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Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.

Posterior approach has been performed for two surgical circumstances: One is used in providing exposure for a limited resection of the middle and lower portion of the sacrum (below S2 vertebra) along with the coccyx, such as chordoma involving distal sacrum. The other is in a combined abdominosacral approach for total sacral resection of larger tumor involving S1.

Background: The management of recurrent rectal cancer is challenging. At the present time pelvic exenteration with en bloc sacrectomy offers the only hope of lasting cure. Objective: The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. Data Sources: Search conducted on ‘Pub Med’ for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. Study Selection: Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. Main outcome measure: Disease free survival following sacrectomy for recurrent rectal cancer. Results: A total of 220 recurrent rectal cancer patients were included from 7 studies, of which 160 were male and 60 were female. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) litres. An R0 (>1mm resection margin) resection was achieved in 78% of patients. Disease free survival associated with R0 resection was 55% at a median follow up period of 33 (17-60) months; however, none of the patients with R1 (

Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality.This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution.This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes.Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital.One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers.This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy.Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival.Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors.This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.

The incidence of rectal cancer remains high – there are 13,000 new cases each year in the United Kingdom (population 60 million). A small proportion of these cases will present with direct posterior invasion of the tumour with involvement of the sacrum. Moreover, 5–15 % of patients who undergo resection with intent to cure will develop local recurrence of their tumour. Such recurrences may involve the neorectum ± the adjacent genito-urinary organs, the pelvic sidewall, the sacrum or a combination of these three sites. There is, therefore, a small but definite cohort of patients with either primary or recurrent rectal cancer with sacral involvement. Those suitable for resection need careful preoperative assessment and a well thought-out and executed surgical strategy.

Purpose The purpose of this study is to assess the value of extended (lateral) lymphadenectomy (EL) in the operative management of locally advanced and recurrent rectal cancer. Methods Patients that underwent exenterative surgery for locally advanced or recurrent rectal cancer between 2006 and 2009 were included in the study. A decision for EL was taken at the local multidisciplinary meeting based on the radiological findings. Perioperative and oncological outcomes were assessed and compared between the EL and non-EL group prospectively. Results Forty-one consecutive patients were included in the study (EL = 17). The median age was 57 (40–71) for EL and 66 (39–81) years for non-EL. Of patients, 27 (EL = 13) and 14 (EL = 4) underwent pelvic exenteration and abdominosacral resection, respectively. Twelve (EL = 7) patients were diagnosed with locally advanced primary rectal cancer. Thirty-one (EL = 12) patients received neoadjuvant radiotherapy. The median intraoperative time, blood loss and hospital stay were 9 h (3–13), 1.5 l (0.3–7) and 14 days (12–72), respectively, for the EL group, and 8 h (4–15), 1.6 l (0.25–17) and 14 days (10–86), respectively, for the non-EL (p ≥ 0.394). Morbidity was similar between the two groups (EL = 4, non-EL = 9; p = 0.344). Complete tumour resection (R0) was achieved in 30 (73.17%) patients, 12 (70.58%) in the EL group and 18 (75%) in the non-EL group (p = 0.649). There was no significant difference in 5-year survival (EL = 60.7%, non-EL = 75.2%; p = 0.447), local recurrence (EL = 53.6%, non-EL = 65.4%; p = 0.489) and disease-free survival (EL = 53.6%, non-EL = 51.4%; p = 0.814). Conclusions The present study demonstrated that EL does not provide a statistically significant advantage in survival or recurrence rates, for patients with locally advanced primary or recurrent rectal cancer.

STUDY DESIGN.: Operative technique. OBJECTIVE.: To report a new technique for sacral resection, with short-term preliminary results. SUMMARY OF BACKGROUND DATA.: Although various reports analyzed en bloc excision of sacral tumors, there are still technical problems to improve protection of nerve roots, preserve surrounding structures, and reduce intraoperative bleeding, while maintaining the oncological result. METHODS.: Thirteen patients were resected for their sacrococcygeal tumor by following the described technique. Two patients had undergone previous surgery elsewhere. The sacrum was exposed by a posterior midline incision and complete soft-tissue dissection. Lateral osteotomies were performed through the sacral foramina using a threadwire saw (devised by Tomita and Kawahara) and Kerrison rongeurs, to avoid damage to the sacral roots. After proximal osteotomy, the sacrum was laterally elevated and mobilized to allow dissection of presacral structures. Mean surgical time was 5.5 hours (range; 1.5-8). Mean blood loss was 2961 mL (range; 1000-8000 mL). RESULTS.: Level of resection was proximal in 9 patients and at S3 or below in 4. Margins were wide in 10 patients, marginal in 1, and intralesional in 2. At a mean follow-up of 35.5 months, 9 patients were disease free, while the tumor recurred locally in 4 cases. Complications requiring surgery were seen in 1 case. CONCLUSION.: The reported technique allows wide margins with preservation of roots, and reduction in blood loss and operative time. Indications for posterior-only approach can be extended to resection proximal to S3, when there is minimal pelvic invasion and none or partial involvement of sacroiliac joints. However, the long-term benefits of this technique need to be evaluated.

