Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Abstract

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.

Surgical, survival and quality of life outcomes in over 1000 pelvic exenterations: lessons learned from a large Australian case series

“…Pelvic exenteration has evolved over the last three decades with advances in preoperative tumour staging and imaging, careful patient selection with the introduction of multidisciplinary team discussions, perioperative management, improvement in surgical techniques, and evolving to a more radical philosophy. 25 Encouraging early results have been supported by a number of reports, especially following the establishment of the PelvEx Collaborative, which facilitated the international collaboration and publication of pelvic exenteration research across several surgical units worldwide, including our centre. 26,27 The present study reports on the largest cohort of patients undergoing pelvic exenteration in a single, highvolume, specialized referral centre.…”

“…1 Our centre has previously described the evolution of pelvic exenteration outcomes over time, demonstrating an association between improved surgical margins, mortality rates and overall survival with the increase in annual surgical volume and a more aggressive surgical approach to achieve an R0 margin. 10,25 This may explain the differences in outcomes between the current study and the PelvEx collaborative data, as most of the included centres have contributed very small sample sizes (e.g. one of the PelvEx reports includes 27 centres contributing a total of 1184 patients).…”

Outcomes Following Pelvic Exenteration for Locally Recurrent Rectal Cancer With and Without En Bloc Sacrectomy

“…These data support the growing consensus that extended resection with sacrectomy to achieve clear operative margins is feasible but should also be considered part of routine practice for advanced pelvic oncology units that manage patients with LRRC. 22 In this study, most patients who underwent PE for LRRC had a sacrectomy as part of their resection. Although patients undergoing exenterative surgery at the authors' center are subject to selection bias secondary to state and national referral pathways, this finding is reflective of the unit approach to posteriorly infiltrating/presacral tumors.…”

Development and validation of a patient reported outcome measure for health-related quality of life for locally recurrent rectal cancer: a multicentre, three-phase, mixed-methods, cohort study

“… 9 However, in recent times, there has been a growing recognition that health-related quality of life (HrQoL) also needs to be appropriately measured with integrated reporting in this patient population. 10 This will provide broader based, patient-centred, contextual relevance to clinical and oncological outcomes such as morbidity, recovery, and survival. Dual outcome reporting of clinical and patient-reported outcome data aligns well with patient priorities in this setting, with equal value placed on overall survival and maintaining HrQoL.…”