Pelvic exenteration and sphincter preservation: an analysis of 96 cases

BACKGROUND: Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results. METHODS: Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed. RESULTS: Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival. CONCLUSIONS: The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.     

Surgery with intraoperative radiotherapy for sarcomas of the pelvic girdle: A pilot experience

Sarcomas of the pelvic girdle represent difficult treatment problems. Many are not treatable for cure, and among the patients who are technically resectable, there is high risk for local tumor recurrence and distant spread. Intraoperative radiotherapy (IORT) has been used in conjunction with surgical resection in five patients with extensive sarcomas of the pelvic girdle. Patients underwent a hemipelvectomy and IORT (dose 20–30 Gy) to the sacral resection margin and surrounding soft tissues. Three patients developed pulmonary metastases within 3 months and eventually died from metastastic disease (8–38 months). Two patients have remained disease-free (43 and 53 months). Four patients (80%) have remained locally free of tumor with follow-ups of 8–53 months. The only treatment complication was late osteonecrosis of the coccyx which appeared 7 months after treatment. By contrast, six historical control patients with sarcomas of the pelvic girdle treated with resection alone showed a local control rate of only 27% over a 40-month follow-up. On the basis of this preliminary experience, it appears that IORT may substantially help to control local disease in patients with grossly resectable sarcomas of the bony pelvis.     

Predictors for long-term survival after interdisciplinary salvage surgery for advanced or recurrent gynecologic cancers

BACKGROUND AND OBJECTIVES: We wanted to identify factors which allow predicting long-term survival after pelvic exenteration (PE) for locally advanced or recurrent gynecologic malignancies. METHODS: All patients undergoing PE at our institution from 1983 to 2002 were screened. In 203 cases data were obtainable and analyzed with respect to factors predicting outcome considering morbidity, mortality, and survival. Follow-up data and data concerning late complications not documented in our records were obtained by telephone interviews. RESULTS: Mean age was 55 (22-77) years. PE was performed for locally advanced (36%) or recurrent (64%) cervical (n = 133), endometrial (n = 26), vaginal (n = 23), vulvar (n = 10), and ovarian cancer (n = 11, cases with rectum and/or bladder resections). In 13.4% (n = 26) the intent of the procedure was palliation in the remaining cure. Procedures performed were anterior (n = 91), posterior (45), or total (n = 67) PE. 53% of patients underwent preoperative radio-chemotherapy, 11.8% as a neoadjuvant treatment. Mean OR time was 8.1 hr, an average of 5.6 units of packed red blood cells were perioperatively transfused. Microscopically complete resection was achievable in n = 69 patients. Perioperative mortality was 1% (n = 2). Seventy-one percent (n = 144) of patients were available for follow-up. Five-year overall survival in patients treated with a curative intent was 21%, 5-year survival in those patients with complete resection was 32%. Forty-two percent of patients with a complete resection without lymph node involvement, age 30-50, curative intention, and the absence of a pelvic sidewall infiltration survived 5 years or longer. CONCLUSION: In our series a 5-year survival rate of over 40% could be achieved for nodal-negative patients without pelvic sidewall infiltration when treated with curative intent and after complete resection.     

Management of advanced pelvic cancer by exenteration.

AIM: To describe our results in managing locally advanced primary or recurrent pelvic malignancies. METHOD: Investigations included: clinical, laboratory, endoscopic (rectoscopy and colonoscopy) examinations, ultrasound scan, and CT scan or MRI of the abdomen and pelvis, to determine the extent of the pelvic malignancy. A careful explorative laparatomy of abdomen and pelvis was performed, followed by anterior, posterior or total pelvic exenteration. RESULTS: In the period June 1995-Jan 2002, 7 anterior, 2 posterior and 51 total pelvic exenterations were performed in 60 patients, distributed as follows: 28 for rectal cancer (12 primary, 16 recurrent), 20 for cervical cancer (9 primary, 11 recurrent) and 12 for other pelvic malignancies. The median survival time and overall 5-year survival rates were as follows: primary rectal cancer--50 months and 32%; recurrent rectal cancer--31 months and 17%; primary cervical cancer--46.4 months and 41% and recurrent cervical cancer--23.4 months and 16%. During the same period, 559 of our patients were treated for primary or recurrent rectal cancer by different types of straightforward resection. CONCLUSION: Pelvic exenteration is justifiable in cases of locally advanced primary and recurrent malignancies of rectum, cervical cancer and possibly in cases of other pelvic malignancies.     