The sacrum is the only mechanical connection between the spine and pelvis/lower extremities. In the setting of a primary, or in select patients a locally advanced recurrent malignancy, curative treatment requires en-bloc sacrectomy. In addition to the surgery in this area being challenging due to the complexity of the pelvic anatomy, adjacent visceral and vascular structures; spinal-pelvic continuity is often lost. Historically following sacral resection patients were left “un-reconstructed” and the spinal column floated between the remaining pelvis, forming a soft-tissue sling which can become painful and lead to a poor patient outcome. Our institution has pioneered a means to reconstruct these defects following high sacral resection in order to restore continuity between the spine, pelvis and femur which has been shown to improve patient outcomes. The purpose of this article is to describe a biomechanical approach to sacral reconstruction.

Chordoma is a relatively rare, locally aggressive tumor which is known to arise from embryonic remnants of the notochord and to occur exclusively along the spinal axis, with a predilection for the sacrum. Although chordoma typically presents as a single lesion, a few cases of metastasis have been reported and the prognosis of such patients may be poor. Chordomas are slowly growing tumors with insidious onset of symptoms, making early diagnosis difficult. Recent improvements in imaging have provided valuable information for early diagnosis. The optimal treatment for sacral chordoma is en bloc sacral resection with wide surgical margins. Improvement in surgical techniques has widened the opportunities to provide effective treatment. However, the effects of adjuvant treatment options are still both unclear and controversial. Substantial progress has been made in the study of molecular-targeted therapy. The authors review the current surgical and adjuvant treatment modalities, including molecular-targeted therapy, available for management of sacral chordoma.

Patients with malignant lumbosacral pelvic lesions present a difficult surgical challenge. Because of the insidious onset of symptoms, lesions are often diagnosed late in their course, and by that time they have attained a large size. Surgical resection is made more difficult by the complex surrounding anatomy and involvement of the sacral nerves responsible for bowel, bladder, and sexual function. Spinopelvic reconstruction is often required after resection. This article presents techniques for sacral resection and subsequent spinopelvic reconstruction. Biomechanical studies are summarized on construct stability, and recommendations are made as to when reconstruction is required. The expected bowel and bladder functional outcomes are summarized, based on the level of sacral resection.

目的:後方浸潤をともなう直腸癌に対する仙骨合併切除の周術期経過と根治性について検討した.方法:1991～2002年において,後方浸潤をともなう直腸癌36症例(原発性;5例,局所再発;31例)を対象とし,骨盤内臓全摘+仙骨切除(TPES;25例)と直腸切断+仙骨切除(APRS;11例)を行った.なお,仙骨切除は仙骨前アプローチで行った.結果:両術式における手術時間,出血量,Morbidity,術後在院期間は,APRS症例で296.0±72.6分,2,443±1,697m1,45%,38.4±18.4日,TPES症例で441.6±111.7分,3,257±2,251ml,68%,62.4±30.6日であった.組織学的後方浸潤の程度別の5年生存率は,仙骨皮質浸潤8例;0%,仙骨前結合織浸潤9例;14.8%,非浸潤19例;49.8%であり,予後に有意差を認めた.結論:後方浸潤直腸癌に対する仙骨前アプローチによる仙骨合併切除は比較的安全な根治手術法と思われるが,仙骨皮質への浸潤例では根治的意義は少ない.

O T m m l a m a t p o o b e t any surgeons consider a tumor unresectable once it nfiltrates the sacrum. Reluctance to remove parts of the acrum in radical cancer surgery is based on a number of oncerns. Many surgeons fear uncontrollable blood loss f the presacral venous plexus is opened during operaion. They worry about extensive neurologic damage nd instability of the pelvic ring, and they are afraid hat tumors that extend into the sacrum have such poor rognosis that extensive radical resection will not transate into worthwhile gains in survival and that the qualty of life during that time will be extremely poor. In this article, we report on the practice of sacral reection in the Netherlands Cancer Institute. We describe ome aspects of indications and surgical technique and e report on our experience in 26 procedures, with focus n perioperative events, postoperative recovery, and lastng functional effects.

