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Pelvic Exenteration for Locally Advanced Rectal Cancer: an Initial Experience from North-east India.

ABSTRACT: Pelvic exenteration is a surgery done to achieve margin negative resection in locally advanced rectal cancer infiltrating pelvic organs anterior to it. A retrospective observational study of patients undergoing pelvic exenteration for locally advanced rectal cancer was done at a single surgical unit of a tertiary care cancer centre. The period of study was from 1st January 2019 to 30th June 2021. A total of twelve patients underwent pelvic exenteration for locally advanced rectal cancer during the study period. The median duration of surgery was 310 min (range 250 to 380 min). The median duration of hospital stay was 14 days (range 12 to 30 days). Seven patients had documented postoperative complications, either major or minor, with a complication rate of 58.3%. Three patients required re-admission for complications. Two patients had COVID19 infection in the postoperative period but had uneventful recovery. Margin negative resection (R0) was achieved in eight patients (66.67%). Pelvic exenteration for locally advanced rectal cancer is a definitive surgery associated with a high morbidity rate.

Supplementary information

The online version contains supplementary material available at 10.1007/s13193-022-01529-3.

SUBMITTER: Das G

PROVIDER: S-EPMC8896847 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:The presence of lateral pelvic lymph nodes (LPLN) in advanced rectal cancer entails challenges with ongoing debate regarding the role of prophylactic dissection vs. neoadjuvant radiation treatment. This article highlights the most recent data of both approaches: bilateral LPLN dissection in every patient with low rectal cancer (Rb) as per the Japanese guidelines, vs. the developing approach of neoadjuvant radiotherapy as per Eastern countries. In addition, we also accentuate the importance of a combined approach published by Sammour et al. where a simple "one-size-fits-all" strategy should be abandoned. Rectal cancer treatment is well-established in Western countries. Patients with advanced rectal cancer will undergo radiation ± chemo neoadjuvant therapy followed by TME. In the Dutch TME trial, TME plus radiotherapy showed that the presacral area was the most frequent site of recurrence and not the lateral pelvic wall. Supporting this data, the Swedish study also concluded that LPLN metastasis is not an important cause of local recurrence in patients with low rectal cancer. Therefore, Western approach is CRM-orientated and prophylactic LPLN dissection is not performed routinely as the NCCN guideline does not recommend its surgical removal unless metastases are clinically suspicious. The paradigm in Eastern countries differs somewhat. The Korean study demonstrated that adjuvant radiotherapy without lateral lymph node dissection was not enough to control local recurrence and LPLN metastases. The Japanese Trial JCOG 0212 demonstrated the effects of LPLN dissection in reducing local recurrence in the lateral pelvic compartment. We agree with Sammour and Chang on the fact that rather than a mutual exclusivity approach, we should claim for an approach where all available modalities are considered and used to optimize treatment outcomes, classifying patients into 3 categories of LPLN: low risk cT1/T2/earlyT3 (and Ra) with clinically negative LPLN on MRI; Moderate risk (cT3+/T4 with negative LPLN on MRI) and high risk (clinically abnormal LPLN on MRI). Treatment modality should be based on detailed pretreatment workup and an individualized approach that considers all options to optimize the treatment of patients with rectal cancer in the West or the East.

Project description:Purpose:Proton therapy can potentially improve the therapeutic ratio over conventional radiation therapy for oropharyngeal squamous cell cancer (OPSCC) by decreasing acute and late toxicity. We report our early clinical experience with intensity-modulated proton therapy (IMPT). Materials and Methods:We retrospectively reviewed patients with OPSCC treated with IMPT at our center. Endpoints include local regional control (LRC), progression-free survival (PFS), overall survival (OS), tumor response, and toxicity outcomes. Toxicity was graded as per the Common Terminology Criteria for Adverse Events v4.03. Descriptive statistics and Kaplan-Meier method were used. Results:We treated 46 patients from March 2015 to August 2017. Median age was 58 years, 93.5% were male, 67% were nonsmokers, 98% had stage III-IVB disease per the 7th edition of the AJCC [American Joint Committee on Cancer] Cancer Staging Manual, and 89% were p16 positive. Twenty-eight patients received definitive IMPT to total dose of 70 to 74.4 Gy(RBE), and 18 patients received postoperative IMPT to 60 to 66 Gy(RBE) following transoral robotic surgery (TORS). Sixty-four percent of patients received concurrent systemic therapy. There were no treatment interruptions or observed acute grade 4 or 5 toxicities. Eighteen patients had percutaneous endoscopic gastrostomy (PEG) tube placement; the majority (14) were placed prophylactically. The most common grade 3 acute toxicities were dermatitis (76%) and mucositis (72%). The most common late toxicity was grade 2 xerostomia (30%). At a median follow-up time of 19.2 months (interquartile range [IQR], 11.2-28.4), primary complete response was 100% and nodal complete response was 92%. One patient required a salvage neck dissection owing to an incomplete response at 4 months. There were no recorded local regional or marginal recurrences, PFS was 93.5%, and OS was 95.7%. Conclusion:Our early results for IMPT in OPSCC are promising with no local regional or marginal recurrences and a favorable toxicity profile. Our data add to a body of evidence that supports the clinical use of IMPT. Randomized comparative trials are encouraged.

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Pelvic Exenteration for Locally Advanced Rectal Cancer: an Initial Experience from North-east India.

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