Surgical Management of Advanced Pelvic Cancer. Группа авторов

       Dennis P. Schaap1, Joost Nederend2, Harm J.T. Rutten1, and Jacobus W.A. Burger1

       1 Department of Surgery, Catharina Hospital Eindhoven, The Netherlands

       2 Department of Radiology, Catharina Hospital Eindhoven, The Netherlands

Background

      Multidisciplinary team meetings (MDTMs) have been implemented to deal with the complexity of cancer care [1]. The aim of these meetings is to provide a structured discussion platform to plan patient care [2–7]. The goal is to benefit from the collective knowledge of all specialties in order to optimize staging, treatment, and follow‐up. Furthermore, it can facilitate assessment for patients’ inclusion in clinical trials.

      The organization of the MDTM is time consuming and comes with costs. Delaying decisions until the MDTM has taken place can sometimes delay treatment. MDTM results in a significant change in diagnosis or treatment planning, ranging from 18.5 to 36% and 11.0 to 14.5% respectively [8–14].The role of adequate preoperative tumor staging and discussion in an MDTM resulted in more patients receiving neoadjuvant treatment, increased local control, and R0 resections [15].

The governing body for the quality of care for patients with cancer in the Netherlands is the Stichting voor Oncologische Samenwerking (Foundation for Oncological Collaboration, SONCOS) [16]. SONCOS represents 29 national societies involved in cancer care, including the Society for Medical Oncology, the Society of Surgical Oncology, and the Society of Radiation Oncology. SONCOS delivers a yearly report stating the conditions that must be fulfilled by any multidisciplinary team caring for cancer patients. Dutch physicians are obliged to adhere to these conditions. Furthermore, all Dutch medical centers have agreed to standardize data registry with a national database to monitor the effect of changes in treatment strategy on quality measurements as shown in Figure 2.1. Hence, factors improving the quality of care can be identified and applied easily in order to improve patient outcome. MDTMs across the Netherlands can deal with the majority of patients with pelvic cancer from gastroenterological, urological, or gynecological origin. However, patients with locally advanced and recurrent pelvic cancer should be discussed in a specialized MDTM [16].

Complex Pelvic Cancer MDTM

Patients with locally advanced primary and recurrent pelvic cancers are associated with a higher risk of local recurrence, distant metastases, and poor survival. Furthermore, these complex pelvic tumors require several specialties for an accurate preoperative evaluation, neoadjuvant and/or adjuvant therapy with a multidisciplinary surgical approach, (Table 2.1). Preoperative treatments providing downstaging are essential to both increase the chance of radical resections and prevent unnecessarily extensive resections that lead to impairment. Centralization is warranted, to identify those patients who require this specialized care.

Figure 2.1 National registries help to monitor outcome. In this control chart for proportions, a decrease in R+ resection rate seems to be statistically significant and leads to differences in the mean R+ resection rate. This moment (referred to as ‘out of control’) coincides with the change of preoperative treatment in locally recurrent pelvic cancer patients (unpublished data). CL, Control limit; UCL, upper control limit.

      In order to work toward a situation in which all patients with locally advanced cancers are discussed in a complex cancer MDTM, it is essential that it is easily accessible for physicians outside the specialized center.

Staging, Restaging, and Pathological Assessment

      Staging

      Radiologic assessment of local and distant disease in the setting of advanced pelvic cancer can be challenging. Therefore all diagnostic imaging is assessed by radiologists and nuclear medicine physicians with specific expertise in cancer imaging prior to the MDTM. An expert radiologist familiar with surgical principles may anticipate the expected organ involvement. Regular contact in the oncological network ensures that referring hospitals know which scan sequences and modalities that are required.

Table 2.1 Differences between hospitals caring for “regular” colorectal cancer patients and hospitals caring for locally advanced and recurrent pelvic cancer patients (Example from The Netherlands).

Regular care for colorectal cancer	Specialized pelvic cancer care
Consultants with special interest in colorectal cancer	Consultants with special interest in locally advanced and pelvic cancer
Two radiologists	Two radiologists with verifiable expertise in evaluation of locally advanced and recurrent pelvic cancer, before and after neoadjuvant treatment
Two surgeons	Two surgeons with verifiable technical expertise in treatment of locally advanced and recurrent pelvic cancer. At least one surgeon with expertise in treatment of stage 4 colorectal cancer
One pathologist	Pathologist with specific expertise in evaluation of specimens of the pelvis and effects of neoadjuvant therapy
One radiation oncologist	Radiation oncologist with expertise in treatment of locally advanced and recurrent pelvic cancer. Expertise in IORT = Intra‐operative radiotherapy
One medical oncologist	Medical oncologist with specific expertise in curative treatment of patients with locally advanced and recurrent pelvic cancer
	Extra: Oncological urologist with expertise in urinary deviation
	Extra: Oncological gynecologist with expertise in postoperative care and recovery
	Extra: plastic and reconstructive surgeon with expertise in reconstruction of large oncological defects
24/7 intervention radiology	Experience with acquiring tissue from the pelvis and placing drains in the pelvis, including transgluteal approaches
Stomatherapy nurse clinic	Stomatherapy nurse experienced in care of urinary stoma
protocol for referral for IORT	Provides IORT
MDTM operates according to national guideline	MDTM discusses many patients that cannot be treated according to national guideline
Includes all patients in Dutch Surgical Colorectal Audit (DSCA)	Includes only T4 in audit. Registers all patients in prospective databases, compares with other T4/locally recurrent rectal cancer (LRRC) centers, and publishes results

      Restaging