Pelvic exenteration: Pre-, intra-, and post-operative considerations

This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the ‘holy grail’ of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE.Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial.The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed ‘higher and wider’ dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches.Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the ‘empty pelvis syndrome’, urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.     

Pelvic exenteration: Pre-, intra-, and post-operative considerations

This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the ‘holy grail’ of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE.Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial.The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed ‘higher and wider’ dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches.Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the ‘empty pelvis syndrome’, urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.     

Recurrent vulvar cancer

Opinion statement Recurrent vulvar cancer occurs in an average of 24% of cases after primary treatment after surgery with or without radiation. The relatively few primary vulvar cancers, combined with the low proportion of recurrences, has made it difficult to perform randomized studies to document the most appropriate therapeutic modalities. Most reports are small retrospective studies and anecdotal reviews that have emphasized the importance of surgery and have led to new approaches with respect to chemoradiation. Traditionally, the most accepted treatment of vulvar cancer has been and continues to be surgery. Recently, radiation and chemotherapy have been combined with very encouraging results. The therapeutic modality used depends on the location and extent of the recurrence. Most recurrences occur locally near the original resection margins or at the ipsilateral inguinal or pelvic lymph nodes. Lateralized local vulvar recurrences treated with a wide radical local excision with inguinal lymphadectomy results in an excellent cure rate of 70%. With a central pelvic recurrence with antecedent radiotherapy involving the urethra, upper vagina, and rectum, total pelvic exenteration is indicated in a select group of patients with curative intent. Radiotherapy or chemoradiation concomitantly with wide radical local excision of an advanced vulvar has proven successful in avoiding an exenteration, with improved survival and less morbidity. Prospective and retrospective studies have shown excellent results using radiation or chemoradiation with wide radical local excision in patients with locally advanced disease in whom adequate resection margins are difficult to achieve (with a central lesion requiring exenteration) or with debilitating medical conditions that preclude surgery. In these patients, chemoradiation has shown favorable results when used before a wide local resection. In patients with advanced local disease, external beam and interstitial radiation has been used for palliative and curative intent with encouraging results. Regional recurrences to the inguinal and pelvic lymph nodes have been shown to have a poor prognosis with a high mortality rate. We recommend that inguinal recurrences without prior radiation therapy undergo excision followed by radiotherapy with chemosensitization. In patients with previous radiation to the inguinal lymph nodes, we try to avoid any excisional procedures because of the high rate of complications. We offer these patients brachytherapy for palliation. With pelvic recurrences, we recommended chemoradiation as the treatment modality. In the subset of patients with distant metastasis, chemotherapy may be offered; however, few studies have been performed to advocate any single combination. The literature supports the use of 5-fluorouracil or cisplatin as single agents or in combination to have sensitivity against squamous cells. There are few studies revealing improvement in 5-year survival, thus these patients may benefit from recruitment into research protocols.     

Adjuvant postoperative radiation therapy for rectal adenocarcinoma.

From October 1975 to August 1988, 261 patients at high risk for local recurrence after curative resection of rectal carcinoma underwent high-dose postoperative irradiation. Patients received 45 Gy by a 4-field box usually followed by a boost to 50.4 Gy or higher when small bowel could be excluded from the reduced field. Since January 1986, patients also received 5-fluorouracil (5-FU) for 3 consecutive days during the first and last week of radiotherapy. Five-year actuarial local control and disease-free survival decreased with increasing stage of disease; patients with Stage B2 and B3 disease had local control rates of 83% and 87% and disease-free survivals of 55% and 74%, respectively. In patients with Stage C1 through C3 tumors, local control rates ranged from 76% to 23%, and disease-free survivals ranged from 62% to 10%, respectively. For patients with Stage C disease, disease-free survival decreased progressively with increasing lymph node involvement, but local control was independent of the extent of lymph node involvement. For each stage of disease, local control and disease-free survival did not correlate with the dose of pelvic irradiation. Preliminary data from this study suggest a trend toward improved local control for patients with Stage B2, C1, and C2 tumors who receive 5-FU for 3 consecutive days during the first and last weeks of irradiation compared with patients who do not receive 5-FU. Current prospective randomized studies are addressing questions regarding the optimum administration of chemotherapy with pelvic irradiation for patients following resection of rectal carcinoma.     

