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10.1245/ASO.2006.03.073
Annals of Surgical Oncology 13:740-744 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Is En-Bloc Resection of Locally Recurrent Rectal Carcinoma Involving the Urinary Tract Indicated?

Luca Stocchi, MD1, Heidi Nelson, MD, FACS2, Daniel J. Sargent, PhD2, Donald E. Engen, MD2 and Michael G. Haddock, MD2

1 Department of Colorectal Surgery, A30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195
2 Division of Colon and Rectal Surgery, Gonda 9S, Mayo Clinic and Mayo Foundation, 200 First Street S.W., Rochester, Minnesota 55905

Correspondence: Address correspondence and reprint requests to: Heidi Nelson, MD, FACS; E-mail: nelson.heidi{at}mayo.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: This study investigated morbidity, mortality, and long-term survival after multimodality management of locally recurrent rectal carcinoma involving the urinary tract.

Methods: A total of 82 patients (63 males) were identified during 1987 to 2000. Data sources were a prospectively collected database of intraoperative radiotherapy, institutional tumor registry, and chart review. The median follow-up was 3.3 years and lasted until death or for at least 2 years on all patients.

Results: A total of 20 (24%) of 82 patients had resection of urogenital tract structures without reconstruction. Sixty-two patients (76%) underwent reconstruction with ileal conduit (43%), ureteroneocystostomy (15%), or miscellaneous (18%). The mean number of fixation sites was 2.8 (SD, 1.5), and the mean number of organs at least partially resected was 2.6 (SD, 1.3). Eighty percent of patients underwent intraoperative radiotherapy among adjuvant treatments. Postoperative mortality was 2% (2 of 82), and morbidity was 39% (32 of 82), most frequently consisting of neuropathy and urinary leak (6% each). The overall 1-, 3-, and 5-year survival rates were 82%, 45%, and 19%, respectively. The median survival was 2.6 years. The number of sites involved was the only survival predictor at multivariate analysis (P < .001).

Conclusions: A multimodality approach for locally recurrent rectal carcinoma involving the urinary tract carries acceptable morbidity, mortality, and potential for long-term survival. The number of fixation sites correlates with a poorer prognosis.

Key Words: Rectal carcinoma • Local recurrence • Urinary diversion • Pelvic exenteration • Ileal conduit • Ureteroneocystostomy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Locally recurrent rectal cancer can be successfully treated with surgery and adjuvant treatment in select cases.1–7 In the largest series published to date, the overall 5-year survival for all patients who underwent surgery was 25% and increased to 37% if negative resection margins could be achieved.8

In some cases, en-bloc resection of involved adjacent structures such as the bladder, prostate, and ureters can become necessary to remove the recurrent tumor. This can increase morbidity and mortality5,9 and presents the operating surgeon with unique technical challenges that necessitate a multimodality and multidisciplinary approach.

Although results from such extensive surgical procedures have been reported in the literature,10,11 the experience with these extended procedures for recurrent rectal carcinoma is still limited, and long-term outcomes have not been analyzed. The purpose of this study was to analyze the morbidity, mortality, and oncological outcomes of surgical treatment for recurrent rectal carcinoma involving the urinary tract.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients who underwent en-bloc resection of recurrent rectal carcinoma extending into genitourinary tract structures at the time of operation were selected among all cases undergoing maximal surgical resection for recurrent rectal carcinoma during 1987 through 2000. All patients had undergone previous resection of primary rectal carcinoma located within the distal 15 cm of the rectum. Most cases were diagnosed by using computed tomographic (CT) scan of the abdomen and pelvis. Preoperative urological evaluation did not include routine cystoscopy or retrograde pyelography. In general, an abdominopelvic CT scan was sufficient to the urologist as a preoperative assessment. Pelvic magnetic resonance imaging and positron emission tomography scans were used selectively once the technology was available. Most of the patients included in this study underwent preoperative radiation (45–54 Gy in 1.8 fractions) and received a 5-fluorouracil–based chemotherapy regimen. Patients were restaged 3 to 5 weeks after completion of their planned treatment before undergoing surgery. Patients with preoperative or intraoperative evidence of extrapelvic disease were excluded from analysis. Resection margins considered by the operating surgeon to be at risk for tumor involvement were analyzed by frozen-section examination. In case of margins positive for tumor at frozen section, additional resection margins were obtained until frozen section was negative for tumor and as allowed by the specific anatomical location of the recurrent tumor. Technical details and indications for external beam radiation treatment and intraoperative radiotherapy (IORT) have been described previously.12

Cases were identified and data were collected from a prospective IORT database. Tumor registry and chart review provided supplemental information as necessary. All patients had follow-up for at least 2 years or until death.

