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10.1245/ASO.2005.10.004
Annals of Surgical Oncology 12:786-792 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Hydronephrosis Does Not Preclude Curative Resection of Pelvic Recurrences After Colorectal Surgery

Leonard R. Henry, MD1, Elin Sigurdson, MD, PhD1, Eric Ross, PhD2 and John P. Hoffman, MD1

1 Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111
2 Department of Biostatistics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111

Correspondence: Address correspondence and reprint requests to: John P. Hoffman, MD; E-mail: jp_hoffman{at}fccc.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: In one third of patients who die of rectal cancer, a pelvic recurrence after resection represents isolated disease for which re-resection may provide cure. These extensive resections can carry high morbidity. Proper patient selection is desirable but difficult. Hydronephrosis has been documented previously to portend a poor prognosis, and some consider it a contraindication to attempted resection. It was our goal to review our experience and either confirm or refute these conclusions.

Methods: We performed a retrospective analysis of 90 patients resected with curative intent for pelvic recurrence at our center from 1988 through 2003. Seventy-one records documented the preoperative presence or absence of hydronephrosis. Clinical and pathologic data were recorded. The groups with and without hydronephrosis were compared.

Results: There were 15 patients with hydronephrosis in this study and 56 without. Although patients with hydronephrosis had shorter overall survival, disease-free survival, and rate of local control, none of these differences was statistically significant. Patients in the hydronephrosis group were younger and had higher-stage primary tumors and larger recurrent tumors. Subsequently, they underwent more extensive resections and were more likely to be treated with adjuvant therapies. There was no difference in the rate of margin-negative resections between the groups.

Conclusions: Hydronephrosis correlates with younger patients with larger recurrent tumors undergoing more extensive operations and multimodality therapy but does not preclude curative (R0) resection or independently affect overall survival, disease-free survival, or local control. We believe that it should not be considered a contraindication to attempting curative resection.

Key Words: Hydronephrosis • Colorectal cancer • Recurrence • Salvage


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Local recurrence after surgical resection of rectal cancer occurs in anywhere from 3.5% to 38% of patients.1,2 Surgical extirpation is the only realistic chance for cure. However, many local recurrences occur in the setting of simultaneous metastatic disease that may or may not be appreciated at the time of local recurrence. Autopsy data suggest that only approximately one third of patients who die from rectal cancer recurrence have disease isolated to the pelvis.3 It is this select group of patients in whom complete resection may offer a chance for cure.

Resection of pelvic recurrence, however, is often technically demanding and frequently requires en-bloc resection of adjacent organs. The potential for serious morbidity from these resections cannot be ignored.4 Optimal patient selection is desirable but difficult.

Several retrospective studies have identified adverse prognostic factors to consider when approaching a patient with a locally advanced primary or recurrent rectal cancer.5–18 Hydronephrosis is considered by some to be an adverse prognostic factor.5,6,15,16,19 However, to our knowledge, only two previous articles have specifically addressed this issue, and both included small numbers and were from the same institution.5,6 These studies both concluded that hydronephrosis precluded curative resection and that its presence should be considered a contraindication to attempts at resection.

The collective experience at our center runs somewhat contrary to that opinion. We wished to review our experience with resection of pelvic recurrences in patients with hydronephrosis to either support or refute the conclusion that its presence precludes curative resections.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A retrospective review was conducted of patients who had undergone attempted curative resection of a pelvic recurrence at our institution from 1988 through 2003. Ninety such operations were performed. In 71 of this group, the record was sufficient to accurately assess the presence or absence of hydronephrosis.

Demographic, clinical, pathologic, and management data were collected with regard to both the primary and recurrent tumors. Primary cancers located <12 cm from the anal verge were considered rectal. The primary location and initial operation are listed in Table 1Go. Four patients in the group without hydronephrosis had a prior recurrence already resected. The presence or absence of hydronephrosis with the recurrent tumor was verified from preoperative imaging studies including computed tomographic scan, intravenous pyelography, or ultrasonography. The operations performed were separated on the basis of the preoperative presence or absence of an intact rectum (restorative vs. nonrestorative) and the extent of resection required to resect the recurrence (extramural vs. intramural tumors for patients with rectal restoration and tumor-only vs. en-bloc resections in patients without restored rectal continuity). By definition, extramural recurrences and en-bloc resections required the resection of additional organs or tissues in addition to the recurrent tumor or rectum (extended resection), and intramural recurrences and localized tumors were resected with limited resections. Postoperative complications were recorded. Death was attributed to postoperative complications when it occurred within 30 days of operation or if the patient never left the hospital. Groups with and without hydronephrosis were compared for similarity and outcomes after resection.


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  		TABLE 1. Primary tumor location and prior operations
 
Statistical analysis was conducted with SAS software (SAS Institute, Cary, NC). Group comparisons were analyzed for differences by Fisher’s exact test. Univariate analysis of the effect of hydronephrosis on survival time and disease-free survival was assessed with log-rank tests. Multivariate analyses were conducted with logistical regression and the Cox proportional hazards model. For all tests, a P value of .05 was considered significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 71 patients (44 men and 27 women), 15 underwent resection in the setting of hydronephrosis (14 unilateral and 1 bilateral). At exploration, extra-pelvic disease was identified in two patients with hydronephrosis (liver metastasis and serosal implant) and in one (liver metastasis) without hydronephrosis. Extrapelvic sites were resected in conjunction with the pelvic recurrence. Group comparison is demonstrated in Table 2Go. Patients with hydronephrosis were younger, had a greater percentage of stage ≥II primary tumors, and had larger recurrent tumors. Subsequently, they were more likely to undergo extended resections and be treated with additional therapies in addition to surgical resection (chemotherapy, radiotherapy, or chemoradiotherapy).


