N.
Question
Type of response
1
How many patients with LRRC were managed within the MDT of your unit in a 24-month period between January 2013 and December 2014?
Range
2
How many patients were operated upon within the same period for rectal cancer?
Range
3
Was the patient directly referred to your unit by a GP or referred by another hospital/consultant?
Multiple options
4
Do you follow current guidelines for the preoperative radiological staging pathway?
Y/N
5
How many patients underwent MRI before surgery?
Multiple options
6
How many patients received presurgical irradiation?
Multiple options
7
How many of those patients were previously radiated with a neoadjuvant intent for the primary tumor?
Range
8
What was the nature of the recurrence requiring surgery?
Multiple options
9
What kind of surgery was performed?
Multiple options
10
What was the median hospital stay in days?
Range
11
What was the 30-day mortality rate?
Range
12
What was the grade 3–4 Clavien-Dindo complication rate?
Range
13
Was surgery for pelvic recurrence associated with surgery for metastases?
Y/N
14
If yes, what kind of resection?
Multiple options
15
Was surgery for pelvic recurrence only palliative?
Y/N
15.3 Results
15.3.1 Number of Treated Cases
The majority of involved centers treat fewer than ten cases per year of pelvic recurrence (18/37) despite most of these units having >20 cases of RC referred per year (34/37). These data clearly depict that referral of patients with recurrent pelvic CRC to a surgical unit does not follow a predetermined and dedicated regional or territorial pathway. Referrals occur preferentially from other specialists (26/37; namely, medical oncologists), and only seldom (7/37) from the general practitioner or from another surgical unit (4/37).
15.3.2 High-Resolution Imaging Facilities and Guidelines
All centers reported following current guidelines for preoperative imaging, and this is apparently confirmed by the large majority of units in which magnetic resonance imaging (MRI) was performed before any therapeutic decision was made (26/37). Interestingly, a few centers dealt with pelvic recurrence cases without performing high-resolution MRI (3/37), and the remaining centers used it in <50% of patients.
15.3.3 Preoperative Radiation
Adoption of presurgical radiotherapy (RT) was quite diffuse. Patients were operated on for pelvic recurrence without receiving neoadjuvant RT in 10/37 centers. The remaining units (27/37) performed surgery after RT. Patients with a pelvic relapse received no preoperative RT for their primary tumor in <50% of cases in nearly half of the responding centers (18/37): in the remaining units, patients had already received a course of RT before surgery for the rectal tumor.
15.3.4 Type of Recurrence Treated
Extrapelvic recurrence was treated in four centers; anastomotic recurrence was reported by seven centers. Central pelvic recurrences were mostly treated in 22/37 centers, and nodal recurrences were reported by four units.
15.3.5 Type of Surgery
Posterior pelvectomy was the most common approach in 9/37 centers and anterior pelvectomy in 6/37. Total pelvic exenteration was the operation of choice in six centers. In 15/37 centers, all approaches were used, including sacrectomy if needed. In one center no surgery was performed.
15.3.5.1 Additional Surgery
Additional surgery was mainly for liver metastases, and the surgical procedure was predominantly deemed curative in only ten centers in which operations with a palliative intent were performed.
15.3.6 Outcome Reporting: Hospital Stay, Mortality Rate, Complications Rate
Hospital stay ranged from 6 to 30 days; 30-day mortality reached 16% in two centers (range 0–16), with the majority of them declaring no postoperative deaths. Grade 3–4 complication rates ranged from 0% to 100%.
15.4 Discussion
Extensive surgery for locally recurrent CRC can improve survival and provide acceptable morbidity rates in selected patients [13]. Along with neoadjuvant and adjuvant chemoradiation therapy, it often offers curative treatment in patients once considered untreatable [14].
Multidisciplinary team experience is crucial. Hospital volume strictly relates to the confidence acquired by the team, and the number of referrals quite easily depicts the opportunity to increase patient quality of care and outcomes. Despite the fact that in several countries centralization of RC therapy has been introduced and implemented, in Italy, referral of RC patients is still not governed by national or regional programs. Differences in surgical approach and in the diagnostic pathways used can be seen even within the same metropolitan areas, with some patients going straight to surgery without proper staging and multidisciplinary case discussion. Also, surgery is often performed in low-volume hospitals, and despite the surgeon’s experience possibly being adequate, not always guarantees optimal outcome. The same situation exists for pelvic recurrence: established team experience is a fundamental factor in achieving the expected outcome for such a demanding clinical circumstance [15–17].
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