Андрология и генитальная хирургия. 2024; 25: 112-120
Мультидисциплинарный подход в лечении рецидива рака прямой кишки с вовлечением мочевых путей
https://doi.org/10.62968/2070-9781-2024-25-3-112-120Аннотация
Цель исследования. Оценить непосредственные и отдаленные онкологические результаты хирургического лечения рецидива рака прямой кишки с вовлечением мочевых путей. Показать необходимость мультидисциплинарного подхода в лечении местнораспространенного рецидива рака прямой кишки.
Материалы и методы. За период с 2018-го по 2022 г. нами обследовано 53 пациента, которые были распределены по следующим группам: инфертильные пациенты с необструктивной азооспермией и сопутствующим варикоцеле (n = 13) – группа 1; инфертильные пациенты с обструктивной азооспермией (n = 29) – группа 2; фертильные пациенты с подтвержденным отцовством и патологией яичка, требующей гистологической верификации с целью исключения онкопатологии яичек (n = 11) – группа 3. Каждому пациенту была выполнена TESE с забором тестикулярной ткани и ткани уретры с целью сравнения бактериального пейзажа и контроля чистоты метода. Полученный материал был взят для последующего секвенирования с использованием высокопроизводительного метода (NGS).
Результаты. Средний возраст пациентов составил 51,6 ± 13,0 года. Гендерный состав – мужчины 6, женщины – 8 человек. Наибольшее количество рецидивов (88%) развилось при первичном КРР нижне- и среднеампулярного отделов прямой кишки. В 57,2% наблюдений пациентам проводилась предоперационная химиотерапия и химиолучевая терапия. Примерно 64% первичных операций выполнено открытым доступом. Рецидив КРР при pT3-T4 инвазии диагностирован в 72% наблюдений. Поражение лимфатических узлов при первичном лечении выявлено у 57,2% пациентов с рецидивом КРР. В 2 наблюдениях выполнена первичная операция с R2 границей резекции, рецидив выявлен в сроки 11 и 13 мес., одно гистологическое заключение указало на R1 резекцию, рецидив отмечен через 6 мес. Адьювантная химиотерапия проведена 10 (71,4%) первично оперированным пациентам, 2 (14,3%) – послеоперационная лучевая терапия. Средние сроки выявления рецидива от первичной операции – 16,5 [12–28] мес., интервал Диагноз-Лечение составил 7 [1–11] дней. Расширенные комбинированные вмешательства, включающие удаление рецидива с резекцией толстой кишки, гинекологический и урологический этапы (RR+CR+GR+UR) составили 36%, удаление рецидива с резекцией толстой кишки и урологическим этапом (RR+CR+UR) выполнено в 43% наблюдений, удаление рецидива без толстокишечного этапа (RR+GR+UR и RR+UR) – 3 (21%) пациентам. Реконструктивные этапы по восстановлению деривации мочи выполнены 12 (85,7%) пациентам. Средняя длительность операции составила 412,5[205-490] мин., интраоперационная кровопотеря – 275 [150–400] мл. У 3 (21,4%) пациентов в раннем послеоперационном периоде диагностированы осложнения категории III по классификации Clavien–Dindo. Системная воспалительная реакция в 1 наблюдении отнесена к категории осложнений Clavien–Dindo IV. Длительность послеоперационного периода составила 25,5 [14–30] дня. Послеоперационная летальность составила 0%. При патогистологическом исследовании R1 резекция выявлена в 3 (21,4%) случаях. Адьювантная химиотерапия проведена 8 (57,1%) пациентам, 1 (7,1%) в комбинации с курсом ДЛТ. В период 24 мес. после операции летальность составила 14,3%. В указанный период наблюдения повторные рецидивы диагностированы у 3 (21,4%) пациентов, один повторно оперирован. Опухолевая прогрессия в виде появления отдаленных метастазов отмечена у 4 (28,6%) больных, из них в 1 наблюдении прогрессия сочеталась с повторным рецидивом.
