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The management of recurrent pelvic malignancy

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Presentation on theme: "The management of recurrent pelvic malignancy"— Presentation transcript:

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

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5 Things could be worse

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7 TWO-timing Shane Warne has been caught cheating with ANOTHER woman.
EXCLUSIVE: SHANE'S AT IT AGAIN Cheat Aussie star's two-month affair By Megan Lloyd Davies And Richard Smith MESSAGES: Warne sent a string of texts

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9 Presentation PAIN

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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

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38 Rectus abdominus flap

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40 Anatomical points

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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 clearance
9%

66 Anterior exenteration 7%

67 Rectal resection with primary anastomosis 4%

68 Sacrectomy 16%

69 Cumulative survival R0 vs R1 resections

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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

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75 ENGLAND WIN THE ASHES

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

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85 Best practice?

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