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Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis?
The American Journal of Surgery 182 (2001) 274 –277
Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis? Charles Cheng, M.D.*, Miguel A. Rodriguez-Bigas, M.D., Nicholas Petrelli, M.D. Division of Surgical Oncology, Roswell Park Cancer Institute, State University of New York at Buffalo, Elm and Carlton Sts., Buffalo, NY 14263, USA Manuscript received February 9, 2001; revised manuscript June 9, 2001
Abstract Background: The prognosis for patients with recurrent rectal adenocarcinoma is not uniformly fatal if one can safely and selectively reoperate on a subset of patients with resectable disease. Even with careful selection, many patients undergo exploratory laparotomy and do not have resectable disease. We have reported that the presence of hydronephrosis in the setting of recurrent rectal carcinoma portends a poor outcome because of invariable association with unresectable disease. The purpose of this study was to update our experience of patients presenting with unilateral or bilateral hydronephrosis and recurrent rectal cancer. Methods: A retrospective chart review of 142 patients with recurrent rectal cancer evaluated at our institution from January 1989 to December 1999 was performed. Results: Twenty-seven of 142 patients referred for the management of recurrent rectal cancer had unilateral or bilateral hydronephrosis. Fifteen (55%) of these patients had distant metastatic disease. Twelve patients (45%) with hydronephrosis and local recurrent disease on evaluation were analyzed. Six of the 12 patients underwent exploratory laparotomy, with none found to have resectable disease. Their mean survival after diagnosis of recurrent disease was 14 months. Conclusions: Based on our results, the presence of hydronephrosis (unilateral or bilateral) in recurrent rectal adenocarcinoma portends a survival equivalent to the presence of distant metastasis. Therefore, we do not believe potential curative surgery has a role for patients with locally recurrent rectal adenocarcinoma in the presence of hydronephrosis. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Recurrent; Rectum; Carcinoma; Hydronephrosis; Surgery
Annually, there are approximately 37,200 new rectal adenocarcinoma cases in the United States [1]. Of these, the recurrence rate after a curative resection varies between 6% and 50% [2,3]. In an autopsy series reported by Welch and Donaldson [4], 25% of patients died from primary rectal adenocarcinoma with local recurrence alone. The prognosis of patients with recurrent rectal carcinoma is poor, with the median survival close to 1 year [5,6]. However, with proper patient selection, some patients may have a survival benefit from surgical extirpation of the recurrent tumor [7]. In 1992, our institution published a series of patients with locally recurrent rectal carcinoma in the presence of preoperative unilateral or bilateral hydronephrosis [8] identifying a subset of patients who were deemed unresectable at the time of surgical exploration. This report is a follow-up of our experience.
* Corresponding author. Tel.: ⫹1-716-845-8983; fax: ⫹1-716-845-3434.
Patients and methods From January 1989 to December 1999, 148 medical records of patients with recurrent rectal carcinoma were retrospectively reviewed. Six patients had histology other than adenocarcinoma (carcinoid and melanoma) and were therefore excluded from the study. Primary rectal adenocarcinoma was defined as a tumor located within 15 cm from the anal verge via endoscopy. One hundred forty two patients comprised the population for this study. Demographics and tumor characteristics were recorded. One hundred fifteen patients (81%) presented with local recurrence or distant metastatic disease without hydronephrosis. Twenty-seven (19%) patients had unilateral or bilateral hydronephrosis as part of the recurrent disease. Fifteen of 27 patients (56%) had unilateral or bilateral hydronephrosis and distant metastasis. Twelve patients (44%) had unilateral or bilateral hydronephrosis and local recurrence alone. These 12 patients form the basis of this report.
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 7 0 6 - 1
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
275
Table 1 Stage of primary tumor for patients evaluated TNM
Stage
Number
T2N0 T3N0 T3N1-3 Unknown
I II III Unknown
3 4 4 1
Patients were evaluated for potential resection by history and physical, complete metabolic panel (electrolytes, liver function enzymes), complete blood count, carcinoembryonic antigen, chest radiograph, and computed tomography of the abdomen and pelvis. All patients were followed up either at our institution, y correspondence with the referring physician, or by direct contact with family members. Estimated survival distributions were calculated by the method of Kaplan and Meir [9]. Tests of significance with respect to survival distributions were based on the log-rank test [10]. The Institutional Review Board approved this study.
