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Li C, Wu M, Zhang W, Jiang X, Zhang L, Wang G, He L. Large cell neuroendocrine carcinoma of the cervix: a case report. Front Oncol 2024; 14:1419710. [PMID: 39114303 PMCID: PMC11303192 DOI: 10.3389/fonc.2024.1419710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/05/2024] [Indexed: 08/10/2024] Open
Abstract
Large Cell Neuroendocrine Carcinoma (LCNEC) of the cervix is an extremely rare but highly aggressive type of cervical cancer and it requires multimodal therapy to improve their quality of life. At present, there are no established, standardized treatment protocols for managing large cell neuroendocrine carcinoma of the cervix. In this report, we present a case of a patient with cervical LCNEC, Who was a 39-year-old woman who presented with irregular vaginal bleeding accompanied by lower abdominal distension for over a month. Examination revealed a cauliflower-like cervical mass approximately 4cm in diameter, with the normal cervical architecture distorted and partially fused to the vaginal wall. Following further investigations, the stage assigned was IVB, and who was started on neoadjuvant chemotherapy with the TC (paclitaxel + carboplatin) regimen but during neoadjuvant chemotherapy, The patient developed a vaginal urinary leakage. Then, The patient underwent a comprehensive treatment regimen that included pelvic exenteration, urinary system reconstruction, pelvic floor reconstruction, and chemotherapy. Given the patient's positive immunohistochemistry for EGFR, the treatment was combined with the anti-angiogenic drug, bevacizumab. The patient achieved complete remission following the comprehensive treatment. Through this case to explore individualized treatment for cervical LCNEC.
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Affiliation(s)
- Chunmei Li
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
| | - Maoyuan Wu
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
| | - Wenwen Zhang
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
| | - Xiaoling Jiang
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
| | - Lixia Zhang
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
| | - Gangcheng Wang
- Department of Abdominal and Pelvic Tumor Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lianli He
- Department of Gynecology, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, Guizhou, China
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2
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Certelli C, Palmieri L, Federico A, Oliva R, Conte C, Rosati A, Vargiu V, Tortorella L, Chiantera V, Foschi N, Ardito F, Lodoli C, Bruno M, Santullo F, De Rose AM, Fagotti A, Fanfani F, Scambia G, Gallotta V. Robotic approach for the treatment of gynecological cancers recurrences: A ten-year single-institution experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108526. [PMID: 39024693 DOI: 10.1016/j.ejso.2024.108526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/20/2024] [Accepted: 06/30/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Although the management of gynecological cancers recurrences may be challenging, due to the heterogeneity of recurrent disease, the aim of this work is to present a descriptive analysis of gynecological malignancies recurrences in our institution treated by robotic approach. MATERIALS AND METHODS We performed a retrospective review and analysis of data of patients who underwent robotic surgery for recurrent gynecological malignancies at Catholic University of the Sacred Hearth, Rome, from January 2013 to January 2024. RESULTS A total of 54 patients underwent successful robotic cytoreductive surgery. The median age was 63 years; the median BMI was 33 kg/m2 and most of the patients (59 %) were obese. In 12 cases (22 %) the relapse presented was the second or third relapse. The most frequent patterns of recurrence were represented by lymph nodes (41 %), followed by peritoneal (26 %), pelvic (22 %) and parenchymal (11 %). In all patients complete cytoreduction was achieved. In 29 patients (54 %) the surgical field was previous treated. The median operative time and estimated blood loss were, respectively, 270 min and 100 ml. There were 2 intraoperative complications, managed endoscopically; 10 early postoperative complications, and 3 late postoperative complications. The 2-year progression-free-survival and overall survival were, respectively, 39.8 % and 72.3 %. CONCLUSION Robotic approach in the treatment of recurrent gynecological cancers should be considered in selected patients with oligometastatic disease, in high-volume centers with expert surgeons, particularly in obese patients.
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Affiliation(s)
- Camilla Certelli
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy.
| | - Luca Palmieri
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Alex Federico
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Oliva
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Carmine Conte
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Rosati
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Virginia Vargiu
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vito Chiantera
- Gynecologic Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Nazario Foschi
- Division of Urology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Matteo Bruno
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Agostino M De Rose
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Anna Fagotti
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Francesco Fanfani
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Valerio Gallotta
- Gynecologic Oncology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Van Trappen P, Walgraeve MS, Roels S, Claes N, De Cuypere E, Baekelandt F, Arentsen H. Robotic-Assisted Pelvic Exenteration for Cervical Cancer: A Systematic Review and Novel Insights into Compartment-Based Imaging. J Clin Med 2024; 13:3673. [PMID: 38999239 PMCID: PMC11242832 DOI: 10.3390/jcm13133673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Patients with persistent or recurrent cervical cancer, following primary treatment with concurrent chemoradiation, represent a subgroup eligible for pelvic exenteration. In light of the substantial morbidity associated with open pelvic exenterations, minimally invasive surgical techniques have been introduced. This systematic review aims to analyze and discuss the current literature on robotic-assisted pelvic exenterations in cervical cancer. In addition, novel aspects of compartment-based magnetic resonance imaging (MRI) are highlighted. Methods: This systematic review followed the PRISMA guidelines, and a comprehensive literature search on robotic-assisted pelvic exenterations in cervical cancer was conducted to assess, as main objectives, early and late postoperative complications as well as oncological outcomes. Inclusion and exclusion criteria were applied to select eligible studies. Results: Among the reported cases of robotic-assisted pelvic exenterations in cervical cancer, 79.4% are anterior pelvic exenterations. Intraoperative complications are minimal and early/late major complications averaged between 30-35%, which is lower compared to open pelvic exenterations. Oncological outcomes are similar between robotic and open pelvic exenterations. Sensitivity for locoregional invasion increases up to 93% for compartment-based MRI in colorectal cancer. A refined delineation of the seven pelvic compartments for cervical cancer is proposed here. Conclusions: Robotic-assisted pelvic exenterations have demonstrated feasibility and safety, with reduced rates of major complications compared to open surgery, while maintaining surgical efficiency and oncological outcomes. Compartment-based MRI holds promise for standardizing the selection and categorization of pelvic exenteration procedures.
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Affiliation(s)
- Philippe Van Trappen
- Department of Gynecological Oncology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
| | - Marie-Sofie Walgraeve
- Department of Radiology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
| | - Sarah Roels
- Department of Radiation Oncology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
| | - Nele Claes
- Department of Medical Oncology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
| | - Eveline De Cuypere
- Department of Medical Oncology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
| | - Frederic Baekelandt
- Department of Urology, AZ Sint-Lucas Hospital Bruges, Sint-Lucaslaan 29, 8310 Bruges, Belgium
| | - Harm Arentsen
- Department of Urology, AZ Sint-Jan Hospital Bruges, Ruddershove 10, 8000 Bruges, Belgium
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Isohashi F, Yoshida K, Murakami N, Masui K, Ishihara S, Ohkubo Y, Kaneyasu Y, Kinoshita R, Kotsuma T, Takaoka Y, Tanaka E, Nagao A, Ogawa K, Yamazaki H. Reirradiation for recurrent gynecologic cancer using high-dose-rate brachytherapy in Japan: A multicenter survey on practice patterns and outcomes. Radiother Oncol 2024; 195:110269. [PMID: 38583719 DOI: 10.1016/j.radonc.2024.110269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE The aim of the study is to examine the present status of reirradiation with high-dose-rate (HDR) brachytherapy for recurrent gynecologic cancer in Japan and to determine the role of this therapy in clinical practice. MATERIALS AND METHODS A retrospective multicenter chart review was performed for reirradiation for gynecologic cancer using HDR brachytherapy. Each center provided information on patient characteristics, treatment outcomes, and complications. RESULTS The study included 165 patients treated at 9 facilities from 2000 to 2018. The analysis of outcomes included 142 patients treated with curative intent. The median follow-up time for survivors was 30 months (range 1-130 months). The 3-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 53 % (95 %CI: 42-63 %), 44 % (35-53 %), and 61 % (50-70 %) for cervical cancer; 100 % (NA), 64 % (30-85 %), and 70 % (32-89 %) for endometrial cancer; and 54 % (13-83 %), 38 % (6-72 %), and 43 % (6-78 %) for vulvar and vaginal cancer, respectively. In multivariate analysis, interval to reirradiation (<1 year) was a significant risk factor for OS, PFS and LC; Gross Tumor Volume (≥25 cm3) was a significant risk factor for OS. Toxicities were analyzed in all enrolled patients (n = 165). Grade ≥ 3 late toxicities occurred in 49 patients (30 %). A higher cumulative EQD2 (α/β = 3) was significantly associated with severe complications. CONCLUSION Reirradiation with HDR brachytherapy for recurrent gynecologic cancer is effective, especially in cases with a long interval before reirradiation.
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Affiliation(s)
- Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan.
| | - Ken Yoshida
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan; Department of Radiation Oncology, Juntendo University, Hongo, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunichi Ishihara
- Department of Radiology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan; Department of Radiology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yu Ohkubo
- Department of Radiation Oncology, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Hiroshima, Japan; Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Hiroshima, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiation Oncology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yuji Takaoka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Saito Yukoukai Hospital, Ibaraki, Osaka, Japan
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Denys A, Thielemans S, Salihi R, Tummers P, van Ramshorst GH. Quality of Life After Extended Pelvic Surgery with Neurovascular or Bony Resections in Gynecological Oncology: A Systematic Review. Ann Surg Oncol 2024; 31:3280-3299. [PMID: 38459419 DOI: 10.1245/s10434-023-14649-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/09/2023] [Indexed: 03/10/2024]
Abstract
BACKGROUND Extended pelvic surgery with neurovascular or bony resections in gynecological oncology has significant impact on quality of life (QoL) and high morbidity. The objective of this systematic review was to provide an overview of QoL, morbidity and mortality following these procedures. METHODS The registered PROSPERO protocol included database-specific search strategies. Studies from 1966 onwards reporting on QoL after extended pelvic surgery with neurovascular or bony resections for gynecological cancer were considered eligible. All others were excluded. Study selection (Rayyan), data extraction, rating of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers. RESULTS Of 349 identified records, 121 patients from 11 studies were included-one prospective study, seven retrospective studies, and three case reports. All studies were of very low quality and with an overall serious risk of bias. Primary tumor location was the cervix (n = 78, 48.9%), vulva (n = 30, 18.4%), uterus (n = 21, 12.9%), endometrium (n = 15, 9.2%), ovary (n = 8, 4.9%), (neo)vagina (n = 3, 1.8%), Gartner duct/paracolpium (n = 1, 0.6%), or synchronous tumors (n = 3, 1.8%), or were not reported (n = 4, 2.5%). Bony resections included the pelvic bone (n = 36), sacrum (n = 2), and transverse process of L5 (n = 1). Margins were negative in 70 patients and positive in 13 patients. Thirty-day mortality was 1.7% (2/121). Three studies used validated QoL questionnaires and seven used non-validated measurements; all reported acceptable QoL postoperatively. CONCLUSIONS In this highly selected patient group, mortality and QoL seem to be acceptable, with a high morbidity rate. This comprehensive study will help to inform eligible patients about the outcomes of extended pelvic surgery with neurovascular or bony resections. Future collaborative studies can enable the collection of QoL data in a validated, uniform manner.