Locally advanced rectal cancer with a pelvic kidney complicating adjuvant radiation therapy

The simultaneous occurrence of colorectal malignancy with pelvic kidney is unusual. We report a case of locally advanced rectal cancer stage III disease, T3N2M0, with a pelvic kidney complicating adjuvant radiation therapy. We recommend preoperative evaluation of the pelvic kidney to allow for its protection by translocation or heterotopic autologous transplantation. Occasionally a nephrectomy may be necessary. Otherwise extended lymph node dissection is not performed; hence, adequate treatment of the primary rectal cancer is compromised. The sequela of inadequate surgical excision and suboptimal radiation therapy is early relapse. © 1996 Wiley-Liss, Inc.     

Intraoperative radiation therapy in the management of gynecologic and genitourinary malignancies

Women with locally advanced primary or recurrent gynecologic malignancies have a poor prognosis. The doses of external radiation necessary to treat gross or microscopic recurrent disease in patients previously irradiated exceed the doses tolerated by normal tissue [1,3-5]. IORT has been added to the treatment armamentarium in this group of patients to maximize local control and minimize the radiation exposure to dose-limiting surrounding structures. In addition, IORT may improve the long-term local control and the overall survival rates in women with pelvic sidewall or para-aortic nodal recurrence [1,4,5]. The most encouraging results are seen in cases of microscopic residual disease following surgical debulking [4,6]. In gynecologic malignancies, IORT has served to reiterate the importance of optimal surgical resection. Higher 5-year disease-free and overall survival rates have been documented in women who have microscopic residual disease, compared with those who have gross residual disease [1,3-6]. IORT in the management of GU malignancies has not been used extensively. In RCC, where surgery alone often results in suboptimal treatment results, IORT seems to be well tolerated and controls local disease [2,27,29,30]. Because of the chemoresistant nature of RCC, IORT may play an important role in the future in the management of locally advanced and recurrent RCC. In bladder cancer, IORT had been used in combination with chemotherapy and EBRT, as part of bladder-sparing protocols. The data suggest that IORT in this patient population is also well tolerated, and may become more widely used as less radical surgical procedures gain clinical importance. IORT in the treatment of prostate and testicular cancers has not been used frequently, given the highly efficacious treatment modalities currently available to treat these malignancies. A review of institutional experiences with IORT may allow the establishment of guidelines for patient selection. These criteria, in turn, may be useful in the design of clinical trials. The construction, execution, and evaluation of clinical trials are mandatory to adequately assess the role of IORT in the treatment of patients with gynecologic and GU malignancies.     

Pelvic exenteration for carcinoma of the colon and rectum.

Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation.     

Preoperative staging of rectal cancer with computerized tomography. Accuracy, efficacy, and effect on patient management

Twenty-three consecutive patients with rectal cancer were evaluated by pelvic computerized tomography (CT). The study was designed to assess the accuracy of preoperative CT staging. The results showed that the CT and surgical and/or pathologic staging agreed in 18 patients. In two patients, the pelvic extent was correctly assessed, but small liver implants were not recognized. In three patients, CT over-estimated the extent of disease. The authors also studied whether or not CT yielded significant new information, which was not obtainable by other diagnostic methods. In most patients this was the case. Finally, the authors wanted to know the extent to which this knowledge influenced the decision about how to treat the patient. Computerized tomography findings influenced the treatment in less than 50% of the patients. It is concluded that the accuracy in staging, and the addition of new and unique information justified the routine use of CT prior to surgical intervention in all patients with known invasive rectal cancer.     

Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer

Urinary and sexual dysfunction are common problems after rectal cancer surgery, and the likely cause is damage to the pelvic autonomic nerves during surgery. In recent years, attention has been focused on preserving the autonomic nerves through a technique which is usually combined with total mesorectal excision or radical pelvic lymphadenectomy. The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. We will demonstrate the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes, and review the medical literature on sexual and urinary dysfunction after rectal cancer surgery with and without autonomic nerve preservation.     

The role of radical surgery in carcinoma of the endometrium

A minority of women with endometrial cancer present with disease beyond the uterine corpus. Where disease has spread to the uterine cervix, extended or radical surgery may be curative without the need for adjuvant treatment. Radical surgery has a potential major role in the management of locally advanced disease together with adjuvant radiotherapy and/or chemotherapy. Radical pelvic surgery remains the only curative option for isolated pelvic recurrence in the previously irradiated patient. A number of published studies report a survival benefit from surgical cytoreduction in women with extra-pelvic metastases and recurrent disease, although the degree of surgical effort required in order to achieve an optimal result varies. Women with a single site of metastasis or recurrence seem most likely to benefit. However, the value of radical pelvic and abdominal procedures in advanced and recurrent disease must be balanced against the associated high morbidity and the resulting quality of life for the individual woman. Many women with endometrial cancer are elderly and have limiting co-morbidities. The treatment modality and the appropriate extent of surgery must therefore be determined on an individual patient basis.     

Treatment of locally advanced rectal cancer with external beam radiation, surgical resection, and intraoperative radiation therapy

To try to improve the local control and survival of patients with locally advanced rectal cancer we have used a combination of high-dose pre-operative radiation therapy to 5,040 cGy followed by surgical resection and intraoperative electron beam radiation therapy (IORT) when there was visible or palpable residual disease, microscopically positive surgical margins, or persisting tumor adherence. A total of 75 patients were taken to surgery for resection +/- IORT who did not have distant metastases. Of the 49 patients with primary tumors, 11 did not have IORT as the tumor was thought to be completely resected. Of these 11, there were two local recurrences and a 3-year survival of 71%. Thirty-six patients with primary tumors had resection (20 complete, 16 partial) plus IORT, with a 3-year survival of 58% and three local failures. Twenty-six additional patients were treated for locally advanced recurrence of whom four could not receive IORT because of pelvic size or the extent of tumor. Of the 22 who received IORT, 7/9 with complete resection, 2/8 with partial resection, and 1/5 with no resection had local control with an overall 3-year actuarial survival of 32%. The local control and survival results in the primary tumors appear favorable compared to other series in the literature and suggest benefit to the use of IORT. For patients treated for local recurrence, local control and long-term survival can be obtained, but the results are not as encouraging as for the primary tumors.     

Superficial inguinal and radical ilioinguinal lymph node dissection in patients with palpable melanoma metastases to the groin--an analysis of survival and local recurrence

The present study addresses the question whether an extended ilioinguinal dissection as compared to an only superficial inguinal dissection improves survival and/or local tumour control after the appearance of palpable melanoma metastases to the groin. We retrospectively analysed the data of 104 patients with 69 ilioinguinal and 35 superficial inguinal dissections (median follow up 127 months). Prognostic factors of survival and groin recurrence were assessed using Kaplan-Meier estimation and Cox proportional hazards model. By multifactorial analysis, metastatic involvement of two lymph nodes or less was associated with a significantly better survival rate than involvement of >2 or pelvic nodes (p=0.0002). After radical ilioinguinal dissection, patients with extremity-located primaries had a better prognosis than patients with truncal primaries (p=0.03). Tumour infiltration of the ilio-obturator compartment was found to be an independent factor of poor prognosis (p=0.0009). The probability of recurrence in the dissected groin paralleled the number of positive nodes and significantly increased if intransits were observed (p=0.0002). The extent of surgery, Breslow thickness, epidermal ulceration, sex, age and adjuvant chemotherapy neither significantly influenced survival nor local control rates. In summary, when metastatic inguinal nodes become palpable, the presence of pelvic metastases indicates systemic disease. After therapeutic groin dissection, local recurrence and survival depend rather on regional tumour burden than on the extent of surgery.     

