Perineal Recurrence after Abdominoperineal of Carcinoma of the Rectum *

W . X,V. GREEN, M.D., 1"V, A. B L A N K , M.D. Toledo, Ohio

Resection

MANAGEMENT Of perineal recurrence after abdominoperineat resection of carcinoma of the rectmn, is a problem which inevitably confronts the surgeon who deals with cancer of the terminal portion of the colon and rectmn. Although a small percentage of these patients can be salvaged, treatment of the majority consists of palliation. It is the surgeon's responsibility to evaluate the extent of the recurrence and to work closely with the family physician and others who can contribute to the care of these unfor- tunate patients. 'At no time s!~ould the patient be permitted to feel that he is being abandoned by the surgeon who performed the initial operation. He should not be referred from one specialist to another as a means of avoiding an unpleasant respon- sibility.

Since most of these patients will not get well, the surgeon must devote carel'ul thought to planning therapy that will be in their best interests. He should not be- come unduly influenced by what possibly might be accomplished by a purely tech- nical procedure. Those who are responsible for the care of these patients should heed the admonition of Schulz, z who believed that as physicians we must neither deny the right of man to die or to live.

The records of our patients who had perineal recurrences were reviewed because of our dissatisfaction with the rather ha!> hazard treatment 1hat haci been given. ~'~ "" s. Fits

report is not based upon a mere review o[

Read at the meeting of the American Procto- logic Society Miami Beach, Florida, April 30 to May 3, 1962.

125

statistics, but upon a very careful appraisal of personal experiences with these unfor- tunate persons during their period of su6 [ering, frustration and fear. At the outset it became apparent that we would be deal- ing with matters of an intimate nature such as the personality o[ the patient and his ability to tolerate minor discomfort or en- dure severe pain. On account o[ its philo- sophic overtones, and because it deals with subjective characteristics and experiences of the patient, this presentation cannot be considered a stricth' scientific treatise.

The early signs of perineal recurrence are vague and difficult to evah,.ate. The earliest symptom most frequently mentioned is a dull ache, affecting the legs or the peri- neum and sometimes both. The perineal discomfort is usually aggravated by pro- longed sitting. An incident that should arouse suspicion of recurrence is delayed healing of the perineal wound. 4 We have placed the burden of responsibility for follow-up examination upon the patient, asking him to return at regular yearly in- tervals, or earlier, if he should become aware of symptoms after the perineal wound had healed. This study has con- vinced us of the importance of establishing a vigorous and strict plan o[ follow-up examinations similar to that proposed by Bacon and Berkley3

As we have h~dicated, d:e outlook f'or

patients with perineal recurrence is poor. In our group of 25 patients, there are only two (8.0 per cent) whom we believe to be free o[ cancer. The remainder (99 per cent) could only look forward to eventual death°

126 GREEN AND BLANK

These pat ients deserve and merit sympa- thetic Understanding. Trea tmen t must be based upon providing comfort and meeting' psychologic needs, instead of devoting all attention merely to prolonging what, in the majority of instances, is a miseraMe existence.

Survey of Patients

The 25 patients whose records we have reviewed comprised approximately t0 per cent of 242 patients upon whom we have performed abdominoperinea! operations for carcinoma of die rectum and rectosig- mold. This is a higi~er rate than was re- corded by McDonald and Wiiliamson,S who reported recurrence in only seven (6 8 per cent) of 103 patients. This limited sta- t!stical analysis will empl~asize points that are pertinent to the recognition and man- agement of the condition.

The youngest pat ient was 96 years o:hl anti the oldest was 75 with an average age 0[ 5'3 years:.: T h e comparative youth of most of the patients indicated that recurrence was likely to occur and the ratio of men to women was ] .5: 1.

"vVith the :exception Of one squamous cell carcinoma, all of the tumors were adenocar- cinomas. According to Dukes! classification, two of the original tumors were graded A seven were B and 16 were C. T h e ma.}oritv of these recurrences followed removal of tumors of the type in which the prognosis was poor when t:he patient ,was first en- countered. After the initial abdominoperi- neal resection, the earliest recurrence was recognized after three months:and the latest after an elapse of seven and one half years with an average of 17 months. In the two patients wl~o are living and well, the first evidence~ after .:he ~..;o.: , 7 o~ ~ a~ operation, == 04

perineal recurrence occurred after f0=Ur years and seven months in one patient and after seven ::and one half years in the other. This emphasizes the observation made =by Dunphy s that t he longer the interval be-

tween the initial resection and the recur° rence, the better the prognosis.