Results The mean age of the patients with unilateral and bilateral hydronephrosis and local recurrence was 59 years (range 48 to 71). There were 7 male and 5 female patients. The stage of the primary tumor is illustrated in Table 1. The mean disease-free interval between the primary tumor resection and the time of recurrence was 29 months (range 7 to 60). Six of the 12 patients received adjuvant radiation for the original primary tumor. Hydronephrosis occurred bilaterally in 5 patients and unilaterally in 7 patients (4 in the left ureter and 3 in the right ureter). All of these patients had investigations as outlined above and were found to have no extrapelvic disease. Six of the 12 patients underwent exploratory laparotomy with the recurrent disease deemed unresectable. Table 2 illustrates the reasons for unresectability. Of the remaining 6 patients, 2 patients refused surgery, 1 patient had pelvic sidewall involvement at the time of presentation, and 3 patients were not offered surgery based on our previous published experience [8].
Fig. 1. Survival after onset of rectal cancer recurrence. Comparison of patients with isolated local recurrent disease associated with hydronephrosis (n ⫽ 12) and patients with metastatic disease with or without local disease (n ⫽96).
After the diagnosis of recurrence, the mean survival time for the 12 patients who presented with hydronephrosis was 14 months (range 7 to 23). The mean time of survival after diagnosis of recurrence for those patients who underwent surgery and for those patients who were observed was 14.0 months and 14.8 months, respectively. Two of the 12 patients were alive on last follow-up. One patient had an exploratory laparotomy and was alive with disease at 19 months. The second patient was observed with disease at 16 months. The mean survival for the 3 patients who were not offered surgery was 16 months. The survival of patients with local recurrence alone and hydronephrosis was analyzed. There was no significant difference in survival after recurrence for patients with hydronephrosis and locally recurrent disease compared with patients without hydronephrosis and distant metastasis (P ⫽ 0.22; Fig. 1). The survival of the 12 patients with hydronephrosis and locally recurrent disease compared with those with distant disease only was not statistically significant (P ⫽ 0.09; Fig. 2).
Comments Table 2 Reasons for unresectability in explored patients Patient Primary Reason for unresectability surgery 1 2 3 4 5 6
APR APR APR LAR APR APR
Fixation to pelvic sidewall with iliac vessel encasement Extrapelvic disease in liver Pelvic sidewall involvement Pelvic sidewall involvement Extrapelvic disease with carcinomatosis Pelvic sidewall involvement
APR ⫽ abdominoperineal resection; LAR ⫽ low anterior resection.
Sixty percent to 80% of the recurrences after curative treatment of primary rectal cancer occur within 2 years after primary resection. After potentially curative abdominoperineal resection, multiple series have reported recurrence rates ranging from 3.7% to 38% [11–14]. The majority of patients with recurrent disease will not be resectable for cure. In their clinical series, Gilbert et al [15] reported that recurrent rectal adenocarcinoma occurred as an isolated recurrence at a single site in 55% of the cases. In their autopsy series, they reported an isolated recurrence
276
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
Fig. 2. Survival after onset of rectal cancer recurrence. Comparison of patients with isolated local recurrent disease associated with hydronephrosis (n ⫽ 12) and patients with distant metastatic disease only (n ⫽ 45).
