Abstract
Background
Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns.
Methods
Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted.
Results
Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8–28]), a local disease–free interval of <12 months (4.2 [1.8–9.8]), and pain radiating to the buttock or further (4.2 [1.6–11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4–40]). Of the patients with recurrence, 56% had failures confined locally or to the lung.
Conclusions
ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease–free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.
Similar content being viewed by others
References
Stearns MWJ. Diagnosis and management of recurrent pelvic malignancy following combined abdominoperineal resection. Dis Colon Rectum 1980; 23:359–61
Wanebo HJ, Whitehill R, Gaker D, Wang GJ, Morgan R, Constable W. Composite pelvic resection, an approach to advanced pelvic cancer. Arch Surg 1987; 122:1401–6
Wanebo HJ, Koness RJ, Turk PS, Cohen SI. Composite resection of posterior pelvic malignancy. Ann Surg 1992; 215:685–95
Pearlman NW, Stiegmann GV, Donohue RE. Extended resection of fixed rectal cancer. Cancer 1989; 63:2438–41
Simmonds PC. Palliative chemotherapy for advanced colorectal cancer: systematic review and meta-analysis. Colorectal Cancer Collaborative Group. BMJ 2000; 321:531–5
Meyerhardt JA, Mayer RJ. Systemic therapy for colorectal cancer. N Engl J Med 2005; 352:476–87
Hoffman JP, Riley L, Carp NZ, Litwin S. Isolated locally recurrent rectal cancer: a review of incidence, presentation, and management. Semin Oncol 1993;20:506–19
Lingareddy V, Ahmad NR, Mohiuddin M. Palliative reirradiation for recurrent rectal cancer. Int J Radiat Oncol Biol Phys 1997; 38:785–90
Wong CS, Cummings BJ, Brierley JD, et al. Treatment of locally recurrent rectal carcinoma: results and prognostic factors. Int J Radiat Oncol Biol Phys 1998; 40:427–35
Cohen AM, Minsky BD. Aggressive surgical management of locally advanced primary and recurrent rectal cancer. Dis Colon Rectum 1990; 33:432–8
Wanebo HJ, Marcove RC. Abdominal sacral resection of locally recurrent rectal cancer. Ann Surg 1981; 194:458–71
Brunschwig A, Barber HR. Pelvic exenteration combined with resection of segments of bony pelvis. Surgery 1969; 65:417–20
Wanebo HJ, Antoniuk P, Koness RJ, et al. Pelvic resection of recurrent rectal cancer: technical considerations and outcomes. Dis Colon Rectum 1999; 42:1438–48
Maetani S, Onodera H, Nishikawa T, et al. Significance of local recurrence of rectal cancer as a local or disseminated disease. Br J Surg 1998; 85:521–13
Mannaerts GH, Rutten HJ, Martijn H, Groen GJ, Hanssens PE, Wiggers T. Abdominosacral resection for primary irresectable and locally recurrent rectal cancer. Dis Colon Rectum 2001; 44:806–14
Magrini S, Nelson H, Gunderson LL, Sim FH. Sacropelvic resection and intraoperative electron irradiation in the management of recurrent anorectal cancer. Dis Colon Rectum 1996; 39:1–9
Hahnloser D, Nelson H, Gunderson LL, et al. Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg 2003; 237:502–8
Pearlman NW, Stiegmann GV, Donohue RE. Extended resection of fixed rectal cancer. Cancer 1989; 63:2438–41
Schiessel R, Wunderlich M, Herbst F. Local recurrence of colorectal cancer: effect of early detection and aggressive surgery. Br J Surg 1986; 73:342–4
Temple WJ, Ketcham AS. Sacral resection for control of pelvic tumors. Am J Surg 1992; 163:370–4
Takagi H, Morimoto T, Hara S, Suzuki R, Horio S. Seven cases of pelvic exenteration combined with sacral resection for locally recurrent rectal cancer. J Surg Oncol 1986; 32:184–8
Yamada K, Ishizawa T, Niwa K, Chuman Y, Aikou T. Pelvic exenteration and sacral resection for locally advanced primary and recurrent rectal cancer. Dis Colon Rectum 2002; 45:1078–84
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
Onodera H, Maetani S, Kawamoto K, Kan S, Kondo S, Imamura M. Pathologic significance of tumor progression in locally recurrent rectal cancer: different nature from primary cancer. Dis Colon Rectum 2000; 43:775–81
Wanebo HJ, Koness RJ, Vezeridis MP, Cohen SI, Wrobleski DE. Pelvic resection of recurrent rectal cancer. Ann Surg 1994; 220:586–95
Deckers PJ, Olsson C, Williams LA, Mozden PJ. Pelvic exenteration as palliation of malignant disease. Am J Surg 1976; 131:509–15
Cunningham JD, Enker W, Cohen A. Salvage therapy for pelvic recurrence following curative rectal cancer resection. Dis Colon Rectum 1997; 40:393–400
de Lange EE, Fechner RE, Wanebo HJ. Suspected recurrent rectosigmoid carcinoma after abdominoperineal resection: MR imaging and histopathologic findings. Radiology 1989; 170:323–8
Farouk R, Nelson H, Radice E, Mercill S, Gunderson L. Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers. Am J Surg 1998; 175:283–7
Brown G, Richards CJ, Newcombe RG, et al. Rectal carcinoma: thin-section MR imaging for staging in 28 patients. Radiology 1999; 211:215–22
Fletcher JG, Johnson CD, Krueger WR, et al. Contrast-enhanced CT colonography in recurrent colorectal carcinoma: feasibility of simultaneous evaluation for metastatic disease, local recurrence, and metachronous neoplasia in colorectal carcinoma. AJR Am J Roentgenol 2002; 178:283–90
Gastrointestinal Tumor Study Group. Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med 1985; 312:1465–72
Påhlman L. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997; 336:980–7
Marijnen CA, Nagtegaal ID, Kapiteijn E, et al. Radiotherapy does not compensate for positive resection margins in rectal cancer patients: report of a multicenter randomized trial. Int J Radiat Oncol Biol Phys 2003; 55:1311–20
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
Maetani S, Nishikawa T, Iijima Y, et al. Extensive en bloc resection of regionally recurrent carcinoma of the rectum. Cancer 1992; 69:2876–83
Acknowledgments
Supported by a Grant-in-Aid for Clinical Research for Evidence Based Medicine and a Grant-in-Aid for Cancer Research from the Ministry of Health Labour and Welfare and a grant from the Foundation for Promotion of Cancer Research in Japan.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Akasu, T., Yamaguchi, T., Fujimoto, Y. et al. Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns. Ann Surg Oncol 14, 74–83 (2007). https://doi.org/10.1245/s10434-006-9082-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-006-9082-0