23例软组织肉瘤非计划切除的原因及对策分析*

目的:分析导致软组织肉瘤非计划切除的原因并探讨避免软组织肉瘤非计划切除的策略。方法:自2009年10月至2012年12月新疆医科大学第一附属医院骨科中心骨病骨肿瘤科收治的105 例软组织肉瘤患者资料,其中男性65例,女性40例,平均年龄52岁;接受计划性软组织肉瘤切除术患者82例（计划手术组）,曾于外院接受非计划切除术的软组织肉瘤患者23例（非计划手术组）。 计划手术组患者行广泛切除及根治切除术,非计划手术组患者行扩大切除术。统计分析两组患者一般情况、病灶位置及大小、手术边界、肿瘤复发转移情况,并比较两组患者生存期。结果:非计划手术组达到广泛切除边界的比例明显低于计划手术组（P<0.05）。 非计划手术组患者3 年生存率明显低于计划手术组（P=0.001）。 非计划手术组平均随访18个月（3～36个月）,12例死亡（52.2%）,其中9 例（39.1%）死于肿瘤转移,3 例死于其他疾病;计划手术组平均随访23个月（5～36个月）,15例（18.3%）死亡,其中12例（14.6%）死于肿瘤转移,3 例死于其他疾病。结论:与计划手术相比,软组织肉瘤非计划切除常导致手术范围不足、肿瘤复发转移的风险,可能增高肿瘤所致的死亡率。临床医生应尽量避免非计划切除手术的发生。      

子宫内膜癌患者盆腔加腹主动脉旁淋巴结切除的临床意义

目的 分析子宫内膜癌患者盆腔加腹主动脉旁淋巴结切除的临床意义.方法 选取子宫内膜癌患者71例为研究对象,行盆腔加腹主动脉旁淋巴结切除术,分析患者术后临床特征,以及影响患者盆腔及腹主动脉旁淋巴结转移的危险因素.结果 对盆腔及腹主动脉旁淋巴结患者行切除术后淋巴结转移率较低,分别为21.2%和23.9%,且患者术后并发症较少,仅为7例;线性回归分析提示,影响盆腔淋巴结转移的独立危险因素有肿瘤中低分化、深度肌层浸润、临床分期及脉管浸润,而影响腹主动脉旁淋巴结转移的独立危险有肿瘤低分化、非子宫内膜样癌、深度肌层浸润、盆腔淋巴结转移及淋巴管浸润;71例患者随访1年生存率为87.32%,且发生盆腔加腹主动脉旁淋巴结转移患者的生存率明显低于无淋巴结转移者.结论 盆腔加腹主动脉旁淋巴结切除,有利于提高子宫内膜癌患者的临床治疗效果,而且安全性较高,值得临床推广应用.     

High dose preoperative radiation and sphincter preservation in the treatment of rectal cancer

Abdominoperineal resection and permanent colostomy have been the mainstay of treatment for rectal cancer. Automatic stapling devices have widened the scope of low anterior resection, permitting sphincter preservation for tumors originating in the upper and middle thirds of the rectum. Attempts at sphincter preservation in low rectal cancer has resulted in higher recurrence in the pelvic/perineal tissues (41%, MSKCC). In 1976, we undertook a study to expand the scope of sphincter preservation in patients with rectal cancer. Patients were selected because of the presence of unfavorable tumors or low level of rectal area (3 and 6 cm from the dentate line). Forty-three patients were treated in this program. Follow-up ranges from 24 to 96 months, with a median follow-up of 36 months. Fifteen patients were selected for unfavorable tumor types and 28 patients were selected for low level of tumor, between 3 and 6 cm. Twenty of the 28 patients with low level tumors also had unfavorable tumors. All patients received the full course of preoperative radiation (4000 to 4500 cGy in 5 weeks). Surgery was carried out 4 to 6 weeks following radiation and consisted of a sphincter saving procedure, usually by combined abdominotranssacral resection. There was no perioperative mortality. A single anastomotic breakdown required reconstruction. Thirteen patients in this group have died, 9 of these with disease and 3 without evidence of tumor. There were 6 (14%) local recurrences in the pelvic/perineal area. Survival of all patients at 4 years is 66%. This early experience indicates that the high dose preoperative radiation can minimize local recurrence in unfavorable cancers and allows sphincter saving surgery to be performed with small, safe margins in the lower rectal cancers.     