Заключение. Основным методом лечения местнораспространенного рецидива рака прямой кишки с вовлечением мочевых путей является хирургический. Мультидисциплинарный подход с привлечением в хирургическую бригаду врача-онкоуролога позволило выполнить одномоментное радикальное вмешательство по поводу местнораспространенного рецидива рака прямой кишки с восстановлением деривации мочи без необходимости последующих реконструктивных вмешательств на мочеполовой системе.
Список литературы
1. Wisselink DD, Klaver CEL, Hompes R, Bemelman WA, Tanis PJ. Curative-intent surgery for isolated locoregional recurrence of colon cancer: Review of the literature and institutional experience. Eur J Surg Oncol. 2020 Sep 1;46(9):1673–82.
2. Lopez-Kostner F, Fazio VW, Vignali A, Rybicki LA, Lavery IC. Locally recurrent rectal cancer: predictors and success of salvage surgery. Dis Colon Rectum [Internet]. 2001;44(2):173–8. Available from: https://pubmed.ncbi.nlm.nih.gov/11227932/
3. Sagar PM, Pemberton JH. Surgical management of locally recurrent rectal cancer. Br J Surg [Internet]. 1996;83(3):293–304. Available from: https://pubmed.ncbi.nlm.nih.gov/8665179/
4. Watanabe J, Shoji H, Hamaguchi T, Miyamoto T, Hirano H, Iwasa S, et al. Chemoradiotherapy for Local Recurrence of Rectal Cancer: A Single Center Study of 18 Patients. In Vivo [Internet]. 2019;33(4):1363–8. Available from: https://pubmed.ncbi.nlm.nih.gov/31280231/
5. Harji DP, Griffiths B, McArthur DR, Sagar PM. Surgery for recurrent rectal cancer: higher and wider? Colorectal Dis [Internet]. 2013 Feb;15(2):139–45. Available from: https://pubmed.ncbi.nlm.nih.gov/22564242/
6. Nerli RB, Ghagane SC, Ram P, Shimikore SS, Vinchurkar K, Hiremath MB. Bladder Invasion in Patients with Advanced Colorectal Carcinoma. Indian J Surg Oncol [Internet]. 2018 Dec 1;9(4):547–51. Available from: https://pubmed.ncbi.nlm.nih.gov/30538386/
7. Lau YC, Brown KGM, Lee P. Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more? J Gastrointest Oncol [Internet]. 2019 Dec 1;10(6):1207–14. Available from: https://pubmed.ncbi.nlm.nih.gov/31949941/
8. Kelly ME, Glynn R, Aalbers AGJ, Abraham-Nordling M, Alberda W, Antoniou A, et al. Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. Br J Surg [Internet]. 2018 May 1;105(6):650–7. Available from: https://pubmed.ncbi.nlm.nih.gov/29529336/
9. Chang GJ, Ikoma N, You YN, Bednarski BK, Rodriguez-Bigas MA, Eng C, et al. Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer. J Clin Oncol [Internet]. 2017 Aug 10;35(23):2631–8. Available from: https://pubmed.ncbi.nlm.nih.gov/28657814/
10. Jankowski M, Las-Jankowska M, Rutkowski A, Bała D, Wiśniewski D, Tkaczyński K, et al. Clinical Reality and Treatment for Local Recurrence of Rectal Cancer: A Single-Center Retrospective Study. Medicina (Kaunas) [Internet]. 2021;57(3). Available from: https://pubmed.ncbi.nlm.nih.gov/33808603/
11. Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol [Internet]. 2020 Jul 1;17(7):414–29. Available from: https://pubmed.ncbi.nlm.nih.gov/32203400/
12. Horvat N, Rocha CCT, Oliveira BC, Petkovska I, Gollub MJ. MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management. Radiographics [Internet]. 2019 Mar 1;39(2):367–87. Available from: https://pubmed.ncbi.nlm.nih.gov/30768361/
13. Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol [Internet]. 2011 Oct 1;29(28):3753–60. Available from: https://pubmed.ncbi.nlm.nih.gov/21876084/
14. Akgun E, Ozkok S, Tekin M, Yoldas T, Caliskan C, Kose T, et al. The effects of chemoradiotherapy on recurrence and survival in locally advanced rectal cancers with curative total mesorectal excision: a prospective, nonrandomized study. World J Surg Oncol [Internet]. 2017 Nov 22;15(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29166925/
15. Bhangu A, Ali SM, Cunningham D, Brown G, Tekkis P. Comparison of long-term survival outcome of operative vs nonoperative management of recurrent rectal cancer. Colorectal Dis [Internet]. 2013 Feb;15(2):156–63. Available from: https://pubmed.ncbi.nlm.nih.gov/23190113/
16. Palma CA, van Kessel CS, Solomon MJ, Leslie S, Jeffery N, Lee PJ, et al. Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do? Eur J Surg Oncol [Internet]. 2023 Jul 1;49(7):1250–7. Available from: https://pubmed.ncbi.nlm.nih.gov/36658054/
17. Westberg K, Othman B, Suzuki C, Blomqvist L, Martling A, Iversen H. Magnetic resonance imaging as a predictor of surgical outcome in patients with local pelvic recurrence of colorectal cancer. Eur J Surg Oncol [Internet]. 2021 Aug 1;47(8):2119–24. Available from: https://pubmed.ncbi.nlm.nih.gov/33926780/
18. Kondo A, Sasaki T, Kitaguchi D, Tsukada Y, Nishizawa Y, Ito M. Resection of the urinary bladder for locally advanced colorectal cancer: a retrospective comparison of partial versus total cystectomy. BMC Surg [Internet]. 2019 Jun 17;19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/31208384/
19. McNamara DA, Fitzpatrick JM, O’Connell PR. Urinary tract involvement by colorectal cancer. Dis Colon Rectum [Internet]. 2003 Sep 1;46(9):1266–76. Available from: https://pubmed.ncbi.nlm.nih.gov/12972973/
20. Khan O, Patsouras D, Ravindraanandan M, Abrar MM, Schizas A, George M, et al. Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events. Eur Urol Focus [Internet]. 2021 May 1;7(3):638–43. Available from: https://pubmed.ncbi.nlm.nih.gov/32622667/
21. Harris CA, Solomon MJ, Heriot AG, Sagar PM, Tekkis PP, Dixon L, et al. The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg [Internet]. 2016 Aug 1;264(2):323–9. Available from: https://pubmed.ncbi.nlm.nih.gov/26692078/
Andrology and Genital Surgery. 2024; 25: 112-120
Multidisciplinary approach in the treatment of recurrent rectal cancer involving urinary tract system
https://doi.org/10.62968/2070-9781-2024-25-3-112-120Abstract
Aim. To evaluate immediate and long-term oncological results of surgical treatment of recurrent rectal cancer involving the urinary tract system to show the need for a multidisciplinary treatment approach for locally advanced recurrent rectal cancer.
Material and methods. Retrospective cohort analysis with prospective supported database. Analyzed 14 cases: all patients with locally advanced rectal cancer recurrence involving urinary tract system were operated at the Clinic of Coloproctology and Minimally Invasive Surgery in 2013-2022.
