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472
ve
sacrospinous ligaments
Tumor removal
ba
E. J. Dozois and D. T. Colibaseanu
c
Thecal sac
Gluteus m.
S1 nerve root
Piriformis m.
Sciatic ner
Sacrotuberous and
Fig. 35.9 (a) Posterior transverse osteotomy (thick
dotted black line). Sacrospinous and sacrotuberous
ligament transection. Gluteus maximus muscle is reected
laterally to expose obturator vessels and sciatic nerve. (b)
Laminectomy to identify thecal sac. (c) Dural sac and
sacral root ligation
– The VRAM provides a well-vascularized,
bulky tissue paddle that not only lls dead
space but also can be used to reconstruct
the perineal skin defect.
– In cases where the rectus in not available,
a pedicled omental flap can be a good
second choice if it is robust. It can fill
the pelvic dead space providing
vascularized tissue and has been shown
to decrease risk of pelvic sepsis following
Fig. 35.10 Intraoperative photograph of bula grafts and
instrumented spinopelvic reconstruction following total
sacrectomy
surgery.
– Moreover, the omentum can line the raw
surfaces of the pelvis, preventing the
small bowel from getting trapped in the
• We, as well as others, have found that the use
of a VRAM ap is associated with fewer perineal wound complications.
deep pelvis, which is a common cause of
small bowel obstruction following
exenteration.
35 Colorectal Cancer: Management ofLocal Recurrence
473
• Thigh llet aps are used after hindquarter
amputation and are based on the superior and
inferior gluteal vessels.
• Long anterior hemipelvectomy aps are based
on the vascular muscle distribution supplied
by the supercial femoral artery.
Results ofSurgery
Recurrent Colon Cancer
• Limited data exist on surgical and oncologic
outcomes in patients with locally advanced
recurrent colon cancer.
• Few centers have published their experience,
and patient groups are small and heterogeneous, making denitive conclusions regarding management difcult.
• The best oncologic outcomes are achieved in
patients undergoing R0 resection.
Margin status and location of recurrence
appear to be the most important predictors of outcome in patients with recurrent colon cancer.
– Patients undergoing an R0 resection
survive on average 2 years than those
undergoing R1 resection and 4years longer
than those undergoing R2 resection.
Surgery forRe-recurrent Disease
• In the author’s view, a second colorectal
cancer recurrence is not a contraindication to
curative resection as long as the principles of
determining resectability for primary recurrence are followed.
Resection that Includes theAortoiliac
Axis
• Small series have demonstrated that despite
the complexity of the technique, the surgery
can be performed safely when done by expert
multidisciplinary teams, and overall DFS is
comparable to outcomes seen with locally
advanced disease to nonvascular structures.
Sacropelvic Resections
Recurrent Rectal Cancer
• Published series of surgery for locally
recurrent rectal cancer have been limited by
small numbers and heterogeneous patient
groups.
• However, it is clear that for select patients, R0
resection is possible and overall 5-year survival can be as high as 40%.
• In series published where IORT is a component
of multimodality therapy, meaningful survival
can also be achieved in patients who have R1
or R2 resections.
• Aggressive surgery that includes more lateral
pelvic resections (pelvic sidewall tumors) and
higher sacral resection (above the third sacral
body) is increasingly reported by experienced
centers with good results.
• The importance of an R0 resection in patients
undergoing surgery for recurrent rectal cancer
cannot be overstated.
• Owing to the complex anatomical relationships
of the pelvic structures, some local recurrences
involve multiple xation points and will
require both multivisceral and
neuromusculoskeletal resection to achieve a
negative- margin resection.
• Operations for recurrences involving the
lateral pelvic sidewall or high lumbosacral
skeletal components are among the most
technically challenging to perform.
• In the past, limited data existed regarding both
the safety and the oncologic benets of surgery in these patients. Once thought to be a
common contraindication to surgery for recurrent colorectal cancer, high sacral and other
complex sacropelvic resections are being done
by several centers around the world.