屏障切除术治疗复发性软组织肉瘤的疗效分析

目的：评价屏障切除术治疗复发性软组织肉瘤（STS）的疗效。方法：对81例复发性STS行屏障切除术。27例术中切缘再确认。修复重建73例。手术＋放疗＋化疗3例;手术＋放疗3例;手术＋化疗10例。1例术前隔离热药灌注。结果：术中切缘阳性2例,占7.4%。随访时间平均30个月（12～138个月）,复发13例,占16.0%。屏障切除后的平均复发时间较前次延长18个月。结论：屏障切除术复发率明显低于广泛切除术。     

Soft tissue sarcomas involving the pelvis

BACKGROUND AND OBJECTIVES: Soft tissue sarcomas (STS) of the true pelvis are rare tumors and there is little information in the literature related to pelvic STS. The purposes of this review were to understand the anatomic extension of these tumors to better plan surgical treatment and to determine the outcome of these patients. METHODS: Eighteen consecutive patients presenting between 1987 and 1995 with soft tissue sarcomas involving the true pelvis were retrospectively reviewed at minimum follow-up of 18 months. Cross-sectional imaging was reviewed for each patient to determine the anatomical location of the lesions. RESULTS: The tumors were confined to the true pelvis in 4 patients, extended to the retroperitoneum in three cases, and extended to the thigh in 11 patients. Adjuvant radiation was administered to all but 2 patients who had received radiation to the region in the past and all patients underwent surgical resection (local resection in 13 patients and hindquarter amputation in 5 patients). Surgical resection had a high rate of morbidity and complications including positive resection margins in nine individuals. Of the 18 patients, 11 died at a mean time of 15.5 (2-58) months from surgery, 4 were alive with evidence of disease at a mean time of 44.3 (18-68) months, and 3 were alive with no evidence of disease at a mean time of 57 (43-71) months. CONCLUSIONS: Soft tissue sarcoma of the pelvis is fortunately a rare disease with a high risk of local and systemic disease progression despite treatment with irradiation and surgical resection.     

Image navigation assisted joint-saving surgery for treatment of bone sarcoma around knee in skeletally immature patients

PurposeIt is challenge to perform a native joint preserving resection for skeletally immature patients with bone sarcomas around the knee. We determined whether tumor resection under image-guided navigation make joint-saving surgery possible for juxta-articular sarcomas around knee while adhering oncological principles.MethodsWe performed joint-saving limb salvage surgeries on eight patients with metaphyseal bone sarcomas (6 in proximal tibia, 2 in distal femur). Six tumors extend to and 2 beyond the epiphyseal line. Planned tumor resection under image-guided navigation was employed for obtaining clear surgical margin while maximizing host tissue preservation. All tumors were en bloc removed and intercalary defect were reconstructed by combination of allograft with vascularized fibula flap. All specimens were examined for resection margin. Patients were followed up at average of 40.5 months for evaluating of oncologic and functional outcomes.ResultEntire joints were preserved in 5 patients and partial joints were saved in 3 patients. Clear surgical margins were achieved in all patients. The minimum of surgical margin width in bone is 6 mm in this series. No patient experienced local recurrence. Bone union achieved in all cases during the study period. The average MSTS score was 27.1 at final follow-up.ConclusionsWith careful patient selection, image navigation aided bone tumor resection was proved to be an effective way in joint-saving limb salvage procedures for treating skeletally immature patients with juxta-articular bone sarcomas around the knee.     

Role of pelvic radiotherapy for locally advanced rectal cancer and synchronous unresectable distant metastases

PurposeTo evaluate the efficacy and safety of pelvic irradiation combined systematic chemotherapy in patients with locally advanced (cT3–T4 and/or cN+) rectal cancer and synchronous unresectable distant metastases.Patients and methodsA total of 76 eligible patients who received pelvic radiotherapy and concurrent capecitabine-based chemotherapy were retrospectively reviewed. Patients survival curves were constructed using the Kaplan-Meier method, and a multivariate analysis was performed to identify independent prognostic factors.ResultsMost of the adverse events were mild during the period of combined chemoradiotherapy. Twenty-two patients experienced resection of primary tumour and 16 patients underwent radical surgery of all lesions. Only five patients had pelvic progression during the follow-up period. The median progression-free survival and median overall survival were 13 and 30 months, respectively. Radical surgery of all lesions following chemoradiotherapy was found to be an independent prognostic factor according to multivariate analysis.ConclusionsPelvic irradiation combined with systematic chemotherapy in patients with locally advanced rectal cancer and synchronous unresectable distant metastases is effective and tolerable, both for pelvic and distant control. A curative resection following chemoradiotherapy was associated with prolonged survival.     

