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Oligometastatic Disease Is Not an Absolute Contraindication to Pelvic Exenteration in Selected Patients With Locally
Jennifer K Vu1,2,3, Kilian G M Brown1,2,3,4, Michael J Solomon1,2,3,4
1Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.
Background:
The treatment of locally recurrent rectal cancer has evolved dramatically in recent decades. As the boundaries of exenterative surgery continue to be pushed, one of the unanswered and controversial questions is the role of radical salvage surgery for locally recurrent rectal cancer in the setting of oligometastatic disease.
Objective:
To investigate the impact of synchronous or previously treated distant metastases on survival after pelvic exenteration for locally recurrent rectal cancer.
Design:
Retrospective analysis of a prospectively maintained database.
Settings:
A high-volume specialist exenteration center.
Patients:
Consecutive adult patients undergoing pelvic exenteration with curative intent for locally recurrent rectal cancer between 1994 and 2023.
Main Outcome Measures:
Overall survival from time of pelvic exenteration.
Results:
Of the 300 patients included, 193 (64%) were men, and the median age at the time of pelvic exenteration was 62 years (range, 29-86). The median time from primary rectal cancer surgery to pelvic exenteration was 35 months (range, 4-191). In total, 56 patients (19%) had a history of metastatic disease, of whom 42 (14%) had previously treated metastases and 18 patients (6%) had synchronous metastatic disease (including 4 patients with both synchronous and previously treated metastases). Five-year overall survival rate and median overall survival was 41% and 45 months, respectively. There was a trend toward poorer 5-year overall survival in patients with a history of metastatic disease compared to those without (25% vs 45%); however, this did not reach statistical significance ( p = 0.110), possibly due to a lack of statistical power. Five-year overall survival was 27%, 25%, and 45% for patients with synchronous metastases, previously treated metastases, and no history of metastases, respectively ( p = 0.260).
Limitations:
Findings may not be applicable beyond highly selected patients treated at specialized exenteration centers.
Conclusions:
Long-term survival is achievable in highly selected patients with locally recurrent rectal cancer and synchronous or previously treated distant metastases. Therefore, oligometastatic disease should not be considered an absolute contraindication to exenterative surgery. See Video Abstract .
La Enfermedad Oligometastsica No Es Una Contraindicacin Absoluta Para La Exenteracin Plvica En Pacientes Seleccionados Con Cncer Rectal Localmente Recurrente:
ANTECEDENTES:El tratamiento del cáncer rectal localmente recurrente ha evolucionado drásticamente en las últimas décadas. A medida que se siguen ampliando los límites de la cirugía exenterativa, una de las preguntas sin respuesta y controvertidas es el papel de la cirugía radical de rescate para el cáncer rectal localmente recurrente en el contexto de la enfermedad oligometastásica.OBJETIVO:Investigar el impacto de las metástasis distantes sincrónicas o tratadas previamente en la supervivencia después de la exenteración pélvica para el cáncer rectal localmente recurrente.DISEÑO:Análisis retrospectivo de una base de datos mantenida prospectivamente.ESTABLECIMIENTO:Un centro de exenteración especializado de alto volumen.PACIENTES:Pacientes adultos consecutivos sometidos a exenteración pélvica con intención curativa para cáncer rectal localmente recurrente entre 1994 y 2023.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia general desde el momento de la exenteración pélvica.RESULTADOS:De los 300 pacientes incluidos, 193 (64%) eran varones y la edad media fue de 62 años (rango 29-86). La mediana de tiempo desde la cirugía del cáncer rectal primario hasta la exenteración pélvica fue de 35 meses (rango 4-191). En total, 56 pacientes (19%) tenían antecedentes de enfermedad metastásica; de los cuales 42 (14%) habían sido tratados por metástasis previamente y 18 pacientes (6%) tenían enfermedad metastásica sincrónica (incluidos 4 pacientes con metástasis tanto sincrónicas como tratadas previamente). La supervivencia global a 5 años y la mediana de supervivencia global fueron del 41% y 45 meses, respectivamente. Hubo una tendencia hacia una peor supervivencia global a 5 años en pacientes con antecedentes de enfermedad metastásica en comparación con los que no la tenían (25% frente a 45%); sin embargo, esto no alcanzó la significación estadística ( p = 0,110), posiblemente debido a la falta de poder estadístico. La supervivencia global a los 5 años fue del 27%, 25% y 45% para los pacientes con metástasis sincrónicas, metástasis tratadas previamente y sin antecedentes de metástasis, respectivamente ( p = 0,260).LIMITACIONES:Los hallazgos pueden no ser aplicables más allá de pacientes altamente seleccionados tratados en centros de exenteración especializados.CONCLUSIONES:La supervivencia a largo plazo es alcanzable en pacientes altamente seleccionados con cáncer rectal localmente recurrente y metástasis distantes sincrónicas o tratadas previamente. Por lo tanto, la enfermedad oligometastásica no debe considerarse una contraindicación absoluta para la cirugía de exenteración. (Traducción-Dr. Felipe Bellolio ).
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