Surgical Management of Advanced Pelvic Cancer. Группа авторов

Asymptomatic S1 Symptomatic without pain S2 Symptomatic with pain Tumor fixation F0 No fixation F1 Fixation to one point F2 Fixation to two points F3 Fixation to more than two points Yamada Pattern of pelvic fixation Localized Invasion to adjacent pelvic organs/tissues Sacral invasive Invasion to lower sacrum (≥ S3), coccyx, periosteum Lateral invasive Invasion to sciatic nerve, greater sciatic notch, pelvic sidewall, upper sacrum (S1/2) Wanebo Stages TR1 Limited invasion of muscularis TR2 Full thickness invasion of muscularis propria TR3 Anastomotic recurrence penetrating beyond bowel wall into perirectal soft tissue TR4 Invasion into adjacent organs without fixation TR5 Invasion of bony/ligamentous pelvis Memorial Sloan Kettering Anatomic region Axial Anastomotic, mesorectal, perirectal soft tissue, perineum Anterior Genitourinary tract Posterior Sacrum and presacral fascia Lateral Soft tissues of the pelvic sidewall and lateral bony pelvis Royal Marsden Hospital Planes of dissection on MRI Central (Neo)rectum Intraluminal recurrence Perirectal fat or mesorectal, extraluminal recurrence PR Rectovesical pouch or recto‐uterine pouch of Douglas AA PR Ureters and iliac vessels above peritoneal reflection Sigmoid colon Small bowel Lateral sidewall fascia AB PR Genito‐urinary tract Lateral Ureters Iliac vessels distal to iliac bifurcation Lateral pelvic lymph nodes Sciatic nerve Sciatic notch S1/2 nerve roots Piriformis or obturator internus muscles Posterior Coccyx Presacral fascia Sacrum Retrosacral space Inferior Levator ani muscles External sphincter complex Perineal scar Ischio‐anal fossa

The second radiological reporting approach utilized by the authors of this chapter provides a roadmap for surgical excision, whereby a highly experienced radiologist reports a detailed and unambiguous roadmap for en‐bloc excision of the locally advanced cancer. Such a roadmap will be complemented by accurate exclusion of extrapelvic metastases and incorporate surgically relevant information such as significant coexisting pathology or findings which may challenge the surgical approach. In the authors’ experience, radiologists who personally review and examine patients and then communicate scan findings in the outpatient clinic, alongside their surgical and nursing colleagues, develop much greater insight into patient management and surgical approaches.

      The following principles may help guide radiologists to provide roadmaps for advanced pelvic cancer:

       The radiologically derived roadmap for R0 excision is generally tailored to the maximum disease extent identified on sequential MRI, even in the context of downstaging from neoadjuvant treatment. This principle is based on the knowledge that radiologically occult microscopic foci of viable tumor cells may persist beyond the downstaged tumor margins, (e.g. peritumoral scar tissue) which could lead to R1 resection if resection were based on post‐treatment imaging alone [38–43]. Consequently, fibrosis in direct contact with the tumor on post‐treatment imaging should be regarded as potential tumor extension and therefore incorporated in the planned surgical resection [38, 42,44–55].

       Each radiological roadmap is created by the radiology team in close co‐operation with the surgical team. The roadmap is tailored to the individual patient based on their anatomy, tumor extent, and comorbidity. The detailed description of excision planes and margins should be based on (distance to) intraoperatively assessable and fixed anatomical landmarks, including sacral promontory, ischial tuberosity, ischial spine, piriformis muscle, sacral foramina and nerve roots, sacral ligaments (sacrotuberous, sacrospinous, and ischiococcygeal), gluteal muscles, bifurcation of aorta/common iliac vessels, and origin of the superior gluteal artery (SGA). In practice, the authors of this chapter use the term SLAM (“sacral ligaments and muscle”) to describe the intimately related sacrotuberous, sacrospinous, and ischiococcygeus complex.

       “BONVUE” or “a good view” is a helpful acronym which can be used to remind the team to include a description of bones, organs, nerves, vessels, ureters, and extra (tumor sites).

The key feature of the roadmap approach is that, in contrast to traditional compartment‐based reporting, this system addresses the extent of involvement and resection of individual structures potentially at risk and/or which need to be resected in order to obtain an adequate margin. The structures that are systematically assessed to build the roadmap, with the corresponding surgical considerations, are listed in Table 3.2. For any given patient, a roadmap is constructed based on assessment of the relevant elements in Table 3.2 and their surgical counterparts, which, when combined together, form the definitive surgical strategy.

Case Study

      A 32‐year‐old female patient presented to her local hospital with a perforated PR‐bTME and underwent an emergency laparotomy and fashioning of a defunctioning colostomy prior to downsizing with a combination of radiotherapy and systemic chemotherapy. A diagnostic laparoscopy performed after completion of neoadjuvant treatment showed no evidence of peritoneal metastatic disease. T2‐weighted MRI was obtained prior to initiation of neoadjuvant therapy and to evaluate response approximately 12 weeks after completion of neoadjuvant treatment. A compartment‐based report from the referring unit using a published structure [37] is summarized as follows:

       Above peritoneal reflection: disease present at the level of the peritoneal reflection with likely compromise of the right ureter

       Below peritoneal reflection, anterior: suspected ovarian involvement with involvement of uterus and right adnexal