Multidisciplinary Salvage Surgery in Rectal Cancer

John Northover, St Mark’s Hospital, London

Introduction

Unfortunately recurrent rectal cancer is usually fatal. However, unlike recurrence in several other types of abdominal malignancies, such as pancreatic and gastric cancer, in rectal cancer it is sometimes curable, and frequently at least amenable to good palliation [1]. It is important, therefore, to be vigilant so that opportunities to provide useful intervention are recognised and acted upon appropriately.

An aggressive approach to diagnosis and treatment, allied to the liberal application of common sense, pays dividends mainly in the provision of good palliation in a significant proportion, and long term survival following further surgery for recurrence in 1-5% of the whole cohort initially treated for primary disease [2-5]. Most patients developing recurrence are beyond surgical help, and a key responsibility for surgeons is avoidance of useless intervention in this large group. Recurrence surgery is not for the faint hearted, but with careful selection, much benefit can accrue to patients [6, 7]. Such surgery should be concentrated into tertiary referral centres, where a multidisciplinary team and a broad experience of this taxing field can be brought to bear [6].
In this short presentation I plan to concentrate mainly on the surgical management of local or locoregional recurrence in the pelvis.

Patterns of recurrence

It should of course go without saying that the word ‘recurrence’ is strictly a misnomer - the tumour cells which constitute the recurrence have never gone away! What has ‘recurred’ is our objective awareness of the presence of malignant disease, following previous removal - apparently for cure - of a primary tumour. During the ‘invisible’ period one or several phenomena may have transpired:

• any tumour cells left at the primary site or in its area of regional lymphatic drainage may have multiplied to produce a clinically detectable ‘local’ or ‘locoregional’ recurrence
• some cells free in the systemic circulation or in distant organs may have formed one or more clinically detectable ‘distant’ metastases
• importantly, other such cells may remain undetectable, and liable to produce further clinically detectable metastases at a later stage.

In almost all cases residual cells are multifocal, and, at least around the primary site, not related to ‘virgin’ planes and anatomical structures. Therefore the pattern of disease and the format of any potentially curative surgery is particular to the individual case. Although cure or good palliation may be possible, the clinical approach should be one in which failure is anticipated at all stages until proven otherwise by events.
In the present day US, around 20% of colorectal cancer patients present initially with untreatable, disseminated disease, the rest undergoing attempted surgical cure. Around 40% with Stage B2 or C disease will go on to develop recurrence; about one third will suffer metastasis to the liver, one fifth each to lungs and abdominal cavity, one tenth to the retroperitoneum and just one in twenty at the anastomosis [8]. About one third of rectal cancer cases will develop pelvic recurrence. Of all those patients with B2 or C tumours, only 20% of those developing recurrence will have tumour at a single (and hence potentially operable) site [8, 9]. In a large and careful follow-up of 505 patients in Milan, about half those developing recurrence did so at distant sites only, while a quarter each developed local recurrence alone or with concurrent distant spread [10]; Wanebo’s group found a similar pattern [9].

Aims of treatment

Unfortunately the usual outcome of recurrent disease is the death of the patient, usually within one year of diagnosis [11, 12]. Considerable effort, with enormous scope for ‘good doctoring’, must go into the care of this majority. Many others can be helped surgically, living longer and better lives before succumbing. Just a few will be cured of their recurrence by oft times difficult and dangerous surgery, with an operative mortality of around 10% [13].

AIMS IN TREATING RECURRENT COLORECTAL CANCER

• Providing good non-surgical palliation to many
• Identifying those likely to benefit from surgery - curative or palliative
• Avoiding surgery in the majority beyond surgical assistance
• Being aggressive surgically in the few in whom it might allow cure
• Predicting likelihood of surgical palliation when cure is not possible

Planning surgery includes at all stages a careful hunt for reasons to abort as evidence of incurability is found - previously undetected irresectable disease outside the resectable margins, or direct extension of the ‘resectable’ lesion beyond previously assumed manageable margins [14]. Only when the procedure has succeeded technically, and the patient has experienced a useful and acceptable quality survival can the procedure be deemed a success.
Recurrence is most likely to have been diagnosed following the onset of symptoms [13]. Investigations are aimed at:

• identifying the site and extent of the symptomatic recurrence
• excluding the presence of asymptomatic recurrence elsewhere.

This may require CT or MR scanning, and other supportive radiology as necessary - chest X ray, intravenous urography, etc. If the nature of a scan-detected abnormality is not clear, radio-immunoscintigraphy [15], and/or scan-guided biopsy may be required.
Patterns of recurrence include local or locoregional (25%), peritoneal or retroperitoneal recurrence (20%), and disease in distant organs, most frequently the liver (30%) or lung (20%) [9].