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Affiliation(s)
- Andreas Denys
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Sofie Thielemans
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Rawand Salihi
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
- Department of Gynecology and Obstetrics, AZ St. Lucas Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
| | - Gabrielle H van Ramshorst
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.
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Ubinha ACF, Pedrão PG, Tadini AC, Schmidt RL, dos Santos MH, Andrade CEMDC, Longatto Filho A, dos Reis R. The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature. Cancers (Basel) 2024; 16:817. [PMID: 38398208 PMCID: PMC10886894 DOI: 10.3390/cancers16040817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 02/25/2024] Open
Abstract
Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some cases of advanced tumors, it is associated with several perioperative complications. We believe that careful patient selection is related to better oncologic outcomes and lower complication rates. The objectives of this review are to identify the most current indications for this intervention, suggest criteria for case selection, evaluate recommendations for perioperative care, and review oncologic outcomes and potential associated complications. To this end, an analysis of English language articles in PubMed was performed, searching for topics such as the indication for pelvic exenteration for recurrent gynecologic neoplasms selection of oncologic cases, the impact of tumor size and extent on oncologic outcomes, preoperative and postoperative surgical management, surgical complications, and outcomes of overall survival and recurrence-free survival.
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Affiliation(s)
- Ana Carla Franco Ubinha
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | - Priscila Grecca Pedrão
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (P.G.P.); (A.L.F.)
| | - Aline Cássia Tadini
- Barretos School of Health Sciences, Dr. Paulo Prata-FACISB, Barretos 14785-002, Brazil;
| | - Ronaldo Luis Schmidt
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | - Marcelo Henrique dos Santos
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
| | | | - Adhemar Longatto Filho
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (P.G.P.); (A.L.F.)
- Medical Laboratory of Medical Investigation (LIM), Department of Pathology, Medical School, University of São Paulo, São Paulo 01246-903, Brazil
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4805-017 Guimarães, Portugal
| | - Ricardo dos Reis
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil; (R.L.S.); (M.H.d.S.); (C.E.M.d.C.A.); (R.d.R.)
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Yu JH, Tong CJ, Huang QD, Ye YL, Chen G, Li H, Wen YS, Yang F, Luo NB, Xu GY, Xiong Y. Long-term outcomes of pelvic exenterations for gynecological malignancies: a single-center retrospective cohort study. BMC Cancer 2024; 24:88. [PMID: 38229045 DOI: 10.1186/s12885-024-11836-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Recently, with the advancement of medical technology, the postoperative morbidity of pelvic exenteration (PE) has gradually decreased, and it has become a curative treatment option for some patients with recurrent gynecological malignancies. However, more evidence is still needed to support its efficacy. This study aimed to explore the safety and long-term survival outcome of PE and the feasibility of umbilical single-port laparoscopic PE for gynecologic malignancies in a single medical center in China. PATIENTS AND METHODS PE for gynecological cancers except for ovarian cancer conducted by a single surgical team in Sun Yat-sen University Cancer Center between July 2014 and December 2019 were included and the data were retrospectively analyzed. RESULTS Forty-one cases were included and median age at diagnosis was 53 years. Cervical cancer accounted for 87.8% of all cases, and most of them received prior treatment (95.1%). Sixteen procedures were performed in 2016 and before, and 25 after 2016. Three anterior PE were performed by umbilical single-site laparoscopy. The median operation time was 460 min, and the median estimated blood loss was 600 ml. There was no perioperative death. The years of the operations was significantly associated with the length of the operation time (P = 0.0018). The overall morbidity was 52.4%, while the severe complications rate was 19.0%. The most common complication was pelvic and abdominal infection. The years of surgery was also significantly associated with the occurrence of severe complication (P = 0.040). The median follow-up time was 55.8 months. The median disease-free survival (DFS) was 17.9 months, and the median overall survival (OS) was 25.3 months. The 5-year DFS was 28.5%, and the 5-year OS was 30.8%. CONCLUSION PE is safe for patient who is selected by a multi-disciplinary treatment, and can be a curative treatment for some patients. PE demands a high level of experience from the surgical team. Umbilical single-port laparoscopy was a technically feasible approach for APE, meriting further investigation.
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Affiliation(s)
- Jie-Hai Yu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Chong-Jie Tong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Qi-Dan Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Yun-Lin Ye
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Gong Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Hao Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Head and Neck, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yong-Shan Wen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Colorectal Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Fan Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Nan-Bin Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China
| | - Guang-Yu Xu
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Ying Xiong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China.
- Department of Gynecologic Oncology, Sun Yat-Sen University Cancer Center, No. 651, Dongfeng East Road, Guangzhou, 510060, P. R. China.
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8
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Classen-von Spee S, Baransi S, Fix N, Rawert F, Luengas-Würzinger V, Lippert R, Bonin-Hennig M, Mallmann P, Lampe B. Pelvic Exenteration for Recurrent Vulvar Cancer: A Retrospective Study. Cancers (Basel) 2024; 16:276. [PMID: 38254766 PMCID: PMC10813412 DOI: 10.3390/cancers16020276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Pelvic exenteration (PE) is one of the most radical surgical approaches. In earlier times, PE was associated with high morbidity and mortality. Nowadays, due to improved selection of suitable patients, perioperative settings, and postoperative care, patients' outcomes have been optimized. To investigate patients' outcomes and identify possible influencing clinical and histopathological factors, we analysed 17 patients with recurrent vulvar cancer who underwent PE in our department between 2007 and 2022. The median age was 64.9 years, with a difference of 40 years between the youngest and the oldest patient (41 vs. 81 years). The mean overall survival time was 55.7 months; the longest survival time reached up to 164 months. The achievement of complete cytoreduction (p = 0.02), the indication for surgery (curative vs. palliative), and the presence of distant metastases (both p = 0.01) showed a significant impact on overall survival. The presence of lymphatic metastases (p = 0.11) seems to have an influence on overall survival (OS) time. Major complications appeared in 35% of the patients. Our results support the existing data for PE in cases of recurrent vulvar cancer; for a group of selected patients, PE is a treatment option with good overall survival times and acceptable morbidity.
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Affiliation(s)
- Sabrina Classen-von Spee
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Saher Baransi
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Nando Fix
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Friederike Rawert
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Verónica Luengas-Würzinger
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Ruth Lippert
- Department of Pathology, Evangelisches Krankenhaus Oberhausen, Virchowstraße 20, 46047 Oberhausen, Germany
| | - Michelle Bonin-Hennig
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany;
| | - Björn Lampe
- Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Kreuzbergstraße 79, 40489 Düsseldorf, Germany; (S.B.); (N.F.); (F.R.); (V.L.-W.); (M.B.-H.)
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9
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Recht HS, Shampain KL, Flory MN, Nougaret S, Barber EL, Jha P, Maturen KE, Sadowski EA, Shinagare AB, Venkatesan AM, Horowitz JM. Gynecologic oncology tumor board: the central role of the radiologist. Abdom Radiol (NY) 2023; 48:3265-3279. [PMID: 37386301 DOI: 10.1007/s00261-023-03978-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
This manuscript is a collaborative, multi-institutional effort by members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focus Panel and the European Society of Urogenital Radiology Women Pelvic Imaging working group. The manuscript reviews the key role radiologists play at tumor board and highlights key imaging findings that guide management decisions in patients with the most common gynecologic malignancies including ovarian cancer, cervical cancer, and endometrial cancer.
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Affiliation(s)
- Hannah S Recht
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 800, Chicago, IL, 60611, USA.
| | - Kimberly L Shampain
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Marta N Flory
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Stephanie Nougaret
- Montpellier Cancer Institute, University of Montpellier, Monpellier, France
- IRCM, U1198, University of Montpellier, Monpellier, France
| | - Emma L Barber
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Priyanka Jha
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Katherine E Maturen
- Departments of Radiology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth A Sadowski
- Departments of Radiology and Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Atul B Shinagare
- Department of Radiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Aradhana M Venkatesan
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jeanne M Horowitz
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N. St. Clair Street, Suite 800, Chicago, IL, 60611, USA
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Bizzarri N, Chiantera V, Loverro M, Ercoli A, Vizzielli G, Scambia G. Minimally invasive pelvic exenteration for gynaecological malignancies: the challenge of patients' selection. Facts Views Vis Obgyn 2023; 15:193-196. [PMID: 37742196 PMCID: PMC10643015 DOI: 10.52054/fvvo.15.3.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Pelvic exenteration is a radical procedure representing a salvage option in patients with recurrent or persistent gynaecological malignancies. It can be performed with an open or minimally invasive approach. Different studies have demonstrated optimal peri-operative outcomes of minimally invasive pelvic exenteration with no survival difference when compared with an open approach. In this article, we discuss the importance and the challenge of patient selection for pelvic exenteration and more specifically for minimally invasive pelvic exenteration.
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11
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Nakamura K, Yamashita S, Kigure K, Nishimura T, Ito I, Azuma A, Nakao K, Ando K, Kanuma T. Utility of vaginal vault cytology in the local recurrence of cervical cancer. BMC Womens Health 2023; 23:186. [PMID: 37081439 PMCID: PMC10116747 DOI: 10.1186/s12905-023-02371-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/17/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND In Japan, 8000 women were newly diagnosed with cervical cancer in 2018. The healthcare insurance policy in Japan allows physicians to utilize vaginal volt cytology tests and serum biomarker measurement at every visit and imaging analysis at an adequate interval with screening for recurrence after initial treatment. However, the major surveillance guidelines published in the United States and European countries recommend focusing on pelvic examinations and symptom reviews to avoid unnecessary tests. This study aimed to reassess the benefits of standard surveillance methods adopted in this study by retrospective analysis. METHODS From January 2009 to December 2015, the medical records of patients with recurrence who were initially diagnosed with International Federation of Gynecology and Obstetrics stage I-III cervical cancer were collected for this study. Clinicopathological data were statistically analyzed to identify significant factors. In the first 2 years, the patients underwent regular surveillance, including pelvic examination, serum tumor marker tests, vaginal vault cytology every 1-3 months, and imaging analysis at 6- to 12-month intervals. In the following 2 years, the patients received a regular check with the same methods every 4 months and an annual imaging analysis. Afterward, the patients had regular screening every 6 to 12 months. RESULTS In the study period, 84 of the 981 patients experienced recurrence, and 88.1% had an asymptomatic recurrence. The disease-free interval was not related to the recurrence site. In univariate analysis, primary treatment, recurrence site, and diagnostic method were significant factors for survival outcomes. In contrast, multivariate analysis indicated that only primary treatment was a significant factor. In patients with local recurrence, multivariate analysis demonstrated that radiation as salvage therapy was an independent predictive factor for overall survival after recurrence. CONCLUSIONS In this retrospective study, routine imaging analysis and serum biomarker measurement did not contribute to patient prognosis after recurrence. In contrast, vaginal vault cytology can improve survival after recurrence in some patients. Tailored surveillance methods based on individual disease conditions and treatment modalities can improve post-recurrent survival outcomes.
