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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic abdominosacral resection for locally advanced primary rectal cancer after treatment with mFOLFOX6 plus bevacizumab, followed by preoperative chemoradiotherapy Toshiya Nagasaki, Takashi Akiyoshi, Masashi Ueno, Yosuke Fukunaga, Satoshi Nagayama, Yoshiya Fujimoto, Tsuyoshi Konishi & Toshiharu Yamaguchi Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
Keywords Advanced rectal cancer; laparoscopic abdominosacral resection; laparoscopic surgery Correspondence Takashi Akiyoshi, Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. Tel: +81 3 3520 0111 Fax: +81 3 3520 0141 Email: [email protected] Received: 7 August 2013; revised 5 September 2013; accepted 9 September 2013
Abstract Abdominosacral resection may be the only curative procedure for locally advanced rectal cancer involving the presacral fascia or sacrum. Multimodal therapy might be necessary to prevent local and distant recurrence for such tumors. A 67-year-old man was diagnosed with locally advanced rectal cancer widely involving the right pelvic sidewall and presacral fascia near the S4/5 junction on the right posterolateral side. We performed laparoscopic abdominosacral resection (S4/5) with en bloc right lateral lymph node dissection and seminal vesicle resection to obtain a clear resection margin after systemic chemotherapy with mFOLFOX6 (oxaliplatin, leucovorin, and 5-fluorouracil) plus bevacizumab, followed by preoperative chemoradiotherapy. The total operative time was 660 min, and the estimated blood loss was 550 mL. The final pathological findings revealed no residual cancer cells (pathological complete response). Laparoscopic abdominosacral resection appears to be safe and feasible in selected patients.
DOI:10.1111/ases.12068
Introduction Laparoscopic surgery is an accepted treatment option for colorectal cancer. Indications for laparoscopic surgery for rectal cancer have gradually been extended as surgeons have gained experience and now include procedures such as total pelvic exenteration and abdominosacral resection (1,2). In locally advanced rectal cancer in which the tumor has infiltrated or is close to the sacrum, abdominosacral resection might be the only potentially curative treatment. However, surgery alone is sometimes inadequate for locally advanced, poor-risk rectal cancer classified as cT4 cancer or a tumor with a threatened circumferential resection margin. Recent studies have shown that induction systemic chemotherapy followed by conventional chemoradiotherapy (CRT) might be a promising strategy for poor-risk rectal cancer (3,4). Herein, we report our experience with laparoscopic
52
abdominosacral resection for locally advanced rectal cancer treated with systemic chemotherapy (mFOLFOX6 plus bevacizumab), followed by preoperative CRT.
Case Presentation A 67-year-old man was referred to the Cancer Institute Hospital (Tokyo, Japan) for anal pain. Digital examination revealed a fixed circumferential tumor 8 cm from the anal verge. Histopathological examination revealed a poorly differentiated adenocarcinoma. Initial CT and MRI showed an 8 × 6-cm tumor widely involving the right pelvic sidewall and presacral fascia near the S4/5 junction on the right posterolateral side (Figure 1a). There was no evidence of lymph node or distant metastasis. The patient was considered to have poor-risk disease, and our multidisciplinary team recommended systemic
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic abdominosacral resection
T Nagasaki et al.
Figure 1 Magnetic resonance images. (a) Before systemic chemotherapy, the tumor widely involved the right pelvic sidewall and presacral fascia on the right posterolateral side. (b) After systemic chemotherapy and chemoradiotherapy, the tumor was markedly reduced in size, but invasion to the right pelvic sidewall and presacral fascia remained.
