Morbidity and outcome of pelvic exenteration in locally advanced pelvic malignancies

A systematic review and meta-analysis on mortality rate following total pelvic exenteration in cancer patients

BACKGROUND

Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including female reproductive organs, lower urological organs and involved parts of the digestive system. The aim of this meta-analysis is to estimate the intra-operative mortality, in-hospital mortality, 30- and 90-day mortality rate and overall mortality rate (MR) following TPE in colorectal, gynecological, urological, and miscellaneous cancers.

METHODS

This is a systematic review and meta-analysis in which three international databases including Medline through PubMed, Scopus and Web of Science on November 2023 were searched. To screen and select relevant studies, retrieved articles were entered into Endnote software. The required information was extracted from the full text of the retrieved articles by the authors. Effect measures in this study was the intra-operative, in-hospital, and 90-day and overall MR following TPE. All analyzes are performed using Stata software version 16 (Stata Corp, College Station, TX).

RESULTS

In this systematic review, 1751 primary studies retrieved, of which 98 articles (5343 cases) entered into this systematic review. The overall mortality rate was 30.57% in colorectal cancers, 25.5% in gynecological cancers and 12.42% in Miscellaneous. The highest rate of mortality is related to the overall mortality rate of colorectal cancers. The MR in open surgeries was higher than in minimally invasive surgeries, and also in primary advanced cancers, it was higher than in recurrent cancers.

CONCLUSION

In conclusion, it can be said that performing TPE in a specialized surgical center with careful patient eligibility evaluation is a viable option for advanced malignancies of the pelvic organs.

Elderly gynaecological cancer patients at risk for poor end of life care: a population-based study from the Swedish Register of Palliative Care

Introduction: Poorer end-of-life (EOL) care for elderly cancer patients has been reported. We assessed the impact of age on 13 indicators for the quality of EOL care as well as adherence to 6 national quality indicators in gynaecological cancer patients.Methods: Age-dependent differences in 13 palliative care quality indicators were studied in gynaecological cancer patients registered in the population-based Swedish Register of Palliative Care. Association between the patient's age and each quality indicator was analyzed by logistic regression, adjusted for place of death where appropriate. Adherence to six national quality indicators determined by the Swedish National Board of Health and Welfare was estimated in all patients.Results: We included 3940 patients with the following age distribution: 1.6% were 18-39 years of age, 12.3% 40-59 years, 37.2% 60-74 years, 28.9% 75-84 years and 20% were ≥85 years. Age-dependent differences in implementation rate were present for some of the 13 quality indicators. Compared to elderly cancer patients, younger patients were more likely to be cared for by a specialized palliative care service, more often informed about imminent death as well as assessed for pain. For most national quality indicators, the goal level was not met. Only for the 'on demand prescription for pain', the goal level was reached.Conclusions: EOL care did not meet national quality indicators in this population-based data from Sweden, in particular in the elderly population. Elderly gynaecological cancer patients are at high risk of poorer EOL care without the involvement of specialized palliative care services. Palliative care services need to be implemented across all institutions of EOL care to ensure good and equal care.

Salvage Surgery for Cervical Cancer Recurrences

Cervical cancer usually presents in advanced stages and is treated with chemoradiation. About 15-20 % patients present with local recurrence after chemoradiation. Radical surgical resection is the only treatment modality offering long term survival benefit in recurrent cervical cancer. The most common surgical option for these patients is pelvic exenteration. Radical hysterectomy may be done for patients with a small centrally located recurrence in the cervix with no infiltration of adjacent structures. The aim of this study was to evaluate the morbidity and survival outcome following radical hysterectomy and pelvic exenteration for recurrent cancer cervix. We retrospectively reviewed the medical records of our patients who underwent surgery for cancer cervix recurrence from January 2010 to December 2014. The postoperative morbidity was considered early if it happened in the initial 30 days of surgery and late if it occurred after 30 days. All patients were followed up till February 2015. Survival analysis was done using Kaplan- Meir method. Between January 2010 and December 2014, 20 patients with recurrent cervical cancer underwent radical surgical resection. The median age of the study group was 43 years (range 28-63 years). Seventeen patients had squamous cell carcinoma and 3 had adenocarcinoma. 13 underwent pelvic exenteration and 7 patients underwent radical type 2 hysterectomy with bilateral pelvic lymphnode dissection. In the exenteration group, 8 patients had anterior exenteration, 4 had total exenteration and one had posterior exenteration. Urinary diversion was done by ileal conduit in 8 patients, double barrel colostomy in two and wet colostomy in two patients. There were no immediate postoperative deaths. Operating time, blood transfusions needed and hospital stay was more in the exenteration group compared to radical hysterectomy patients. After pelvic exenteration post-operative complications were seen in 76.9 % of which the most common was of the urinary tract including 3 patients with pyelonephritis, 5 had renal insufficiency and 2 patients developed urinary fistulae. Post-operative morbidity was lower in radical hysterectomy patients. There were two patients in the hysterectomy group who developed vault recurrence while none in the exenteration group had local recurrence. The median follow up time was 19 months (range 9-53 months).Three year overall survival for the entire cohort was 43 %. Median survival time for the exenteration group was 28 months which was significantly higher than 14 months for the radical hysterectomy group. This study shows that radical surgical resection is feasible with good survival outcome and acceptable morbidity in recurrent cancer cervix patients. Radical hysterectomy can be done in selected patients but pelvic exenteration has better long-term survival but with the potential for both short- & long-term complications.

Pelvic exenteration: experience from a rural cancer center in developing world

Background. Pelvic exenteration (PE) is a morbid procedure. Ours is a rural based cancer center limited trained surgical oncology staff. Hence, this audit was planned to evaluate morbidity and outcomes of all patients undergoing PE at our center. Methods. This is a IRB approved retrospective audit of all patients who underwent PE at our center from January 2010 to August 2013. The toxicity grades were retrospectively assigned according to the CTCAE version 4.02 criteria. Chi-square test was done to identify factors affecting grades 3–5 morbidity. Kaplan Meier survival analysis has been used for estimation of median PFS and OS. Results. 34 patients were identified, with the median age of 52 years (28–73 years). Total, anterior, posterior, and modified posterior exenterations were performed in 4 (11.8%), 5 (14.7%), 14 (41.2%), and 11 (32.4%) patients, respectively. The median time for surgery was 5.5 hours (3–8 hours). The median blood loss was 500 mL (200–4000 mL). CTCAE version 4.02 grades 3-4 toxicity was seen in nine patients (25.7%). The median estimated progression free survival was 31.76 months (25.13–38.40 months). The 2-year overall survival was 97.14%. Conclusion. PE related grades 3–5 morbidity of 25.7% and mortality of 2.9% at our resource limited center are encouraging.