SURGICAL MANAGEMENT OF PELVIC MALIGNANCY

Transcription

1 SURGICAL MANAGEMENT OF PELVIC MALIGNANCY Foreword Nicholas J. Petrelli xv Preface xvii Harold J. Wanebo Rectal Cancer Current Management of Rectal Cancer: Total Mesorectal Excision (Nerve Sparing) Technique and Clinical Outcome 137 Dimitra G. Barabouti and W. Douglas Wong This article reviews the studies that set the background for total mesorectal excision (TME). The article describes the anatomy of the mesorectum and the pelvic autonomic nerves and the authors surgical technique for nerve-sparing TME. The impact of TME on cancer recurrence and survival, sphincter preservation, and autonomic nerve preservation is reviewed. Finally, the article discusses TME-based trials that investigate the role of radiation and chemotherapy in the treatment of rectal cancer. Proctectomy with Coloanal Anastomosis 157 Victor W. Fazio and Alexander G. Heriot There has been a gradual progression in rectal cancer surgery from the time of Ernest Miles, when abdominoperineal resection was the procedure of choice, to the current time, with the use of coloanal anastomosis and surgeons striving for sphincter preservation. The incidence of abdominoperineal resection can be as low as 10%, although it is still the appropriate procedure for many patients. Technical developments have allowed the use of coloanal anastomosis, which have been shown to be equivalent in terms of local recurrence and survival and have the advantage of avoidance of a permanent stoma. Acknowledgment of the importance of functional outcome for patients has encouraged the use of reservoirs to preserve function. Surgeons should perform sphincter-preserving VOLUME 14 Æ NUMBER 2 Æ APRIL 2005 vii

2 surgery for most cases of rectal cancer with significant functional preservation. Local Excision: Some Reality Testing 183 Anders Mellgren, Joel Goldberg, and David A. Rothenberger The role of local therapy for curative intent treatment of patients with favorable rectal cancer is highly controversial. Appropriate staging is essential to exclude patients with tumors that penetrate the rectal wall or spread to mesorectal lymph nodes. Studies on the outcome after local excision for rectal cancer are frequently heterogeneous, and results vary significantly. Recent studies indicate that local excision for early rectal cancer has a high rate of recurrence. Based on these results, together with our own experience, we restrict the use of curative intent local excision to only a few highly selected patients. Surgical Management of Pelvic Malignancy: Role of Extended Abdominoperineal Resection/Exenteration/ Abdominal Sacral Resection 197 Harold J. Wanebo, Giovanni Begossi, and Kimberly A. Varker Locoregional recurrence of colorectal cancer remains a significant clinical problem despite the widespread adoption of total mesorectal excision and the more frequent use of adjuvant therapy after primary resection. Radiation therapy may provide palliation for nonresectable recurrence or facilitate resection in selected patients (usually those nonpreviously irradiated). Surgical resection, consisting of salvage anterior resection, abdominoperineal resection, or abdominosacral resection, may be a reasonable option in good performance patients without systemic disease. For patients with unresectable disease, isolated pelvic perfusion may provide effective palliation and in some cases may facilitate resection of borderline resectable patients. Total Pelvic Exenteration with Distal Sacrectomy for Fixed Recurrent Rectal Cancer 225 Yoshihiro Moriya, Takayuki Akasu, Shin Fujita, and Seiichirou Yamamoto Therapeutic policies for locally recurrent cancer vary remarkably because of various recurrent tumors that range from mobile recurrence to huge masses that occupy the pelvis. Whether an emphasis is placed on composite resection or on multimodality treatment for fixed recurrent tumor, surgeons have the same view that the key treatment to obtain local control and survival benefit is R0 surgery. This article describes the surgical indications, contraindications, viii

3 surgical techniques, oncologic outcomes, and complications of total pelvic exenteration with distal sacrectomy. Gynecologic Malignancy New Treatment Concepts for Gynecologic Pelvic Malignancies: Neoadjuvant Therapies 239 Antonella Restivo, Mary Gordinier, and Cornelius O. Granai This article discusses new ideas that challenge status quo treatments of gynecologic pelvic malignancies. In many instances, our current treatments yield excellent results, nevertheless, there are meaningful ways to improve on them. Cervical Cancer: Current Management of Early/Late Disease 249 Wayne A. McCreath, Emery Salom, and Dennis S. Chi The evolution in the surgical management of cervical cancer dates back to the late nineteenth century. Many improvements have been made in the operative technique of the radical hysterectomy and pelvic lymphadenectomy since their original description. The incidence of complications after this procedure has decreased during the past three quarters of a century, to the point where currently the operation affords little additional surgical risk to the patient than a hysterectomy performed for benign disease. Newer laparoscopic approaches are promising, with comparable cure rates and the potential to retain fertility in carefully selected patients. Historically, in patients in whom pelvic lymph nodes were positive for metastatic tumor, the 5-year cure rate was reduced to approximately 60%; however, recent prospective clinical trials of postoperative chemoradiation therapy reported promising 4-year disease-free survival rates of more than 80% in this subset of patients. Surgical Staging of Gynecologic Malignancies: The Role of Laparoscopy and Sentinel Node Technology 267 Robert Kim and Peter G. Rose Laparoscopy or sentinel node technology is assuming an increasingly pertinent role in the diagnosis and staging of gynecologic malignancies with the potential to perform a complete investigation of the abdomen, pelvis, and retroperitoneum and minimize postoperative adhesions and recovery times. Despite the enthusiasm for laparoscopy, which is a minimally invasive technology, oncologists must be mindful that it remains an investigational tool and should be performed by appropriately experienced surgeons. It is unlikely that laparoscopy or sentinel node technology will make traditional laparotomy and lynphadenectomy obsolete. Instead, they should be viewed as a welcome complement rather than competitors to traditional surgical approaches. ix