• In series from specialized centers, authors
have shown that surgery in these complex
patients can be done safely and with meaningful oncologic outcomes.
474
E. J. Dozois and D. T. Colibaseanu
Postoperative Complications
andQuality ofLife
• Despite the complex nature and magnitude of
surgery for local recurrence, several recent
series have demonstrated that these cases can
be done with an operative mortality rate that
ranges from 0% to 3%.
• When it does occur, 30-day mortality is
usually a result of uncontrolled sepsis.
• This is a dramatic improvement compared to
series published 20years ago, where operative
mortality could be as high as 8.5%.
• Several factors are responsible for the
signicant decrease in operative mortality:
better patient selection, improved surgical
technique by experienced specialists, better
anesthesia, and better postoperative ICU
management.
• Early and late complications following surgery
for local recurrence remain a signicant
challenge.
– Most series report intra-abdominal /pelvic
sepsis and wound-related complications as
the most signicant cause of morbidity.
– Other common complications are
postoperative bleeding requiring
transfusion, voiding dysfunction,
prolonged ileus, delayed small bowel
perforation, and late stulas.
• Universally, higher complication rates are
associated with extended resections such a
sacrectomy and exenteration.
• Urologic complications both early (ureteral
obstruction, leak) and late (ureteral stricture)
are reported in many series.
• Little information exists about the impact of
major surgical intervention on quality of life
in patients with recurrent colorectal cancer.
• While oncologic outcomes remain the most
important outcome measure for patients and
physicians deciding on an aggressive surgical
approach, quality of life after surgery must be
considered and discussed with patients so that
they are well informed.
Palliative Approach
• Patients with an asymptomatic recurrence
which is unresectable, either due to presence
of concurrent metastases or because of local
factors, do not warrant surgical intervention.
• In symptomatic patients, external beam
radiotherapy can sometimes relieve
obstruction, decrease bleeding, and reduce
pain.
• Endoscopic stenting is especially helpful with
malignant obstructions and can in some cases
be used to palliate malignant stulas that are
inoperable.
• Patients not candidates for stents may need a
colostomy for symptomatic relief.
• Chemotherapy has been shown to prolong
survival and palliate symptoms in patients
with primary metastatic colorectal cancer, and
the treatment of unresectable recurrent
colorectal cancer is based on extrapolations
from this data.
• Patients in whom a palliative approach is
taken will benet greatly by meeting with a
palliative medicine team to discuss treatment
goals and assist with end-of-life decisions. In
addition, a cancer pain specialist can assist in
reducing suffering through optimal pain
management, and this should be the goal in
patients undergoing a palliative approach.
Colorectal Cancer: Management
ofStage IV Disease
GlennT.Ault andKyleG.Cologne
36
Key Concepts
• Multidisciplinary evaluation is of paramount
importance in the treatment of metastatic
colorectal cancer.
• Positron emission tomography (PET) scan
should be used in the evaluation of metastatic
disease prior to potentially curative surgical
therapy or in cases of equivocal disease, but
not for routine detection of metastatic
disease.
• Patients with incurable metastatic disease and
asymptomatic primary tumors should be considered for initial treatment with
chemotherapy.
• For metastatic colorectal liver lesions, synchronous resection and liver-rst or colon-rst
strategies are all acceptable means of surgical
treatment.
• Resection, ablation, or a combination of ablative and resection techniques can be used to
minimize parenchymal liver resection and
G. T. Ault
Division of Colorectal Surgery, Department of
Surgery, University of Southern California,
Los Angeles, CA, USA
K. G. Cologne (*)
Department of Surgery, Division of Colorectal,
University of Southern California Keck School of
Medicine, Los Angeles, CA, USA
e-mail: Kyle.Cologne@med.usc.edu
preserve function when treating metastatic
colorectal metastases.
