A novel multimodal approach for locally advanced rectal cancer involving the pelvic sidewall

Total mesorectal excision (TME) is the standard surgery for locally advanced rectal cancer. In instances when the primary tumor invades adjacent organs, en-bloc excision is required for a curative resection. However, when lateral pelvic lymph node metastases involve the pelvic sidewall, treatment strategy is not established yet.

We here report on a case treated with a novel multimodal approach consisting of neoadjuvant chemoradiotherapy, followed by TME plus extended lateral pelvic lymph node dissection and en-bloc resection of the internal iliac artery and vein.

There were no complications. Serial sections of the rectum showed only fibrosis and inflammatory cell aggregation. None of the mesorectal nodes contained tumor cells, but one each of the right and left lateral pelvic nodes demonstrated residual adenocarcinoma with foci of necrosis and fibrosis. Chemoradiotherapy increased the circumferential resection margin from 0 mm to 2 mm. An additional 5 mm clearance was obtained following resection of the internal iliac vessels yielding a total clearance margin of 7 mm. The patient remained free of disease 2.5 years after surgery.

This seems to be the only strategy offering the possibility of cure for such a condition.