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Affiliation(s)
- Kazuto Nakamura
- Department of Gynecology, Gunma Prefectural Cancer Center, Ota, Japan.
| | - Soichi Yamashita
- Department of Gynecology, Gunma Prefectural Cancer Center, Ota, Japan
| | - Keiko Kigure
- Department of Gynecology, Gunma Prefectural Cancer Center, Ota, Japan
| | - Toshio Nishimura
- Department of Gynecology, Gunma Prefectural Cancer Center, Ota, Japan
| | - Ikuro Ito
- Department of Obstetrics and Gynecology, Takasaki General Medical Center, Takasaki, Japan
| | - Anri Azuma
- Department of Obstetrics and Gynecology, Takasaki General Medical Center, Takasaki, Japan
| | - Kohshiro Nakao
- Department of Obstetrics and Gynecology, Gunma University, Maebashi, Japan
| | - Ken Ando
- Department of Radiation Oncology, Gunma University, Maebashi, Japan
| | - Tatsuya Kanuma
- Department of Gynecology, Gunma Prefectural Cancer Center, Ota, Japan
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12
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Moolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhuijzen LRCW, Mom CH, Zaal A. Clinical outcomes of pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2023; 171:114-120. [PMID: 36870097 DOI: 10.1016/j.ygyno.2023.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES The aim of this study was to analyze morbidity and survival after pelvic exenteration for gynecologic malignancies and evaluate prognostic factors influencing postoperative outcome. METHODS We retrospectively reviewed all patients who underwent a pelvic exenteration at the departments of gynecologic oncology of three tertiary care centers in the Netherlands, the Leiden University Medical Centre, the Amsterdam University Medical Centre, and the Netherlands Cancer Institute, during a 20-year period. We determined postoperative morbidity, 2- and 5-year overall survival (OS) and 2- and 5-year progression free survival (PFS), and investigated parameters influencing these outcomes. RESULTS A total of 90 patients were included. The most common primary tumor was cervical cancer (n = 39, 43.3%). We observed at least one complication in 83 patients (92%). Major complications were seen in 55 patients (61%). Irradiated patients had a higher risk of developing a major complication. Sixty-two (68.9%) required ≥1 readmission. Re-operation was required in 40 patients (44.4%). Median OS was 25 months and median PFS was 14 months. The 2-year OS rate was 51.1% and the 2-year PFS rate was 41.5%. Tumor size, resection margins and pelvic sidewall involvement had a negative impact on OS (HR = 2.159, HR = 2.376, and HR = 1.200, respectively). Positive resection margins and pelvic sidewall involvement resulted in decreased PFS (HR = 2.567 and HR = 3.969, respectively). CONCLUSION Postoperative complications after pelvic exenteration for gynecologic malignancies are common, especially in irradiated patients. In this study, a 2-year OS rate of 51.1% was observed. Positive resections margins, tumor size, and pelvic sidewall involvement were related to poor survival outcomes. Adequate selection of patients who will benefit from pelvic exenteration is important.
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Affiliation(s)
- L R Moolenaar
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E van Rangelrooij
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - M I E van Poelgeest
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - M van Beurden
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - W J van Driel
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - L R C W van Lonkhuijzen
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - C H Mom
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands.
| | - A Zaal
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
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13
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Vergote I, Ray-Coquard I, Lorusso D, Oaknin A, Cibula D, Van Gorp T. Investigational drugs for recurrent or primary advanced metastatic cervical cancer: what is in the clinical development pipeline? Expert Opin Investig Drugs 2023; 32:201-211. [PMID: 36803278 DOI: 10.1080/13543784.2023.2179483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION Recurrent or primary advanced metastatic cervical cancer (R/M CC) has a poor prognosis with a 5-year-survival rate of 16.5%, demanding novel and improved therapies for the treatment of these patients. The first-line standard of care for R/M CC now benefits from the addition of the immune checkpoint inhibitor, pembrolizumab, to platinum-based chemotherapy with paclitaxel and bevacizumab. Additionally, new options for second-line treatment have become available in recent years. AREAS COVERED Here, we review current investigational drugs and discuss their relative targets, efficacies, and potential within the R/M CC treatment landscape. This review will focus on recently published data and key ongoing clinical trials in patients with R/M CC, covering multiple modes of action, including immunotherapies, antibody-drug conjugates, and tyrosine kinase inhibitors. We searched clinicaltrials.gov for ongoing trials and pubmed.ncbi.nih.gov for recently published trial data, as well as recent years' proceedings from the annual conferences of the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), European Society of Gynaecological Oncology (ESGO), and the International Gynecologic Cancer Society (IGCS). EXPERT OPINION Therapeutics currently attracting attention include novel immune checkpoint inhibitors, therapeutic vaccinations, antibody-drug conjugates, such as tisotumab vedotin, tyrosine kinase inhibitors targeting HER2, and multitarget synergistic combinations.
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Affiliation(s)
- Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium; Belgium and Luxembourg Gynaecological Oncology Group (BGOG), Leuven, Belgium, European Union
| | - Isabelle Ray-Coquard
- Medical Oncology Department, Centre Léon Bérard and University Claude Bernard Lyon 1, GINECO, Lyon, France
| | - Domenica Lorusso
- Gynecologic Oncology Unit, Catholic University of Sacred Heart and Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Ana Oaknin
- Gynecologic Cancer Program, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - David Cibula
- Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic; Central and Eastern European Gynecologic Oncology Group (CEEGOG), Prague, Czech Republic
| | - Toon Van Gorp
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium; Belgium and Luxembourg Gynaecological Oncology Group (BGOG), Leuven, Belgium, European Union
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14
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Bizzarri N, Chiantera V, Loverro M, Sozzi G, Perrone E, Gueli Alletti S, Costantini B, Gallotta V, Tortorella L, Fagotti A, Fanfani F, Ercoli A, Scambia G, Vizzielli G. Minimally invasive versus open pelvic exenteration in gynecological malignancies: a propensity-matched survival analysis. Int J Gynecol Cancer 2023; 33:190-197. [PMID: 36593063 DOI: 10.1136/ijgc-2022-003954] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The primary endpoint of this study was to compare the disease-free survival of patients undergoing open versus minimally invasive pelvic exenteration. The secondary endpoints were cancer-specific survival and peri-operative morbidity. METHODS A multi-center, retrospective, observational cohort study was undertaken. Patients undergoing curative and palliative anterior or total pelvic exenteration for gynecological cancer by a minimally invasive approach and an open approach between June 2010 and May 2021 were included. Patients with distant metastases were excluded. A 1:2 propensity match analysis between patients undergoing minimally invasive and open pelvic exenteration was performed to equalized baseline characteristics. RESULTS After propensity match analysis a total of 117 patients were included, 78 (66.7%) and 39 (33.3%) in the open and minimally invasive group, respectively. No significant difference in intra-operative (23.4% vs 10.3%, p=0.13) and major post-operative complications (24.4% vs 17.9%, p=0.49) was evident between the open and minimally invasive approach. Patients undergoing open pelvic exenteration received higher rates of intra-operative transfusions (41.0% vs 17.9%, p=0.013). Median disease-free survival was 17.0 months for both the open and minimally invasive groups (p=0.63). Median cancer-specific survival was 30.0 months and 26.0 months in the open and minimally invasive groups, respectively (p=0.80). Positivity of surgical margins at final histology was the only significant factor influencing the risk of recurrence (hazard ratio (HR) 2.38, 95% CI 1.31 to 4.31) (p=0.004), while tumor diameter ≥50 mm at the time of pelvic exenteration was the only significant factor influencing the risk of death (HR 1.83, 95% CI 1.08 to 3.11) (p=0.025). CONCLUSION In this retrospective study no survival difference was evident when minimally invasive pelvic exenteration was compared with open pelvic exenteration in patients with gynecological cancer. There was no difference in peri-operative complications, but a higher intra-operative transfusion rate was seen in the open group.
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Affiliation(s)
- Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Matteo Loverro
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Emanuele Perrone
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Fanfani
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Ercoli
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Medical Area (DAME), University of Udine, Udine, Friuli-Venezia Giulia, Italy.,Clinic of Obstetrics and Gynecology - "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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McBain RD, McGauran MFG, Tran KH, Au-Yeung G, Khaw PYL, McNally OM. The changing role for extended resections in an era of advanced radiotherapy techniques and novel therapies in gynaecological malignancy. Eur J Surg Oncol 2022; 48:2308-2314. [PMID: 36184421 DOI: 10.1016/j.ejso.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Pelvic exenteration, first described in 1948 and subsequently refined, may be offered as a last hope of cure to patients with recurrent or locally advanced pelvic tumours, where radiotherapy is not an option. It is a complex, morbid, ultra-radical procedure involving en-bloc resection of the female reproductive organs, lower urinary tract, and a portion of the rectosigmoid. This article discusses the evolution of and current indications for pelvic exenteration in gynaecologic oncology as well as the reasons for its decline: primary and secondary prevention of cervical cancer (the recurrence of which is the most common indication for exenteration); improvements in treatment of cervical, endometrial, vaginal and vulvar cancer in the primary and recurrent setting; and the advent of novel therapies.
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Affiliation(s)
- R D McBain
- Royal Women's Hospital, Melbourne, Australia; Mercy Hospital for Women, Melbourne, Australia; Peter McCallum Cancer Centre, Melbourne, Australia.
| | - M F G McGauran
- Mercy Hospital for Women, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - K H Tran
- Peter McCallum Cancer Centre, Melbourne, Australia
| | - G Au-Yeung
- University of Melbourne, Melbourne, Australia; Peter McCallum Cancer Centre, Melbourne, Australia
| | - P Y L Khaw
- University of Melbourne, Melbourne, Australia; Peter McCallum Cancer Centre, Melbourne, Australia
| | - O M McNally
- Royal Women's Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Peter McCallum Cancer Centre, Melbourne, Australia
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16
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Using Bakri balloon as a visceral replacement for occupying pelvic cavity in pelvic exenteration, a case report. Int J Surg Case Rep 2022; 99:107646. [PMID: 36261941 PMCID: PMC9568762 DOI: 10.1016/j.ijscr.2022.107646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance Total pelvic exenteration is the choice treatment for locally advanced or recurrent cervical cancers. However, the procedure is usually associated with serious complications. One of the most common complications is “empty pelvic syndrome”. In this case report, we described a novel method to investigate its efficacy in prevention of empty pelvic syndrome. Case presentation A 51-year-old woman presented with recurrent cervical cancer underwent TPE after chemoradiotherapy. After removing the organs of the pelvic cavity, a silicone-made Bakri balloon was placed in there through the laparotomy incision. The balloon was removed 5 days later through the vaginal canal. She was followed for 6 months after the surgery and did not experience neither complications nor the recurrence of the cervical cancer. Clinical discussion We intended to use a novel technique by placing a Bakri balloon in the pelvic cavity after the total pelvic exenteration. The silicone-made balloon creates an appropriate physical barrier to support colon and small intestine loops and other pelvic contents. Conclusion Bakri balloon, which has been used to control the post-partum hemorrhage, can be a useful tool to provide a physical barrier to prevent the descending of intestinal loops and a breeding ground for reconstruction of the pelvic floor. Total pelvic exenteration is the choice treatment for locally advanced or recurrent cervical cancers. One of the most common complications is “empty pelvic syndrome”. Bakri balloon can be used as physical barrier to prevent the descending of intestinal loops.