at a single site in 27% of patients, whereas disseminated disease occurred in 73% [15]. Thus there is an overestimate of isolated local recurrence clinically by about 30%. The discrepancy is thought to be underdiagnosis of disseminated disease in the clinical setting. We have reported that patients with unilateral or bilateral hydronephrosis in the setting of recurrent rectal carcinoma are unresectable for cure [8]. In the current series of patients with isolated locally recurrent disease in the setting of hydronephrosis, the mean survival after diagnosis was 14 months. Wanebo et al [16] reported 47 patients with recurrent rectal carcinoma who underwent extended pelvic resections. Twenty-two patients required pelvic exenteration along with sacral resection. The 5-year estimated survival was 24% (median survival 36 months), with 5 patients surviving longer than 5 years. The authors emphasized the importance of obtaining a histologically negative margin on resection. However, the presence of hydronephrosis in their patients was not mentioned. In addition, their extended pelvic resections had significant morbidities of up to 50% and a high perioperative mortality of 8.5% [16]. In another series by Wanebo et al [17], there was an improvement of survival with decreased perioperative mortality. Although there may be an improvement in survival and mortality, the concomitant morbidities for an abdominosacral resection cannot be ignored. Supporting an aggressive approach to locally recurrent rectal adenocarcinomas, Pearlman et al [18] reported on the technique of sacropelvic resection in relation to locally advanced or recurrent anorectal cancer. Ten patients had recurrent rectal cancer and some degree of ureteral obstruction, which was not defined. Disease-free survival was reported to be 60% at 4 years for the patients in the study [18]. Curley et al [19] also supported an aggressive approach to recurrent colorectal carcinoma by selecting out patients who
could be surgically resected with a negative margin. The procedures involved for the 23 patients reported were total pelvic exenteration, posterior exenteration, low anterior resection with cystectomy, and contiguous organ resection. They reported a 5-year survival rate of 54% [19]. In a series of 45 patients with locally recurrent rectal cancer who underwent curative resection by Bozzetti et al [20], 21 patients (47%) could be resected with a negative margin. In this series, a negative margin had a direct correlation with improved 5-year survival (19% versus 0%). Because less than 10% of all patients who underwent surgical treatment benefited from surgery, these investigators no longer recommend surgery as the primary option for treating locally recurrent rectal carcinoma. They, however, did not analyze their series of patients with respect to the presence of hydronephrosis. The significance of complete ureteral obstruction was described by Lopez et al [21] as a “local sign of invasive carcinoma beyond the limits of operability for cure.” When the obstruction is due to compression rather than invasion, they suggest that resection may not be contraindicated. We now have reported 19 patients, including the patients analyzed in the previously published series, with recurrent rectal cancer and unilateral or bilateral hydronephrosis who underwent exploration. All were found to be unresectable for cure. In our experience, patients who present with unilateral or bilateral hydronephrosis in the setting of recurrent rectal cancer could not be resected for cure due to either local sacral, sidewall invasion, or distant metastasis. The survival of patients with hydronephrosis and locally recurrent disease was similar to those with distant disease. At our institution, all patients with locally recurrent disease undergo extensive evaluation in order to rule out extrapelvic disease. This includes a careful history and physical to determine if the patient has any locally extensive disease (pelvic pain, radicular pain). The metastatic workup consists of a chest roentgenogram, computed axial tomography of the abdomen and pelvis, magnetic resonance imaging of the pelvis as needed, and an image-guided biopsy of the sacrum if involvement by tumor is suspicious. More recently, we also have incorporated positron emission tomography recently. If there is no evidence of extrapelvic disease, no bony or sidewall involvement, and no hydronephrosis, exploratory laparotomy is recommended with the goal of curative resection. It is important to note that pelvic sidewall or presacral involvement are not considered signs of unresectable disease in many institutions as has been described in this Comments section. The availability of intraoperative radiation or brachytherapy has been effective as potential adjunctive therapies in this setting [22]. Also, the recent development of preoperative chemoradiation may downstage these recurrences such that the surgeon can resect these tumors with free margins. We think that an aggressive surgical approach offers patients with recurrent rectal carcinoma the best potential for survival. However, careful patient selection is important
