Multimodal Treatment of Recurrent Pelvic Colorectal Cancer (Updates in Surgery)

"This book analyzes all aspects of modern multimodal treatment of locally recurrent rectal cancer in the pelvis in order to offer a panoramic overview of the different therapeutic options and enable the reader to balance their benefits and drawbacks. Indications for surgery and the surgical techniques themselves, including reconstruction techniques after major exenterative surgery, are clearly described and evaluated. The role of new imaging tools, such as MRI and PET-CT, in staging recurrences and guiding therapy is assessed and detailed consideration is given to the use of neoadjuvant and iterative radiotherapy and the indications for systemic chemotherapy. Morbidity, mortality, oncologic outcomes, and quality of life issues are carefully analyzed and options for pain control and palliation are examined. Finally, a national survey is presented on the state of the art in the surgical treatment of locally recurrent rectal cancer in Italy. While there has been a dramatic fall in the incidence of local pelvic recurrences, their treatment remains a major clinical challenge which requires a multidisciplinary approach and careful selection of the most appropriate strategy in each case. This book will aid practitioners in making the correct decisions in individual patients."--Publisher's description Cover 1 Title page 3 Copyright page 4 Foreword 5 Preface 8 Contents 10 Contributors 12 1. Follow-Up Strategy After Primaryand Early Diagnosis 17 1.1 Introduction 17 1.2 Basis for Follow-Up 17 1.3 Risk Assessment 18 1.4 Follow-Up Tests 18 1.4.1 History and Clinical Examinations 19 1.4.2 Carcinoembryonic Antigen 19 1.4.3 Liver Function Tests 20 1.4.4 Liver Imaging 20 1.4.5 Chest Imaging 20 1.4.6 Endoscopy 21 1.4.7 PET Scanning 22 1.5 Intensive Versus Less-Intensive Follow-Up 22 1.6 Cost of Follow-Up 23 1.7 Current Guidelines and Recommendations 23 1.8 Follow-Up Following Complete ResponseAfter Chemoradiation 25 1.9 Conclusions 26 2. Clinical Presentation and Classifications 30 2.1 Introduction 30 2.2 Clinical Presentation 30 2.3 Classification of Recurrent Colorectal Cancer in the Pelvis 31 2.3.1 Pilipshen et al. (1984) 33 2.3.2 Suzuki et al. (1995) 34 2.3.3 Guillem et al. (1998) 34 2.3.4 Wanebo et al. (1999) 35 2.3.5 Yamada et al. (2001) 35 2.3.6 Boyle et al. (2005) 36 2.3.7 Kusters et al. (2010) 36 2.3.8 Georgiou et al. (2013) 37 2.4 Conclusions 37 3. Imaging Modalities 40 3.1 Introduction 40 3.2 Generalities 40 3.2.1 Computed Tomography 41 3.2.2 Positron Emission Tomography and Positron EmissionTomography/Computed Tomography 42 3.2.3 Magnetic Resonance Imaging 44 3.2.4 Contrast-Enhanced and Dynamic Contrast-EnhancedMagnetic Resonance Imaging 45 3.2.5 Diffusion-Weighted Magnetic Resonance Imaging 45 3.3 Systematic Literature Review 47 3.4 Conclusions 49 4. Role of Positron EmissionTomography/Computed Tomography 54 4.1 Introduction 54 4.2 Clinical Practice 55 4.2.1 Role of PET/CT at Different Circulating CEA Levels 55 4.2.2 What is the Most Accurate Imaging Modality for AssessingCRC Recurrence? 57 4.2.3 Response Assessment 59 4.2.4 Pitfalls 60 4.3 Conclusions 60 5. Role of Radiotherapy 64 5.1 Introduction 64 5.2 Intensity-Modulated Radiation Therapy 66 5.3 Intraoperative Radiation Therapy 66 5.4 Stereotactic Body Radiotherapy 67 5.5 Carbon Ion Radiotherapy 67 5.6 Conclusions 68 6. Indications for Systemic Chemotherapy 71 6.1 Introduction 71 6.2 Ongoing Studies 71 6.3 Recurrence Risk and Surveillance Strategies 73 6.3.1 Resectable Disease 73 6.3.2 Nonresectable Disease 75 6.4 Discussion 76 7. Indications for Surgery and SurgicalTechniques 78 7.1 Introduction 78 7.2 Role of Surgery 80 7.2.1 Pelvic Exenterations 80 7.2.2 Patient Selection 80 7.3 Surgical Techniques 82 7.4 Lateral Pelvic Wall Involvement 86 7.5 Greater Sciatic Notch Extension 86 7.6 Vascular Reconstruction 87 7.7 Role of Concomitant Sacral Resection 87 7.8 Conclusions 88 8. Mortality and Morbidity 91 8.1 Introduction 91 8.2 Intraoperative Complications 92 8.2.1 Tamponade and Other Means of Occlusion 93 8.3 Postoperative