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17
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Cibula D, Lednický Š, Höschlová E, Sláma J, Wiesnerová M, Mitáš P, Matějovský Z, Schneiderová M, Dundr P, Němejcová K, Burgetová A, Zámečník L, Vočka M, Kocián R, Frühauf F, Dostálek L, Fischerová D, Borčinová M. Quality of life after extended pelvic exenterations. Gynecol Oncol 2022; 166:100-107. [PMID: 35568583 DOI: 10.1016/j.ygyno.2022.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of the study was to compare health-related quality of life (QoL) and oncological outcome between gynaecological cancer patients undergoing pelvic exenteration (PE) and extended pelvic exenteration (EPE). EPEs were defined as extensive procedures including, in addition to standard PE extent, the resection of internal, external, or common iliac vessels; pelvic side-wall muscles; large pelvic nerves (sciatic or femoral); and/or pelvic bones. METHODS Data from 74 patients who underwent PE (42) or EPE (32) between 2004 and 2019 at a single tertiary gynae-oncology centre in Prague were analysed. QoL assessment was performed using EORTC QLQ-C30, EORTC CX-24, and QOLPEX questionnaires specifically developed for patients after (E)PE. RESULTS No significant differences in survival were observed between the groups (P > 0.999), with median overall and disease-specific survival in the whole cohort of 45 and 49 months, respectively. Thirty-one survivors participated in the QoL surveys (20 PE, 11 EPE). No significant differences were observed in global health status (P = 0.951) or in any of the functional scales. The groups were not differing in therapy satisfaction (P = 0.502), and both expressed similar, high willingness to undergo treatment again if they were to decide again (P = 0.317). CONCLUSIONS EPEs had post-treatment QoL and oncological outcome comparable to traditional PE. These procedures offer a potentially curative treatment option for patients with persistent or recurrent pelvic tumour invading into pelvic wall structures without further compromise of patients´ QoL.
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Affiliation(s)
- D Cibula
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic.
| | - Š Lednický
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - E Höschlová
- Department of Psychology, Faculty of Arts, Charles University in Prague, Czech Republic
| | - J Sláma
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - M Wiesnerová
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - P Mitáš
- Second surgical clinic - cardiovascular surgery, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Z Matějovský
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Hospital Na Bulovce, Czech Republic
| | - M Schneiderová
- First surgical clinic - thoracic, abdominal and injury surgery, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - P Dundr
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - K Němejcová
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - A Burgetová
- Department of radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - L Zámečník
- Clinic of urology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - M Vočka
- Department of Oncology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - R Kocián
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - F Frühauf
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - L Dostálek
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - D Fischerová
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - M Borčinová
- Gynaecologic oncology centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
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18
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Glane LT, Hegele A, Wagner U, Boekhoff J. Gynecologic Oncology: Pelvic Exenteration for Advanced or Recurring Cervical Cancer - A Single Center Analysis. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:308-315. [PMID: 35530642 PMCID: PMC9066540 DOI: 10.21873/cdp.10110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM Cervical cancer is the most common gynecological indication for pelvic exenteration (PE). It is an ultima ratio approach to cure advanced or recurring tumors. This study aimed to evaluate data from a Single Center Institution in order to assess morbidity, mortality and survival data. PATIENTS AND METHODS Data of 24 patients, who underwent anterior (APE) or total PE (TPE) for cervical cancer at the University Hospital Marburg between 2011 and 2016, were extracted and retrospectively evaluated. Survival analysis was conducted using the Kaplan-Meyer method. RESULTS Lymph node status was pN0, pN1 and pNX in 33.3%, 20.8% and 45.8% respectively. Negative margins could be achieved in 70.8%. A total of 16.7% of patients presented with metastatic disease, while 20.8%, 37.5% and 20.8% received 1, 2 or 3 modalities of treatment respectively; 20.8% underwent up-front PE. Predominant urinary diversion was an ileum conduit (66.7%). No complications were noted for 16.7%, major complications (≥Clavien Dindo 3) in 41.7%. Overall survival was 29.2% with a median overall survival (mOS) of 19.1 months. Curative PE was undertaken in 20 cases, with 2- and 3-year survival rates of 52.6% and 29.4% respectively. and a mOS of 24 months. Positive margins, metastatic disease, positive lymph nodes, TPE and a surgical time >6 h had a significant impact on OS. CONCLUSION PE for cervical cancer remains a feasible option in cases of advanced or recurring tumors when alternative treatment options would fail. For selected patients it may represent a chance of cure with acceptable complication and satisfactory survival rates.
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Affiliation(s)
- Luisa Ter Glane
- Department of Urology and Pediatric Urology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
| | - Axel Hegele
- Urological Center Mittelhessen, DRK Hospital, Biedenkopf, Germany
- Department of Radiotherapy and Radiooncology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
| | - Uwe Wagner
- Department of Gynecology, Gynecological Oncology and Gynecological Endocrinology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
| | - Jelena Boekhoff
- Department of Gynecology, Gynecological Oncology and Gynecological Endocrinology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
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19
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Tominaga T, Nonaka T, Fukuda A, Moriyama M, Oyama S, Ishii M, Takamura K, Tsurumoto T, Sawai T, Nagayasu T. Usefulness of structured-cadaveric training for trans-anal pelvic exenteration. Asian J Endosc Surg 2022; 15:299-305. [PMID: 34617393 DOI: 10.1111/ases.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Structured training using cadaveric simulation is useful for trans-anal surgery; however, no studies have examined the effectiveness of cadaveric training for advanced trans-anal surgery including pelvic exenteration (PE). METHODS Twelve colorectal surgeons attended a total of 10 cadaveric simulation training courses between 2016 and 2021 and completed a questionnaire at the end of the program. We divided 14 consecutive patients who underwent trans-anal PE between 2015 and 2021 into two groups: pre-training group and post-training group, and compared the clinico-pathological features between the groups. RESULTS The median length of clinical experience of the surgeons was 12 years. There was high score agreement among the surgeons that the course was useful for recognition of anatomical and layer structure, training for trans-anal total mesorectal excision and trans-anal PE, and reducing complications specific to the trans-anal approach. Compared with the pre-training group, patients in the post-training group had a higher rate of two-team surgery (77.8% vs 0%, P = .021), and shorter time to specimen removal (273 vs 423 min, P = .045). CONCLUSIONS Structured-cadaveric training has potential use as a technical step-up in advanced trans-anal surgery that might contribute to better short-term outcomes in the clinical setting.
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Affiliation(s)
- Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Akiko Fukuda
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Masaaki Moriyama
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Shosaburo Oyama
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Mitsutoshi Ishii
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Keiko Takamura
- Center of Cadaver Surgical Training, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Toshiyuki Tsurumoto
- Center of Cadaver Surgical Training, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Terumitsu Sawai
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
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20
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Abdulrahman GO, Das N, Chandrasekaran TV, Khot U, Drew PJ, Bose P, Vet JN, Tofazzal N, Roberts S, Lutchman Singh K. Pelvic Exenteration for the Treatment of Locally Advanced Vulvar Cancer in South West Wales. Cancers (Basel) 2022; 14:cancers14071767. [PMID: 35406539 PMCID: PMC8997009 DOI: 10.3390/cancers14071767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
The treatment of locally advanced vulvar carcinoma (LAVC) represents a major challenge. We investigated the role of pelvic exenteration as a treatment of LAVC. Women who underwent pelvic exenteration for primary and recurrent LAVC in our centre between 2001 and 2019 were included. Among the 19 women included during the study period, 14 women (73.7%) had primary LAVC while 5 women (26.3%) had recurrent disease. Surgical resection margins were microscopically clear (R0) in 94.7% of patients—14/14 undergoing primary treatment and 4/5 undergoing treatment for recurrent disease. Complete closure of the wound was achieved in 100% of women, with no wound left to heal by secondary intention. Tumour size was a predictor of requiring myocutaneous flap reconstruction, with all tumours less than 40 mm undergoing primary closure, while almost all tumours 40 mm diameter or greater (14/15 women) required flap reconstruction (p = 0.001). The 30-day major morbidity rate was 42% and there was no perioperative death. The mean overall survival was 144.8 months (2–206 months), with 1-, 2- and 5-year survival rates of 89.5%, 75.1% and 66.7%, respectively. In our centre, a primary surgical approach to the management of LAVC has resulted in good survival outcomes with acceptable morbidity rates.
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Affiliation(s)
- Ganiy Opeyemi Abdulrahman
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
| | - Nagindra Das
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
| | - Thipparajapura V. Chandrasekaran
- Department of Gastrointestinal and Colorectal Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK; (T.V.C.); (U.K.)
| | - Umesh Khot
- Department of Gastrointestinal and Colorectal Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK; (T.V.C.); (U.K.)
| | - Peter J. Drew
- Welsh Centre for Burns and Plastic Surgery, Swansea Bay University Health Board, Swansea SA6 6NL, UK;
| | - Pradeep Bose
- Department of Urology, Swansea Bay University Health Board, Swansea SA6 6NL, UK;
| | - Jessica N. Vet
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
| | - Nasima Tofazzal
- Department of Cellular Pathology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (N.T.); (S.R.)
| | - Shaun Roberts
- Department of Cellular Pathology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (N.T.); (S.R.)
| | - Kerryn Lutchman Singh
- Swansea Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, Swansea Bay University Health Board, Swansea SA2 8QA, UK; (G.O.A.); (N.D.); (J.N.V.)
- Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
- Correspondence:
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21
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Extended pelvic resection for gynecological malignancies: A review of out-of-the-box surgery. Gynecol Oncol 2022; 165:393-400. [PMID: 35331571 DOI: 10.1016/j.ygyno.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/27/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
The term 'out-of-the-box surgery' in gynecologic oncology was recently coined to describe the resection of tumor growing out of the endopelvic cavity. In the specific case of pelvic sidewall involvement, a laterally extended pelvic resection may be required. As previously defined by Höckel, this resection requires the en bloc removal of structures including the pelvic sidewall muscles, bones, nerves, and/or major vessels. This complex radical procedure leads to tumor-free margins in more than 75% of the patients, with reliable functional results. The rate of recurrence and overall survival are directly correlated with clear resection margins. Progress in imaging, surgical techniques, and perioperative care currently offer the opportunity to attempt surgical curative resection in selected patients for whom palliative therapy was the only alternative. However, the procedure is associated with a high rate of major postoperative complications affecting up to 60% of patients. Multidisciplinary expert centers are the most likely to achieve this complex surgery with favorable oncological outcomes. The aim of this review is to summarize the key issues of out-of-the-box surgery in gynecologic cancer.