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
for surgery to impart a survival benefit. Pelvic sidewall and sacrum involvement of the tumor precludes one from adequate resection. The more radical procedures such as the sacropelvic resection exemplified by Wanebo et al have concomitant high morbidity and mortality. In the setting of unilateral or bilateral hydronephrosis, we have shown that the natural history of patients with locally recurrent rectal adenocarcinoma is similar to patients with distant disease. We, therefore, do not believe that a surgical exploration should be undertaken. These patients should be palliated for the presenting symptoms. We realize that only 6 of 12 patients in our report underwent surgical exploration and that we can be criticized for our conclusion based on a small number of patients. Hence, we encourage other authors to publish their experience in this group of patients who present with unilateral or bilateral hydronephrosis to confirm or refute our results. References [1] Greenlee RT, Hill-Harmon M, Murray T, Thun M. Cancer statistics 2001. CA Cancer J Clin 2001;51:15–36. [2] Krook JE, Moertel CG, Gunderson LL. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709–15. [3] Ross A, Rusnak C, Weinerman B, et al. Recurrence and survival after surgical management of rectal cancer. Am J Surg 1999;177:392–5. [4] Welch JP, Donaldson GA. The clinical correlation of an autopsy study of recurrent colorectal cancer. Ann Surg 1979;189:496 –502. [5] Danzi M, Ferulano GP, Abate S, et al. Survival and locations of recurrence following abdomino-perineal resection for rectal cancer. J Surg Oncol 1996;31:235–9. [6] Polk HC, Spratt JS. The results of treatment of perioneal recurrence of cancer of the rectum. Cancer 1979;43:952–5. [7] Holm T, Cedermard B, Rutqvist LE. Local recurrence of rectal adenocarcinoma after “curative” surgery with and without preoperative radiotherapy. Br J Surg 1994;81:452–5.
277
[8] Rodriguez-Bigas M, Herrera L, Petrelli N. Surgery for recurrent rectal adenocarcinoma in the presence of hydronephrosis. Am J Surg 1992; 164:18 –21. [9] Kaplan EL, Meir P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457– 86. [10] Cox DR. Regression models and life-tables. J R Stat Soc B 1972;34: 187–220. [11] Pilipshen SJ, Heilweil M Quan SHQ, et al. Pattern of pelvic recurrence following definitive resection of rectal cancer. Cancer 1984;53: 1354 – 62. [12] Moosa AR, Ree PC, Marks JE, et al. Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum and rectosigmoid. Br J Surg 1975;62:727–30. [13] DeAzevedo JP, Dozois RR, Gunderson LL. Locally recurrent rectal cancer: surgical strategy. World J Surg 1992;16:490 – 4. [14] Wilking N, Herrera L, Petrelli NJ, Mittelman A. Pelvic and perineal recurrences after abdominoperineal resection for adenocarcinoma of the rectum. Am J Surg 1985;150:561–3. [15] Gibert JM, Jeffrey I, Evans M, Kark AE. Sites of recurrent tumour after “curative” colorectal surgery: implication for adjuvant therapy. Br J Surg 1984;71:203–5. [16] Wanebo HJ, Koness RJ, Turk PS, Cohen SI. Composite resection of posterior pelvic malignancy. Ann Surg 1992;215:685–95. [17] Wanebo HJ, Antoniuk P, Koness RJ, et al. Pelvic resection of recurrent rectal cancer: technical considerations and outcomes. Dis Colon Rectum 1999;42:1438. [18] Pearlman NW, Donohue RE, Stiegmann GV, et al. Pelvic and sacropelvic exenteration for locally advanced or recurrent anorectal cancer. Arch Surg 1987;122:537– 41. [19] Curley SA, Carlson GW, Shumate CR, et al. Extended resection for locally advanced colorectal carcinoma. Am J Surg 1992;163:553–9. [20] Bozzetti F, Bertario L, Rossetti C, et al. Surgical treatment of locally recurrent rectal carcinoma. Dis Colon Rectum 1997;40:1421– 4. [21] Lopez MJ, Kraybill WG, Downey RS, et al. Exenterative surgery for locally advanced rectosigmoid cancers. Is it worthwhile? Surgery 1987;102:644 –51. [22] Abuchaibe O, Calvo F, Azinovic I, et al. Intraoperative radiotherapy in locally advanced recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 1993;26:859 – 67.
Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis? Charles Cheng, M.D.*, Miguel A. Rodriguez-Bigas, M.D., Nicholas Petrelli, M.D. Division of Surgical Oncology, Roswell Park Cancer Institute, State University of New York at Buffalo, Elm and Carlton Sts., Buffalo, NY 14263, USA Manuscript received February 9, 2001; revised manuscript June 9, 2001
Abstract Background: The prognosis for patients with recurrent rectal adenocarcinoma is not uniformly fatal if one can safely and selectively reoperate on a subset of patients with resectable disease. Even with careful selection, many patients undergo exploratory laparotomy and do not have resectable disease. We have reported that the presence of hydronephrosis in the setting of recurrent rectal carcinoma portends a poor outcome because of invariable association with unresectable disease. The purpose of this study was to update our experience of patients presenting with unilateral or bilateral hydronephrosis and recurrent rectal cancer. Methods: A retrospective chart review of 142 patients with recurrent rectal cancer evaluated at our institution from January 1989 to December 1999 was performed. Results: Twenty-seven of 142 patients referred for the management of recurrent rectal cancer had unilateral or bilateral hydronephrosis. Fifteen (55%) of these patients had distant metastatic disease. Twelve patients (45%) with hydronephrosis and local recurrent disease on evaluation were analyzed. Six of the 12 patients underwent exploratory laparotomy, with none found to have resectable disease. Their mean survival after diagnosis of recurrent disease was 14 months. Conclusions: Based on our results, the presence of hydronephrosis (unilateral or bilateral) in recurrent rectal adenocarcinoma portends a survival equivalent to the presence of distant metastasis. Therefore, we do not believe potential curative surgery has a role for patients with locally recurrent rectal adenocarcinoma in the presence of hydronephrosis. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Recurrent; Rectum; Carcinoma; Hydronephrosis; Surgery
Annually, there are approximately 37,200 new rectal adenocarcinoma cases in the United States [1]. Of these, the recurrence rate after a curative resection varies between 6% and 50% [2,3]. In an autopsy series reported by Welch and Donaldson [4], 25% of patients died from primary rectal adenocarcinoma with local recurrence alone. The prognosis of patients with recurrent rectal carcinoma is poor, with the median survival close to 1 year [5,6]. However, with proper patient selection, some patients may have a survival benefit from surgical extirpation of the recurrent tumor [7]. In 1992, our institution published a series of patients with locally recurrent rectal carcinoma in the presence of preoperative unilateral or bilateral hydronephrosis [8] identifying a subset of patients who were deemed unresectable at the time of surgical exploration. This report is a follow-up of our experience.
* Corresponding author. Tel.: ⫹1-716-845-8983; fax: ⫹1-716-845-3434.
Patients and methods From January 1989 to December 1999, 148 medical records of patients with recurrent rectal carcinoma were retrospectively reviewed. Six patients had histology other than adenocarcinoma (carcinoid and melanoma) and were therefore excluded from the study. Primary rectal adenocarcinoma was defined as a tumor located within 15 cm from the anal verge via endoscopy. One hundred forty two patients comprised the population for this study. Demographics and tumor characteristics were recorded. One hundred fifteen patients (81%) presented with local recurrence or distant metastatic disease without hydronephrosis. Twenty-seven (19%) patients had unilateral or bilateral hydronephrosis as part of the recurrent disease. Fifteen of 27 patients (56%) had unilateral or bilateral hydronephrosis and distant metastasis. Twelve patients (44%) had unilateral or bilateral hydronephrosis and local recurrence alone. These 12 patients form the basis of this report.
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 7 0 6 - 1
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
275
Table 1 Stage of primary tumor for patients evaluated TNM
Stage
Number
T2N0 T3N0 T3N1-3 Unknown
I II III Unknown
3 4 4 1
Patients were evaluated for potential resection by history and physical, complete metabolic panel (electrolytes, liver function enzymes), complete blood count, carcinoembryonic antigen, chest radiograph, and computed tomography of the abdomen and pelvis. All patients were followed up either at our institution, y correspondence with the referring physician, or by direct contact with family members. Estimated survival distributions were calculated by the method of Kaplan and Meir [9]. Tests of significance with respect to survival distributions were based on the log-rank test [10]. The Institutional Review Board approved this study.
