DOI: http://dx.doi.org/10.18203/2349-2902.isj20204685

Pelvic exenteration for locally advanced and local recurrent primary rectal cancer: a 5 years Asian retrospective cohort study and lessons to learn

Yeen Chin Leow, Fitjerald Henry, Fei Yee Lee

Abstract


Background: Locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC) were deemed incurable, but with surgical advancement, pelvic exenteration has emerged as a curative option. Although colorectal cancer cases are common, pelvic exenterations are limited to several centres in Malaysia. The study aimed to determine the outcomes of pelvic exenteration from the centre in terms of complete resection, local recurrence rate, mortality rate and complications rate.

Methods: Retrospective data collection was done for pelvic exenteration surgeries of LARC and LRRC from year 2014 till 2018 in a Malaysian tertiary referral centre. Demographic data, types of pelvic exenteration, postoperative complications, postoperative histopathology for complete resection (R0) and local recurrence were collected from the hospital medical records.

Results: From 2014 till 2018, 51 cases of pelvic exenteration were done, with a mean age of 55.8±12.4 years and predominance of male gender (55%). Thirty-four cases (66.7%) completed the exenteration. A mere 24 cases (47.1%) had complete preoperative imaging of computed tomography (CT scan), pelvic magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET/CT) scan. R0 resection was achieved in 23 cases (67.6%). Complications were found in 44.8% of patients including anastomotic leak, collection, surgical site infection or cardiac/lung complications. The 30-days postoperative mortality rate is 3.9%. The six-months local recurrence rate was 5.8% and one-year local recurrence rate was 7.8%.

Conclusion: Pelvic MRI and PET-CT scan is suggested to be compulsory for all pelvic exenteration candidates to ensure a good outcome. Multidisciplinary team approach is needed preoperatively to discuss the feasibility of pelvic exenteration to optimise the outcomes of this surgery.


Keywords


Pelvic exenteration, LARC, LRRC

Full Text:

PDF

References


Lopez M, Petros J, Augustinos P. Development and evolution of pelvic exenteration: historical notes. Semin Surg Oncol. 1999;17:147-51.

Brunschwig A. Pelvic exenteration for carcinoma of the lower colon. Surg. 1956;40(4):691-9.

Cai Y, Li Z, Gu X, Fang Y, Xiang J, Chen Z. Prognostic factors associated with locally recurrent rectal cancer following primary surgery (Review). Oncol Lett. 2014;7(1):10-16.

Lee DJ, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: How far have we come? World J Gastroenterol. 2017;23(23):4170-80.

Feletto E, Yu XQ, Lew JB, St John DJB, Jenkins MA, Macrae FA et al. Trends in Colon and Rectal Cancer Incidence in Australia from 1982 to 2014: Analysis of Data on Over 375,000 Cases. Cancer Epidemiol Biomarkers Prev. 2019;28(1):83-90.

Austin KK, Solomon MJ. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum. 2009;52(7):1223-33.

Teixeira SC, Ferenschild FT, Solomon MJ, Rodwell L, Harrison JD, Young JM et al. Urological leaks after pelvic exenterations comparing formation of colonic and ileal conduits. Eur J Surg Oncol. 2012;38(4):361-6.

Solum AM, Riffenburgh RH, Johnstone PA. Survival of patients with untreated rectal cancer. J Surg Oncol. 2004;87(4):157-61.

Quyn AJ, Austin KK, Young JM, Poggioli G. Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life. Eur J Surg Oncol. 2016;42(6):823-8.

Tan KK, Pal S, Lee PJ, Rodwell L, Solomon MJ. Pelvic exenteration for recurrent squamous cell carcinoma of the pelvic organs arising from the cloaca--a single institution's experience over 16 years. Colorectal Dis. 2013;15(10):1227-31.

Milne T, Solomon MJ, Lee P, Young JM, Stalley P, Harrison JD et al. Sacral resection with pelvic exenteration for advanced primary and recurrent pelvic cancer: a single-institution experience of 100 sacrectomies. Dis Colon Rectum. 2014;57(10):1153-61.

Ahmadi N, Tan K-K, Solomon MJ, Al-Mozany N, Carter J. Pelvic Exenteration for Primary and Recurrent Gynecologic Malignancies Is Safe and Achieves Acceptable Long-Term Outcomes. J Gynecol Surg. 2014;30(5):255-9.

Yang TX, Morris DL, Chua TC. Pelvic exenteration for rectal cancer: a systematic review. Dis Colon Rectum. 2013;56(4):519-31.

PelvEx C. Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg. 2019;269(2):315-21.

Brown KG, Koh CE, Solomon MJ, Qasabian R, Robinson D, Dubenec S. Outcomes After En Bloc Iliac Vessel Excision and Reconstruction During Pelvic Exenteration. Dis Colon Rectum. 2015;58(9):850-56.

Solomon M, Austin K, Masya L, Lee P. Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration. Dis Colon Rectum. 2015;58(11):1114-9.

Solomon MJ. Re-exenteration for recurrent rectal cancer. Dis Colon Rectum. 2013;56(1):4-5.

Powell R, Scott NW, Manyande A, Bruce J, Vögele C, Byrne-Davis LMT et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev. 2016(5):Cd008646.

Pawlik TM, Skibber JM, Rodriguez-Bigas MA. Pelvic exenteration for advanced pelvic malignancies. Ann Surg Oncol. 2006;13(5):612-23.

Wanebo HJ, Koness RJ, Vezeridis MP, Cohen SI, Wrobleski DE. Pelvic resection of recurrent rectal cancer. Ann surg. 1994;220(4):586-97.

Lopez MJ, Standiford SB, Skibba JL. Total pelvic exenteration. A 50-year experience at the Ellis Fischel Cancer Center. Arch Surg. 1994;129(4):390-95.

Registry NC, Institute NC. Malaysian Study on Cancer Survival (MySCan). In: Malaysia MoH, ed 2018;1-57.

Koh C, Solomon M. Management of Locally Advanced and Recurrent Rectal Cancer. In: Patel H, Mould T, Joseph J, Delaney C, eds. Pelvic Cancer Surgery. London: Springer. 2015.

Lemeshow S, Hosmer DW, Klar J, Lwanga SK, World Health O. Adequacy of sample size in health studies / Stanley Lemeshow ... [et al.]. In: Chichester : Wiley; 1990. Available at: https://apps.who.int/iris/handle/10665/41607

PelvEx Collaborative. Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg. 2019;269(2):315-21.

Cornell J, Lawrence V, Lang TA, Secic M. How to report statistics in medicine. Philadelphia: American College of Physicians, 2006. Evidence-based Med. 2007;12:90-91.

Solomon MJ, Brown KG, Koh CE, Lee P, Austin KK, Masya L. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg. 2015;102(13):1710-17.

Messiou C, Chalmers AG, Boyle K, Wilson D, Sagar P. Pre-operative MR assessment of recurrent rectal cancer. Bri J Radiol. 2008;81(966):468-73.

Brown WE, Koh CE, Badgery-Parker T, Solomon MJ. Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer. Dis Colon Rectum. 2017;60(2):144-51.

Austin KK, Herd AJ, Solomon MJ, Ly K, Lee PJ. Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer. Dis Colon Rectum. 2016;59(9):831-5.

Brown KG, Koh CE, Solomon MJ, Choy IC, Dubenec S. Spiral saphenous vein graft for major pelvic vessel reconstruction during exenteration surgery. Ann Vasc Surg. 2015;29(6):1323-6.