chemotherapy. After laparoscopic construction of a sigmoid loop colostomy, the patient underwent six courses of mFOLFOX6 (oxaliplatin [85 mg/m2], leucovorin [200 mg/m2], and 5-fluorouracil [400 mg/m2 as a bolus and 2400 mg/m2 as a 46-h continuous infusion]) plus bevacizumab (5 mg/kg) every 2 weeks. After systemic chemotherapy, abdominal CT showed marked reduction in the tumor size to 5 × 3 cm, but invasion to the presacral fascia remained. Preoperative CRT was performed for local control. The patient underwent CRT using S-1 at a total dose of 50.4-Gy pelvic irradiation. MRI at the completion of CRT showed further reduction in the tumor size to 3 × 2.5 cm, but invasion to the right pelvic sidewall and presacral fascia still remained (Figure 1b). Thus, we planned laparoscopic abdominosacral resection (level S4/5) with en bloc right lateral lymph node dissection and seminal vesicle resection to obtain a safe resection margin. The patient was placed in the lithotomy position under general and epidural anesthesia. Ports were placed as follows: a 12-mm port at the umbilicus for a scope, 12-mm ports at the lower right and left quadrants, and 5-mm ports at the upper right and left abdominal quadrants. Medial-to-lateral retroperitoneal dissection was performed, and the root of the inferior mesenteric artery was divided. After resection of the mesentery of the sigmoid colon, the sigmoid colon was transected with
a linear stapler in immediate proximity to the sigmoidostomy. For dissection of the mesorectum, the left side was dissected at the layer of total mesorectal excision, with preservation of the autonomic nerves, and down to the level of the levator ani muscle. On the right side, the external iliac artery and vein were exposed as the lateral border of dissection. The right hypogastric nerve was divided, and the pelvic plexus was resected with the tumor. The obturator nerve was preserved. The umbilical artery, obturator vessels, and main trunk of the internal iliac artery were divided. The distal internal iliac artery was divided at the entry point to Alcock’s canal. The right vas deferens was divided peripherally, and the dissection was performed on the ventral side of the right seminal vesicle. The vas deferens and seminal vesicle were divided near the beginning of the ejaculatory duct. The neurovascular bundle was divided on the right side of the seminal vesicle. Thus, dissection of the left and anterior side of the rectum was performed sufficiently down to the pelvic floor, leaving the right posterior compartment. Next, we configured the resection line of the sacrum, which sloped down to the left from the right edge of S4/5. Above the edge of S4/5, we divided the inferior vesical vein and the internal iliac vein, exposing the right sacral plexus. We incised the presacral fascia with the presacral venous plexuses through the desired resection line and exposed the surface of the sacrum
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
53
Laparoscopic abdominosacral resection
T Nagasaki et al.
Figure 2 Laparoscopic view of the resection line of the sacrum (arrows). The right sacral plexus was exposed, and the presacral fascia was incised to expose the surface of the sacrum.
(Figure 2). Bleeding from the venous plexus was stopped with electric cautery and by packing absorbable hemostat. For the sacrectomy, the patient was placed in the jackknife position. After closure of the anus, the skin was incised around the anus and the cut was elongated toward the sacral bone. The gluteus maximus muscles were dissected away from the sacral attachments. The sacrospinous and sacrotuberous ligaments were divided to access the pelvic cavity posteriorly. A surgeon’s finger could then be placed into the presacral space above the tumor to confirm the level of sacral division. An oblique sacral osteotomy was performed using the surgeon’s finger as the indicator of the desired resection line, which was configured at the laparoscopic abdominal phase (Figure 3). The entire specimen was removed en bloc through the sacral incision (Figure 4). The perineal wound and defect were closed primarily. The patient’s was returned to the lithotomy position, and intraperitoneal hemostasis was confirmed. The total operative time was 660 min, and the estimated blood loss was 550 mL. There were no intraoperative or postoperative complications, and the patient was discharged on postoperative day 19. The pathological findings of the surgical specimens revealed no residual cancer cells or lymph node metastasis (pathological complete response). Five days after his initial discharge, the patient was rehospitalized for treatment of the ileus, perineal wound infection, and sacral osteomyelitis, but con-
54
Figure 3 Laparoscopic view after the completion of abdominosacral resection with en bloc right lateral lymph node dissection and right seminal vesicle resection. The white dotted line indicates the resection line of the sacrum. White arrows indicate cut end of the (A) umbilical artery, (B) proximal internal iliac artery, (C) distal internal iliac artery, (D) inferior vesical vein, and (E) internal iliac vein. Eia, external iliac artery; Eiv: external iliac vein; Iia, internal iliac artery; Ur, ureter.
servative treatment was successful. Five months after abdominosacral resection, he had mild postoperative voiding dysfunction that required medication as well as erectile dysfunction.