Results The mean age of the patients with unilateral and bilateral hydronephrosis and local recurrence was 59 years (range 48 to 71). There were 7 male and 5 female patients. The stage of the primary tumor is illustrated in Table 1. The mean disease-free interval between the primary tumor resection and the time of recurrence was 29 months (range 7 to 60). Six of the 12 patients received adjuvant radiation for the original primary tumor. Hydronephrosis occurred bilaterally in 5 patients and unilaterally in 7 patients (4 in the left ureter and 3 in the right ureter). All of these patients had investigations as outlined above and were found to have no extrapelvic disease. Six of the 12 patients underwent exploratory laparotomy with the recurrent disease deemed unresectable. Table 2 illustrates the reasons for unresectability. Of the remaining 6 patients, 2 patients refused surgery, 1 patient had pelvic sidewall involvement at the time of presentation, and 3 patients were not offered surgery based on our previous published experience [8].
Fig. 1. Survival after onset of rectal cancer recurrence. Comparison of patients with isolated local recurrent disease associated with hydronephrosis (n ⫽ 12) and patients with metastatic disease with or without local disease (n ⫽96).
After the diagnosis of recurrence, the mean survival time for the 12 patients who presented with hydronephrosis was 14 months (range 7 to 23). The mean time of survival after diagnosis of recurrence for those patients who underwent surgery and for those patients who were observed was 14.0 months and 14.8 months, respectively. Two of the 12 patients were alive on last follow-up. One patient had an exploratory laparotomy and was alive with disease at 19 months. The second patient was observed with disease at 16 months. The mean survival for the 3 patients who were not offered surgery was 16 months. The survival of patients with local recurrence alone and hydronephrosis was analyzed. There was no significant difference in survival after recurrence for patients with hydronephrosis and locally recurrent disease compared with patients without hydronephrosis and distant metastasis (P ⫽ 0.22; Fig. 1). The survival of the 12 patients with hydronephrosis and locally recurrent disease compared with those with distant disease only was not statistically significant (P ⫽ 0.09; Fig. 2).
Comments Table 2 Reasons for unresectability in explored patients Patient Primary Reason for unresectability surgery 1 2 3 4 5 6
APR APR APR LAR APR APR
Fixation to pelvic sidewall with iliac vessel encasement Extrapelvic disease in liver Pelvic sidewall involvement Pelvic sidewall involvement Extrapelvic disease with carcinomatosis Pelvic sidewall involvement
APR ⫽ abdominoperineal resection; LAR ⫽ low anterior resection.
Sixty percent to 80% of the recurrences after curative treatment of primary rectal cancer occur within 2 years after primary resection. After potentially curative abdominoperineal resection, multiple series have reported recurrence rates ranging from 3.7% to 38% [11–14]. The majority of patients with recurrent disease will not be resectable for cure. In their clinical series, Gilbert et al [15] reported that recurrent rectal adenocarcinoma occurred as an isolated recurrence at a single site in 55% of the cases. In their autopsy series, they reported an isolated recurrence
276
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
Fig. 2. Survival after onset of rectal cancer recurrence. Comparison of patients with isolated local recurrent disease associated with hydronephrosis (n ⫽ 12) and patients with distant metastatic disease only (n ⫽ 45).