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22
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Bouraoui I, Bouaziz H, Tounsi N, Ben Romdhane R, Hechiche M, Slimane M, Rahal K. Survival After Pelvic Exenteration for Cervical Cancer. J Obstet Gynaecol India 2022; 72:66-71. [PMID: 35125740 PMCID: PMC8804146 DOI: 10.1007/s13224-021-01502-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/15/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The purpose of this work was to identify the results of pelvic exenteration for recurrent, persistent or locally advanced cervical cancer in terms of survival performed for 41 patients in Salah Azaiez Institute. PATIENTS AND METHODS We conducted a retrospective unicentric study. The association between PE and OS was estimated using the method of Kaplan-Meier using SPSS ver 24. RESULTS Median age at the time of intervention was 53.9 years old. FIGO stage IIB was the most frequent (46.3%). Eighteen patients had pelvic exenteration after neoadjuvant treatment. Resection margins were free of tumor in 83.3% of cases. Twenty-three patients underwent pelvic exenteration for recurrence of cervical cancer treated. The median time of recurrence was 23.4 months. Free resection margins were obtained in 69.5% of cases. Postoperative complications were noted in 61% of patients. Two deaths were seen in the early postoperative period. After a median follow-up of 40.5 months, 24.4% of recurrences were noted. Overall survival at 5 years was 51% and recurrence-free survival at one year was 39%. Prognostic factors which impact overall and recurrence-free survival were the size of recurrence and resection margins after exenteration. The time between the end of initial treatment and recurrence was the only predictive factor of recurrence after pelvic exenteration. CONCLUSION Pelvic exenteration remains a curative treatment of cervical cancer in certain indications despite high morbidity. A rigorous preoperative selection of candidate may reduce the morbidity and improve the survival of patients.
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Affiliation(s)
- Imen Bouraoui
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
| | - Hanen Bouaziz
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
| | - Nesrine Tounsi
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
| | | | - Monia Hechiche
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
| | - Maher Slimane
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
| | - Khaled Rahal
- Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia
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23
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Pleth Nielsen CK, Sørensen MM, Christensen HK, Funder JA. Complications and survival after total pelvic exenteration. Eur J Surg Oncol 2022; 48:1362-1367. [PMID: 34998633 DOI: 10.1016/j.ejso.2021.12.472] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/26/2021] [Accepted: 12/29/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival. METHODS Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed. RESULTS The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients. CONCLUSION The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
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24
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Chuter R, Glassborow E, Speight R, Clarke M, Murray L, Radhakrishna G, Lavin V, Aspin L, Aldred M, Gregory S, Richardson J, Handley J. A treatment planning comparison of photon stereotactic ablative radiotherapy and proton beam therapy for the re-irradiation of pelvic cancer recurrence. Phys Imaging Radiat Oncol 2022; 21:78-83. [PMID: 35243036 PMCID: PMC8881531 DOI: 10.1016/j.phro.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients who experience a pelvic cancer recurrence in or near a region that received initial radiotherapy, typically have few options for treatment. Organs at risk (OAR) have often reached their dose constraint limits leaving minimal dose remaining for standard re-irradiation (reRT). However, photon based stereotactic ablative radiotherapy (SABR) has been utilised for reRT with promising initial results although meeting OAR constraints can be challenging. Proton beam therapy (PBT) could offer an advantage. MATERIALS AND METHODS SABR plans used for treatment for ten pelvic reRT patients were dosimetrically compared to PBT plans retrospectively planned using the same CT and contour data. PBT plans were created to match the CTV dose coverage of SABR treatment plans with V100% ≥95%. An 'as low as reasonably achievable' approach was taken to OAR tolerances with consideration of OAR dose from the initial radiation (using equivalent dose in 2 Gy fractions). RESULTS Dosimetric comparison of relevant OAR statistics showed a decrease in OAR dose using PBT over SABR in all patients, with equivalent target coverage. The largest statistically significant reduction was seen for the colon D0.5 cm3 with a median reduction from 13.1 Gy to 5.9 Gy. There were statistically significant dose reductions in the median dose to small bowel, sacral plexus and cauda equina. CONCLUSION PBT has the potential for significant dose reductions for OARs in the pelvic reRT setting compared to SABR. However, it remains unclear if the magnitude of these OAR dose reductions will translate into clinical benefit.
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Affiliation(s)
- R. Chuter
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Heath, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - E. Glassborow
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - R. Speight
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M. Clarke
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - L. Murray
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - G. Radhakrishna
- Clinical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - V. Lavin
- Clinical Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - L. Aspin
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M Aldred
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S Gregory
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J. Richardson
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Heath, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - J. Handley
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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25
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Bizzarri N, Foschi N, Loverro M, Tortorella L, Santullo F, Rosati A, Gueli Alletti S, Costantini B, Gallotta V, Ferrandina G, Fagotti A, Fanfani F, Ercoli A, Chiantera V, Scambia G, Vizzielli G. Indocyanine Green to Assess Vascularity of Ileal Conduit Anastomosis During Pelvic Exenteration for Recurrent/Persistent Gynecological Cancer: A Pilot Study. Front Oncol 2021; 11:727725. [PMID: 34950574 PMCID: PMC8691262 DOI: 10.3389/fonc.2021.727725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Pelvic exenteration performed for recurrent/persistent gynecological malignancies has been associated with urological short- and long-term morbidity due to altered vascularization of tissues for previous radiotherapy. The aims of the present study were to describe the use of intravenous indocyanine green (ICG) to assess vascularity of urinary diversion (UD) after pelvic exenteration for gynecologic cancers, to evaluate the feasibility and safety of this technique, and to assess the postoperative complications. Methods Prospective, observational, single-center, pilot study including consecutive patients undergoing anterior or total pelvic exenteration due to persistent/recurrent gynecologic cancers between August 2020 and March 2021 at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. All patients underwent intravenous injection of 3–6 ml of ICG (1.25 mg/ml) once the UD was completed. A near-infrared camera was used to evaluate ICG perfusion of anastomoses (ileum–ileum, right and left ureter with small bowel, and colostomy or colorectal sides of anastomosis) a few seconds after ICG injection. Results Fifteen patients were included in the study. No patient reported adverse reactions to ICG injection. Only 3/15 patients (20.0%) had an optimal ICG perfusion in all anastomoses. The remaining 12 (80.0%) patients had at least one ICG deficit; the most common ICG deficit was on the left ureter: 3 (20.0%) vs. 1 (6.7%) patient had no ICG perfusion on the left vs. right ureter, respectively (p = 0.598). 8/15 (53.3%) and 6/15 (40.0%) patients experienced grade ≥3 30-day early and late postoperative complications, respectively. Of these, two patients had early and one had late postoperative complications directly related to poor perfusion of anastomosis (UD leak, ileum–ileum leak, and benign ureteric stricture); all these cases had a suboptimal intraoperative ICG perfusion. Conclusion The use of ICG to intraoperatively assess the anastomosis perfusion at time of pelvic exenteration for gynecologic malignancy is a feasible and safe technique. The different vascularization of anastomotic stumps may be related to anatomical sites and to previous radiation treatment. This approach could be in support of selecting patients at higher risk of complications who may need personalized follow-up.
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Affiliation(s)
- Nicolò Bizzarri
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Nazario Foschi
- UOC Clinica Urologica, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Matteo Loverro
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lucia Tortorella
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Santullo
- UOC Chirurgia Peritoneo e Retroperitoneo, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Andrea Rosati
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Salvatore Gueli Alletti
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Barbara Costantini
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Valerio Gallotta
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gabriella Ferrandina
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Ercoli
- Department of Gynecologic Oncology and Minimally-Invasive Gynecologic Surgery, Università Degli Studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Vito Chiantera
- ARNAS Ospedali Civico Di Cristina Benfratelli, Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Giovanni Scambia
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vizzielli
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Obstetrics and Gynecology Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy
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Cianci S, Arcieri M, Vizzielli G, Martinelli C, Granese R, La Verde M, Fagotti A, Fanfani F, Scambia G, Ercoli A. Robotic Pelvic Exenteration for Gynecologic Malignancies, Anatomic Landmarks, and Surgical Steps: A Systematic Review. Front Surg 2021; 8:790152. [PMID: 34917648 PMCID: PMC8669266 DOI: 10.3389/fsurg.2021.790152] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Pelvic exenteration represents the last resort procedure for patients with advanced primary or recurrent gynecological malignancy. Pelvic exenteration can be divided into different subgroup based on anatomical extension of the procedures. The growing application of the minimally invasive surgical approach unlocked new perspectives for gynecologic oncology surgery. Minimally invasive surgery may offer significant advantages in terms of perioperative outcomes. Since 2009, several Robotic Assisted Laparoscopic Pelvic Exenteration experiences have been described in literature. The advent of robotic surgery resulted in a new spur to the worldwide spread of minimally invasive pelvic exenteration. We present a review of the literature on robotic-assisted pelvic exenteration. The search was conducted using electronic databases from inception of each database through June 2021. 13 articles including 53 patients were included in this review. Anterior exenteration was pursued in 42 patients (79.2%), 2 patients underwent posterior exenteration (3.8%), while 9 patients (17%) were subjected to total exenteration. The most common urinary reconstruction was non-continent urinary diversion (90.2%). Among the 11 women who underwent to total or posterior exenteration, 8 (72.7%) received a terminal colostomy. Conversion to laparotomy was required in two cases due to intraoperative vascular injury. Complications' report was available for 51 patients. Fifteen Dindo Grade 2 complications occurred in 11 patients (21.6%), and 14 grade 3 complications were registered in 13 patients (25.5%). Only grade 4 complications were reported (2%). In 88% of women, the resection margins were negative. Pelvic exenteration represents a salvage procedure in patients with recurrent or persistent gynecological cancers often after radiotherapy. A careful patient selection remains the milestone of such a mutilating surgery. The introduction of the minimally invasive approach has led to advantages in terms of perioperative outcomes compared to classic open surgery. This review shows the feasibility of robotic pelvic exenteration. An important step forward should be to investigate the potential equivalence between robotic approaches and the laparotomic one, in terms of long-term oncological outcomes.