Pelvic recurrence

Incidence

Pelvic recurrent disease after primary surgery for rectal cancer affects a very variable proportion of cases, which may be related to variability in primary surgical technique [16]. It may well be that ‘avoidable’ pelvic recurrence - disease left behind which might have been removable in the hands of another surgeon - is more likely to be resectable at a second procedure than recurrence from a ‘low recurrence practice’.

Investigations

As pelvic recurrence usually begins in the tissues between the pelvic organs, and is developing in a confined space, the key steps are to define the site and extent of the disease, and in particular to clarify any involvement of other organs. Important questions to be answered are as follows:

• Are the pelvic side walls, and the vessels and nerves applied to them, involved?
• Are the urogenital organs invaded, and if not, what margin of clearance is apparent?

After full investigation if may remain unclear as to whether surgical extirpation is likely to be achievable. Examination under anaesthesia remains a valuable part of the work-up of these patients. Once all the information has been gleaned, and if there is the feeling that an attempt at cure is possible, the surgeon, preferably with the radiologist, should carry out the operation ‘in his head’, go through each step of the planned procedure, seeking reassurance that at each stage it will be possible to move on to the next element of the operation. This is an important part of the process; it can be a great surgical misfortune - mainly borne by the patient - to begin a dissection for real, and to pass beyond the point of no return (for instance, by dividing the colon above a colorectal anastomosis, rendering the distal colon ischaemic) before realising that the way ahead is blocked by some unforeseen circumstance.

Aspects of surgery for pelvic recurrence

There are several principles of potentially radical surgery in this difficult situation:

• If anterior resection was the primary procedure, it is very unlikely that a restorative operation would be sensible at the laparotomy to treat recurrence
• Involvement of other organs, or the lower sacrum, does not preclude an attempt at cure, so long as the pelvic side wall structures are not involved
• It is advisable to include radiotherapy ± chemotherapy in the treatment plan
• If a distal rectal stump can be preserved well below a re-resection, re-anastomosis may be possible two years later should the patient request it at that stage, when the risk of further recurrence begins to diminish
• If tumour lies close to an adjacent structure, and involvement thereof is equivocal despite investigations, it is advisable to assume involvement if cure is the target, and to include the organ in the extirpation, rather than risk a trial dissection, which may open the tumour, losing the chance of cure.

Surgical techniques

Anterior, posterior and complete exenteration of the pelvic organs are big operations, with considerable functional sequelae, significant risks of morbidity and mortality, but also a worthwhile chance of cure in properly selected cases [17-19]. These procedures are best performed as joint efforts involving a colorectal surgeon, urologist, and an orthopaedic surgeon if partial sacrectomy is contemplated, when a close shave of the sciatic and other nerves will need expert assessment (some neurosurgeons have a remarkable and frightening propensity to dive directly into tumours, and are therefore best avoided as allies in sacral surgery!) Partial cystectomy, particularly around the bladder base, is again better performed with the support of a urological colleague.
If radical removal of the tumour is possible, and if the pathologist can confirm that it has been achieved, the patient has a chance of survival equivalent to that of a patient with a C2 tumour undergoing primary surgery. Most series are small, and made smaller by the finding at operation or on pathological examination that resection has not been achieved; amongst those patients in whom radicality has been achieved, around one third can expect to survive five years [9, 20].
Those patients with small bowel obstruction due to involvement of loops adherent to pelvic recurrence deserve special mention. It is tempting to regard obstruction uniformly as a terminal event, but many can resume normal bowel function for several months by judicious selection and bypass, if complete resection is out of the question [21].

Role of adjuvant therapy

This high risk group should generally be considered for pre- or post-operative radiotherapy ± chemotherapy [22]. Evidence points strongly towards an effect on subsequent local relapse, though survival improvement has not been demonstrated conclusively.
An interesting aspect of this issue is the possible role of intra-operative radiotherapy (IORT). Early reports appeared almost 20 years ago, suggesting that addition of IORT to standard surgery and perioperative radiation at least delayed subsequent relapse in those undergoing incomplete resection [23, 24]. Use of intraoperative brachytherapy in the patient who had already received high dose external beam therapy was reported by the same group, with acceptable morbidity and a probably favourable effect on local control [25]. Others have reported fair sized series more recently, with guarded endorsement of the approach [26, 27].

Summary

Recurrence of colorectal cancer is common, and usually fatal. This should not engender a negative approach. Efficient and thoughtful work-up allows many patients to benefit from good palliation, and in a small proportion, attempts at radical therapy can produce cures. Surgical care of this difficult subgroup should be concentrated into tertiary referral centres to maximise expertise, thereby optimising outcome.

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