Th e average interval between recogni- tion of the recurrence and death was 20 months in the 15= patients known to be dead. One :=patient was lost to foiiow tip and of nine still living, only two can be considered to be free of cancer~

Conventional a n d accepted types of treatment were employed for these patients and Several underwent two or more kinds of therapy; no chemotherapy was employed~ Two patients, at their insistence, were given Krebiozen, whic:h had n o demonstrable effect on the course of the disease; this the> apy was administered in addit ion to the accep:ted forms of treatment° Ali but two of the patients required narcotics; of these, eight were kept fairly comfortable by ad- ministering narcotics alone. Irradiation, either with 200 KV or cobalt, was employed in tei~ patients; seven underwent local resec- tion ',eft the re¢:urreut tumor; [our ,,had cordotomy and three received intrathecal injections. All forms of t reatment were utilized primari!y for the control of pain and :ihe resuhs will be dis:cussed latex" in this paper.

Only four patients, including the two previously inenti0ned as now free of disease, lived=as long as efive years after the initial

:

operatfon. T h e others who are still living alld suffering wit!i recurrent cancer will undo:ubtedly die before they have reached the five-year limit.

Methods of Relieving Pain

Narcotics: \Vid~ the exception of the two 7 " , patients who ila~i n o ( ~sc:om!o~t, a~a]gesics

and narcotics, in various forms and strengths and give~ at w~rions sciges of the i!haess, we_re empl.oy, ed to p~ovhle corn_fort. Even al:ter relief= from severe pain had keen provided, narcotics of various strengths were frequently required to control discomfort that =had persisted. Some patients h a d be- come addicted tO the drug and ottlers, aibter

PERINEAL RECURRENCE OF CARCINOMA OF THE RECTUM 127

the severe pain had been relieved, had a low tolerance for the vague discomfort that persisted. This observation raises the point that it might b e better to employ definitive t reatment for the relief of pain before the pat ient has become addicted to the use of narcotics, ra ther than defer such treatment until the narcotics are no longer effective.

Bonica 2 established three fundamental principles for the use of narcotics. A spe- cific drug should be chosen for a specific indication instead of prescribing indis- criminately all drugs classed as narcotics. T h e smallest amount of the drug required for the desired effect should be given; some- times in our desire to provide comfort for these unfor tunate individuals we are prone to give excessive doses. T h e chosen drug should be administered by the opt imal route, provqded it. can be adapted to the home care of the Fatient and administered by a member of his family. Bonica believes that the highest degq:ee of physican-patient relat ionship is a potent factor in enhancing the effect of this type of management . Many of :these patients, knowing that their pain is caused by an incurable condition, will not use the drug as frequently as they should because of their fear of addiction.

Irradiation: Of ten patients who received irradiation, three were treated by deep x-ray and seven by cobalt 6. There were two pa- tients who received .two courses of irradia- tion, ahhough the treatment was not com- pleted in either. A third patient had three courses of cobalt therapy and was relieved of pain after each. T h e third course was given because the recurrent tumor h a d broken through the per ineum and pre- vented the patient from sitting comfortably. After the last course, the entire per ineum sloughed and comp!ica~ed the terminai care. This emphasizes the point made by ~VVise and Smedel s that repeated t reatment of the same a r ea should be given for pain of great severity and only as a last resort.

Satisfactory relief from pain was obtained in mOSt of these patients and lasted for a period varying from two to eight months, or an average of three months° This is a shorter period than the four-and-one-half- month average reported by ~Nise and Smedel. In the majori ty of these patients, there was a demonstrable temporary regres- sion in the size of the tumor. This fact leads us to speculate that reduction in the size of the recurrent tumor was a factor responsible for the relief of pain.

Radia t ion sickness was a complication that was anticipated and it occurred in a few of out-pat ients . However, we believe that the benefit derived f rom treatment overshadowed this side effect. Although relief from pain was of comparat ively short durat ion in most patients, we believe that the results warrant its continued ttse. T h e fact that the pat ients knew that they were not being abandoned and that something was being done in an a t tempt to help them cannot be i ~ o r e d .

Local Excision: This procedure was car- ried out on six patients, and the two pa- tients who are l iving and apparent ly free of cancer belonged in this group.

