ASO Author Reflections: Challenges in the Management of Synchronous Prostate Cancer and Rectal Cancer: Towards Double Or
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Challenges in the Management of Synchronous Prostate Cancer and Rectal Cancer: Towards Double Organ Preservation? Alexandre Doussot, MD, PhD, and Zaher Lakkis, MD, PhD Department of Digestive Surgical Oncology – Liver Transplantation Unit, University Hospital of Besanc¸on, Besanc¸on, France
PAST The prostate and the rectum are two pelvic organs with some anatomical and surgical commonalities. However, considering their respective oncologic management and outcomes, prostate cancer (PC) and rectal cancer (RC) constitute two different entities. Consequently, managing synchronous PC and RC is challenging. Also, because this clinical situation is rare, available data are lacking. To date, existing data are limited to case reports and only one small multicenter series where patients underwent pelvic radiotherapy (RT) of 45–50.4 Gy with 1.8–2 Gy per fraction and a total dose delivered to the prostate ranging between 70.0 and 79.2 Gy, followed by rectal resection for locally advanced RC.1 This series reported acceptable surgical outcomes with an RT toxicity profile limited to grade 1 and a complete R0 resection rate of 100%. As a management alternative, the authors suggested conventional chemoradiotherapy for RC followed by total mesorectum excision (TME) when R0 resection is achievable, combined with prostate boost in case of low-risk PC. PRESENT The present multicenter study from the GRECCAR group reported outcomes in 25 consecutive patients undergoing rectal resection for a mid-low RC with synchronous PC treated at 9 tertiary-care centers between 2008
and 2018.2 This small number of patients underscores the rarity of this clinical situation. All patients had low or mid RC and most presented with low- or intermediate-risk PC. Management mostly consisted of rectal chemoradiotherapy or pelvic radiotherapy combined with TME (n = 16) or more rarely pelvic exenteration. Among the five patients who underwent pelvic exenteration, two died postoperatively. In contrast, in 16 patients who underwent anterior resection with colorectal or coloanal anastomosis, 90-day mortality was nil and severe morbidity occurred in three patients due to anastomotic leak. Overall, one can suggest that pelvic exenteration might be considered only when RC complete resection seems not achievable through TME. Regarding oncological outcomes, the overall complete R0 resection rate was 96% (n = 24). While three patients (12%) experienced biopsy-proven distant RC recurrence, no PC recurrence was documented. Three-year OS and RFS were 80.2% and 68.6%, respectively. Alternatively, staged management could be envisioned. In this setting, whether PC or RC should be managed first remains unknown. Nevertheless, impaired postoperative and oncological outcomes of RC have been reported in cases with previous PC management.3 Given the paucity of available data for synchronous PC and RC, a multidisciplinary approach is key and should consider both patient status and tumor features. Such an approach is summarized in the
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