To assess safety of rectum removal with distal sacral resection.The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures.Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases.Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.Цель исследования - оценка безопасности удаления прямой кишки с резекцией дистальной части крестца. Материал и методы. Проанализированы непосредственные результаты хирургического лечения первичного и рецидивного местно-распространенного рака прямой кишки и анального канала с фиксацией к крестцу. Всем 32 пациентам выполнены расширенные комбинированные операции с резекцией крестца на уровне от SII до SV. У 12 пациентов опухоль была фиксирована только к крестцу (F1), у 10 имелось две точки фиксации (F2), у 3 - три точки фиксации (F3) и у 7 определялось 4 точки фиксации (F4) к различным структурам малого таза. Результаты и обсуждение. При фиксации опухоли только к крестцу средняя интраоперационная кровопотеря и продолжительность операции составили 551±81 мл и 320±20 мин, что значимо меньше, чем при выполнении операции с резекцией крестца при большем количестве точек фиксации опухоли (при F2 - 1278±551 мл и 433±45 мин, F3 - 2200±600 мл и 620±88 мин, F4 - 2157±512,5 мл и 519±52,3 мин) (р0,05). Осложнения, потребовавшие повторного оперативного вмешательства, были зафиксированы у 9% (n=3) пациентов. Среди 23 пациентов, которым были сохранены мочевыводящие пути, нарушения мочеиспускания развились у 42% (n=10). Во всех наблюдениях по задней поверхности препарата край резекции был негативным. Вывод. Комбинированные операции с дистальной сакрумэктомией при распространении опухоли на крестец оптимальны для проведения радикального вмешательства с отрицательным краем резекции и выполнимы в условиях специализированного стационара онкологом или колопроктологом, специализирующимся на операциях при местно-распространенных опухолях прямой кишки.

Background The incidence of rectal cancer recurrence after surgery is 5–45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer. Aim To evaluate the surgical and oncological outcome of such treatment. Patients and methods Between 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2–3 interface in 10 patients, at S3–4 in 15 patients and S4–5 in 3 patients. Results Forty patients, male to female ratio 1.7:1, median age 45 years (range 25–65 years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%. Conclusion Extended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.

PURPOSE: Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics. METHODS: Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996). and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy. RESULTS: The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P

Sarcomas and locally recurrent colorectal carcinomas are disease entities in which sacral resection is an effective alternative for meaningful palliation with a limited cure expectation.

PURPOSE: The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation. METHODS: Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and Intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection. RESULTS: Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002). CONCLUSION: The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

To describe the experience of sacrectomy with extended radical resection in the treatment of locally recurrent rectal cancer.Resections of the bony pelvis, especially the sacrum, are becoming more common as part of extended radical exenterations for patients with recurrent rectal cancer. However, sacrectomy has been shown to carry a significant decrease in survival. Morbidity rates have been associated with the level of the sacrectomy (ie,S3 junction).An analysis was conducted using prospective data from patients with recurrent rectal cancer who underwent pelvic exenteration involving sacrectomy from July 1998 until June 2011. The impact of the proximal level of sacrectomy [low (≤S3) vs high (≥S2-S3 disc)] was compared.Of 240 exenteration patients, 79 underwent sacrectomy, with 49 for recurrent rectal cancer. An R0 margin was achieved in 36 (74%) patients. Achievement of clear operative margins (R0) conferred a large and significant benefit for disease-free survival compared with R1 and R2 resections (median 45 months vs 19 and 8 months, respectively; P = 0.045). Complications were reported in 40 (82%) patients, with major and minor complications in 19 (39%) and 38 (78%) patients, respectively. The proximal level of the sacrectomy (high vs low) did not significantly impair the ability to achieve a clear margin and was not associated with an increase in major or minor complications.This large, single-center series has demonstrated that extended pelvic exenteration involving sacrectomy has excellent R0 margins and survival rates for recurrent rectal cancer. A high sacrectomy has comparable results with a more distal abdominosacral resection.

(1995). Sacral Resection of Posterior Pelvic Malignancy. Cancer Investigation: Vol. 13, No. 4, pp. 375-380.

