1. The management of recurrent pelvic malignancy
Pete Sagar
The General Infirmary at Leeds
England

5. Things could be worse

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9. Presentation
PAIN

11. The problem 8-10 000 cases annually of rectal cancer in the UK
Local pelvic recurrence in 5-15%

12. Treatment – radiotherapy/chemotherapy
Good initial palliation
Long term survivors are rare
Reserved for end stage disease

13. Treatment - surgery Multimodality therapy Team approach essential
Technical demands

14. Preoperative assessment
Biopsy to confirm diagnosis
CT chest and abdomen
MRI pelvis
EUA
Fitness for operation

15. The Leeds MDT meeting

16. Accommodation for relatives

17. Accommodation for relatives (NHS)

18. Patterns of pelvic invasion
Localised type
Sacral invasion
Pelvic side wall invasion

19. Localized type
Recurrent tumour is localized to the adjacent tissues or connective tissue

20. Peri-anastomotic recurrence

21. Perineal recurrence

22. Mucinous adenocarcinoma

23. Sacral invasion
Recurrent tumour invades the lower sacrum (S3, S4, S5) or coccyx

24. Chordoma with sacral invasion

25. Sacral invasion - gadolinium enhanced

26. Lateral invasion
Recurrent tumour invades pelvic side wall

27. Pelvic side wall invasion

28. Vesico-ureteric junction

29. Planes of attack

30. APR+S vs TPE+S

38. Rectus abdominus flap

40. Anatomical points

44. When not to operate

45. Choose your patient!

46. Contraindications Extrapelvic disease Invasion of S1 or S2
Invasion through greater sciatic notch
Extensive pelvic side wall involvement
ASA IV-V

47. Para-aortic nodal involvement

48. Greater sciatic notch involvement

49. Surgical intervention contraindicated

50. Extension through both greater sciatic foramina

51. Technical tips

52. Perianastomotic recurrence

53. Peri-anastomotic recurrence
Residual mesentery
Anticipate tearing around the anastomosis
Beware the medial course of the ureters

54. Anterior invasion into bladder

55. Anterior spread Trial dissection Plane anterior to the bladder APER
Involve the urologist

56. Sidewall vessel involvement
vessels

57. Pelvic side wall BLEEDING Suture Fibrillar surgicell Argon beamer
Be prepared to pack

58. Presacral space, no direct invasion

59. Pre-sacral mass Control iliac vessels before dissection of mass
Incise peritoneum and develop plane between mass and sacrum
Beware spongy tumour

60. Direct invasion into the sacrum

61. Direct invasion of the sacrum
Choose level of sacrectomy carefully
Frozen section
Beware bleeding from pre-sacral veins

62. Posterior
exenteration
35%

63. Total
exenteration
30%

64. Resection of mass alone
15%

65. Gynaecological clearance9%

66. Anterior
exenteration 7%

67. Rectal resection with
primary anastomosis 4%

68. Sacrectomy
16%

69. Cumulative survival R0 vs R1 resections

71. Outcome One third will live five years
One third will recur locally (?re-operate)
One third will die of disseminated disease

72. Conclusion Multidisciplinary management Surgery prime modality
Surgical team approach essential

75. ENGLAND WIN THE ASHES

78. Intra-operative radiotherapy
Delivery of high biological equivalent
Dose limiting structures are displaced
45-60 Gy EBRT pre op
Deliver remainder at operation

85. Best practice?