Multivisceral Resection in Rectal Cancer

Abstract

The treatment of locally advanced rectal cancer (T3/4 or N1/2) is challenging and requires a multidisciplinary approach including diagnostic radiology, medical oncology, pathology, radiation therapy, and surgery. Unlike many solid tumors, locally advanced or locally invasive rectal cancer is not necessarily unresectable (Lopez 2001). Indeed, over the past 30 years, it has been shown that a significant percentage of even large colorectal tumors remain localized and do not metastasize; therefore, en-bloc resection with clear margins can lead to cure (Lopez 2001; Gebhardt et al. 1999, Nakafusa et al. 2004; Lehnert et al. 2002; Klaassen et al. 2004; Govindarajan et al. 2006). In a study by Spratt and Spjut involving examination of more than 1,000 colorectal tumors, two-thirds of the large or locally invasive tumors had reportedly not metastasized even to locoregional lymph nodes (Spratt and Spjut 1970). However, up to 15% of rectal cancer tumors adhere to or invade adjacent pelvic organs. Since the surgeon cannot easily distinguish a malignant fistula from an inflammatory adhesion (Gebhardt et al. 1999), and because separation of a malignant fistula can lead to local tumor dissemination and recurrence, multivisceral resection should be considered. Advanced planning, with strict adherence to the principles of surgical oncology, is necessary when treating these difficult cases.y approach including diagnostic radiology, medical oncology, pathology, radiation therapy, and surgery. Unlike many solid tumors, locally advanced or locally invasive rectal cancer is not necessarily unresectable (Lopez 2001). Indeed, over the past 30 years, it has been shown that a significant percentage of even large colorectal tumors remain localized and do not metastasize; therefore, en-bloc resection with clear margins can lead to cure (Lopez 2001; Gebhardt et al. 1999; Nakafusa et al. 2004; Lehnert et al. 2002; Klaassen et al. 2004; Govindarajan et al. 2006). In a study by Spratt and Spjut involving examination of more than 1,000 colorectal tumors, two-thirds of the large or locally invasive tumors had reportedly not metastasized to even locoregional lymph nodes (Spratt and Spjut 1970). However, it is important to recognize that up to 15% of rectal cancer tumors will be adherent to or invasive into adjacent pelvic organs. Since the surgeon cannot easily differentiate a malignant fistula from an inflammatory adhesion (Gebhardt et al. 1999), and because separation of a malignant fistula can lead to local tumor dissemination and recurrence, multivisceral resection should be considered. Advanced planning, with strict adherence to the principles of surgical oncology, is necessary when treating these difficult cases.