The use of silicone expander and cecal transposition after pelvic exenteration.

AIMS: Describe a new approach for pelvic floor treatment employing a temporary mechanical support device with silicone expander, with or without association to cecal transposition. METHODS: From January 2000 to June 2006, 106 patients were submitted to pelvic exenteration. A retrospective evaluation was done of the last 30 patients previously submitted to total pelvic exenteration without neither urinary nor faecal sphincter preservation who latter were submitted to a pelvic floor treatment with silicone expander with or without association to cecal rotation. RESULTS: Twenty-six patients were female and four male. The most common primary neoplasm site were of gynecological origin (20 cases). The median follow-up period was 12 months (0.36-38). Only one patient presented small intestine loops slipping after expander removal. No other patient had small intestine loops slippage into the pelvis, probably because of cecal transposition. All patients were submitted to a post-operative CT scan to confirm that intestinal loops remained out of the pelvis. Six patients presented pelvic hollow infection after device removal. All cases had complete resolution with local cleaning using physiological solution associated with systemic antibiotic therapy, except one who needed a trans-abdominal surgical approach. CONCLUSIONS: Pelvic floor treatment employing a temporary mechanical support device with silicone expander, associated or not to cecal transposition is a low-morbidity procedure. The most common complication is pelvic floor infection, but maintaining a cutaneous perineal hole allows easy access and treatment of possible pelvic abscesses as well as early recurrence diagnosis.     

骨盆肿瘤的手术治疗

目的探讨骨盆肿瘤的切除与重建方式。方法1991年7月～2006年12月,20例骨盆肿瘤患者接受骨盆肿瘤切除手术,其中18例又接受重建手术。男12例,女8例。软骨肉瘤9例,骨巨细胞瘤5例,尤文氏肉瘤1例,骨嗜酸性肉芽肿1例,腺泡状肉瘤1例,转移癌3例。根据Enneking骨盆肿瘤分区:I区7例,II区8例,III区5例。I区的2例切除范围较局限未重建。重建方法为I区肿瘤切除后使用自体腓骨重建2例,斯氏钉 骨水泥重建1例,钢板 骨水泥重建2例。II区的肿瘤切除后4例行股骨头旷置,2例行人工半骨盆置换,2例行钢板、骨水泥 人工全髋关节植入方式重建。III区的肿瘤切除后,5例均采用钢板 骨水泥重建。术后随访3个月～15年。结果局部复发5例,再次接受复发灶切除2例,放弃治疗3例。所有股骨头旷置病例均无复发。死亡6例。侵犯I、III区的肿瘤切除后,患者步态基本正常。侵犯II区的肿瘤切除后行人工半骨盆置换或行钢板、骨水泥 人工全髋关节植入的患者,半年后行走基本正常。接受股骨头旷置的患者,有较满意的活动度,行走时跛行。结论骨盆肿瘤切除重建的原则是首先完整切除肿瘤,然后再作功能重建。重建方式的选择应考虑各种方法的优缺点,尽量减少并发症的发生。     

Extracorporeal irradiation for malignant bone tumors

PURPOSE: Extracorporeal irradiation (ECI) has been used selectively in the management of primary malignant bone tumors since 1996. We report our techniques for ECI and the short-term oncologic and orthopedic outcomes. METHODS AND MATERIALS: Sixteen patients with primary malignant bone tumors were treated with ECI from 1996 to 2000. The median age was 14 years. The histologic diagnoses were Ewing's sarcoma (11), osteosarcoma (4) and chondrosarcoma (1). The treated sites were femur (7), tibia (4), humerus (2), ilium (2), and sacrum (1). Following induction chemotherapy in Ewing's sarcomas and osteosarcoma, en bloc resection of the tumor and tumor-bearing bone was performed. A single dose of 50 Gy was delivered to the bone extracorporeally using either a linear accelerator (9 cases) or a blood product irradiator (7 cases). The orthopedic outcome was recorded using a standard functional scale. RESULTS: At a median follow-up of 19.5 months, there were no cases of local recurrence or graft failure. One patient required amputation due to chronic osteomyelitis. For the 10 patients with follow-up greater than 18 months, the functional outcomes were graded good to excellent. CONCLUSION: The short-term oncologic and orthopedic results are encouraging and suggest that ECI provides a good alternative for reconstruction in limb conservative surgery in selected patients. This technique should only be used in a multidisciplinary setting, where careful follow-up is available to assess the long-term outcomes.     