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  		TABLE 2. Comparison of study groups
 
Three patients (4.3%) in this series died from postoperative complications: one each from sequelae secondary to myocardial infarction, cerebrovascular accident, and respiratory failure. Eight (53%) of 15 patients with and 28 (51%) of 55 without hydronephrosis had postoperative complications. There was no difference with regard to the prevalence or variety of complications between groups. Table 3Go lists the most frequent postoperative complications in this study.


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  		TABLE 3. Most frequent operative complications
 
Margins and Local Control
Eight (53%) of 15 patients with hydronephrosis had margin-negative (R0) resections. Despite the extended resections, there was no statistically significant difference in the rate of negative, microscopically positive, or grossly positive margin resections between the two groups. Seven patients with hydronephrosis received either brachytherapy (n = 6) or intraoperative radiotherapy. Of the 56 without hydronephrosis, 17 received brachytherapy (n = 16) or intraoperative radiotherapy (n = 1; not significant). At a similar length of follow-up, 7 (47%) of the 15 patients with hydronephrosis and 36 (68%) of 53 without hydronephrosis had maintained local control (P = .145; Table 4Go).


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  		TABLE 4. Outcomes
 
Survival
The median follow-up for the entire group was 27 months. Patients with hydronephrosis had a shorter overall and disease-free survival (31 and 16 months, respectively) than patients without (43 and 23 months, respectively). However, these differences did not reach statistical significance. Estimated 5- year survivals are 15% with hydronephrosis and 45% without (Fig. 1Go). Median survival was best for those with negative margins (57 months with hydronephrosis vs. 78 months without), worst in those with gross residual disease remaining (14 months with hydronephrosis and 11 months without), and intermediate in those with microscopically positive margins (31 months with hydronephrosis and 25 months without).



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  		FIG. 1. Overall survival in patients with and without hydronephrosis undergoing attempted curative resections (not significant).

 
To further assess for an independent effect of hydronephrosis on outcomes, we further evaluated survival and local control between the two groups within a multivariate model with tumor size and extent of resection. In doing so, the suggested negative effect of hydronephrosis on overall survival, disease-free survival, and local control was lost entirely. Representative survival curves are given in Figs. 2Go and 3Go. These figures demonstrate no effect of hydronephrosis on overall survival when the recurrent tumor size and extent of the operation are controlled.



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  		FIG. 2. Overall survival in patients with and without hydronephrosis undergoing attempted curative resection of large (>5-cm) tumors (not significant).

 


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  		FIG. 3. Overall survival in patients with and without hydronephrosis undergoing extended (extramural and en-bloc) resections of pelvic recurrences (not significant).

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We envision hydronephrosis occurring in the setting of pelvic recurrences under two circumstances. First, the ureter may be obstructed relatively high in the pelvis along the lateral side wall. Tumor in this proximity to the lateral side wall would likely be difficult to resect with negative margins. Prior authors have demonstrated the adverse effect of side-wall invasion.17 In a study by Cheng et al.,5 four of six patients with hydronephrosis were found to have unresectable disease because of side-wall involvement.

In the second circumstance, anterior and centrally located recurrences may obstruct one or both ureters as they enter the bladder, yet these are amenable to radical resection with good oncological outcome. The generally good outcome reported here probably reflects selection of patients and is corroborated by the high percentage of extended operations (i.e., exenteration including the bladder) among patients with hydronephrosis.

Patients with hydronephrosis in this study were younger and had a higher percentage of primary tumors of stage ≥ 2. These differences are likely explained by the tendency for more aggressive management of younger, healthier patients and patients who underwent local excision as a first procedure. These patients with low-stage disease would likely have recurrence in or near the excision site and would therefore be less likely to develop hydronephrosis.

Additionally, we found that patients with hydronephrosis had a significantly higher percentage of tumors >5 cm. It would logically follow that they would require more extended resections to achieve negative margins and would also be treated with additional therapy.

A potential criticism of this study is that the number of patients with hydronephrosis was not large enough to demonstrate a statistically significant difference in outcome between the two groups. Although it is true that the outcomes in patients with hydronephrosis were generally worse in terms of overall survival, disease-free survival, and local control, when other differences between the groups were controlled, the negative effect was lost. In fact, when subjected to multivariate analysis, the hazard ratios for hydronephrosis with respect to survival and local control were well below 1.0. Because of the number of covariates and small sample size, however, we do not interpret this low hazard ratio to represent an actual benefit to patients with hydronephrosis, but we believe that it certainly diminishes the possibility of type II error in this study.

Our data suggest that reasonable rates of local control (47%) and survival (median overall survival, 31 months; median disease-free survival, 16 months) can be obtained in selected patients undergoing resection in the setting of hydronephrosis. Hydronephrosis seemed to act as a marker for larger tumors more likely to require more extended resections and additional therapy, but it did not independently affect survival or local control. We therefore do not consider the presence of hydronephrosis as a contraindication to attempting curative resection in these patients.

Received for publication October 7, 2004. Accepted for publication April 21, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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