ABSTRACT
BACKGROUND AND OBJECTIVES: Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort. METHODS: Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma. RESULTS: There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n = 831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age ≥ 60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P < .001). Overall survival (OS) was 50 months. After adjustment of significant covariates, negative margin status (adjusted HR, 0.6, 95% CI, 0.5-0.8; P < .001) and receipt of perioperative radiation or chemoradiation (adjusted HR, 0.5; 95% CI, 0.4-0.6; P < .001) were significantly associated with decreased risk of death. Only 71% of the patients received perioperative radiation. CONCLUSIONS: Pelvic exenterations are being performed safely in Coc-accredited hospitals. However, up to one fourth of patients undergo resections with positive margins or are subject to underutilization of perioperative radiation therapy. Increased use of radiation may increase negative margin resections and improve patient outcomes.
ABSTRACT
OBJECTIVES: To categorize sites of recurrence of retroperitoneal sarcomas (RPS) and correlate to clinical treatment volumes of postoperative radiation therapy (PORT) with or without intraoperative radiation therapy (IORT). METHODS: A retrospective review of patients with RPS who received PORT between 1990 and 2008 was done. Tumor recurrences were subdivided as local tumor bed, regional adjacent retroperitoneal fascial tissues, peritoneal diffuse seeding, and distant metastases. RESULTS: PORT was given to 33 patients, 20 of whom also received IORT. Local recurrences appeared in 4 (12%) cases. Regional recurrences appeared in 8 (26%) cases, including 5 with in-field recurrence and 3 with edge-of-field recurrence. Edge-of-field recurrences developed in 3 of 11 (27%) patients whose clinical presentation was local recurrence compared with none of 20 patients whose clinical presentation was a primary tumor (P=0.037). Late grades 3 to 4 gastrointestinal toxicities appeared in 1 of 10 (10%) patients who received intensity-modulated radiation therapy (IMRT) with a minimum 15-month follow-up compared with 4 of 15 (27%) patients who received standard RT. CONCLUSIONS: Use of techniques such as IORT and IMRT can deliver a dose of approximately 60 Gy to the tumor bed and 44 to 51 Gy to the surrounding retroperitoneal fascial planes. Acute and late gastrointestinal toxicities were less frequent with IMRT compared with conventional PORT with IORT. These results may provide the basis for comparison of various adjuvant therapy strategies for RPS. As radiation therapy is a loco-regional treatment, results should be reported by tumor recurrence subtypes of local, regional, peritoneal, and distant.