Complications 96 8.3.1 Surgical and Technical Skills and Patients Selection 96 8.3.2 Pelvic Exenteration 97 8.3.3 Sacropelvic Resection 99 8.3.4 Lateral Pelvic Wall Involvement 101 8.4 Conclusions 102 9. Techniques of Urological Reconstruction 107 9.1 Introduction 107 9.2 Radical Cystectomy 108 9.3 Partial Cystectomy 109 9.4 Enterocystoplasty with Partial Cystectomy 109 9.5 Urinary Diversion 110 9.5.1 Ileal Conduit Diversion 111 9.5.2 Colon Conduit Diversion 112 9.6 Ureterointestinal Anastomoses 112 9.7 Small-Bowel Anastomoses 113 9.8 Conclusions 113 10. Transpelvic Rectus Abdominis FlapReconstruction FollowingAbdominoperineal Resection 115 10.1 Introduction 115 10.2 Regional Anatomy 120 10.3 Flap Design and Dimensions 121 10.4 Operative Technique 131 10.5 Flap Transposition 140 10.6 Reconstruction of Perineal Region 142 10.7 Abdominal Wall Reconstruction 143 10.8 Complications 145 10.9 Conclusions 146 11. Oncological Outcomes 148 11.1 Introduction 148 11.2 Oncological Outcomes in Nonoperative Managementof PRCRC 149 11.3 Multimodal Treatment and Palliative Resection 149 11.4 Multimodal Treatment and Radical Resection 151 11.4.1 Multimodal Treatment and Radical Nonextended Resection 152 11.4.2 Multimodal Treatment and Extended Resection 153 11.4.3 Multimodal Treatment Including IORT 154 11.5 Conclusions 155 12. Quality of Life 159 12.1 Introduction 159 12.2 Quality of Life Scores 160 12.2.1 EORTC QLQ-C30 160 12.2.2 EORTC QLQ-CR38/EORTC QLQ-CR29 160 12.2.3 SF-36 161 12.2.4 FACT-C 161 12.2.5 BPI 161 12.2.6 ICIQ-SF 161 12.2.7 Stoma-QoL 161 12.2.8 FIQL 162 12.2.9 PAC-QOL 162 12.2.10 QALY 162 12.3 HR-QoL after Surgery for Local Recurrence ofRectal Cancer 162 12.3.1 Functional Dimension 163 12.3.2 Symptomatic Dimension 164 12.3.3 Financial and Occupational Impact 166 12.4. Conclusions 166 13. Pain Control and Palliative Treatments 169 13.1 Introduction 169 13.2 Features of Pelvic and Perineal Cancer Pain 170 13.3 Pharmacological Approaches 170 13.4 Interventions and Palliative Treatments 173 13.4.1 Spinal Analgesia 173 13.4.2 Neurolytic Superior and Inferior Hypogastric Plexus Blocks 174 13.4.2.1 Superior Hypogastric Plexus Block 174 13.4.2.2 Inferior Hypogastric Plexus Block 174 13.4.3 Neurolysis of the Ganglion Impar 175 13.4.4 Radiofrequency Ablation 175 13.4.5 Presacral Plexus Neurolytic Block 175 13.5 Conclusions 175 14. Local Failure After ConservativeTreatment of Rectal Cancer 178 14.1 Introduction 178 14.2 Conservative Approach for Early Rectal Cancer 179 14.2.1 Conclusion 181 14.3 Conservative Approach After PCRT 181 14.3.1 Wait-and-See Policy 181 14.3.2 Local Excision 182 14.3.3 Conclusion 184 14.4 Salvage Surgery After Conservative Treatments 184 14.4.1 Conclusion 185 15. Italian Survey on the SurgicalTreatment of Locally RecurrentColorectal Cancer 188 15.1 Introduction 188 15.2 Methods 189 15.3 Results 190 15.3.1 Number of Treated Cases 190 15.3.2 High-Resolution Imaging Facilities and Guidelines 191 15.3.3 Preoperative Radiation 191 15.3.4 Type of Recurrence Treated 191 15.3.5 Type of Surgery 191 15.3.5.1 Additional Surgery 191 15.3.6 Outcome Reporting: Hospital Stay, Mortality Rate,Complications Rate 192 15.4 Discussion 192 15.5 Conclusions 193 Front Matter....Pages i-xvii Follow-Up Strategy After Primary and Early Diagnosis....Pages 1-13 Clinical Presentation and Classifications....Pages 15-24 Imaging Modalities....Pages 25-38 Role of Positron Emission Tomography/Computed Tomography....Pages 39-48 Role of Radiotherapy....Pages 49-55 Indications for Systemic Chemotherapy....Pages 57-63 Indications for Surgery and Surgical Techniques....Pages 65-77 Mortality and Morbidity....Pages 79-94 Techniques of Urological Reconstruction....Pages 95-102 Transpelvic Rectus Abdominis Flap Reconstruction Following Abdominoperineal Resection....Pages 103-135 Oncological Outcomes....Pages 137-147 Quality of Life....Pages 149-158 Pain Control and Palliative Treatments....Pages 159-167 Local Failure After Conservative Treatment of Rectal Cancer....Pages 169-178 Italian Survey on the Surgical Treatment of Locally Recurrent Colorectal Cancer....Pages 179-186