Prospective IORT database information included demographics, presence of symptoms, date and type of surgical procedure to treat the primary tumor, and date and type of operation performed for recurrent rectal carcinoma. Intraoperative data collected included the number and location of sites of recurrence, the number of organs at least partially removed, and the intent of surgery. Possible sites of tumor fixation were classified as perianastomotic recurrence, sacrum, right pelvis, left pelvis, nodal recurrence, bladder, right or left ureter, prostate, vagina, uterus, ovaries, and seminal vesicles. The total number of involved sites was generated on the basis of the operative and pathology reports. The American Society of Anesthesiologists (ASA) classification was noted as a measure of comorbidities. Postoperative morbidity (30 days), mortality, hospital stay, and overall survival were noted, along with adjuvant treatments received.

Survival curves were generated by using the Kaplan-Meier method, and univariate analysis was performed with the log-rank test. The Cox proportional hazards model was used to perform multivariate analysis. Two-sided probability values were considered as statistically significant when <.05. Because of the small sample size, direct statistical comparisons to the larger group of patients with locally recurrent rectal carcinoma were not made.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The mean age (±SD) was 62 ± 9.6 years. All patients had undergone surgical treatment of primary rectal carcinoma with curative intent. Previous outside hospital records were used to assess the stage of primary tumors. Staging information was not available in 10 patients, and nodal staging was not available in an additional 4 patients. Staging of the remaining primary tumors is listed in Table 1Go. The great majority of cases (88%) were symptomatic, and most patients presented with perineal or lower back pain. In keeping with the mean age, most patients had some underlying comorbidities (ASA status III), and in keeping with the standard practice, most (87%) had received external beam radiotherapy and 5-fluorouracil–based chemotherapy (Table 1Go). CT imaging of the abdomen and pelvis was performed in all patients. Two CT scans obtained from outside institutions were not available for re-review. In the remaining 80 patients, CT was accurate in determining the extent of urinary tract involvement in 54 patients (68% of cases). In 2 patients (3%) CT overestimated the extent of urinary tract involvement, whereas in 24 patients (30%) the extent of urinary tract involvement was underestimated, thus resulting in changes in treatment decided at the time of operation. The mean time elapsed from the primary operation to that for recurrent rectal carcinoma was 38 months (range, 2 months to 18 years).


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  		TABLE 1. Patient characteristics, previous treatment, and adjuvant therapy for recurrent rectal carcinoma (82 patients)
 
The mean and median length of hospital stay were 15.2 ± 9.5 days and 12.0 days (range, 6–51 days), respectively. The mean number of involved sites was 2.8 ± 1.5, and the mean number of organs resected was 2.5 ± 1.3. The mean operative time was 529 minutes ± 174 minutes. One patient underwent creation of an ileal conduit for palliative purposes to relieve bilateral ureteral obstruction after his locally recurrent carcinoma was found to be unresectable at the time of operation. The remaining procedures performed are listed in Table 2Go.


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  		TABLE 2. Types of resectional procedures performed
 
There were two deaths. A 65-year-old man died from sepsis related to a small-bowel anastomotic leak that occurred after pelvic exenteration and ileal conduit reconstruction. A 70-year-old man with chronic renal failure developed postoperative hemorrhage that led to multiorgan failure after salvage abdominoperineal resection with en-bloc resection of both seminal vesicles.

A total of 32 patients experienced at least one postoperative complication, corresponding to an overall morbidity of 39%. Details on specific complications are listed in Table 3Go. Postoperative morbidity decreased nonsignificantly with experience from 44% during 1987 through 1994 to 36% in patients treated during 1995 to 2000 (P = .32). A higher ASA classification was also nonsignificantly associated with increased postoperative morbidity (ASA II, 27%; ASA III, 42%; ASA IV, 67%; P = .27). Creation of an ileal conduit was the most common type of urological reconstruction performed (Table 4Go).


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  		TABLE 3. Postoperative morbidity (32 patients; overall morbidity, 39%)
 

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  		TABLE 4. Urological reconstructions or procedures performed (65 patients)
 
The median survival was 2.6 years. The overall survival was 82% at 1 year after surgery (95% confidence interval [CI], 74%–91%), 45% at 3 years (95% CI, 35%–58%), and 19% at 5 years (95% CI, 12%–32%). Factors that predicted decreased survival at univariate and multivariate analyses are listed in Table 5Go. Positive intraoperative margins occurred in 59% of cases and were associated with reduced median overall survival when compared with negative tumor margins (2.4 vs. 3.9 years; P < .003; Table 5Go). Only the number of sites involved by tumor was predictive of decreased survival at multivariate analysis. The relationship between sites of fixation and survival is shown in Table 6Go.