• Cytoreduction and hepatic artery infusion of
chemotherapy (HIPEC) may be considered in
appropriately selected patients treated at specialized centers with expertise in this technique, although it has not been demonstrated
to be superior to modern systemic
chemotherapy.
• Metastases to organs other than the liver, lung,
ovary, or peritoneum are uncommon and commonly occur in conjunction with widely metastatic disease. Thus, resection rarely has an
impact on overall survival and should only be
undertaken in select circumstances after multidisciplinary evaluation.
• Treatment of metastatic disease in the elderly
requires consideration of the performance status, frailty, and impact of various treatments
on quality of life.
Introduction
• Despite screening protocols, approximately
20% of colorectal cancer patients present with
established distant metastasis.
• While there has been considerable progress in
the treatment of advanced colorectal cancer,
the vast majority of stage IV patients are
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_36
475
476
G. T. Ault and K. G. Cologne
unfortunately not curable by current treatment
protocols.
• Computed tomography (CT) scan or magnetic
resonance imaging (MRI) generally detects
metastases at the time of the initial staging of
the cancer.
• Once the diagnosis of stage IV disease is
made, a multidisciplinary team should plan
appropriate curative or palliative therapy.
• Treatment approaches must be individualized
based on the extent of resectability of local
and distant disease, the presence or absence of
symptoms, performance status, and
comorbidities.
• For patients with good performance status and
minimal symptoms from the primary site of
the cancer, standard treatment is systemic chemotherapy, which has been proven to prolong
survival and quality of life.
– Surgical resection of the primary tumor is
indicated if symptoms cannot be controlled
with chemotherapy.
• Select patients can be considered for resection
of the primary tumor and metastatic lesions,
which may be curative.
• First-line therapy with either FOLFOX or
FOLFIRI now has been shown to yield major
responses in up to 50% of previously untreated
patients and achieves minor responses or stable disease in an additional 20% of patients.
• Over the past 15years, the median survival for
patients with metastatic disease who are
treated with chemotherapy has improved from
9 to 12months and is currently greater than
24months and may be as long as 36months.
• No imaging modality is infallible, and in cases
of uncertainty, multiple imaging modalities or
tissue biopsy may be required to conrm the
diagnosis, as it dramatically changes the prognosis and perhaps the treatment strategy as
well.
Computed Tomography
• Computed tomography has been the mainstay
of distant staging workup for colorectal
cancer.
• Triple-phase scans allow improved delineation of hepatic metastases (Fig.36.1).
• Though enhancement characteristics differ,
most metastatic lesions are hypoattenuating
on portal venous phases of an abdominal CT.
• Up to 25% of hepatic liver metastases may be
missed on high-quality CT, due mostly either
to size or confusion with other disease
processes.
Positron Emission Tomography (PET)
• PET and combined PET-CT scans are a
modality used both for initial staging and for
Diagnostic Strategies
• Part of the evaluation of newly diagnosed
colorectal cancer includes systemic staging
with cross-sectional imaging of the chest,
abdomen, and pelvis.
• 20–30% of patients will present with evidence
of metastatic disease on this staging workup.
• Increased suspicion should be given to the
presence of metastatic disease when the CEA
level is greater than 20ng/mL.
Fig. 36.1 CT of the abdomen demonstrating liver metastases involving multiple segments of the liver. Treatment
of these requires advanced planning and input in a multidisciplinary setting involving hepatobiliary, interventional
radiology, oncology, and other specialties to determine
planned interventions and timing
36 Colorectal Cancer: Management ofStage IV Disease
477
follow-up imaging. The technology has dramatically improved recently and can now provide very clear pictures of tumor deposits in
distant locations (Fig.36.2).
• Sensitivity of PET-CT for detecting metastatic
lesions ranges from 87% to 100%, which
compares favorably with regular CT where
sensitivities range from 52 to 69%).
• Specicity of PET-CT is also good and ranges
from 94% to 100% (compared with 80–94%
for regular CT).
