Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies-new patients, old problem?

Repair of radiation-induced rectovaginal fistula with rectal stricture by a combined Tuttle, Turnbull-Cutait and Singapore flap approach

Radiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation.

Diagnostic Framework of Pelvic Massive Necrosis with Peritonitis following Chemoradiation for Locally Advanced Cervical Cancer: When Is the Surgery Not Demandable? A Case Report and Literature Review

Concurrent platinum-based chemoradiation (CCRT) is the established treatment for locally advanced cervical cancer and has an acceptable toxicity. Radiation-induced necrosis of the uterus and pelvic tissue is a rare and usually late potential complication. Limited data are available about its management. Here, we describe a case of a patient affected by a locally advanced cervical cancer (stage IVA) who received CCRT, obtaining a partial response with persistence of bladder and rectal infiltration. Unfortunately, after the first brachytherapy dose, the patient developed a worsening clinical picture with fever and altered laboratory data indicative of sepsis; the computed tomography revealed a massive necrosis of the uterus with pelvic abscess and peritonitis. We performed a laparoscopic emergency surgery with removal of the necrotic tissue, supracervical hysterectomy, bilateral-oophorectomy, and abscess drainage. Thereafter, once the severe inflammatory condition was resolved, the patient underwent pelvic exenteration with palliative/curative intent. The postoperative PET/CT was negative for residual disease. However, the patient needed further hospitalization for re-occurrence of peritonitis with multiple abscesses. A careful diagnosis is crucial in locally advanced cervical cancer patients who, after CCRT, present persistent pain and problematic findings at imaging and laboratory parameters. In these cases, radiation-induced necrosis of the pelvis should be suspected. This case helps to clarify the central role of surgery, especially when actinic necrosis leads to complications such as abscess, fistulae, and extensive tissue destruction that cannot be conservatively medically handled. Laparoscopy represents an ideal approach to realizing the correct diagnosis, as well as enabling the performance of important therapeutic surgical procedures.

Duration of postoperative hyperlactatemia has predictive value in recurrent fistula after major definitive surgery for intestinal fistula

Purpose

The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery (DS) for intestinal fistula.

Methods

If the initial postoperative lactate (IPL) > 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L < IPL ≤ 4 mmol/L), group B (mmol/L < IPL ≤ 6 mmol/L), and group C (IPL > 6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C.

Results

The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR: 12–24) vs 24 (IQR: 12–24), p = 0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR = 1.061; 95% CI: 1.029–1.094; p < 0.001) and group C (adjusted OR = 1.059; 95% CI: 1.012–1.129; p = 0.017). In group B, the cutoff point of duration of 42 h had the optimal predictive value (area under ROC = 0.791, sensitivity = 0.717, specificity = 0.794, p < 0.001). In group C, the cutoff point of duration of 54 h had the optimal predictive value (area under ROC = 0.781, sensitivity = 0.730, specificity = 0.804, p < 0.001).

Conclusion

The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.

Biological Rationale and Clinical Evidence of Carbon Ion Radiation Therapy for Adenoid Cystic Carcinoma: A Narrative Review

Adenoid cystic carcinoma (ACC) is a rare, basaloid, epithelial tumor, arising mostly from salivary glands. Radiation therapy can be employed as a single modality for unresectable tumors, in an adjuvant setting after uncomplete resection, in case of high-risk pathological features, or for recurrent tumors. Due to ACC intrinsic radioresistance, high linear energy transfer (LET) radiotherapy techniques have been evaluated for ACC irradiation: while fast neutron therapy has now been abandoned due to toxicity concerns, charged particle beams such as protons and carbon ions are at present the beams used for hadron therapy. Carbon ion radiation therapy (CIRT) is currently increasingly used for ACC irradiation. The aim of this review is to describe the immunological, molecular and clinicopathological bases that support ACC treatment with CIRT, as well as to expose the current clinical evidence that reveal the advantages of using CIRT for treating ACC.

[Surgical treatment of rectovaginal fistula with vaginal rectangular flap]

OBJECTIVE

To evaluate the early and long-term outcomes of rectovaginal fistula closure with vaginal rectangular flap.

MATERIAL AND METHODS

There were 61 patients with rectovaginal fistula for the period 2012-2020. Median age of patients was 35 years [31; 48]. Postpartum fictula was observed in 27 (44.2%) cases, postoperative - 10 (16.4%) patients, inflammatory - 15 (24.6%) patients, other causes - 9 (14.8%) patients. Disease recurrence occurred in 29 (47.5%) patients.