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  		TABLE 5. Predictors of survival
 

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  		TABLE 6. Survival and sites of fixation
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our results show that extended resections for recurrent rectal carcinoma involving the urinary tract can be performed with acceptable morbidity and mortality and still retain the opportunity for cure in select patients. Several limitations affect the results of our study, including a small sample size, a possible selection bias, and a heterogeneous population. In addition, although most of the data were collected prospectively, it had to be supplemented to some extent by retrospective chart review. Despite all these limitations, it is possible to analyze some aspects of cancer outcomes on the basis of this subset of patients, and meaningful conclusions can be drawn from the examination of these data which could assist in patient care, counseling, and quality-of-life improvement.

An essential factor to optimize postoperative outcomes and increase the chance for long-term survival is the multidisciplinary approach to this challenging disease; this includes the direct participation of an experienced urologist as part of the surgical team.13 The urologist is involved in selecting patients who should be considered candidates for such an extensive procedure and, furthermore, is essential in the decision regarding the most appropriate manner of urological reconstruction for each patient. Typically, extensive bladder involvement or involvement of the trigone warrants total cystectomy.

The overall survival of the patient population presented in this study is comparable to that reported in larger series of patients with recurrent rectal carcinoma treated with multimodality therapy but without genitourinary involvement.8 Current results support the application of this same approach for cases with genitourinary involvement.

Although other authors have reported negative resection margins as important predictors of survival in patients undergoing surgical treatment for locally recurrent rectal carcinoma,14–18 in our study this factor was significant only on univariate analysis. Similarly, involvement of the pelvic sidewalls was predictive of decreased survival when compared with different locations of recurrent disease, as reported by Moore et al.,19 but was predictive only at univariate analysis in our study. The only factor that remained predictive at multivariate analysis was the number of involved anatomical sites, and this result would suggest that as the recurrent disease involves multiple sites, it is more likely that at least one of these will be a lateral pelvic sidewall and that resection margins will be positive for tumor. The importance of the number of sites involved by tumors reflects the findings by Hahnloser et al.,8 who analyzed 394 patients undergoing multimodality therapy for recurrent rectal cancer and found that more than 1 area of tumor fixation predicted reduced overall survival. Additional factors, such as the presence of tumor vascular invasion, might play a role in predicting oncological outcomes.15 The retrospective nature of our study conducted during a long period did not allow a consistent collection of this specific variable to be tested as a possible outcome predictor.

Our data also showed the current limitations of CT in evaluating the extent of urinary tract involvement and, therefore, effectively helping to plan the surgical approach. Future advancements in the imaging of the pelvis, such as with positron emission tomography/CT technology, might improve the accuracy of pre-operative evaluation of this unique form of recurrent disease.

Some authors have suggested that pelvic exenteration or similar extended resections for recurrent rectal carcinoma, including urinary reconstructions, might have a significant palliative role even when a resection with curative intent cannot be accomplished.20 Although a significant portion of our relatively small patient population had preoperative symptoms, especially pelvic pain, which were at least partially relieved after surgery, no validated tools were used to evaluate palliation of symptoms or favorable changes in patient quality of life.21 Previous studies on patients undergoing sacrectomy support the hypothesis of improved quality of life after surgery on the basis of symptom improvements and evaluation of patients’ ability to return to work.22 Future studies should examine preoperative and postoperative quality of life in patients treated for recurrent rectal carcinoma. The recent development of more sophisticated, surgery-specific instruments for measurements of the quality of life should enhance the value of the gathered data on quality of life.

In conclusion, our study shows that extensive resections for locally recurrent rectal carcinoma involving the genitourinary tract can be performed with acceptable morbidity and mortality. Although an increased number of tumor fixation sites adversely affects prognosis, this aggressive approach remains the only chance for this select group of patients to achieve long-term cure.