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Affiliation(s)
- Stefano Cianci
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
- *Correspondence: Stefano Cianci
| | - Martina Arcieri
- Department of Biomedical, Dental, Morphological, and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Giuseppe Vizzielli
- Department of Obstetrics Gynecology and Pediatrics, University of Udine, Udine, Italy
| | - Canio Martinelli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Roberta Granese
- Department of Biomedical, Dental, Morphological, and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Obstetrics and Gynecology, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Obstetrics and Gynecology, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Obstetrics and Gynecology, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Ercoli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
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Slevin F, Aitken K, Alongi F, Arcangeli S, Chadwick E, Chang AR, Cheung P, Crane C, Guckenberger M, Jereczek-Fossa BA, Kamran SC, Kinj R, Loi M, Mahadevan A, Massaccesi M, Mendez LC, Muirhead R, Pasquier D, Pontoriero A, Spratt DE, Tsang YM, Zelefsky MJ, Lilley J, Dickinson P, Hawkins MA, Henry AM, Murray LJ. An international Delphi consensus for pelvic stereotactic ablative radiotherapy re-irradiation. Radiother Oncol 2021; 164:104-114. [PMID: 34560186 DOI: 10.1016/j.radonc.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Stereotactic Ablative Radiotherapy (SABR) is increasingly used to treat metastatic oligorecurrence and locoregional recurrences but limited evidence/guidance exists in the setting of pelvic re-irradiation. An international Delphi study was performed to develop statements to guide practice regarding patient selection, pre-treatment investigations, treatment planning, delivery and cumulative organs at risk (OARs) constraints. MATERIALS AND METHODS Forty-one radiation oncologists were invited to participate in three online surveys. In Round 1, information and opinion was sought regarding participants' practice. Guidance statements were developed using this information and in Round 2 participants were asked to indicate their level of agreement with each statement. Consensus was defined as ≥75% agreement. In Round 3, any statements without consensus were re-presented unmodified, alongside a summary of comments from Round 2. RESULTS Twenty-three radiation oncologists participated in Round 1 and, of these, 21 (91%) and 22 (96%) completed Rounds 2 and 3 respectively. Twenty-nine of 44 statements (66%) achieved consensus in Round 2. The remaining 15 statements (34%) did not achieve further consensus in Round 3. Consensus was achieved for 10 of 17 statements (59%) regarding patient selection/pre-treatment investigations; 12 of 13 statements (92%) concerning treatment planning and delivery; and 7 of 14 statements (50%) relating to OARs. Lack of agreement remained regarding the minimum time interval between irradiation courses, the number/size of pelvic lesions that can be treated and the most appropriate cumulative OAR constraints. CONCLUSIONS This study has established consensus, where possible, in areas of patient selection, pre-treatment investigations, treatment planning and delivery for pelvic SABR re-irradiation for metastatic oligorecurrence and locoregional recurrences. Further research into this technique is required, especially regarding aspects of practice where consensus was not achieved.
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Affiliation(s)
- Finbar Slevin
- Leeds Teaching Hospitals NHS Trust, UK; University of Leeds, UK.
| | - Katharine Aitken
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - Filippo Alongi
- IRCCS Ospedale Sacro Cuore Don Calabria, Negrar, Italy; University of Brescia, Italy.
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Monza, Italy.
| | | | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea.
| | | | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloane Kettering Cancer Centre, New York, USA.
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland.
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy.
| | - Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA.
| | - Rémy Kinj
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Switzerland.
| | - Mauro Loi
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Italy.
| | - Anand Mahadevan
- Geisinger Medical Center - Radiation Oncology, Danville, USA.
| | - Mariangela Massaccesi
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica e Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, Roma, Italy.
| | - Lucas C Mendez
- Division of Radiation Oncology, London Health Sciences Centre, Canada.
| | | | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France; CRIStAL, UMR 9181, Lille University, Lille, France.
| | - Antonio Pontoriero
- Department of BIOMORF, Radiation Oncology Unit, University of Messina, Italy.
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Centre, Cleveland, USA.
| | | | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloane Kettering Cancer Centre, New York, USA.
| | | | | | - Maria A Hawkins
- Medical Physics and Biochemical Engineering, University College London, UK.
| | - Ann M Henry
- Leeds Teaching Hospitals NHS Trust, UK; University of Leeds, UK.
| | - Louise J Murray
- Leeds Teaching Hospitals NHS Trust, UK; University of Leeds, UK.
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Gheorghe M, Cozlea AL, Kiss SL, Stanca M, Căpîlna ME, Bacalbașa N, Moldovan AA. Primary pelvic exenteration: Our experience with 23 patients from a single institution. Exp Ther Med 2021; 22:1060. [PMID: 34434274 PMCID: PMC8353644 DOI: 10.3892/etm.2021.10494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022] Open
Abstract
This study was designed with an aim to share our experience of primary pelvic exenterations. The study included 23 patients with different types of pelvic cancer enrolled at a single institution between November 2011 and July 2020. The patient mean age was 55 years (range, 43-72 years) and the oncological indications included: Stage IVa cervical cancer (11 cases, 48.9%), stage IVa endometrial cancer (1 case, 4.3%), stage IVa vaginal cancer (6 cases, 26%), stage IIIb bladder cancer (3 cases, 13%), stage IIIc rectal cancer (1 case, 4.3%) and undifferentiated pelvic sarcoma (1 case, 4.3%). Total, anterior, and posterior pelvic exenterations were performed on 34.4, 56.5 and 13% of cases, respectively. Related to levator ani muscle, 13 (56.5%) pelvic exenterations were supralevatorian, 10 (43.5%) infralevatorian, and 5 (21.7%) were infralevatorian with vulvectomy. No major intraoperative complications occurred. Seven patients (30.5%) developed early complications, 4 of them (17.4%) required reoperation and 1 (4.3%) perioperative death caused by a pulmonary embolism was recorded. Only 1 patient experienced a late complication, a urostomy stenosis. Over a median follow-up period of 35 months, 8 (34.8%) patients died. The median overall survival (OS) was 33 months (range, 1-96 months). The 2-year and 5-year survival rates were 72 and 66%, respectively. Primary pelvic exenteration may be related with various postoperative complications, without high perioperative morality and with long-term survival.
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Affiliation(s)
- Mihai Gheorghe
- First Obstetrics and Gynecology Clinic, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology, 540136 Târgu Mureș, Romania
| | - Alexandra Lavinia Cozlea
- First Obstetrics and Gynecology Clinic, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology, 540136 Târgu Mureș, Romania
| | - Szilard Leo Kiss
- First Obstetrics and Gynecology Clinic, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology, 540136 Târgu Mureș, Romania
| | - Mihai Stanca
- First Obstetrics and Gynecology Clinic, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology, 540136 Târgu Mureș, Romania
| | - Mihai Emil Căpîlna
- First Obstetrics and Gynecology Clinic, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology, 540136 Târgu Mureș, Romania
| | - Nicolae Bacalbașa
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020022 Bucharest, Romania
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Lei T, Guo X, Gong C, Chen X, Ran F, He Y, Shi Q, He J. High-intensity focused ultrasound ablation in the treatment of recurrent ovary cancer and metastatic pelvic tumors: a feasibility study. Int J Hyperthermia 2021; 38:282-287. [PMID: 33612045 DOI: 10.1080/02656736.2021.1889698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To explore the feasibility of high-intensity focused ultrasound (HIFU) ablation for treating metastatic pelvic tumors and recurrent ovary cancer. MATERIALS AND METHODS Eight patients with metastatic pelvic tumors or recurrent ovary cancer were enrolled in this study. Among them, 5 patients had ovarian cancer, 1 had cervical cancer, 1 had endometrial cancer, and 1 had rectal cancer. Six of them received abdominal surgical operation for their primary cancer, no one received radiotherapy. HIFU treatment was performed under conscious sedation. Vital signs were monitored during the procedure, and adverse effects were recorded. Postoperative follow-up was performed to observe pain relief and the improvement of the patient's quality of life. RESULTS The median age of the patients was 54 (range: 33-76) years, with a total of 12 lesions. The average volume of the lesions was 238.0 cm3. Six patients completed 12 months follow-up. Postoperative pain relief rate was 60% (3/5), and the quality of life improved in the short term. The main adverse effect of HIFU was pain in the treated area, with the pain score lower than 4, and all of which was self-relieved within 1 day after HIFU treatment. No serious complications such as skin burn, intestinal perforation, and nerve injury occurred. CONCLUSION HIFU is feasible for the treatment of metastatic pelvic tumors or recurrent ovary cancer without serious complications. Therefore, HIFU seems a promising treatment for recurrent ovary cancer, metastatic pelvic tumors from cervical cancer, endometrial cancer, and rectal cancer.
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Affiliation(s)
- Tingting Lei
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
| | - Xu Guo
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Department of Oncology, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
| | - Chunmei Gong
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Xuelian Chen
- Department of Oncology, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
| | - Feng Ran
- Department of Oncology, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
| | - Yuchun He
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Jia He
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Sichuan, PR China
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30
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Causa Andrieu PI, Woo S, Rios-Doria E, Sonoda Y, Ghafoor S. The role of imaging in pelvic exenteration for gynecological cancers. Br J Radiol 2021; 94:20201460. [PMID: 33960814 DOI: 10.1259/bjr.20201460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Pelvic exenteration (PE) is one of the most challenging gynecologic oncologic surgeries and is an overriding term for different procedures that entail radical en bloc resection of the female reproductive organs and removal of additional adjacent affected pelvic organs (bladder, rectum, anus, etc.) with concomitant surgical reconstruction to restore bodily functions. Multimodality cross-sectional imaging with MRI, PET/CT, and CT plays an integral part in treatment decision-making, not only for the appropriate patient selection but also for surveillance after surgery. The purpose of this review is to provide a brief background on pelvic exenteration in gynecologic cancers and to familiarize the reader with the critical radiological aspects in the evaluation of patients for this complex procedure. The focus of this review will be on how imaging can aid in treatment planning and guide management.
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Affiliation(s)
| | - Sungmin Woo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Eric Rios-Doria
- Department of Gynecological Surgery, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Yukio Sonoda
- Department of Gynecological Surgery, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Soleen Ghafoor
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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31
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Ter Glane L, Hegele A, Wagner U, Boekhoff J. Pelvic exenteration for recurrent or advanced gynecologic malignancies - Analysis of outcome and complications. Gynecol Oncol Rep 2021; 36:100757. [PMID: 33898694 PMCID: PMC8059060 DOI: 10.1016/j.gore.2021.100757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023] Open
Abstract
Overall survival was 25.5% with a median follow-up of 47 months. Positive resection margins had a negative impact on survival. Neoadjuvant treatment correlated with achieving negative margins. 19% had no postoperative complications, major complications were observed in 40.4%
Pelvic exenterations are known to be a last resort therapeutic option for advanced or recurrent gynecologic malignancies, which are known to have poor prognosis. All women treated with anterior (APE) or total (TPE) pelvic exenteration at our University hospital within a five-year period were identified and their data retrospectively analysed. Parameters such as demographic information, tumor type and stage, previous therapy as well as complication rate and overall survival were evaluated. 47 women were enrolled in this study. Most common indication for PE was cervical cancer (51.1%) followed by carcinoma of the vagina (17%), vulva (10.6%), endometrium (8.5%), ovaries (4.3%) and uterus (2.1%). Patients had received 1, 2 or 3 treatment modalities prior in 12.8%, 38.8% and 21.2% respectively. Predominant urinary diversion was ileum conduit (75.5%). Major complications (Clavien Dindo ≥ III) were observed in 40.4%, none in 19.2%. Early mortality was 4.3%. Median Overall Survival (mOS) was 14 months with 2- and 3-year survival rates of 38.8% and 21.2% respectively. After a median follow up of 47 months, 25.5% were still alive. Excluding patients with metastatic disease (n = 10), mOS was 20.6 months with 2- and 3-year survival rates of 46% and 35.2%. OS was significantly worse for patients with positive margins (p = 0.003). Receiving neoadjuvant treatment (25.5%) correlated with negative margins (p = 0.013) but not with overall survival. PE is feasible with acceptable complication and mortality rates. The long-time benefit is notable bearing in mind the extensive nature of the malignancies and the procedure undertaken.