• Limitations include a size resolution of about
1 cm and limited ability to detect mucinous
tumors due to low tumor cell/volume ratio.
• National Comprehensive Cancer Network
(NCCN) guidelines do not recommend routine use of PET-CT to evaluate metastatic
lesions except in equivocal ndings or in cases
where patients are allergic to IV contrast
which would otherwise limit the usefulness of
regular CT.
• In cases where patients are being considered
for potentially curative resection of recurrent/
metastatic tumor, PET-CT will change management in up to 20% of cases, primarily by
detecting occult metastases, which would render the planned resection palliative.
Magnetic Resonance Imaging
• MRI is particularly helpful in characterizing
equivocal lesions of the liver, especially those
that fall below the resolution of PET.
• Sensitivity of MRI at detecting response of
liver lesions to neoadjuvant treatments may be
better than PET.
Fig. 36.2 PET-CT scan and various phases. Lesions may not always show up or appear active on all phases of
imaging
478
G. T. Ault and K. G. Cologne
• MRI cannot routinely be used in patients with
pacemakers, implantable cardiac debrillators, cochlear implants, and other orbital foreign bodies.
Contrast-Enhanced Ultrasound
• Contrast-enhanced ultrasound (CEUS) is a
relatively new imaging modality to assess the
liver.
• It is highly operator dependent but in experienced hands may be highly accurate.
• A potential limitation is that chemotherapyinduced fatty inltration of the liver may limit
diagnostic accuracy.
Biopsy
• In equivocal cases where imaging characteristics are not suspicious of colorectal metastases, tissue biopsy conrmation remains an
option. A small percentage of patients will
have a histologic process other than the primary malignancy.
Multidisciplinary Evaluation
• Multidisciplinary evaluation is of critical
importance to caring for patients with metastatic disease.
• As there is often no one agreed-upon absolute
treatment strategy, it is important to have consensus from treating oncologists, radiation
oncologists, and various surgical disciplines
such as colorectal, hepatobiliary, thoracic, and
gynecology.
• It is estimated that only 20–30% of patients
with identied metastatic disease will have
potentially resectable disease.
• Goals of multidisciplinary evaluation should
include relief of symptoms, quality of life
improvement, and determining the best means
of prolonging life expectancy. A typical algorithm can be found in Fig.36.3.
Surgical Emergency
• Tumors at the primary site may cause a surgical emergency, even in the setting of metastatic disease.
• In these cases, surgical intervention should be
undertaken to relieve the immediate, lifethreatening issue, such as perforation with
peritonitis, lower GI bleeding, or large bowel
obstruction.
• If possible, and if it can be performed with
limited morbidity, an oncologic surgical resection should be performed.
• A primary anastomosis can be performed in
select, low-risk patients but carries the potential that it may delay chemotherapy and other
Metastatic colorectal cancer
Multidisciplinary conference evaluation
Obstructing / perforated tumor
Widely metastatic disease
Colectomy / stent / colostomy
Palliative chemotherapy
Restage and assess response
Fig. 36.3 Treatment algorithm for metastatic colorectal cancer
Resectable disease
Consider simultaneous (liver) vs
staged surgical resection
(± neoadjuvant chemotherapy*)
36 Colorectal Cancer: Management ofStage IV Disease
479
life-sustaining treatments if an anastomotic
leak should occur.
Palliative Management ofPrimary
Cancer: Laser, Fulguration,
andStents
Incidence andPresentation
• Approximately 8–29% of patients with
colorectal cancer initially present with symptoms of partial or complete bowel
obstruction.
• The majority of patients with obstructing
colorectal carcinomas have either stage III or
stage IV disease.
• Acute malignant colon or rectal obstruction is
an indication for emergent surgical
intervention.
– However, these emergency operations are
associated with a mortality rate of 15–34%
and a morbidity rate of 32–64% despite
advances in perioperative care.
– Therefore, alternative palliative endolumi-
nal strategies aimed at relieving obstruction have gained increasing popularity over
the past decades.