The Role of Surgical Staging for Cervical Cancer

Recent trends in gynecologic oncology have favored surgical staging of disease not only to define local extent, but more importantly nodal involvement. For cervical cancer, surgical staging includes intraperitoneal exploration, cytological washings, direct tumor palpation, and para-aortic with or without pelvic lymph node (LN) dissection. In the Gynecologic Oncology Group (GOG) experience, extraperitoneal selective para-aortic lymphadenectomy was associated with a lower risk of enteric complications following radiation for advanced cervical cancer and was, therefore, judged to be the preferred surgical procedure. In the GOG data base, para-aortic LN involvement was the most significant prognostic factor in multivariate analysis. If para-aortic LN were negative, pelvic LN metastases and tumor size were the most significant independent prognostic factors. Progression-free interval at 5 years decreased from 57% for patients with negative nodes to 34% and 12% for patients with pelvic or para-aortic LN metastases, respectively. As such, surgical staging must retain an integral role in protocol development to assure equal stratification of prognostic variables and, thereby, assess the benefit of innovative treatments for locally advanced cervical cancer in randomized prospective trials. The potential for lymphanglography and laparoscopy as alternatives to laparotomy are reviewed.     

Myometrial penetration of endometrial carcinoma as a prognostic factor for patients receiving pre- or postoperative radiation therapy

From 1966-1980, 227 patients with Stage I endometrial carcinoma were treated by total abdominal hysterectomy, bilateral salpingo-oophorectomy, and either pre- or postoperative external beam pelvic irradiation. All therapy was delivered with megavoltage equipment. There was at least a 4-week interval between irradiation and surgery for 164 patients treated preoperatively. No significant differences were found in subsequent survival or local control at 5 years for those patients left with no residual tumor (81% survival/97% local control), disease confined to the mucosa (83% survival/93% local control), or invasion of the inner half of the myometrium (81% survival/93% local control). However, patients left with deeper myometrial penetration showed a significantly poorer survival rate of 57% (p = 0.02) and a local control rate of only 65% (p = 0.006). For 63 patients treated postoperatively, there was no significant difference in 5-year survival or local control for those patients with disease limited to the inner 1/2 of the myometrium (80% survival/93% local control) compared with more extensive myometrial invasion (75% survival/86% local control). As patients with deep myometrial penetration irradiated postoperatively showed survival rates comparable to patients with lesser extent of invasion, the adverse prognostic effect of deep penetration appears to have been attenuated by subsequent pelvic irradiation. By contrast, residual deep myometrial invasion remained a significant adverse prognostic indicator for patients treated preoperatively. For this group, further treatment seems necessary and postoperative vaginal brachytherapy and/or adjuvant chemotherapy should be considered.     

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.     

The wind of change in the therapy of lung cancer

Total mesorectal excision has been established as a standard surgical procedure for rectal cancer. MRI is now routinely used for preoperative staging of rectal cancer and provides accurate assessment of the tumor relative to the circumferential margin, that is, the mesorectal fascia. This identifies patients at risk of local recurrence and those likely to benefit from neoadjuvant therapy. Compared with CT and ultrasound, MRI is more reliable for the evaluation of the extent of locoregional disease, planning radiation therapy, assessing postoperative changes and pelvic recurrence. The evaluation of nodal metastases remains a challenge with routine MRI. In this review, we describe the role of MRI in staging rectal cancer as well as highlight some limitations and recent advances to overcome these.     