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Affiliation(s)
- L Ter Glane
- Department of Urology and Pediatric Urology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
| | - A Hegele
- Department of Urology and Pediatric Urology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany.,Urological Center Mittelhessen, DRK Hospital Biedenkopf, Germany
| | - U Wagner
- Department of Gynecology, Gynecological Oncology and Gynecological Endocrinology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
| | - J Boekhoff
- Department of Gynecology, Gynecological Oncology and Gynecological Endocrinology, University Hospital of Giessen and Marburg (UKGM), Marburg, Germany
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Floberg JM, Zhang J, Muhammad N, DeWees TA, Inkman M, Chen K, Lin AJ, Rashmi R, Jayachandran K, Edelson BT, Siegel BA, Dehdashti F, Grigsby PW, Markovina S, Schwarz JK. Standardized Uptake Value for 18F-Fluorodeoxyglucose Is a Marker of Inflammatory State and Immune Infiltrate in Cervical Cancer. Clin Cancer Res 2021; 27:4245-4255. [PMID: 33820781 DOI: 10.1158/1078-0432.ccr-20-4450] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/09/2021] [Accepted: 04/01/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Chemoradiotherapy for locally advanced cervical cancer fails in over a third of patients. Biomarkers with therapeutic implications are therefore needed. We investigated the relationship between an established prognostic marker, maximum standardized uptake value (SUVmax) on 18F-fluorodeoxyglucose positron emission tomography, and the inflammatory and immune state of cervical cancers. EXPERIMENTAL DESIGN An SUVmax most prognostic for freedom from progression (FFP) was identified and compared with known prognostic clinical variables in a cohort of 318 patients treated with definitive radiation with prospectively collected clinical data. Gene set enrichment analysis (GSEA) and CIBERSORT of whole-transcriptome data from 68 patients were used to identify biological pathways and immune cell subpopulations associated with high SUVmax. IHC using a tissue microarray (TMA, N = 82) was used to validate the CIBERSORT findings. The impact of macrophages on cervical cancer glucose metabolism was investigated in coculture experiments. RESULTS SUVmax <11.4 was most prognostic for FFP (P = 0.001). The GSEA showed that high SUVmax is associated with increased gene expression of inflammatory pathways, including JAK/STAT3 signaling. CIBERSORT and CD68 staining of the TMA showed high SUVmax tumors are characterized by a monocyte-predominant immune infiltrate. Coculture of cervical cancer cells with macrophages or macrophage-conditioned media altered glucose uptake, and IL6 and JAK/STAT3 signaling contribute to this effect. CONCLUSIONS SUVmax is a prognostic marker in cervical cancer that is associated with activation of inflammatory pathways and tumor infiltration of myeloid-derived immune cells, particularly macrophages. Macrophages contribute to changes in cervical cancer glucose metabolism.See related commentary by Williamson et al., p. 4136.
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Affiliation(s)
- John M Floberg
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jin Zhang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Naoshad Muhammad
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Todd A DeWees
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Phoenix, Arizona
| | - Matthew Inkman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin Chen
- Washington University School of Medicine, St. Louis, Missouri
| | - Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ramachandran Rashmi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kay Jayachandran
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian T Edelson
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Barry A Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Farrokh Dehdashti
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Perry W Grigsby
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Julie K Schwarz
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri. .,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri.,Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri
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Jain V, Debnath S, Rawal S. Salvage robotic anterior pelvic exenteration for cervical cancer: technique and feasibility. J Robot Surg 2021; 15:945-953. [PMID: 33515209 DOI: 10.1007/s11701-021-01195-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
The aim of our study was to explain the technique and evaluate the feasibility and safety of robotic anterior pelvic exenteration in cases of residual/recurrent cervical cancer as a salvage therapy. The study was conducted as a retrospective review of all the cases of central residual/recurrent cervical cancer who underwent anterior pelvic exenteration by robotic approach with curative intent at our centre between January 2013 and December 2019. Information regarding various treatment related parameters like duration of surgery, estimated blood loss, length of hospital stay, early and late complications and recurrence and survival was collected and evaluated. 14 patients underwent anterior pelvic exenteration by robotic approach in this period. The median age of patients at time of exenteration was 52.5 years. 13 out of 14 patients had received combined chemoradiation as a part of intial treatment. The median duration of surgery was 305 min with a median estimated blood loss of 135 ml and median length of hospital stay of 6.5 days. Early complications like urosepsis, uretero-ileal anastomotic leak and paralytic ileus occurred in 36% patients and late complications like ureteric stricture and bowel perforation occurred in 28.6% patients. Negative surgical margins could be achieved in all the patients. Over a median follow-up period of 17.5 months, five patients developed recurrence and five patients experienced mortality, with four out of five patients dying due to recurrent disease. The 12-month DFS was 68.2% and the 12-month OS was 77.1%. Robotic anterior pelvic exenteration is a safe and feasible option in selected patients with recurrent/residual cervical cancer as a salvage procedure, with acceptable morbidity and mortality.
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Affiliation(s)
- Vandana Jain
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector-V, Rohini, Delhi, 110085, India.
| | - Subrata Debnath
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector-V, Rohini, Delhi, 110085, India
| | - Sudhir Rawal
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector-V, Rohini, Delhi, 110085, India
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Utilization and perioperative outcome of minimally invasive pelvic exenteration in gynecologic malignancies: A national study in the United States. Gynecol Oncol 2021; 161:39-45. [PMID: 33402282 DOI: 10.1016/j.ygyno.2020.12.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/22/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy. METHODS This comparative effectiveness study is a retrospective population-based analysis of the National Inpatient Sample from 10/2008-9/2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were evaluated based on the use of laparoscopic or robotic-assisted surgery. Patient demographics and intraoperative/postoperative complications related to a minimally invasive surgical approach were assessed. RESULTS Among 1376 women who underwent pelvic exenteration, 49 (3.6%) had the procedure performed via a minimally invasive approach. The majority of minimally invasive cases were robotic-assisted (51.0%). Women in the minimally invasive group were more likely to be old, white, have cervical/uterine cancers, and receive urinary diversion, but less frequently received vaginal reconstruction or colostomy when compared to those in the open surgery group (P < 0.05). Overall perioperative complication rates were similar between the minimally invasive and open surgery groups (79.6% versus 77.7%, P = 0.862), but the minimally invasive group had a decreased risk of high-risk complications compared to the open surgery group (adjusted-odds ratio 0.19, 95% confidence interval 0.07-0.51). Specifically, a minimally invasive approach was associated with decreased incidence of sepsis and thromboembolism compared to an open approach (P < 0.05). The minimally invasive group had a shorter length of stay (median, 9 versus 14 days) and lower total charge (median, $127,875 versus $208,591) compared to the open surgery group (P < 0.05). CONCLUSION Laparotomy remains the main surgical approach for pelvic exenteration for gynecologic malignancy and minimally invasive surgery was infrequently utilized during the study period in the United States. Before widely adopting this surgical approach, the utility and role of minimally invasive pelvic exenteration requires further investigation.
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Pelvic Exenteration for Primary Advanced and Recurrent Vaginal Cancer: Clinical Outcome for 37 Patients. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Reed N, Balega J, Barwick T, Buckley L, Burton K, Eminowicz G, Forrest J, Ganesan R, Harrand R, Holland C, Howe T, Ind T, Iyer R, Kaushik S, Music R, Sadozye A, Shanbhag S, Siddiqui N, Syed S, Percival N, Whitham NL, Nordin A, Fotopoulou C. British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2020; 256:433-465. [PMID: 33143928 DOI: 10.1016/j.ejogrb.2020.08.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 01/20/2023]
Abstract
Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.
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Affiliation(s)
- Nick Reed
- Beatson Oncology Centre, Glasgow, United Kingdom.
| | | | | | - Lynn Buckley
- Clinical Nurse Specialist, Hull University Teaching Hospitals NHS Trust, United Kingdom
| | | | | | | | | | | | | | | | - Thomas Ind
- Royal Marsden Hospital, London, United Kingdom
| | - Rema Iyer
- East Kent Hospitals University Foundation NHS Trust, United Kingdom
| | | | - Robert Music
- Jo's Cervical Cancer Trustt, London, United Kingdom
| | | | - Smruta Shanbhag
- University Hospitals Coventry and Warwickshire NHS Trust, United Kingdom
| | | | - Sheeba Syed
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Natasha Lauren Whitham
- Lancashire Teaching Hospitals (Royal Preston Hospital, Fulwood, Lancashire), United Kingdom
| | - Andy Nordin
- East Kent Gynaecological Oncology Centre, East Kent Hospitals University Foundation Nhs Trust, Queen Elizabeth The Queen Mother Hospital, Margate, United Kingdom
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Lewandowska A, Szubert S, Koper K, Koper A, Cwynar G, Wicherek L. Analysis of long-term outcomes in 44 patients following pelvic exenteration due to cervical cancer. World J Surg Oncol 2020; 18:234. [PMID: 32878646 PMCID: PMC7469312 DOI: 10.1186/s12957-020-01997-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/11/2020] [Indexed: 01/15/2023] Open
Abstract
Background Pelvic exenteration (PE) may be associated with prolonged overall survival (OS) in selected patients with advanced or recurrent cervical cancer. However, the factors related to improved survival following PE are not clearly defined. The aim of this study was to perform a retrospective analysis of OS rates in a group of patients undergoing PE in order to identify the factors related to improved long-term outcomes. Methods Our study group consisted of 44 patients, including 21 squamous cell cancer (SCC) patients, 22 patients with adenocarcinomas (AC) of the cervix, and one patient with undifferentiated cervical carcinoma. The patients were categorized according to the type of surgery, namely, primary surgery (12 patients) or surgery due to cancer recurrence (32 patients). Results In the group of patients with recurrent cervical cancer, we found that improved OS correlated with the SCC histological type and the presence of vaginal fistula. The need for reoperation within 30 days and the presence of severe adverse events significantly worsened the prognosis. We found a non significant trend toward improved survival in those patients with tumor-free margins. Lymph node metastases, the initial stage of the disease, the time to recurrence, and a history of hysterectomy had no impact on patients’ OS. In the group of patients undergoing primary PE, we observed a trend toward improved survival among those diagnosed with vaginal fistula. Conclusions Pelvic exenteration seemed to improve the long-term outcomes for patients with SCC cancer recurrence and vaginal fistula whose surgery was unrelated to severe adverse events.
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Affiliation(s)
- Agnieszka Lewandowska
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Bielanski Hospital, Ceglowska 80 St, 01-809, Warsaw, Poland
| | - Sebastian Szubert
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Bielanski Hospital, Ceglowska 80 St, 01-809, Warsaw, Poland.,Clinical Department of Gynecological Oncology, The Franciszek Lukaszczyk Oncological Center, Bydgoszcz, Poland
| | - Krzysztof Koper
- Department of Chemotherapy, The Franciszek Lukaszczyk Oncological Center, Bydgoszcz, Poland
| | - Agnieszka Koper
- Department of Chemotherapy, The Franciszek Lukaszczyk Oncological Center, Bydgoszcz, Poland
| | - Grzegorz Cwynar
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Bielanski Hospital, Ceglowska 80 St, 01-809, Warsaw, Poland
| | - Lukasz Wicherek
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Bielanski Hospital, Ceglowska 80 St, 01-809, Warsaw, Poland.
