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Published byRosemary Bradley Modified over 9 years ago
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The management of recurrent pelvic malignancy
Pete Sagar The General Infirmary at Leeds England
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Things could be worse
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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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Presentation PAIN
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The problem 8-10 000 cases annually of rectal cancer in the UK
Local pelvic recurrence in 5-15%
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Treatment – radiotherapy/chemotherapy
Good initial palliation Long term survivors are rare Reserved for end stage disease
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Treatment - surgery Multimodality therapy Team approach essential
Technical demands
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Preoperative assessment
Biopsy to confirm diagnosis CT chest and abdomen MRI pelvis EUA Fitness for operation
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The Leeds MDT meeting
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Accommodation for relatives
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Accommodation for relatives (NHS)
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Patterns of pelvic invasion
Localised type Sacral invasion Pelvic side wall invasion
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Localized type Recurrent tumour is localized to the adjacent tissues or connective tissue
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Peri-anastomotic recurrence
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Perineal recurrence
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Mucinous adenocarcinoma
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Sacral invasion Recurrent tumour invades the lower sacrum (S3, S4, S5) or coccyx
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Chordoma with sacral invasion
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Sacral invasion - gadolinium enhanced
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Lateral invasion Recurrent tumour invades pelvic side wall
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Pelvic side wall invasion
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Vesico-ureteric junction
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Planes of attack
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APR+S vs TPE+S
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Rectus abdominus flap
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Anatomical points
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When not to operate
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Choose your patient!
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Contraindications Extrapelvic disease Invasion of S1 or S2
Invasion through greater sciatic notch Extensive pelvic side wall involvement ASA IV-V
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Para-aortic nodal involvement
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Greater sciatic notch involvement
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Surgical intervention contraindicated
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Extension through both greater sciatic foramina
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Technical tips
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Perianastomotic recurrence
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Peri-anastomotic recurrence
Residual mesentery Anticipate tearing around the anastomosis Beware the medial course of the ureters
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Anterior invasion into bladder
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Anterior spread Trial dissection Plane anterior to the bladder APER
Involve the urologist
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Sidewall vessel involvement
vessels
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Pelvic side wall BLEEDING Suture Fibrillar surgicell Argon beamer
Be prepared to pack
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Presacral space, no direct invasion
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Pre-sacral mass Control iliac vessels before dissection of mass
Incise peritoneum and develop plane between mass and sacrum Beware spongy tumour
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Direct invasion into the sacrum
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Direct invasion of the sacrum
Choose level of sacrectomy carefully Frozen section Beware bleeding from pre-sacral veins
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Posterior exenteration 35%
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Total exenteration 30%
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Resection of mass alone
15%
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Gynaecological clearance
9%
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Anterior exenteration 7%
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Rectal resection with primary anastomosis 4%
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Sacrectomy 16%
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Cumulative survival R0 vs R1 resections
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Outcome One third will live five years
One third will recur locally (?re-operate) One third will die of disseminated disease
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Conclusion Multidisciplinary management Surgery prime modality
Surgical team approach essential
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ENGLAND WIN THE ASHES
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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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Best practice?
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