Survival after pelvic exenteration for T4 rectal cancer

Background: The purpose of this study was to analyse retrospectively the pooled results after pelvic exenteration for locally advanced T4 rectal cancer. Historically, patients with T4 rectal cancers requiring pelvic exenteration have been offered only palliative surgery or no operation. Methods: The basic treatment principle was preoperative (chemo)radiotherapy, radical surgery and, in some patients, adjuvant chemotherapy. Risk factors for local recurrence, distant metastases and overall survival were studied in univariable and multivariable analyses. Results: Ninety-five patients with T4 rectal cancer who underwent pelvic exenteration in two tertiary referral centres up to 2013 were studied. Clear margins (R0) were achieved in 87percent of patients. Adjuvant chemotherapy was administered in 33percent, independent of the resection margin, lymph node status and postoperative T category. The 5-year local recurrence rate was 17percent, with a distant metastasis rate of 16percent and overall survival rate of 62percent. In multivariable analysis the only factor associated with death was omission of adjuvant chemotherapy (P=0016). The effect of adjuvant chemotherapy was more pronounced in the elderly: patients aged over 70 years who had chemotherapy had a 5-year overall survival rate of 80percent, compared with 39percent of elderly patients who did not receive chemotherapy (P=0019). Conclusion: Pelvic exenteration led to an R0 resection rate of 87percent for T4 rectal cancer, giving good local control and overall survival comparable to population-based colorectal cancer survival rates. Adjuvant chemotherapy may improve overall survival further, even in the elderly.