• If the patient has minimal symptoms and there
is no radiographic evidence of high-grade
obstruction, many patients with partially
obstructing colon and rectal cancers will
respond to aggressive chemotherapy.
• In those patients with partially obstructing
rectal cancers, the addition of radiation therapy is also well tolerated and can be highly
effective.
• Patients must be instructed to monitor their
symptoms closely and to report any signs of
worsening obstruction immediately.
• For patients with advanced obstruction, nonsurgical palliative options include laser therapy, fulguration, and colonic self-expanding
metal stents.
• If less invasive endoluminal strategies are not
successful in patients with unresectable malignant obstruction of the colon and rectum, surgical creation of palliative proximal diverting
stoma or intestinal bypass should be
performed.
Laser Therapy andFulguration
• Laser therapy has been utilized for palliation
of obstructing rectal cancers.
• Although it can be effective in palliating
obstruction, multiple sessions are often
required in order to achieve lasting relief of
symptom.
• Serious complications like bleeding, perforation, and severe pain have been reported in
5–15% of patients, especially those undergoing multiple treatment sessions.
• Surgical fulguration of rectal cancers is
another method of opening the rectal lumen
and relieving obstruction.
• Fulguration, in combination with endoluminal
debulking, can remove a large volume of
tumor.
• However, unlike laser therapy, fulguration and
debulking require hospital admission and
regional or general anesthesia.
• In general, both fulguration and laser therapy
have given way to stenting.
Self-Expanding Intraluminal Metal Stents
• Since their introduction in 1991, colonic stents
have become an effective method of palliation
for obstruction in colorectal cancer patients,
especially those with unresectable metastatic
disease or used in an effort to decompress an
obstructed patient preoperatively.
• Especially in nonoperative stage IV patients
or those that have signicant comorbidities,
these self-expanding metallic stents can potentially dilate the lumen, providing quick relief
of symptoms.
• Stents can be placed in patients using moderate sedation in the endoscopy suite with the
aid of uoroscopy.
• It should be noted emergency surgery is recommended over stent placement in those
480
G. T. Ault and K. G. Cologne
patients with evidence of colonic obstruction
and systemic toxicity. Presence of systemic
toxicity may indicate the presence of ischemia
and/or perforation, which requires immediate
evaluation and the potential for emergency
surgery.
• Stenting can achieve long-term palliation in
patients who are not operative candidates.
– More than 75% of patients can achieve
adequate palliation with stenting, although
tumor ingrowth, stent migration, and perforation, especially those receiving bevacizumab, may occur.
– If these stent-related complications occur,
it may necessitate reintervention either
with an additional stent or with other palliative measures such as laser or argon
plasma coagulation therapy or surgery.
• There are limited data evaluating stent placement proximal to the splenic exure.
• Complications reported in the literature for
colonic and rectal stents include stent malpositioning, perforation, stent migration, tumor
ingrowth (through the stent interstices), tumor
overgrowth (beyond the ends of a stent), stool
impaction, bleeding, tenesmus, and post-procedure pain (Fig.36.4). Perforation and stent
migration occur with the highest frequency.
• Stenting of cancers in the mid to low rectum
may result in urgency, pain, and
incontinence.
Fig. 36.4 Perforation of the bowel in a colonic stent.
(Courtesy of Philip Y.Pearson, MD)
• Stents left in situ for long periods (many
months or years) may erode through the bowel
wall and cause signicant morbidity to adjacent organ involvement, subacute perforation,
stulas, etc.
• While the complications associated with
stents and other less invasive endoluminal
strategies should not be taken lightly, one
must keep in mind that emergency operations
for malignant colon and rectal obstruction
have a signicant mortality rate of 15–34%
and a high morbidity rate of 32–64%.
The Challenge ofPrimary Tumor
Management inAsymptomatic
Stage IV Colorectal Cancer:
ToResect or Not toResect?