Results. The age of the patients was 51.6 ± 13.0 years, 6 men, 8 women. The greatest recurrence number was (88%) finded in group of primary colorectal cancer of the lower and middle parts of the rectum. In 57.2% observations patients received preoperative chemotherapy or combination with radiotherapy. Approximately 64% of primary operations were performed using an open approach. Recurrence of CRC with pT3-T4 invasion was diagnosed in 72% of cases. Metastatic damage of lymphatic nodes after primary surgery were identified in 57.2% of cases. In 2 observations primary surgery was performed with R2 resection margin, relapse in that cases was detected after 11 and 13 months. One histopathological report indicated R1 resection, relapse noted after 6 months. Adjuvant chemotherapy was performed in 10 cases (71.4%), in two cases (14.3%) – postoperative radiation therapy. Average time for recurrence detecting after primary operation was 16.5 [12-28] months. Advanced combined interventions including recurrence removal with colon resection, gynecological and urological stages (RR+CR+GR+UR) amounted to 36%, recurrence removal with resection colon and urological stage (RR+CR+UR) was performed in 43% of cases, recurrence removal without the colonic stage (RR+GR+UR and RR+UR) - 3 (21%) patients. Reconstructive surgery to restore urine derivation were performed in 12 (85.7%) cases. The average duration of the procedures was 412.5[205-490] minutes, intraoperative blood loss - 275 [150-400] ml. Early postoperative complications are classified as Clavien-Dindo III. One patient with SIRS was classified as a complication Clavien-Dindo IV. The duration of the postoperative period was 25.5 [14-30] days. Postoperative mortality was 0%. According pathohistological examination R1 resection was detected in 3 (21.4%) cases. Adjuvant chemotherapy was performed 8 (57.1%) patients, in 1 case (7.1%) combination with a course of radiotherapy. During the period 24 months after surgery the mortality rate was 14.3%, repeated relapses diagnosed in 3 (21.4%) patients, one was reoperated. Distant metastases was noted in 4 (28.6%) patients, of which in 1 case with repeated recurrence.
Discussion. Our urogenital bacterial diversity analysis showed that human testicular tissue is not a microbiologically sterile environment and also presented new data associated with testicular tissue and its possible relations with male infertility.
Conclusion. The main treatment method for locally advanced rectal cancer recurrence involving the urinary tract system is surgical. Multidisciplinary approach with the involvement in the surgical team urologist oncologist made it possible to perform a one-stage radical intervention for locally advanced recurrence of rectal cancer with restoration of derivation urine without the need for subsequent reconstructive procedures on the urinary system.
References
1. Wisselink DD, Klaver CEL, Hompes R, Bemelman WA, Tanis PJ. Curative-intent surgery for isolated locoregional recurrence of colon cancer: Review of the literature and institutional experience. Eur J Surg Oncol. 2020 Sep 1;46(9):1673–82.
2. Lopez-Kostner F, Fazio VW, Vignali A, Rybicki LA, Lavery IC. Locally recurrent rectal cancer: predictors and success of salvage surgery. Dis Colon Rectum [Internet]. 2001;44(2):173–8. Available from: https://pubmed.ncbi.nlm.nih.gov/11227932/
3. Sagar PM, Pemberton JH. Surgical management of locally recurrent rectal cancer. Br J Surg [Internet]. 1996;83(3):293–304. Available from: https://pubmed.ncbi.nlm.nih.gov/8665179/
4. Watanabe J, Shoji H, Hamaguchi T, Miyamoto T, Hirano H, Iwasa S, et al. Chemoradiotherapy for Local Recurrence of Rectal Cancer: A Single Center Study of 18 Patients. In Vivo [Internet]. 2019;33(4):1363–8. Available from: https://pubmed.ncbi.nlm.nih.gov/31280231/
5. Harji DP, Griffiths B, McArthur DR, Sagar PM. Surgery for recurrent rectal cancer: higher and wider? Colorectal Dis [Internet]. 2013 Feb;15(2):139–45. Available from: https://pubmed.ncbi.nlm.nih.gov/22564242/