In four patients who had pain, relief of varying degrees was provided and lasted from two to four months. T h e relief from pain p rov ided by this form of t reatment alone was not as effective as that obtained by' irradiation. One exception was noted in a patient who had complete relief from pain for eight months, but in his case the surgical resection was followed in a few weeks by cobalt therapy.

No serious complicat ion resuhed from perineat resection, atthougl~ it was followed in one pat ient by acute epididymitis.

Apparent ly perinea:t excision affords the best o p p o r t u n h y ~o rid the patient o_~ can- cer if the recurrence occurred near the surface and was well localized, t t helps establish the diagnosis where it is in doubt and by diminishing tire size of an inoper-

128 GREEN AND BLANK

able lesion, it affords temporary relief from pain.

Cordotomy: Cordotomy was done on four patients because of severe and constant pain. No relief was obta ined in one, prob- ably because of an inadequate operation. In two patients the cordotomy had to be repeated before a satisfactory result was obtained. Only one of these, who had what could be considered a satisfactory result, had complete relief from pa 'n . The re- maining two continued to have mild peri- neal discomfort requir ing cont inued use of narcotics, but in amounts less than had been required prior to the operation. None of these patients had postcordotomy blad- der disturbance, but all three who obtained relief from pain had an associated weakness in their legs, one having complete paralysis of one extremity.

ln t ra thecal Injections: Th ree patients were given intrffthecat injections of absolute alcohol or phenol in glycerin for the con- trol o£ pain. T h e period of reIief varied from two weeks to three months and re- peated in~ections were required. T h e period of effectiveness was less than the variation from two weeks to a year or more reported by Perese,S using subarachnoid alcohol block. Leg weakness occurred in two of these three patients and all devel- oped urinary retention, requir ing an in- dwelling catheter. However, it should be noted that the tumor had already invaded the bIadder in two of the patients who develope d retention. Bonica stated that in terrupt ion of the nerve pathways is a useful procedure when the lesion cannot be contro!led :by palliative resection or by cobalt therapy'. From our very l imited ex- perience, we are inc!ined t o believe that intratheca! injections compared favorab!y with irradiation in the relief of pain and required tess time and energy of the debili- tated patient. Results after cordotomy were not appreciably different from those obtained by intrathecal injection, tntra-

thecat injection is a tess formidable proce- dure than cordotomy and can be repeated with ease. i t also has the advantage of permit t ing the use of a test dose to deter- mine the proper location for the injection.

Survival Following Perineal Resection

Some comment shoukl be made concern- hlg the two women who have survived after removal of a perineal recurrence and are apparent ly free of disease. In one, whose tumor was classified as Dukes ' type B, the first recurrence was noted four and one half years after the initial operation. FOto lowing perineal excision of the lesion, the tumor recurred twice within a period of t!aree }'ears. A resection was done each time and the last procedure was augmented by 200 KV x-ray therapy because of what was thought to be incomplete removal of" all tumor tissue. This pa t ient is alive and apparent ly free of disease 20 years after the initial operat ion and t5 years after the third and last resection that was fotlowed by irradiation. T h e other patient, whose original tumor was Dukes' type A, had a recurrence seven and one ha l f years after initial abdominoper ineal resection. T h e recurrent lesion was removed by local exci- sion in March 196l and there was no evi- dence of malignancy when the patient was last examined.

T h e well-localized, superficial and acces- sible nature ot7 th.ese lesions, as well as the absence of discomfort in bo th patients, con- trasts sharply with the firmly implanted and infiltrated tumors that produced discomfort and pain in the ma jo r i ty of patients. In these two patients, we believe we were dea!- ing with lesions unlike those usually found in recurrent perine~l carcinoma and that ~hey may have been cav~s.ed by seeding. IK dais view is correct, it would emphasize the point made by M c D o n a M and Will iamson that when the perineal recurrence is due to impiantat ion, ra ther than to incompIete removal of the tumor, immedia te and tad-

PER[NEAL RECURRENCE OF CAKCINOMA OF THE RECTUM 129

ical surgical r e m o v a l p rovides the best ot> p o r t u n i t y for sav ing the pa t i en t .