Internal hemipelvectomy for bone sarcomas in children and young adults: surgical considerations.

AIMS: Pelvic bone sarcomas in children and young adults are rare, and associated with a poor prognosis and a high rate of local recurrence. Primary goals of treatment include prevention of local recurrence and distant metastases. A secondary goal is maintenance of quality of life by avoiding major amputative surgery. This is why internal hemipelvectomy (a limb-sparing surgery) is advocated whenever possible. The focus of our presentation is surgical issues in the context of resection and reconstruction of the pelvis in the first two decades of life. MATERIALS AND METHODS: Between January 1988 and June 1998, 27 patients were treated and operated on (follow-up time 1.5-12 years). There were 17 males and 10 females. Their age ranged between 2 and 22 years. There were 24 patients with Ewing's sarcoma (ES) and three with other bone sarcomas. In 19 patients the tumour involved the entire or part of the iliac bone (in some cases with extension to the sacrum). In five patients the tumour involved the pubis and/or ischium. In three patients the tumour involved the sacrum with some extension to the posterior iliac bone. All patients received neoadjuvant and adjuvant chemotherapy and radiotherapy with different protocols (related to the origin of referral). RESULTS: Twenty-seven patients underwent internal hemipelvectomy. According to Enneking's classification there were: type I-10; type II-one; type III-six; type IV-five (including one localized sacrectomy); type I+IV-five patients. In 15 patients some kind of reconstruction was needed and in 12 no reconstruction was done. Four wound infections occurred that were managed successfully by surgical debridement, antibiotics and local wound care. In one case removal of the 'implant' was needed. No primary or secondary amputations were performed in the series. The rate of local recurrence was 22%. Functional status at the last follow-up visit or before death, according to the AMSTS functional rating system: excellent-six; good-17; fair-three and poor-one. All patients except the one poor result maintained their walking ability during the follow-up time. CONCLUSIONS: Internal hemipelvectomy is achievable in most cases and justified for better quality of life in children, adolescents and young adults with sarcomas. Further efforts are needed to improve the reconstructive options in the pelvis.     

盆腔恶性肿瘤并发急性下肢深静脉血栓形成的腔内介入治疗（附32例）

目的:探讨盆腔恶性肿瘤并发急性下肢深静脉血栓形成（DVT）原因及腔内治疗经验。方法:对2009年1月至2015年3月收治经导管接触性溶栓（CDT）及球囊扩张（PTA）或联合支架植入（髂静脉狭窄≥50%时）治疗32例盆腔恶性肿瘤并发急性下肢DVT患者临床资料进行回顾性分析。结果:32例患者CDT前均置入腔静脉滤器（VCF）,溶栓时间为（5.3±2.6） d,尿激酶用量（320±130）万U,溶栓后下肢深静脉平均通畅率为（83.7±16.9）%,溶栓期间仅3例出现轻度出血,调整用药后消失。13例髂静脉狭窄≥50%行支架植入治疗,共植入支架17枚;11例髂静脉狭窄在30%～49%之间仅行PTA;8例髂静脉狭窄＜30%未行球囊扩张及支架植入。治疗期间无症状性肺栓塞（PE）发生。30例患者获得随访,随访（13.6±5.4）个月,6例下肢深静脉血栓复发,其中1 例支架内血栓复发,4例血栓复发原髂静脉狭窄在30%～49%之间,1例血栓复发原髂静脉狭窄＜30%。均再次CDT联合PTA及支架植入治疗成功。结论:盆腔恶性肿瘤及放疗是发生急性下肢DVT、血栓复发的危险因素,血管腔内介入治疗是积极有效的治疗方法;当髂静脉狭窄超过30%时,我们建议支架植入治疗。     

A prospective study on radical and nerve-preserving surgery for rectal cancer in The Netherlands