at a single site in 27% of patients, whereas disseminated disease occurred in 73% [15]. Thus there is an overestimate of isolated local recurrence clinically by about 30%. The discrepancy is thought to be underdiagnosis of disseminated disease in the clinical setting. We have reported that patients with unilateral or bilateral hydronephrosis in the setting of recurrent rectal carcinoma are unresectable for cure [8]. In the current series of patients with isolated locally recurrent disease in the setting of hydronephrosis, the mean survival after diagnosis was 14 months. Wanebo et al [16] reported 47 patients with recurrent rectal carcinoma who underwent extended pelvic resections. Twenty-two patients required pelvic exenteration along with sacral resection. The 5-year estimated survival was 24% (median survival 36 months), with 5 patients surviving longer than 5 years. The authors emphasized the importance of obtaining a histologically negative margin on resection. However, the presence of hydronephrosis in their patients was not mentioned. In addition, their extended pelvic resections had significant morbidities of up to 50% and a high perioperative mortality of 8.5% [16]. In another series by Wanebo et al [17], there was an improvement of survival with decreased perioperative mortality. Although there may be an improvement in survival and mortality, the concomitant morbidities for an abdominosacral resection cannot be ignored. Supporting an aggressive approach to locally recurrent rectal adenocarcinomas, Pearlman et al [18] reported on the technique of sacropelvic resection in relation to locally advanced or recurrent anorectal cancer. Ten patients had recurrent rectal cancer and some degree of ureteral obstruction, which was not defined. Disease-free survival was reported to be 60% at 4 years for the patients in the study [18]. Curley et al [19] also supported an aggressive approach to recurrent colorectal carcinoma by selecting out patients who
could be surgically resected with a negative margin. The procedures involved for the 23 patients reported were total pelvic exenteration, posterior exenteration, low anterior resection with cystectomy, and contiguous organ resection. They reported a 5-year survival rate of 54% [19]. In a series of 45 patients with locally recurrent rectal cancer who underwent curative resection by Bozzetti et al [20], 21 patients (47%) could be resected with a negative margin. In this series, a negative margin had a direct correlation with improved 5-year survival (19% versus 0%). Because less than 10% of all patients who underwent surgical treatment benefited from surgery, these investigators no longer recommend surgery as the primary option for treating locally recurrent rectal carcinoma. They, however, did not analyze their series of patients with respect to the presence of hydronephrosis. The significance of complete ureteral obstruction was described by Lopez et al [21] as a “local sign of invasive carcinoma beyond the limits of operability for cure.” When the obstruction is due to compression rather than invasion, they suggest that resection may not be contraindicated. We now have reported 19 patients, including the patients analyzed in the previously published series, with recurrent rectal cancer and unilateral or bilateral hydronephrosis who underwent exploration. All were found to be unresectable for cure. In our experience, patients who present with unilateral or bilateral hydronephrosis in the setting of recurrent rectal cancer could not be resected for cure due to either local sacral, sidewall invasion, or distant metastasis. The survival of patients with hydronephrosis and locally recurrent disease was similar to those with distant disease. At our institution, all patients with locally recurrent disease undergo extensive evaluation in order to rule out extrapelvic disease. This includes a careful history and physical to determine if the patient has any locally extensive disease (pelvic pain, radicular pain). The metastatic workup consists of a chest roentgenogram, computed axial tomography of the abdomen and pelvis, magnetic resonance imaging of the pelvis as needed, and an image-guided biopsy of the sacrum if involvement by tumor is suspicious. More recently, we also have incorporated positron emission tomography recently. If there is no evidence of extrapelvic disease, no bony or sidewall involvement, and no hydronephrosis, exploratory laparotomy is recommended with the goal of curative resection. It is important to note that pelvic sidewall or presacral involvement are not considered signs of unresectable disease in many institutions as has been described in this Comments section. The availability of intraoperative radiation or brachytherapy has been effective as potential adjunctive therapies in this setting [22]. Also, the recent development of preoperative chemoradiation may downstage these recurrences such that the surgeon can resect these tumors with free margins. We think that an aggressive surgical approach offers patients with recurrent rectal carcinoma the best potential for survival. However, careful patient selection is important
