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Sacral Resection With Pelvic Exenteration for Advanced Primary and Recurrent Pelvic Cancer: A Single-Institution Experience of 100 Sacrectomies.
Milne, Tony B.Sc., M.B.B.S. (Hons.) 1,2; Solomon, Michael J. M.B.B.C.H. (Hons.), M.Sc., F.R.A.C.S., F.R.C.S.I. 1,2,3; Lee, Peter M.B.B.S., B.Sc., F.R.A.C.S. 1,2; Young, Jane M. M.B.B.S., M.P.H, Ph.D., F.A.F.P.H.M. 1,4; Stalley, Paul M.B.B.S. (Hons.), F.R.A.C.S., F.A.Orth.A. 5; Harrison, James D. M.P.H., Ph.D. 1; Austin, Kirk K. S. B.Sc., A.F.R.C.S.I., F.R.A.C.S. 1,2
[Article] Diseases of the Colon & Rectum. 57(10):1153-1161, October 2014.

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BACKGROUND: Recurrent and advanced primary pelvic cancers present a complex clinical issue requiring multidisciplinary care and radical extended surgery. Sacral resection is necessary for tumors that invade posteriorly but is associated with increased morbidity and mortality.

OBJECTIVE: This study aimed to analyze the morbidity and survival associated with pelvic exenteration involving sacrectomy for advanced pelvic cancers at a single institution.

DESIGN: This study used patient demographics, operative and pathologic reports, and prospective survival data to determine factors affecting patient outcomes.

SETTINGS: Data were collected for patients who had operations between July 1998 and April 2012 at Royal Prince Alfred Hospital.

PATIENTS: One hundred patients underwent pelvic exenteration with a sacrectomy for advanced pelvic cancers. Sacrectomy was performed for 18 primary and 61 recurrent rectal cancers, 17 anal cancers, and 4 other cancers.

MAIN OUTCOME MEASURES: This study looked at postoperative major and minor morbidity rates, as well as disease-free and overall survival rates after sacral resection. It compared the outcomes of high sacrectomy (at or above S2) versus low sacrectomy.

RESULTS: Clear margins were achieved in 72 of 100 patients. The overall complication rate was 74% (43% major and 67% minor) with no 30-day or in-hospital mortality. Estimated overall and disease-free survival rates after curative resection were 38% and 30% at 5 years. Involved margins (p = 0.006), lymph node involvement (p = 0.008), and anterior organ invasion (p = 0.008) had a negative impact on patient survival. High sacrectomy increased the incidence of neurologic deficit postoperatively (p = 0.04) but did not alter the rate of R0 resection or patient survival.

LIMITATIONS: Retrospective data were required to analyze patient morbidity, as well as operative and pathologic factors.

CONCLUSIONS: This series supports sacral resection for curative surgery in advanced pelvic cancers, achieving excellent R0 and long-term survival rates. Cortical bone invasion and high sacrectomy were not contraindications to surgery and had acceptable outcomes.