Summary and Condusions

T h e records of" 25 pa t ien t s who ha(! peri- neal recur rences af ter a b d o m i n o p e r i n e a l resec t ion for ca rc inoma of the r ec tum have been reviewed. T h e s t a n d a r d forms of t r ea tmen t , and the results ob t a ined , have been given. Fo r most of these pat ients , the prognosis was poo r and the t r ea tmen t was, of necessity, d i r ec ted to the re l ief of pain. Several pa t i en t s were given more than one

form of t r e a t m e n t and it w o u l d have been mean ing less to a t t e m p t analysis of each in- d iv idua l ly . Pa in is a subjec t ive s y m p t o m and canno t be measured scientificallyo W h e n d e t e r m i n i n g the degree of relief' f rom pain , we rely u p o n the eva lua t i on of the pa t ien t , as wet1 as ou r own. T h e subjec t ive n a t u r e of the symptoms and the smal l nun'> bey of records r e v i e w e d made it imposs ib le to reach c lea>cut conclusions. F r o m this s tudy, however , we have ga ined ceruf in im- pressions tha t wil l be useful in h a n d l i n g

this p r o b l e m .

M a n a g e m e n t of these pa t ien t s is usua l ly l i t t le more than the choice o[ the pa l l i a t ive t he rapy best s:uited to the p r o b l e m pre- sented by each pa t ien t , Al l these pa t ien ts are not necessar i ly d o o m e d to d ie of the o r ig ina l disease; an in i t i a l eva lua t i on mus t be m a d e at tim ear l ies t sign of r ecur rence to d e t e r m i n e if salvage is possible. More i m p o r t a n t t han wha t can be done techni- cal ly for the p a t i e n t is u t i l i z a t i o n af s o u n d j u d g m e n t in d e t e r m i n i n g what can be done tha t wi l t be in his best interests .

'The use of narcot ics in the con t ro l of pa in in these pa t i en t s has a useful place, These drugs shou ld not be used indis- criminar~ely, b m sho tdd be prescr iSed for the specific needs of the i n d i v i d u a l pa t i en t . Cons ide r a t i on shou ld be given to the em- p l o y m e n t of a d d e d me thods of r e l i ev ing pa in before the p a t i e n t has become a d d i c t e d m the drug .

I r r a d i a t i o n is an effective fo rm of rel, iev- ing pain , b u t its resul ts a re of shor t dura - t ion and its r e p e a t e d use can l ead to ser ious

compl ica t ions . Surgical r e m o v a l can p rov ide comple t e

e x t i r p a t i o n of the disease in o n l y a few instances. I t is useful in d iagnos is and in o b t a i n i n g t e m p o r a r y re l ief f rom pain .

C o r d o t o m y a n d i n t r a theca l in jec t ions p lay an i m p o r t a n t role in re l i ev ing the pa t i en t ' s pain . Bo th are fo l lowed by leg weakness and u r i n a r y r e t en t ion , bu t these are of l i t t le consequence c o m p a r e d to the comfor t p r o v i d e d for the pa t i en t . In t ra - thecal i n j ec t ion is a much less f o rmida b l e p rocedu re than c o r d o t o m v a n d a l t h o u g h its results are of shor t e r ( lu ra t ion , it can be safely and easily r epea ted .

None of these forms of t r e a t m e n t can be sa id to be en t i re ly satisfactory° T h e type of. t!~erapy tha t seems to achieve the best resul t usual ly is the last give.n, before death .

R e f e r e n c e s

l. Bacon H. E. and J, L. Berkley: The rationale of re-resection for recurrent cancer of the eohm and rectmn. Dis. Cohm& Rectum 2: 5:19. 1959.

2, Bnnica, J. J.: The Management of Pain. Phila- delphia, Lea and Febiger, t953, p, 565; I492.

3. Dunphy. J. E.: Metastatic and recurrent cancer of the colon and rectum: Surgical significance and management. Dis. Colon ~ Rectum 2: 77 1959.

4. Jackson. B. R. and W. El. Daniel: Recurrent carcinoma of the rectt-,m, surgical treannent. California M'ed. 9t: I.t9, 1959.

5. McDonaM. G. O. and A. R. Wiltiamson: Dis- semination of cancer of the colon and rec- tum: Special reference to four cases of tocaI implantation in perinea! wounds. Dis. Colon ,'h Rectum .~g: I17. 1960.

6, Perese. D. 5[.: Sabarachnoid atcotmt block in the management of pain of malignant dis- ease. Arch, Surg. 75:347, [958.

7, Schulz, 5[, D.: Radiotherapy in advanced and incurable malignant disease. Radiology 59: 321. t957,

8. Wise, R. E. and M. L Smedeh Palliative treat- ment of recurrent rectosigmoidal neoplasms with two million volt radiation. S. Clim Nortli America 39: 775. 1959.