Locally advanced cancer investigation & Planning surgery
Using a very vivid example, Mr. Jenkins introduces the topic of management of locally advanced cancer. About 30% of patients presenting with rectal cancer will have a locally advanced tumors, which may even involve obstruction, fistulation and/or bleeding. Approximately 5 to 10% of those will require radical exenterative surgery, which involves a complex procedure. Nevertheless, locally advanced tumors have better outcomes than recurrent tumors.
Pelvic exenteration is the only modality that can potentially be curative for selected patients when performed in a referral center. It is considered when a primary rectal cancer extends through the rectal wall and mesorectal fascia, invading either anterior, posterior or laterally. R0 resection is the most important predictive factor for survival, yielding five-year overall survival rate after pelvic exenteration for locally advanced rectal cancer ranging between 22 to 66%. Much of the data comes from PelvEx Collaboration, a multicenter database created to assess the outcomes of pelvic exenteration.
A multidisciplinary board is essential for decision-making, based on a patient-centered approach. A multimodal approach including radiotherapy and chemotherapy contributes to survival improvement. Undoubtedly, radiology is key to plan the surgery. Different surgical options include anterior pelvic exenteration, posterior pelvic exenteration, sacrectomy, pelvic side-walls, and total pelvic exenteration. Intraoperative therapy is also another option to prevent R1 resection while reducing surgical morbidity.
Pelvic exenteration is a very morbidity-prone procedure and complications are to be considered when planning these surgeries. Prior to surgery, discussion by the multidisciplinary committee and with the patient is needed to address whether potential complications are acceptable for the patients. Nonetheless, once recovered from the surgery, the majority of patients will report gradual improvement in quality of life following pelvic exenteration.