Oligometastatic Disease Is Not an Absolute Contraindication to Pelvic Exenteration in Selected Patients With Locally Recurrent Rectal Cancer.

Background: The treatment of locally recurrent rectal cancer has evolved dramatically in recent decades. As the boundaries of exenterative surgery continue to be pushed, one of the unanswered and controversial questions is the role of radical salvage surgery for locally recurrent rectal cancer in the setting of oligometastatic disease.

Objective: To investigate the impact of synchronous or previously treated distant metastases on survival following pelvic exenteration for locally recurrent rectal cancer.

Design: Retrospective analysis of a prospectively maintained database.

Settings: A high-volume specialist exenteration center.

Patients: Consecutive adult patients undergoing pelvic exenteration with curative intent for locally recurrent rectal cancer between 1994 and 2023.

Main outcome measures: Overall survival from time of pelvic exenteration.

Results: Of the 300 patients included, 193 (64%) were male and the median age was 62 years (range, 29-86). Median time from primary rectal cancer surgery to pelvic exenteration was 35 months (range, 4-191). In total, 56 patients (19%) had a history of metastatic disease; of which 42 (14%) had previously treated metastases and 18 patients (6%) had synchronous metastatic disease (including 4 patients with both synchronous and previously treated metastases). Five-year and median overall survival was 41% and 45 months, respectively. There was a trend toward poorer 5-year overall survival in patients with a history of metastatic disease compared to those without (25% vs 45%); however, this did not reach statistical significance (p = 0.110), possibly due to lack of statistical power. Five-year overall survival was 27%, 25% and 45% for patients with synchronous metastases, previously treated metastases, and no history of metastases, respectively (p = 0.260).

Limitations: Findings may not be applicable beyond highly selected patients treated at specialized exenteration centers.

Conclusions: Long-term survival is achievable in highly selected patients with locally recurrent rectal cancer and synchronous or previously treated distant metastases. Therefore, oligometastatic disease should not be considered an absolute contraindication to exenterative surgery. See Video Abstract.