Aim To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma. Methods A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences. Results At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic. Conclusion Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Study Design: Retrospective case series. Objective: To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors. Summary of Background Data: Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign. Methods: We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test. Results: No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection. Conclusion: Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Options for resection in patients with pelvic cancer are determined largely by the nature and location of the tumor. Secondary lesions especially may require a full hemipelvectomy or a composite resection. The preoperative evaluation should include assessment of the patient’s mental status as well as medical condition. Adjuvant preoperative or postoperative chemotherapy or radiation therapy may be useful. Considerable morbidity and mortality are associated with abdominosacral resection, but palliation of pain is often achieved and many patients return to their normal lifestyle after rehabilitation.

A new surgical technique for sacral resection through a posterior approach only: description and preliminary results

A new surgical technique of sacral resection by posterior approach: description and results

Major sacral resection generally is reserved for patients with malignant lesions. Because of the uncommon nature of these diseases, little is known about outcomes of surgical treatment. The current authors describe the retrospective analysis of bowel and bladder function in patients having major sacral resection at their institution during a 10-year period. Fifty-three patients were identified. In patients who had unilateral sacrectomy, in whom the contralateral sacral nerves were preserved, normal bowel and bladder function was retained in 87% and 89%, respectively. In patients who had bilateral S2-S5 nerve roots sacrificed, all had abnormal bowel and bladder function. In patients who had bilateral S3-S5 resection, normal bowel and bladder function was retained in 40% and 25%, respectively. In patients who had bilateral S4-S5 resection, with preservation of the S3 nerves bilaterally, normal bowel and bladder function was retained in 100% and 69%, respectively. In patients who had asymmetric sacral resections, with preservation of at least one S3 nerve root, normal bowel and bladder function was retained in 67% and 60%, respectively. These results show that unilateral resection of sacral roots or preservation of at least one S3 root in bilateral resection preserves bowel and bladder function in the majority of patients.

PURPOSE: Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics. METHODS: Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996). and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy. RESULTS: The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P

Ziel des vorgestellten Konzeptes war die Senkung der hohen postoperativen Morbiditat durch Wundkomplikationen nach Beckenexenteration mit Os sacrum Teilresektion. Seit 1996 operierten wir 4 Patienten mit infiltriertem Lokalrezidiv eines Rectum Karzinoms nach der „Wanebo Prozedur“ und rekonstruierten den Beckenboden nach 10 bis 16 Tagen mit dem freien latissimus dorsi Lappen. Der mikrochirurgische Gewebetransfer fuhrte zu rascher und vollstandiger Wundheilung und Verkurzung der stationaren Behandlung auf durchschnittlich 60 Tage. Es traten keine peri- oder postoperativen Wundkomplikationen auf. Die Uberlebenszeit betrug zwischen 9 und 30 Monaten. Exzellente Wundheilung, Stabilitat, Totraumbeseitigung und Drainage des Lymphodems sprechen fur die verzogerte Primarrekonstruktion des Beckenbodens mit dem freien latissimus dorsi Lappen und fuhrten zu einer deutlichen Senkung der postoperativen Morbiditat.

Limb-salvage surgery has improved remarkably. However, surgery for pelvic bone tumor is not so well developed. In malignant bone and soft tissue tumors of the extremities, a wide, tumor-free surgical margin is mandatory, but, it is often impossible in a pelvic tumor because of its complicated anatomical location. Especially in a sacral tumor, many difficult problems arise following resection, such as radicality of tumor resection, sacrifice of nerve plexus, reconstruction of pelvic continuity, and compromise of adjacent pelvic organs.

• Tumors involving the sacrum are difficult to treat. These include both primary tumors of the sacrum and locally invasive colorectal carcinomas. Sacral resection is often the only effective alternative for meaningful palliation or cure of sacral tumors. A review of 20 cases of sacral resections for primary sacral tumors (8) and locally invasive anorectal cancers (12) is presented. The mortality (0%) and morbidity (35% urinary complications, 25% wound disruptions, 1600-mL median blood loss) compare favorably with reports in the literature. Long-term survival was achieved with primary tumors of the sacrum. Local control of disease was achieved in the majority of patients with rectal cancer, with good palliation of preoperative pain. Long-term survival, however, is rare in this group. Surgical resection of sacral tumors can be undertaken with acceptable morbidity and mortality in selected patients. ( Arch Surg . 1990;125:911-913)