Vesico-ureteric junction

Planes of attack

APR+S vs TPE+S

Rectus abdominus flap

Anatomical points

When not to operate

Choose your patient!

Contraindications

• Extrapelvic disease

• Invasion of S1 or S2

• Invasion through greater sciatic notch

• Extensive pelvic side wall involvement

• ASA IV-V

Para-aortic nodal involvement

Greater sciatic notch involvement

Surgical intervention contraindicated

Extension through both greater sciatic foramina

Technical tips

Perianastomotic recurrence

Peri-anastomotic recurrence

• Residual mesentery

• Anticipate tearing around the anastomosis

• Beware the medial course of the ureters

Anterior invasion into bladder

Anterior spread

• Trial dissection

• Plane anterior to the bladder

• APER

• Involve the urologist

Sidewall vessel involvement

vessels

Pelvic side wall

• BLEEDING

• Suture

• Fibrillar surgicell

• Argon beamer

• Be prepared to pack

Presacral space, no direct invasion

Pre-sacral mass

• Control iliac vessels before dissection of mass

• Incise peritoneum and develop plane between mass and sacrum

• Beware spongy tumour

Direct invasion into the sacrum

Direct invasion of the sacrum

• Choose level of sacrectomy carefully

• Frozen section

• Beware bleeding from pre-sacral veins

Posterior

exenteration

35%

30%

Total

exenteration

Resection of mass alone

15%

9%

Gynaecological clearance

7%

Anterior

exenteration

Rectal resection with

primary anastomosis

4%

Sacrectomy

16%

Cumulative survival R0 vs R1 resections

Outcome

• One third will live five years

• One third will recur locally (?re-operate)

• One third will die of disseminated disease

Conclusion

• Multidisciplinary management

• Surgery prime modality

• Surgical team approach essential

ENGLAND WIN THE ASHES

Intra-operative radiotherapy

• Delivery of high biological equivalent

• Dose limiting structures are displaced

• 45-60 Gy EBRT pre op

• Deliver remainder at operation

Best practice?

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