The management of recurrent
pelvic malignancy
Pete Sagar
The General Infirmary at Leeds
England
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Presentation
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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
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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
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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
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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%
Total
exenteration
30%
Resection of
mass alone
15%
Gynaecological
clearance
9%
Anterior
exenteration
7%
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
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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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