RESULTS

Median follow-up period was 36.2 [6; 64] months. Postoperative recurrence of rectovaginal fistula occurred in 19 (31.1%) patients. Length of hospital-stay ranged from 3 to 36 days (median 14 [12; 16]). We analyzed the relationship between the risk of disease recurrence and various factors, including etiology of rectovaginal fistula, localization and diameter of the fistula, intraoperative cautery, previous surgeries and preventive colostomy.

CONCLUSION

Vaginal rectangular flap is effective for rectovaginal fistula. Multivariate analysis confirmed two significant risk factors of postoperative recurrence: diameter of fistula over 5 mm and its localization in the rectum above the upper border of surgical anal canal (more than 7 mm from the dentate line).

A rare cause of esophagopleural fistula due to intensity-modulated proton therapy: a case report and review of literature

Esophagopleural fistula (EPF), initially described in 1960, is an abnormal communication between the esophagus and the pleural cavity which can occur due to congenital malformation or acquired due to malignancy or iatrogenic treatment. The most common presenting symptoms are of a respiratory infection, such as fever, chest tenderness, cough and imaging findings consistent with pleural fluid consolidation. In this report, we present a 59-year-old man who exhibited shortness of breath, productive cough, and significant weight loss for 2 weeks. His medical history was significant for smoking-related lung disease and pulmonary squamous cell carcinoma (SCC). His SCC (T4N0) was diagnosed 6 years prior to this presentation and was treated with chemoradiotherapy. The cancer recurred a year ago and he was treated with intensity-modulated proton therapy (IMPT) and consolidation chemotherapy. During admission, he was found to have an EPF by CT scan after initially failing antibiotic treatment for suspected complicated pneumonia and pleural effusion. Multiple attempts of esophagopleural fistula closure were made using endoscopic self-expandable metallic stents and placement of an esophageal vacuum-assisted closure device. However, these measures ultimately failed and, therefore, he required an iliocostalis muscle flap (Clagett window) procedure for closure. Esophageal pulmonary fistulae should be suspected whenever patients have undergone thoracic IMPT and may present with acute pulmonary complications, particularly pneumonia refractory to antibiotic treatment. This case reviews the current literature, potential complications, and treatment options for esophagopleural fistulas.

Use of the Martius advancement flap for low rectovaginal fistulas

AIM

The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short- and long-term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues.

METHOD

Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien-Dindo classification. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre- and postoperatively.

RESULTS

The mean follow-up was 42 ± 29 months (range 3-101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45-70 min), and the median hospital stay was 3.5 days (range 3-5 days). No major complications occurred. Pre- and postoperative CCIS did not differ [1 (range 0-3.5)]. The postoperative SF-12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001).

CONCLUSION

The Martius procedure should be considered as the first-line method of treatment in carefully selected cases of LRVF.

Risk factors for fistula formation after interstitial brachytherapy for locally advanced gynecological cancers involving vagina

Purpose

To determine risk factors for fistula formation after interstitial brachytherapy (ISBT) in patients with advanced gynecologic cancers.

Material and methods

We performed an Institutional Review Board (IRB) approved retrospective review of 44 patients treated with transperineal template-based ISBT from 2011 to 2017 at a major metropolitan county and university health system. All patients were treated with image-guided high-dose-rate ISBT. Statistical analysis was performed using the χ² test to identify factors correlated with fistula formation. Survival and tumor control outcomes were calculated using Kaplan Meier analyses.

Results

Patients had a mean age of 53 years (range, 28-81 years), a mean external beam dose of 43.1 Gy (range, 42.5-51.3 Gy), and a mean brachytherapy dose of 22.8 Gy (range, 21.3-30 Gy). Two of 44 patients had fistulas that could be definitively attributed to therapy for a fistula rate of 4.5%. Six additional patients (13.6%) developed fistula after treatment with associated recurrent disease but were included in the causality analysis. We analyzed patient tumor and treatment factors, and on univariate analyses we found that age ≥ 60 years, Hispanic ethnicity, bladder involvement, rectal D2 cc ≥ 70 Gy, and whether patients had post-radiation biopsies were predictors for fistula formation. The 1-year overall survival (OS), progression-free survival (PFS), and local control (LC) were 85%, 58.5%, and 76.9%, respectively, with a mean follow-up time 23 months (range, 4.0-68.8 months).

Conclusions

We identified factors that predict fistula formation in patients with advanced gynecologic tumors treated with ISBT. These factors can be used to stratify patients into a high-risk group, with potential for modification of brachytherapy planning to reduce their risk of fistula formation.