Discussion When locally advanced rectal cancer involves the sacrum or presacral fascia, the only curative operation is en bloc
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic abdominosacral resection
T Nagasaki et al.
reports of open abdominosacral resection for locally advanced primary rectal cancer (6,7). In conclusion, laparoscopic abdominosacral resection is feasible for locally advanced primary rectal cancer after neoadjuvant therapy in selected patients.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References
Figure 4 Resected specimen.
resection of the sacrum. However, reports on laparoscopic abdominosacral resection are very limited (2,5). Laparoscopic surgery has some advantages over open surgery, including less postoperative pain, less blood loss, and good visualization. The present tumor involved not only the presacral fascia, but also the right pelvic sidewall, and we performed en bloc right lateral lymph node dissection and right seminal vesicle resection. Lateral lymph node dissection might not be necessary because there was no suspicious lateral lymph node metastasis. However, to avoid the unintentional injury of important structures such as the obturator nerve, we decided to expose the entire anatomical landmark in the lateral pelvic area for safety. Under clear visualization, we sufficiently mobilized the rectum down to the pelvic floor, leaving the right posterior compartment, and sacrectomy was easily performed in the perineal phase. Thus, the estimated blood loss was less than that in previous
1. Mukai T, Akiyoshi T, Ueno M et al. Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer. Asian J Endosc Surg 2013; 6: 314–317. 2. Williams GL, Gonsalves S, Bandyopadhyay D et al. Laparoscopic abdominosacral composite resection for locally advanced primary rectal cancer. Tech Coloproctol 2008; 12: 299–302. 3. Willett CG, Duda DG, Czito BG et al. Targeted therapy in rectal cancer. Oncology (Williston Park) 2007; 21: 1055–1065. 4. Emmanouilides C, Sfakiotaki G, Androulakis N et al. Frontline bevacizumab in combination with oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX) in patients with metastatic colorectal cancer: A multicenter phase II study. BMC Cancer 2007; 7: 91. 5. Lengyel J, Sagar PM, Morrison C et al. Multimedia article. Laparoscopic abdominosacral composite resection. Dis Colon Rectum 2009; 52: 1662–1664. 6. Bhangu A, Brown G, Akmal M et al. Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer. Br J Surg 2012; 99: 1453–1461. 7. Ferenschild FTJ, Vermaas M, Verhoef C et al. Abdominosacral resection for locally advanced and recurrent rectal cancer. Br J Surg 2009; 96: 1341–1347.
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
55
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic abdominosacral resection for locally advanced primary rectal cancer after treatment with mFOLFOX6 plus bevacizumab, followed by preoperative chemoradiotherapy Toshiya Nagasaki, Takashi Akiyoshi, Masashi Ueno, Yosuke Fukunaga, Satoshi Nagayama, Yoshiya Fujimoto, Tsuyoshi Konishi & Toshiharu Yamaguchi Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
Keywords Advanced rectal cancer; laparoscopic abdominosacral resection; laparoscopic surgery Correspondence Takashi Akiyoshi, Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan. Tel: +81 3 3520 0111 Fax: +81 3 3520 0141 Email: [email protected] Received: 7 August 2013; revised 5 September 2013; accepted 9 September 2013
Abstract Abdominosacral resection may be the only curative procedure for locally advanced rectal cancer involving the presacral fascia or sacrum. Multimodal therapy might be necessary to prevent local and distant recurrence for such tumors. A 67-year-old man was diagnosed with locally advanced rectal cancer widely involving the right pelvic sidewall and presacral fascia near the S4/5 junction on the right posterolateral side. We performed laparoscopic abdominosacral resection (S4/5) with en bloc right lateral lymph node dissection and seminal vesicle resection to obtain a clear resection margin after systemic chemotherapy with mFOLFOX6 (oxaliplatin, leucovorin, and 5-fluorouracil) plus bevacizumab, followed by preoperative chemoradiotherapy. The total operative time was 660 min, and the estimated blood loss was 550 mL. The final pathological findings revealed no residual cancer cells (pathological complete response). Laparoscopic abdominosacral resection appears to be safe and feasible in selected patients.
DOI:10.1111/ases.12068
Introduction Laparoscopic surgery is an accepted treatment option for colorectal cancer. Indications for laparoscopic surgery for rectal cancer have gradually been extended as surgeons have gained experience and now include procedures such as total pelvic exenteration and abdominosacral resection (1,2). In locally advanced rectal cancer in which the tumor has infiltrated or is close to the sacrum, abdominosacral resection might be the only potentially curative treatment. However, surgery alone is sometimes inadequate for locally advanced, poor-risk rectal cancer classified as cT4 cancer or a tumor with a threatened circumferential resection margin. Recent studies have shown that induction systemic chemotherapy followed by conventional chemoradiotherapy (CRT) might be a promising strategy for poor-risk rectal cancer (3,4). Herein, we report our experience with laparoscopic
52
abdominosacral resection for locally advanced rectal cancer treated with systemic chemotherapy (mFOLFOX6 plus bevacizumab), followed by preoperative CRT.