Rectal cancer radiotherapy

Adjuvant therapy for rectal cancer has undergone significant modifications over the past 30 years, including the addition of radiation therapy, significant improvements in surgical technique, and the administration of systemic therapy. Historically, curative resection commonly required an abdominoperineal resection and permanent colostomy. Adjuvant radiation therapy not only improved local control and overall survival, but allowed the opportunity for sphincter-preserving resections in patients with adequate sphincter function and tumors located approximately 1-2 cm from the dentate line. Local recurrence, a primary mode of failure in rectal cancer, has been improved by the development of the total mesorectal excision, with en-bloc resection of the rectum and its lymphovascular mesentery, the mesorectum. Removing micrometastatic disease within the mesorectum has also enhanced sphincter preservation without compromising local control or survival. Locoregional recurrence has remained a significant issue for patients with locally advanced disease (node positive or high T stage). Multiple studies have shown that the addition of chemotherapy further improves outcomes versus surgery alone or combined surgery and radiation, due both to the radiosensitizing properties of certain systemic agents as well as to the direct cytotoxic effect of the chemotherapy on micrometastatic disease. Adjuvant concurrent chemoirradiation in locally advanced rectal cancer confers a significant improvement in local control and overall survival compared with either modality alone. The future direction of treatment for rectal cancer will certainly consist of improved imaging and other diagnostic techniques to determine more accurately the need for adjuvant therapy. Multimodality therapy with radiotherapy administered in combination with systemic and biologic agents as radiation sensitizers is currently under investigation and may allow for improved local control and perhaps allow for minimizing the extent of surgery in selected situations.     

Skeletal metastases from cancer of the uterine cervix: frequency, patterns, and radiotherapeutic significance

The records of eight hundred two patients who received primary radiotherapy for invasive cervical cancer between 1969 and 1985 were reviewed. The incidence of bone metastasis was 1.9% (15/802). Lumbar spine involvement was the most common site, followed by the pelvic bones. Lumbar spine involvement was characterized by unilateral destruction of one or several contiguous vertebrae. All 10 patients with lumbar spine involvement were associated with a para-spinal mass. In seven of ten patients, this bone destruction due to direct extension from metastatic para-aortic tumor was the only recurrent cancer. In contrast, involvement of a long bone, a rib or the skull indicates hematogenous bone metastasis. When a spine X ray or bone scan is positive in the lumbar area in a cervical cancer patient with back pain, a CT scan should be performed to determine the extent of the underlying tumor. This will allow more accurate establishment of a radiation treatment plan, and will improve the chances for successful palliation.     

Unique considerations in the patient with rectal cancer

In the past two decades, substantial progress has been made in the adjuvant management of colorectal cancer. Chemotherapy has improved overall survival in patients with node-positive (N+) disease. In contrast with colon cancer, which has a low incidence of local recurrence, patients with rectal cancer have a higher incidence requiring the addition of pelvic radiation therapy (chemoradiation). Patients with rectal cancer have a number of unique management considerations: for example, the role of short-course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? This review will address these and other controversies specific to patients with rectal cancer.     

Traitement locaux ablatifs de la maladie oligométastatique : les progrès technologiques modifient les profils évolutifs cliniques

Systemic treatments rarely allow durable disease control at a metastatic stage. However, distinct metastatic profiles should be considered: from an oligometastatic state (one to five metastases) to disseminated metastases. Biomolecular mechanisms of metastatic spread and patterns of presentation and care were studied. A review of the literature focusing on local ablative treatments of oligometastases was performed. Improvement of local treatments, including surgical ablation, radiofrequency and irradiation (mostly with stereotactic radiotherapy) allow for metastatic control rates at treated sites of over 70% and increased survival with preserved quality of life. Improvements of ablative local treatments have dramatically modified the management of the oligometastatic disease. Metastatic disease may become in rare occasions a chronic disease, with some patients experiencing prolonged remission or even cure, provided proper selection of patients for local aggressive treatments using optimal criteria and scores that remains to be defined.