4 Pelvic Exenteration of Gynecologic Malignancy: Indications, and Technical and Reconstructive Considerations 289 Nicholas C. Lambrou, J. Matt Pearson, and Hervy E. Averette Aside from radical hysterectomy, perhaps the single most defining surgical procedure for the practicing gynecologic oncologist is pelvic exenteration. The most important considerations involved are patient selection and intraoperative decision making regarding the type of exenterative procedure that would provide adequate margins while minimizing the extent of the resection and subsequent reconstruction. It is important for a surgeon to have an understanding of which patients potentially will benefit from pelvic exenteration and which patients are best suited for the procedure. In this article we discuss selection and preoperative evaluation of candidates for exenteration, surgical techniques involved, postoperative considerations, and the indication of palliation. Urologic Oncology Surgical Management of Prostate Cancer: Optimizing Patient Selections and Clinical Outcome 301 Paul D. Maroni and E. David Crawford Deciding on treatment for localized prostate cancer can be troublesome for patients and physicians. This malignancy represents a tremendous source of suffering, but many men live for long periods with clinically insignificant disease. Surgical therapy does impact the course of the disease, but certain patients seem to benefit more than others. Unfortunately, surgery is coupled with substantial side effects relating to urinary and sexual functioning. This article compiles available data to assist the struggling care provider in selecting appropriate patients for radical prostatectomy. Bladder Cancer Resection/Ablation 321 Federico A. Corica and Thomas E. Keane This article discusses current controversies in superficial and invasive transitional cell carcinoma of the bladder and incorporates the issues of whether resection or ablation is the most appropriate strategy. In the superficial area, there is an urgent need for better and less invasive diagnostic methods. Improved pathologic assessment and prognostic indicators are required, and the development of better adjuvant strategies may improve what are disappointing recurrence and progression rates. Concerning invasive and advanced disease, surgery as a component of multimodality therapy clearly has a role. Physicians objectives, however, must be to improve these therapies such that they can reduce their dependence on extirpative therapies and focus more on the molecular level to correct the basic defects which have led to the disease state. Novel therapeutic strategies combining immune system stimulants or x

5 genetic manipulation with the newer generation of cytotoxic agents after cytoreductive therapy therefore deserve further study. The answer to these problems lies neither in the clinic nor in the laboratory but in the continuing cooperation of both. Laparoscopic Lymph Node Dissection in Urologic Cancer 353 Eliecer Kurzer and Raymond J. Leveillee Laparoscopic lymph node dissection plays a well-defined but limited role in urologic oncology. Laparoscopic lymph node dissection for prostate and testicular cancer represents the spectrum of expertise needed to perform these operations successfully. With adherence to the oncologic principles mandated in surgery, multiple studies have confirmed the feasibility, safety, and efficacy of this procedure over the long term. This article describes the indication, techniques, and complications for both laparoscopic pelvic and retroperitoneal lymph node dissections in urologic malignancy. Standard Reconstruction Techniques: Techniques of Ureteroneocystostomy During Urinary Diversion 367 Murugesan Manoharan and Hari S.G.R. Tunuguntla A simple end-to-side freely refluxing ureteroenteric anastomosis into an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure with the lowest overall complication rate. Continued peristalsis in the afferent ileal limb reduces but does not eliminate reflux. The potential benefit of conventional antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and associated reoperation rates. There are no clear answers to the question of which is the better technique at present, however. Long-term randomized, prospective studies comparing the refluxing and nonrefluxing techniques are warranted. Musculoskeletal Sarcomas Internal Hemipelvectomy for the Management of Pelvic Sarcomas 381 Henry J. Mankin and Francis J. Hornicek Bone and soft-tissue malignancies that arise in the pelvis are difficult to treat, mainly because of the anatomic site, the proximity to neurovascular and visceral structures, and the problems with reconstruction after resection. Rehabilitation is also a difficult task, and many patients are disabled after the surgery. The alternative of a formal hemipelvectomy is not a comfortable thought for the patient or the physician, and the disability for these patients far exceeds the more conservative approaches. The Orthopaedic Oncology Service has performed 344 resections for high-grade malignancy; the demographic, clinical, and complication outcome xi

6 data are known for 206 patients treated from 1972 to The results show that the principal problems are local recurrence, metastases, local complications at the site requiring further surgery, and a poor survival rate. Extended Pelvic Resection for Sarcoma or Visceral Tumors Invading Musculoskeletal Pelvis 397 Lloyd A. Mack and Walley J. Temple Current literature supports composite pelvic resections for most cancers invading the musculoskeletal pelvis or primary pelvic sarcoma invading visceral organs. New techniques of delivering preoperative radiotherapy, including intraoperative electron beam radiation or the use of intraperitoneal silastic spacers to protect small intestine, will likely improve resectability and local control rates. Composite pelvic resections improve disease-free survival and provide an overall cure rate better than with other malignancies, such as pancreatic or esophageal cancer. It is critical that all individuals are given a choice of surgery versus nonoperative palliative options in potentially curative yet locally advanced pelvic cancers. Ablative Techniques Image-Guided Ablative Techniques in Pelvic Malignancies: Radiofrequency Ablation, Cryoablation, Microwave Ablation 419 Caroline J. Simon and Damian E. Dupuy Newer, minimally invasive percutaneous treatment options in the management of pelvic malignancies exist. These treatments include percutaneous cryoablation, radiofrequency ablation, and microwave ablation. This article focuses on the principles of therapy, methods of treatment, and current uses and experiences of these percutaneous modalities in the treatment and management of pelvic recurrences and metastases. Index 433 xii