Received for publication March 11, 2005. Accepted for publication October 12, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Wanebo HJ, Koness RJ, Vezeridis MP, et al. Pelvic resection of recurrent rectal cancer. Ann Surg 1994; 220:586–95; discussion 595–7.[CrossRef][Medline]
  2. Mannaerts GH, Martijn H, Crommelin MA, et al. Intraoperative electron beam radiation therapy for locally recurrent rectal carcinoma. Int J Radiat Oncol Biol Phys 1999; 45:297–308.[Medline]
  3. Wiggers T, Mannaerts GH, Marinelli AW, et al. Surgery for locally recurrent rectal cancer. Colorectal Dis 2003; 5:504–7.[Medline]
  4. Reerink O, Mulder NH, Botke G, et al. Treatment of locally recurrent rectal cancer, results and prognostic factors. Eur J Surg Oncol 2004; 30:954–8.[CrossRef][Medline]
  5. Yamada K, Ishizawa T, Niwa K, et al. Pelvic exenteration and sacral resection for locally advanced primary and recurrent rectal cancer. Dis Colon Rectum 2002; 45:1078–84.[CrossRef][Medline]
  6. Wiig JN, Tveit KM, Poulsen JP, et al. Preoperative irradiation and surgery for recurrent rectal cancer. Will intraoperative radiotherapy (IORT) be of additional benefit? A prospective study. Radiother Oncol 2002; 62:207–13.[CrossRef][Medline]
  7. Hashiguchi Y, Sekine T, Kato S, et al. Indicators for surgical resection and intraoperative radiation therapy for pelvic recurrence of colorectal cancer. Dis Colon Rectum 2003; 46:31–9.[Medline]
  8. Hahnloser D, Haddock MG, Nelson H. Intraoperative radiotherapy in the multimodality approach to colorectal cancer. Surg Oncol Clin North Am 2003; 12:993–1013, ix.[Medline]
  9. Ike H, Shimada H, Ohki S, et al. Outcome of total pelvic exenteration for locally recurrent rectal cancer. Hepatogastroenterology 2003; 50:700–3.[Medline]
  10. Russo P, Ravindran B, Katz J, et al. Urinary diversion after total pelvic exenteration for rectal cancer. Ann Surg Oncol 1999; 6:732–8.[Abstract]
  11. Husain A, Curtin J, Brown C, et al. Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies. Gynecol Oncol 2000; 78:208–11.[Medline]
  12. Suzuki K, Dozois RR, Devine RM, et al. Curative reoperations for locally recurrent rectal cancer. Dis Col Rectum 1996; 39:730–6.[CrossRef][Medline]
  13. Fujisawa M, Nakamura T, Ohno M, et al. Surgical management of the urinary tract in patients with locally advanced colorectal cancer. Urology 2002; 60:983–7.[CrossRef][Medline]
  14. Bakx R, van Tinteren H, van Lanschot JJ, Zoetmulder FA. Surgical treatment of locally recurrent rectal cancer. Eur J Surg Oncol 2004; 30:857–63.[Medline]
  15. Shoup M, Guillem JG, Alektiar KM, et al. Predictors of survival in recurrent rectal cancer after resection and intraoperative radiotherapy. Dis Colon Rectum 2002; 45:585–92.[CrossRef][Medline]
  16. Moriya Y, Akasu T, Fujita S, Yamamoto S. Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis. Dis Colon Rectum 2004; 47:2047–53; discussion 2053–4.[CrossRef][Medline]
  17. Lindel K, Willett CG, Shellito PC, et al. Intraoperative radiation therapy for locally advanced recurrent rectal or recto-sigmoid cancer. Radiother Oncol 2001; 58:83–7.[CrossRef][Medline]
  18. Rodel C, Grabenbauer GG, Matzel KE, et al. Extensive surgery after high-dose preoperative chemoradiotherapy for locally advanced recurrent rectal cancer. Dis Colon Rectum 2000; 43:312–9.[CrossRef][Medline]
  19. Moore HG, Shoup M, Riedel E, et al. Colorectal cancer pelvic recurrences: determinants of resectability. Dis Colon Rectum 2004; 47:1599–606.[Medline]
  20. Kakuda JT, Lamont JP, Chu DZ, Paz IB. The role of pelvic exenteration in the management of recurrent rectal cancer. Am J Surg 2003; 186:660–4.[CrossRef][Medline]
  21. Esnaola NF, Cantor SB, Johnson ML, et al. Pain and quality of life after treatment in patients with locally recurrent rectal cancer. J Clin Oncol 2002; 20:4361–7.[Abstract/Free Full Text]
  22. Magrini S, Nelson H, Gunderson LL, Sim FH. Sacropelvic resection and intraoperative electron irradiation in the management of recurrent anorectal cancer. Dis Col Rectum 1996; 39:1–9.[CrossRef][Medline]



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