C. Cheng et al. / The American Journal of Surgery 182 (2001) 274 –277
for surgery to impart a survival benefit. Pelvic sidewall and sacrum involvement of the tumor precludes one from adequate resection. The more radical procedures such as the sacropelvic resection exemplified by Wanebo et al have concomitant high morbidity and mortality. In the setting of unilateral or bilateral hydronephrosis, we have shown that the natural history of patients with locally recurrent rectal adenocarcinoma is similar to patients with distant disease. We, therefore, do not believe that a surgical exploration should be undertaken. These patients should be palliated for the presenting symptoms. We realize that only 6 of 12 patients in our report underwent surgical exploration and that we can be criticized for our conclusion based on a small number of patients. Hence, we encourage other authors to publish their experience in this group of patients who present with unilateral or bilateral hydronephrosis to confirm or refute our results. References [1] Greenlee RT, Hill-Harmon M, Murray T, Thun M. Cancer statistics 2001. CA Cancer J Clin 2001;51:15–36. [2] Krook JE, Moertel CG, Gunderson LL. Effective surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med 1991;324:709–15. [3] Ross A, Rusnak C, Weinerman B, et al. Recurrence and survival after surgical management of rectal cancer. Am J Surg 1999;177:392–5. [4] Welch JP, Donaldson GA. The clinical correlation of an autopsy study of recurrent colorectal cancer. Ann Surg 1979;189:496 –502. [5] Danzi M, Ferulano GP, Abate S, et al. Survival and locations of recurrence following abdomino-perineal resection for rectal cancer. J Surg Oncol 1996;31:235–9. [6] Polk HC, Spratt JS. The results of treatment of perioneal recurrence of cancer of the rectum. Cancer 1979;43:952–5. [7] Holm T, Cedermard B, Rutqvist LE. Local recurrence of rectal adenocarcinoma after “curative” surgery with and without preoperative radiotherapy. Br J Surg 1994;81:452–5.
277
[8] Rodriguez-Bigas M, Herrera L, Petrelli N. Surgery for recurrent rectal adenocarcinoma in the presence of hydronephrosis. Am J Surg 1992; 164:18 –21. [9] Kaplan EL, Meir P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457– 86. [10] Cox DR. Regression models and life-tables. J R Stat Soc B 1972;34: 187–220. [11] Pilipshen SJ, Heilweil M Quan SHQ, et al. Pattern of pelvic recurrence following definitive resection of rectal cancer. Cancer 1984;53: 1354 – 62. [12] Moosa AR, Ree PC, Marks JE, et al. Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum and rectosigmoid. Br J Surg 1975;62:727–30. [13] DeAzevedo JP, Dozois RR, Gunderson LL. Locally recurrent rectal cancer: surgical strategy. World J Surg 1992;16:490 – 4. [14] Wilking N, Herrera L, Petrelli NJ, Mittelman A. Pelvic and perineal recurrences after abdominoperineal resection for adenocarcinoma of the rectum. Am J Surg 1985;150:561–3. [15] Gibert JM, Jeffrey I, Evans M, Kark AE. Sites of recurrent tumour after “curative” colorectal surgery: implication for adjuvant therapy. Br J Surg 1984;71:203–5. [16] Wanebo HJ, Koness RJ, Turk PS, Cohen SI. Composite resection of posterior pelvic malignancy. Ann Surg 1992;215:685–95. [17] Wanebo HJ, Antoniuk P, Koness RJ, et al. Pelvic resection of recurrent rectal cancer: technical considerations and outcomes. Dis Colon Rectum 1999;42:1438. [18] Pearlman NW, Donohue RE, Stiegmann GV, et al. Pelvic and sacropelvic exenteration for locally advanced or recurrent anorectal cancer. Arch Surg 1987;122:537– 41. [19] Curley SA, Carlson GW, Shumate CR, et al. Extended resection for locally advanced colorectal carcinoma. Am J Surg 1992;163:553–9. [20] Bozzetti F, Bertario L, Rossetti C, et al. Surgical treatment of locally recurrent rectal carcinoma. Dis Colon Rectum 1997;40:1421– 4. [21] Lopez MJ, Kraybill WG, Downey RS, et al. Exenterative surgery for locally advanced rectosigmoid cancers. Is it worthwhile? Surgery 1987;102:644 –51. [22] Abuchaibe O, Calvo F, Azinovic I, et al. Intraoperative radiotherapy in locally advanced recurrent colorectal cancer. Int J Radiat Oncol Biol Phys 1993;26:859 – 67.