6. Nerli RB, Ghagane SC, Ram P, Shimikore SS, Vinchurkar K, Hiremath MB. Bladder Invasion in Patients with Advanced Colorectal Carcinoma. Indian J Surg Oncol [Internet]. 2018 Dec 1;9(4):547–51. Available from: https://pubmed.ncbi.nlm.nih.gov/30538386/
7. Lau YC, Brown KGM, Lee P. Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more? J Gastrointest Oncol [Internet]. 2019 Dec 1;10(6):1207–14. Available from: https://pubmed.ncbi.nlm.nih.gov/31949941/
8. Kelly ME, Glynn R, Aalbers AGJ, Abraham-Nordling M, Alberda W, Antoniou A, et al. Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. Br J Surg [Internet]. 2018 May 1;105(6):650–7. Available from: https://pubmed.ncbi.nlm.nih.gov/29529336/
9. Chang GJ, Ikoma N, You YN, Bednarski BK, Rodriguez-Bigas MA, Eng C, et al. Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer. J Clin Oncol [Internet]. 2017 Aug 10;35(23):2631–8. Available from: https://pubmed.ncbi.nlm.nih.gov/28657814/
10. Jankowski M, Las-Jankowska M, Rutkowski A, Bała D, Wiśniewski D, Tkaczyński K, et al. Clinical Reality and Treatment for Local Recurrence of Rectal Cancer: A Single-Center Retrospective Study. Medicina (Kaunas) [Internet]. 2021;57(3). Available from: https://pubmed.ncbi.nlm.nih.gov/33808603/
11. Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol [Internet]. 2020 Jul 1;17(7):414–29. Available from: https://pubmed.ncbi.nlm.nih.gov/32203400/
12. Horvat N, Rocha CCT, Oliveira BC, Petkovska I, Gollub MJ. MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management. Radiographics [Internet]. 2019 Mar 1;39(2):367–87. Available from: https://pubmed.ncbi.nlm.nih.gov/30768361/
13. Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol [Internet]. 2011 Oct 1;29(28):3753–60. Available from: https://pubmed.ncbi.nlm.nih.gov/21876084/
14. Akgun E, Ozkok S, Tekin M, Yoldas T, Caliskan C, Kose T, et al. The effects of chemoradiotherapy on recurrence and survival in locally advanced rectal cancers with curative total mesorectal excision: a prospective, nonrandomized study. World J Surg Oncol [Internet]. 2017 Nov 22;15(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29166925/
15. Bhangu A, Ali SM, Cunningham D, Brown G, Tekkis P. Comparison of long-term survival outcome of operative vs nonoperative management of recurrent rectal cancer. Colorectal Dis [Internet]. 2013 Feb;15(2):156–63. Available from: https://pubmed.ncbi.nlm.nih.gov/23190113/
16. Palma CA, van Kessel CS, Solomon MJ, Leslie S, Jeffery N, Lee PJ, et al. Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do? Eur J Surg Oncol [Internet]. 2023 Jul 1;49(7):1250–7. Available from: https://pubmed.ncbi.nlm.nih.gov/36658054/
17. Westberg K, Othman B, Suzuki C, Blomqvist L, Martling A, Iversen H. Magnetic resonance imaging as a predictor of surgical outcome in patients with local pelvic recurrence of colorectal cancer. Eur J Surg Oncol [Internet]. 2021 Aug 1;47(8):2119–24. Available from: https://pubmed.ncbi.nlm.nih.gov/33926780/
18. Kondo A, Sasaki T, Kitaguchi D, Tsukada Y, Nishizawa Y, Ito M. Resection of the urinary bladder for locally advanced colorectal cancer: a retrospective comparison of partial versus total cystectomy. BMC Surg [Internet]. 2019 Jun 17;19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/31208384/
19. McNamara DA, Fitzpatrick JM, O’Connell PR. Urinary tract involvement by colorectal cancer. Dis Colon Rectum [Internet]. 2003 Sep 1;46(9):1266–76. Available from: https://pubmed.ncbi.nlm.nih.gov/12972973/
20. Khan O, Patsouras D, Ravindraanandan M, Abrar MM, Schizas A, George M, et al. Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events. Eur Urol Focus [Internet]. 2021 May 1;7(3):638–43. Available from: https://pubmed.ncbi.nlm.nih.gov/32622667/
21. Harris CA, Solomon MJ, Heriot AG, Sagar PM, Tekkis PP, Dixon L, et al. The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg [Internet]. 2016 Aug 1;264(2):323–9. Available from: https://pubmed.ncbi.nlm.nih.gov/26692078/
