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
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
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%
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