Surgery for locally advanced recurrent colorectal cancer involving the aortoiliac axis: can we achieve R0 resection and long-term survival?

Background: Locally advanced, recurrent colorectal cancer involving the aortoiliac axis may be considered a contraindication for curative surgery because of the technical challenges of achieving a negative margin resection and an assumed poor prognosis.
Objective: The aim of this study was to assess oncologic outcomes and the ability to achieve an R0 resection in these patients.
Design: A retrospective review of a prospectively maintained colorectal cancer database identified 406 consecutive patients who underwent surgery for locally recurrent colorectal cancer between 1997 and 2007.
Setting: This study was conducted at an academic multidisciplinary tertiary center.
Patients: The demographic and clinicopathological features of patients undergoing resection for locally advanced disease involving the aortoiliac axis at our institution were reviewed.
Results: Twelve patients (7 women, median age 51 years) were identified. Major vessel involvement included internal iliac artery (n = 7), common iliac artery (n = 5), external iliac artery (n = 3), aorta (n = 3), internal iliac vein (n = 2), and external iliac vein (n = 1). R0 resection was achieved in 7 patients, and R1 resection in 5. Eleven patients received intraoperative radiation therapy. Vascular reconstruction (3 aorta, 5 common iliac, 3 external iliac) included synthetic interposition grafts, femoral-femoral bypasses, or primary anastomosis. One patient underwent venous reconstruction of the external iliac vein. No graft complications were encountered, and graft patency at 4 years was 100%. Thirty-day morbidity was seen in 9 patients, 8 of whom had Clavien grade <3. Thirty-day mortality was nil. Overall and disease-free survival at 4 years was 55% and 45%.
Limitations: This study was limited by its sample size, retrospective design, and the number of outcome events.
Conclusion: R0 resection of locally advanced recurrent colorectal cancer involving the aortoiliac axis was achieved in over 50% of patients. Overall and disease-free survival was comparable to outcomes seen with locally advanced disease to nonvascular structures.