• Optimal rst-line therapy for patients who
present initially with unresectable stage IV
disease remains controversial. Some advocate
initial resection of the primary, while others
recommend initial chemotherapy if the primary tumor is asymptomatic.
• In the era of modern chemotherapy, patients
can experience increased length and quality of
life with 5-FU-based multi-agent
chemotherapy.
• Prophylactic resection of the primary tumor
can provide long-term local control.
– This must be weighed against the risk of
surgical complications resulting in delay in
chemotherapy and other palliative
treatments.
– Particularly in rectal cancer, complications
arising from surgery have been shown to
delay initiation of chemotherapy beyond
8weeks postoperatively.
• There is a paucity of prospective randomized,
controlled trials addressing the question of
whether patients with asymptomatic or minimally symptomatic primary tumors and stage
IV disease should have the primary resected
as a rst step.
– Virtually all studies have been retrospective, and
selection bias has been inherent to the study
design, making rm conclusions impossible.
36 Colorectal Cancer: Management ofStage IV Disease
481
• Currently, routine surgery for the asymptomatic primary tumor in the setting of unresectable metastatic disease is not
recommended.
Surgical Therapy ofLiver
Metastases
• Liver metastases are a common occurrence,
and surgical resection represents the best
opportunity for long-term cure.
• Approximately 20–30% of patients have
potentially resectable lesions at the time of
diagnosis.
• With appropriate selection, 5-year survival
has been reported around 30% (range
15–67%).
• Even with modern chemotherapy for
colorectal cancer, surgery for metastatic
cancer (if possible) has consistently been
shown to improve 5-year survival and quality of life and should be considered when
possible.
• Newer liver strategies may allow a staged
resection, portal vein embolization, or a combination of resection, embolization, and other
strategies to ablate or otherwise treat or downsize liver lesions, which may allow a greater
percentage of patients to undergo some form
of treatment.
– This underscores the importance of multi-
disciplinary evaluation of these patients.
• The main reason for failure in treated patients
is intrahepatic recurrence of the tumor, which
occurs in 60–70% of patients, one third of
whom die within 2years of surgery for hepatic
metastases.
• Evidence to support each of these strategies
below is very limited and largely based on
small, single-institution series. Survival analyses across multiple studies suggest there is
little difference between simultaneous, colonrst and liver-rst strategies. As such, the
agreed-upon treatment strategy should depend
on the local expertise at an individual
institution.
Combination Liver andColon
Resection
• There is evidence to suggest that this approach
results in a similar long-term outcome when
compared to those undergoing staged therapy.
• Similarly, simultaneous resection does not increase
overall morbidity, though there is an inherent
selection bias in trials examining this issue.
• This approach is typically done for relatively
minor resections, which can include
lobectomy.
Liver-First Strategy
• In patients with liver metastases from colorectal cancer, it is the metastatic disease in the
liver (particularly if >3cm in size) that is the
primary determinant of overall survival.
– This is a potential reason for addressing the
liver disease rst, particularly in the setting
of larger metastatic lesions where the primary lesion is asymptomatic.
– As there is some evidence to suggest the
primary lesion has a low chance of becoming symptomatic during follow-up, it is
reasonable to proceed with treatment of the
metastatic disease rst.
• This also may avoid unnecessary colorectal
surgery (and its associated morbidity) in
patients who go on to develop incurable metastatic disease.
• There is evidence to suggest that a “liver-rst”
strategy may still allow patients with potentially curable disease to undergo both liver and
colon resection over time.
• The liver-rst approach can be combined with
neoadjuvant chemotherapy for borderline
resectable lesions or to allow tumor biology to
dictate those lesions that are likely to progress
rapidly prior to surgery.
– While this has been recommended as stan-
dard of care by some, others have disputed
this and still recommend surgical resection
followed by adjuvant chemotherapy due to
the effect of chemotherapy-associated steatosis that can increase surgical morbidity.
• The liver-rst strategy has a particular advantage in the setting or rectal cancer, where the