INTRODUCTION: Preservation of the pelvic autonomic nerves is thought to lower bladder and sexual dysfunction after rectal cancer surgery. A prospective study was undertaken in a Dutch population to evaluate functional outcome, local recurrence and survival of a Japanese operative technique combining nerve preservation with radical tumour resection. METHODS: Forty-seven patients were operated upon by a Japanese surgeon. Voiding and sexual function were prospectively analysed using questionnaires. Two-year follow-up on urinary function was complete in 73%, and 2-year follow-up of male sexual function was complete in 77%. Median follow-up for survival and recurrence was 42 months and was complete in all patients. RESULTS: Five patients (19%) developed minor urinary incontinence in the period between 1 and 2 years of follow-up. Six patients (22%) had a persistently elevated frequency of voiding. There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunctions. None of the patients reported major incontinence of urine. Impotence was related to sacrifice of the inferior hypogastric plexus and ejaculatory dysfunction was related to sacrifice of the superior hypogastric plexus. Sexual function did not change during follow-up. Of 42 curatively-operated patients, three (7.1%) developed local recurrence. Sixty-seven per cent were overall free of recurrence. Disease-free survival was 57%. CONCLUSIONS: Preservation of the pelvic autonomic nerves minimizes bladder dysfunction after rectal cancer surgery. The preservation of the total autonomic nerve system is essential for normal sexual function in male patients. Nerve preservation does not compromise radicality in mesorectal excision. Mesorectal excision should involve identification and preservation of the pelvic autonomic nerves.     

Radiation-induced sarcomas of the chest wall

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.     

T4 rectal cancer treated with preoperative chemoradiation to the posterior pelvis followed by multivisceral resection: patterns of failure and limitations of treatment

PURPOSE: To analyze the overall pattern of treatment failure and sites of pelvic disease recurrence relative to the radiation fields used in treating patients with clinically staged T4 rectal cancer with preoperative chemoradiation followed by multivisceral resection. METHODS AND MATERIALS: Between 1990 and 1998, 45 patients with T4 rectal cancer were treated with preoperative chemoradiation. Clinical staging was according to the system of the American Joint Cancer Committee and was based on endoscopic ultrasonography, chemotherapy (CT), and physical examination. A diagnosis of T4 disease required evidence of invasion of a contiguous structure on CT (n = 31) or endorectal ultrasonography (n = 6), vaginal mucosal involvement on pelvic examination (n = 6), or a combination of these findings (n = 2). Chemoradiation was delivered with 18 MV photons using a 3-field belly-board technique. The median total dose was 45 Gy in all patients (range 45-63). Nine patients received a boost with external beam radiotherapy (EBRT) (n = 5, 1.8-18 Gy), intraoperative RT (n = 3, 10-20 Gy), or interstitial brachytherapy (n = 1, 20 Gy). All patients received concurrent chemotherapy consisting of protracted venous infusion 5-fluorouracil (300 mg/m(2), 5 d/wk). Resection was not performed in 13 (29%) of the 45 patients because of metastases detected before resection or patient refusal. Multivisceral resection and pelvic exenteration was required in 21 (66%) and 11 (34%) of 32 patients, respectively. We compared the location of pelvic disease recurrence with the RT simulation films. The Kaplan-Meier method was used to calculate the 4-year actuarial pelvic and distant recurrent rates and the overall survival rate. RESULTS: The median length of follow-up was 31.0 months for all patients and 40.0 months for patients alive at last follow-up. When only the resected cases were considered, the local recurrence rate was 20%. Distant metastases occurred in 44% of cases; the overall survival rate was 69%. When all patients were considered, the local recurrence rate was similar (24%), but the rate of distant recurrence (51%) was higher and the overall survival rate lower (50%). Pelvic disease was controlled in all 8 patients whose disease responded well to chemoradiation (either a histologically complete response or microscopic residual disease). Three of 4 patients with close or positive margins had pelvic recurrences despite intraoperative RT and brachytherapy. Nine of the 10 pelvic recurrences occurred in the radiation field. Elective external iliac nodal irradiation was not used, and nodal metastases were not seen in that region. In 1 case, marginal recurrence occurred in a common iliac node at the superior edge of the treatment field. CONCLUSIONS: Despite aggressive multimodality therapy including multivisceral resection, a high rate of pelvic and distant disease recurrence occurred in patients with clinically staged T4 disease. Regional disease recurred almost exclusively in the radiation field. The intraoperative RT and interstitial brachytherapy doses used did not prevent pelvic disease recurrence in patients with close or positive margins. Novel strategies such as higher preoperative doses of RT with or without altered fractionation or more effective radiosensitizers are needed to improve locoregional control in patients with T4 disease. Future strategies must also include more effective systemic therapy.     

Exenterative pelvic surgery—eleven year experience of the Swansea Pelvic Oncology Group

AIMS: To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group. PATIENTS AND METHODS: Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery. RESULTS: Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis. CONCLUSION: With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.