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Isolated Chemotherapeutic Perfusion of Pelvis as Neoadjuvant or Palliative Therapy for Advanced Cancer of the Rectum

Division of Surgical Oncology, Roger Williams Medical Center, Affiliated with Boston University, Providence, Rhode Island

Correspondence: Address correspondence and reprint requests to: Harold J. Wanebo, MD, FACS; E-mail: hwanebo{at}rwmc.org

Introduction: Previously irradiated recurrent rectal cancer is a formidable patient threat with limited treatment options. Isolated pelvic perfusion (IPP) by the balloon-occlusion technique provides high-dose regional chemotherapy that may facilitate resection if appropriate or palliate pain and fungating tumor mass in the symptomatic patient. We currently report our results in 49 recurrent rectal cancer patients (26 had neoadjuvant IPP with intent to resect and 23 had IPP for palliation).

Methods: IPP was done for 1 hour with paclitaxel 30 mg/m², 5 fluorouracil 1500 mg/m², cisplatin/oxaliplatin 60-130 mg/m², and mitomycin C 10 to 15 mg/m² (the latter three achieving pelvic-to-systemic drug ratios of 6–9:1).

Results: Neoadjuvant perfusion in 26 patients achieved a response in 14 patients (made resectable). Seven had R0 resections (clear margins), six by abdominal sacral resection (ABSR), and one by an extended APR. Of seven other patients, one had a complete pathologic response negating planned resection, one had >50% tumor regression in pelvis (but developed distant metastases), and three refused ABSR. Planned ABSR in two patients was aborted because of complicating cardiovascular issues. A variety of medical and cancer issues precluded resection in the remaining 12 of these 26 neoadjuvant patients. Within the neoadjuvant group, median survival was 24 months in the responding (made resectable) group (14 patients) and it was 8 months in the non-resectable group (12 patients), p = 0.0001. In the responding (made resectable) group, seven patients had R0 resections (median survival 26 months) and seven patients were not resected (median survival 18 months), p = 0.0198. In the IPP group for palliation, 17 of 23 patients (74%) had significant relief of pain, and other tumor-related symptoms (mean survival 11 months).

Conclusion: Isolated pelvic perfusion using a simplified balloon-occlusion technique has promise in palliation of or augmenting resectability of advanced rectal malignancy in patients not amenable to treatment with conventional modalities.

Key Words: Isolated pelvic perfusion • Recurrent rectal cancer