Case Presentation A 67-year-old man was referred to the Cancer Institute Hospital (Tokyo, Japan) for anal pain. Digital examination revealed a fixed circumferential tumor 8 cm from the anal verge. Histopathological examination revealed a poorly differentiated adenocarcinoma. Initial CT and MRI showed an 8 × 6-cm tumor widely involving the right pelvic sidewall and presacral fascia near the S4/5 junction on the right posterolateral side (Figure 1a). There was no evidence of lymph node or distant metastasis. The patient was considered to have poor-risk disease, and our multidisciplinary team recommended systemic
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic abdominosacral resection
T Nagasaki et al.
Figure 1 Magnetic resonance images. (a) Before systemic chemotherapy, the tumor widely involved the right pelvic sidewall and presacral fascia on the right posterolateral side. (b) After systemic chemotherapy and chemoradiotherapy, the tumor was markedly reduced in size, but invasion to the right pelvic sidewall and presacral fascia remained.
chemotherapy. After laparoscopic construction of a sigmoid loop colostomy, the patient underwent six courses of mFOLFOX6 (oxaliplatin [85 mg/m2], leucovorin [200 mg/m2], and 5-fluorouracil [400 mg/m2 as a bolus and 2400 mg/m2 as a 46-h continuous infusion]) plus bevacizumab (5 mg/kg) every 2 weeks. After systemic chemotherapy, abdominal CT showed marked reduction in the tumor size to 5 × 3 cm, but invasion to the presacral fascia remained. Preoperative CRT was performed for local control. The patient underwent CRT using S-1 at a total dose of 50.4-Gy pelvic irradiation. MRI at the completion of CRT showed further reduction in the tumor size to 3 × 2.5 cm, but invasion to the right pelvic sidewall and presacral fascia still remained (Figure 1b). Thus, we planned laparoscopic abdominosacral resection (level S4/5) with en bloc right lateral lymph node dissection and seminal vesicle resection to obtain a safe resection margin. The patient was placed in the lithotomy position under general and epidural anesthesia. Ports were placed as follows: a 12-mm port at the umbilicus for a scope, 12-mm ports at the lower right and left quadrants, and 5-mm ports at the upper right and left abdominal quadrants. Medial-to-lateral retroperitoneal dissection was performed, and the root of the inferior mesenteric artery was divided. After resection of the mesentery of the sigmoid colon, the sigmoid colon was transected with
a linear stapler in immediate proximity to the sigmoidostomy. For dissection of the mesorectum, the left side was dissected at the layer of total mesorectal excision, with preservation of the autonomic nerves, and down to the level of the levator ani muscle. On the right side, the external iliac artery and vein were exposed as the lateral border of dissection. The right hypogastric nerve was divided, and the pelvic plexus was resected with the tumor. The obturator nerve was preserved. The umbilical artery, obturator vessels, and main trunk of the internal iliac artery were divided. The distal internal iliac artery was divided at the entry point to Alcock’s canal. The right vas deferens was divided peripherally, and the dissection was performed on the ventral side of the right seminal vesicle. The vas deferens and seminal vesicle were divided near the beginning of the ejaculatory duct. The neurovascular bundle was divided on the right side of the seminal vesicle. Thus, dissection of the left and anterior side of the rectum was performed sufficiently down to the pelvic floor, leaving the right posterior compartment. Next, we configured the resection line of the sacrum, which sloped down to the left from the right edge of S4/5. Above the edge of S4/5, we divided the inferior vesical vein and the internal iliac vein, exposing the right sacral plexus. We incised the presacral fascia with the presacral venous plexuses through the desired resection line and exposed the surface of the sacrum
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
53
Laparoscopic abdominosacral resection
T Nagasaki et al.
Figure 2 Laparoscopic view of the resection line of the sacrum (arrows). The right sacral plexus was exposed, and the presacral fascia was incised to expose the surface of the sacrum.
