Indications and Outcome of Pelvic Exenteration for Locally Advanced Primary and Recurrent Rectal Cancer

In Brief Objective: The outcome of pelvic exenteration was compared in patients with locally advanced primary (LAP) cancer and recurrent rectal cancer (RRC). Background: There are few reports comparing the results of pelvic exenteration for primary advanced rectal cancer and RRC. Methods: Consecutive patients undergoing pelvic exenteration between 2006 and 2011 were identified from a prospectively maintained database. The main endpoints were 3-year disease-free survival (DFS) and local recurrence-free survival (LRFS). Results: Of 100 exenterative operations, 55 were for LAP cancer and 45 for RRC. Exenteration of 1 pelvic compartment was required in 30 cases, 2 compartments in 49 cases, and 3 of 4 compartments in 21 cases. R0, R1, and R2 resections were achieved in 78, 15, and 7 cases, respectively. R0 rates were significantly higher in LAP cancer than in RRC (91% vs 62%, P = 0.001). Three-year DFS for R0, R1, and R2 resections was 67%, 49%, and 0%, respectively (P < 0.001). For R0 resections only, DFS in LAP cancer was 76% and 57% in RRC (P = 0.212). On multivariate analysis, a positive resection margin (hazard ratio, 4.04; P < 0.001) and positive lymph node staging (hazard ratio, 2.43; P = 0.022) were significant predictors of reduced DFS. Three-year LRFS for R0 resection was 86% for LAP cancer and 84% for RRC (P = 0.817). On multivariate analysis, only a positive resection margin was a significant predictor of reduced LRFS (hazard ratio, 5.48; P = 0.002). Conclusions: Resection margin status is more important than primary or recurrent cancer in predicting long-term outcome. Survival after pelvic exenteration, which achieves an R0 resection, is excellent and exenteration should be offered to patients with primary or recurrent cancer where resection beyond the conventional total mesorectal excision plane is required. A clear resection margin is more important than primary or recurrent cancer in predicting long-term cancer-specific outcome.