Slide 1

The management of recurrent pelvic malignancy Pete Sagar The General Infirmary at Leeds England Slide 2 Slide 3 Slide 4 Slide 5 Things could be worse Slide 6 Slide 7 EXCLUSIVE: SHANE'S AT IT AGAIN Cheat Aussie star's two-month affair By Megan Lloyd Davies And Richard Smith MESSAGES: Warne sent a string of texts TWO-timing Shane Warne has been caught cheating with ANOTHER woman. Slide 8 Slide 9 Presentation PAIN Slide 10 Slide 11 The problem 8-10 000 cases annually of rectal cancer in the UK Local pelvic recurrence in 5-15% Slide 12 Treatment radiotherapy/chemotherapy Good initial palliation Long term survivors are rare Reserved for end stage disease Slide 13 Treatment - surgery Multimodality therapy Team approach essential Technical demands Slide 14 Preoperative assessment Biopsy to confirm diagnosis CT chest and abdomen MRI pelvis EUA Fitness for operation Slide 15 The Leeds MDT meeting Slide 16 Accommodation for relatives Slide 17 Accommodation for relatives (NHS) Slide 18 Patterns of pelvic invasion Localised type Sacral invasion Pelvic side wall invasion Slide 19 Localized type Recurrent tumour is localized to the adjacent tissues or connective tissue Slide 20 Peri-anastomotic recurrence Slide 21 Perineal recurrence Slide 22 Mucinous adenocarcinoma Slide 23 Sacral invasion Recurrent tumour invades the lower sacrum (S3, S4, S5) or coccyx Slide 24 Chordoma with sacral invasion Slide 25 Sacral invasion - gadolinium enhanced Slide 26 Lateral invasion Recurrent tumour invades pelvic side wall Slide 27 Pelvic side wall invasion Slide 28 Vesico-ureteric junction Slide 29 Planes of attack Slide 30 APR+S vs TPE+S Slide 31 Slide 32 Slide 33 Slide 34 Slide 35 Slide 36 Slide 37 Slide 38 Rectus abdominus flap Slide 39 Slide 40 Anatomical points Slide 41 Slide 42 Slide 43 Slide 44 When not to operate Slide 45 Choose your patient! Slide 46 Contraindications Extrapelvic disease Invasion of S1 or S2 Invasion through greater sciatic notch Extensive pelvic side wall involvement ASA IV-V Slide 47 Para-aortic nodal involvement Slide 48 Greater sciatic notch involvement Slide 49 Surgical intervention contraindicated Slide 50 Extension through both greater sciatic foramina Slide 51 Technical tips Slide 52 Perianastomotic recurrence Slide 53 Peri-anastomotic recurrence Residual mesentery Anticipate tearing around the anastomosis Beware the medial course of the ureters Slide 54 Anterior invasion into bladder Slide 55 Anterior spread Trial dissection Plane anterior to the bladder APER Involve the urologist Slide 56 Sidewall vessel involvement vessels Slide 57 Pelvic side wall BLEEDING Suture Fibrillar surgicell Argon beamer Be prepared to pack Slide 58 Presacral space, no direct invasion Slide 59 Pre-sacral mass Control iliac vessels before dissection of mass Incise peritoneum and develop plane between mass and sacrum Beware spongy tumour Slide 60 Direct invasion into the sacrum Slide 61 Direct invasion of the sacrum Choose level of sacrectomy carefully Frozen section Beware bleeding from pre-sacral veins Slide 62 Posterior exenteration 35% Slide 63 30% Total exenteration Slide 64 Resection of mass alone 15% Slide 65 9% Gynaecological clearance Slide 66 7% Anterior exenteration Slide 67 Rectal resection with primary anastomosis 4% Slide 68 Sacrectomy 16% Slide 69 Cumulative survival R0 vs R1 resections Slide 70 Slide 71 Outcome One third will live five years One third will recur locally (?re-operate) One third will die of disseminated disease Slide 72 Conclusion Multidisciplinary management Surgery prime modality Surgical team approach essential Slide 73 Slide 74 Slide 75 ENGLAND WIN THE ASHES Slide 76 Slide 77 Slide 78 Intra-operative radiotherapy Delivery of high biological equivalent Dose limiting structures are displaced 45-60 Gy EBRT pre op Deliver remainder at operation Slide 79 Slide 80 Slide 81 Slide 82 Slide 83 Slide 84 Slide 85 Best practice? Slide 86 Slide 87 Slide 88 1-507-284-2511