(Figure 2). Bleeding from the venous plexus was stopped with electric cautery and by packing absorbable hemostat. For the sacrectomy, the patient was placed in the jackknife position. After closure of the anus, the skin was incised around the anus and the cut was elongated toward the sacral bone. The gluteus maximus muscles were dissected away from the sacral attachments. The sacrospinous and sacrotuberous ligaments were divided to access the pelvic cavity posteriorly. A surgeon’s finger could then be placed into the presacral space above the tumor to confirm the level of sacral division. An oblique sacral osteotomy was performed using the surgeon’s finger as the indicator of the desired resection line, which was configured at the laparoscopic abdominal phase (Figure 3). The entire specimen was removed en bloc through the sacral incision (Figure 4). The perineal wound and defect were closed primarily. The patient’s was returned to the lithotomy position, and intraperitoneal hemostasis was confirmed. The total operative time was 660 min, and the estimated blood loss was 550 mL. There were no intraoperative or postoperative complications, and the patient was discharged on postoperative day 19. The pathological findings of the surgical specimens revealed no residual cancer cells or lymph node metastasis (pathological complete response). Five days after his initial discharge, the patient was rehospitalized for treatment of the ileus, perineal wound infection, and sacral osteomyelitis, but con-
54
Figure 3 Laparoscopic view after the completion of abdominosacral resection with en bloc right lateral lymph node dissection and right seminal vesicle resection. The white dotted line indicates the resection line of the sacrum. White arrows indicate cut end of the (A) umbilical artery, (B) proximal internal iliac artery, (C) distal internal iliac artery, (D) inferior vesical vein, and (E) internal iliac vein. Eia, external iliac artery; Eiv: external iliac vein; Iia, internal iliac artery; Ur, ureter.
servative treatment was successful. Five months after abdominosacral resection, he had mild postoperative voiding dysfunction that required medication as well as erectile dysfunction.
Discussion When locally advanced rectal cancer involves the sacrum or presacral fascia, the only curative operation is en bloc
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Laparoscopic abdominosacral resection
T Nagasaki et al.
reports of open abdominosacral resection for locally advanced primary rectal cancer (6,7). In conclusion, laparoscopic abdominosacral resection is feasible for locally advanced primary rectal cancer after neoadjuvant therapy in selected patients.
Acknowledgment The authors have no conflicts of interest or financial ties to disclose.
References
Figure 4 Resected specimen.
resection of the sacrum. However, reports on laparoscopic abdominosacral resection are very limited (2,5). Laparoscopic surgery has some advantages over open surgery, including less postoperative pain, less blood loss, and good visualization. The present tumor involved not only the presacral fascia, but also the right pelvic sidewall, and we performed en bloc right lateral lymph node dissection and right seminal vesicle resection. Lateral lymph node dissection might not be necessary because there was no suspicious lateral lymph node metastasis. However, to avoid the unintentional injury of important structures such as the obturator nerve, we decided to expose the entire anatomical landmark in the lateral pelvic area for safety. Under clear visualization, we sufficiently mobilized the rectum down to the pelvic floor, leaving the right posterior compartment, and sacrectomy was easily performed in the perineal phase. Thus, the estimated blood loss was less than that in previous
1. Mukai T, Akiyoshi T, Ueno M et al. Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer. Asian J Endosc Surg 2013; 6: 314–317. 2. Williams GL, Gonsalves S, Bandyopadhyay D et al. Laparoscopic abdominosacral composite resection for locally advanced primary rectal cancer. Tech Coloproctol 2008; 12: 299–302. 3. Willett CG, Duda DG, Czito BG et al. Targeted therapy in rectal cancer. Oncology (Williston Park) 2007; 21: 1055–1065. 4. Emmanouilides C, Sfakiotaki G, Androulakis N et al. Frontline bevacizumab in combination with oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX) in patients with metastatic colorectal cancer: A multicenter phase II study. BMC Cancer 2007; 7: 91. 5. Lengyel J, Sagar PM, Morrison C et al. Multimedia article. Laparoscopic abdominosacral composite resection. Dis Colon Rectum 2009; 52: 1662–1664. 6. Bhangu A, Brown G, Akmal M et al. Outcome of abdominosacral resection for locally advanced primary and recurrent rectal cancer. Br J Surg 2012; 99: 1453–1461. 7. Ferenschild FTJ, Vermaas M, Verhoef C et al. Abdominosacral resection for locally advanced and recurrent rectal cancer. Br J Surg 2009; 96: 1341–1347.
Asian J Endosc Surg 7 (2014) 52–55 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
55