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Zanini LAG, Reis RJ, Laporte GA, Vieira SC, Zanella JDF, Machado GM. Analysis of the surgical management of patients with recurrent cervical cancer after radiotherapy and chemotherapy. Rev Col Bras Cir 2020; 47:e20202443. [PMID: 32555966 DOI: 10.1590/0100-6991e-20202443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/02/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze the results of morbidity and survival after curative and palliative surgery in recurrent cervical cancer patients who underwent chemoradiation as their primary treatment. Another goal was to assess the factors associated with curative and non-curative procedures. METHODS This was a retrospective cohort consisting of patients undergoing surgery curative and palliative from January 2011 to December 2017 at a high complexity oncology center. Outcome of morbidity was reported according to the Clavien-Dindo classification, and survival analysis was carried out using the Kaplan-Meir method. To assess the factors associated with the procedures, a univariate analysis using the Mann-Whitney U test was performed. RESULTS Two radical hysterectomies, three pelvic exenterations with curative intent, and five palliatives pelvic exenterations were performed. In the curative group, there were major complications in 40% of the cases, and the median survival time was 16 months. In the palliative group, there were major complications in 60% of the cases, and the median survival time was 5 months. Advanced staging (p-value= 0.02), symptoms (p-value=0.04), tumor size greater than five centimeters (p-value=0.04), and more than three organs involved (p-value=0.003) were factors significantly associated with non-curative surgery. CONCLUSIONS The morbidity rates of this study were higher in palliative group, and the median survival time was lower in the palliative group than the curative group, but this difference in survival was not statistically significant. Advanced stage, symptoms, tumor size and number of organs involved are factors that should be taken into consideration when indicating surgical salvage.
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Affiliation(s)
| | - Rosilene Jara Reis
- Santa Casa de Misericórdia of Porto Alegre, Cirurgia oncológica - Porto Alegre - RS - Brasil
| | | | | | - Janice de Fátima Zanella
- Universidade de Cruz Alta, Programa de Pós Graduação em Atenção Integral à Saúde - Cruz Alta - RS - Brasil
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The intelligent knife (iKnife) and its intraoperative diagnostic advantage for the treatment of cervical disease. Proc Natl Acad Sci U S A 2020; 117:7338-7346. [PMID: 32179675 PMCID: PMC7132269 DOI: 10.1073/pnas.1916960117] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clearance of surgical margins in early cervical cancer prevents the need for adjuvant chemoradiation and associated morbidity and allows fertility preservation. Clearance of disease is also crucial in the surgical management of local recurrence of cervical tumors with exenterative surgery. In this study intelligent knife technology was able to discriminate healthy from abnormal lesions on the cervix with high accuracy, highlighting the potential to improve intraoperative management of women treated surgically for cervical cancer and, as a result, patient outcomes. While pilot experiments in vivo are encouraging, accuracy remains to be validated in larger patient cohorts. Future studies could also explore whether this technology could be used for management of cervical preinvasive disease. Clearance of surgical margins in cervical cancer prevents the need for adjuvant chemoradiation and allows fertility preservation. In this study, we determined the capacity of the rapid evaporative ionization mass spectrometry (REIMS), also known as intelligent knife (iKnife), to discriminate between healthy, preinvasive, and invasive cervical tissue. Cervical tissue samples were collected from women with healthy, human papilloma virus (HPV) ± cervical intraepithelial neoplasia (CIN), or cervical cancer. A handheld diathermy device generated surgical aerosol, which was transferred into a mass spectrometer for subsequent chemical analysis. Combination of principal component and linear discriminant analysis and least absolute shrinkage and selection operator was employed to study the spectral differences between groups. Significance of discriminatory m/z features was tested using univariate statistics and tandem MS performed to elucidate the structure of the significant peaks allowing separation of the two classes. We analyzed 87 samples (normal = 16, HPV ± CIN = 50, cancer = 21 patients). The iKnife discriminated with 100% accuracy normal (100%) vs. HPV ± CIN (100%) vs. cancer (100%) when compared to histology as the gold standard. When comparing normal vs. cancer samples, the accuracy was 100% with a sensitivity of 100% (95% CI 83.9 to 100) and specificity 100% (79.4 to 100). Univariate analysis revealed significant MS peaks in the cancer-to-normal separation belonging to various classes of complex lipids. The iKnife discriminates healthy from premalignant and invasive cervical lesions with high accuracy and can improve oncological outcomes and fertility preservation of women treated surgically for cervical cancer. Larger in vivo research cohorts are required to validate these findings.
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Matsuo K, Matsuzaki S, Mandelbaum RS, Matsushima K, Klar M, Grubbs BH, Roman LD, Wright JD. Hospital surgical volume and perioperative mortality of pelvic exenteration for gynecologic malignancies. J Surg Oncol 2020; 121:402-409. [PMID: 31746006 PMCID: PMC7523231 DOI: 10.1002/jso.25770] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES To examine the association between hospital surgical volume and perioperative mortality of pelvic exenteration performed for gynecologic malignancies. METHODS A population-based retrospective study utilizing the Nationwide Inpatient Sample was conducted to examine pelvic exenteration for gynecologic malignancies from 2001 to 2011. Annualized hospital surgical volume was defined as the average number of procedures a hospital performed per year in which at least one case was performed, and this was correlated to perioperative mortality. RESULTS A total 1912 exenterations performed at 181 centers were included. Nearly two thirds of exenteration-performing centers had a minimum surgical volume of one case per year (121 centers, 66.9%). Perioperative mortality rate was 1.8%. In multivariable analysis surgical volume remained an independent factor for perioperative mortality (adjusted-odds ratio 0.21; 95% confidence interval, 0.09-0.49; P < .001). Perioperative mortality rates were 3.7% for the centers with minimum surgical volume (1 exenteration a year), 1.4% for the centers performing more than one but two or less exenterations a year, and 0% for the top decile centers (>2 exenterations a year), respectively (P < .001). CONCLUSION Pelvic exenteration for gynecologic malignancy is a rare surgical procedure with most hospitals performing few cases annually. A higher surgical volume of pelvic exenteration was associated with lower perioperative mortality.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Rachel S. Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany
| | - Brendan H. Grubbs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Lynda D. Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jason D. Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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Cohen AC, Roane BM, Leath CA. Novel Therapeutics for Recurrent Cervical Cancer: Moving Towards Personalized Therapy. Drugs 2020; 80:217-227. [PMID: 31939072 PMCID: PMC7033025 DOI: 10.1007/s40265-019-01249-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While screening programs and HPV vaccination have decreased the incidence of cervical cancer, still over 13,000 cases occur in the USA annually. Early-stage cervical cancer has an excellent long-term prognosis, with 5-year survival for localized disease being > 90%. Survival decreases markedly for both locally advanced and metastatic disease, and both are associated with a higher risk of recurrence. Few effective treatment options exist for persistent, recurrent, or metastatic cervical cancer. In 2014, the anti-VEGF antibody bevacizumab was approved in combination with chemotherapy based on the results of the Phase III GOG-240 study. As the majority of cervical cancers have a viral etiology, which impairs the immune system, immunotherapy using checkpoint inhibitors and other agents, appears to be a promising approach. In June 2018, the US FDA approved the anti-PD1 antibody pembrolizumab for recurrent or metastatic cervical cancer with PD-L1 expression that progressed after one or more lines of chemotherapy. Another anti-PD1 antibody, cemiplimab also shows potential in this setting, either as monotherapy or combined with radiotherapy, and it is currently being evaluated in a Phase III trial. Additional checkpoint inhibitors including nivolumab, durvalumab, atezolizumab, and camrelizumab are in different stages of clinical development for the disease. Finally, an additional targeted approach being pursued involves PARP inhibitors (rucaparib and olaparib are both in Phase II) based on earlier study results.
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Affiliation(s)
- Alexander C Cohen
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon M Roane
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, 1700 6th Avenue South, Room 10250, Birmingham, AL, 35249-7333, USA
| | - Charles A Leath
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, 1700 6th Avenue South, Room 10250, Birmingham, AL, 35249-7333, USA.
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Rema P, Suchetha S, Mathew AP, George P, Mathew A, Thomas S. Pelvic Exenterations for Cervical Cancer Recurrences—a Safe Option in Indian Scenario. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Laporte GA, Zanini LAG, Zanvettor PH, Oliveira AF, Bernado E, Lissa F, Coelho MJP, Ribeiro R, Araujo RLC, Barrozo AJJ, da Costa AF, de Barros Júnior AP, Lopes A, Santos APM, Azevedo BRB, Sarmento BJQ, Marins CAM, Loureiro CMB, Galhardo CAV, Gatelli CN, Quadros CA, Pinto CV, Uchôa DNAO, Martins DRS, Doria-Filho E, Ribeiro EKMA, Pinto ERF, Dos Santos EAS, Gozi FAM, Nascimento FC, Fernandes FG, Gomes FKL, Nascimento GJS, Cucolicchio GO, Ritt GF, de Oliveira GG, Ayala GP, Guimarães GC, Ianaze GC, Gobetti GA, Medeiros GM, Güth GZ, Neto HFC, Figueiredo HF, Simões JC, Ferrari JC, Furtado JPR, Vieira LJ, Pereira LF, de Almeida LCF, Tayeh MRA, Figueiredo PHM, Pereira RSAV, Macedo RO, Sacramento RMM, Cardoso RM, Zanatto RM, Martinho RAM, Araújo RG, Pinheiro RN, Reis RJ, Goiânia SBS, Costa SRP, Foiato TF, Silva TC, Carneiro VCG, Oliveira VR, Casteleins WA. Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer. J Surg Oncol 2019; 121:718-729. [PMID: 31777095 DOI: 10.1002/jso.25759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.
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Affiliation(s)
| | | | | | | | - Enio Bernado
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - Fernando Lissa
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | - Reitan Ribeiro
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Andre Lopes
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | - Cláudio V Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Eric R F Pinto
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | | | - Gunther P Ayala
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Gustavo Z Güth
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - João C Simões
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | - José C Ferrari
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | - Lucas F Pereira
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | - Ramon O Macedo
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | - Rosilene J Reis
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
| | | | | | | | - Tyrone C Silva
- Brazilian Society of Surgical Oncology, Rio de Janeiro, Brazil
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Kroon HM, Dudi-Venkata N, Bedrikovetski S, Thomas M, Kelly M, Aalbers A, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alberda W, Andric M, Antoniou A, Austin K, Baker R, Bali M, Baseckas G, Bednarski B, Beets G, Berg P, Beynon J, Biondo S, Bordeianou L, Brunner M, Buchwald P, Burger J, Burling D, Campain N, Chan K, Chang G, Chew M, C Chong P, Christensen H, Codd M, Colquhoun A, Corr A, Coscia M, Coyne P, Creavin B, Damjanovic L, Daniels I, Davies M, Davies R, de Wilt J, Denost Q, Dietz D, Dozois E, Duff M, Eglinton T, Enriquez-Navascues J, Evans M, Fearnhead N, Frizelle F, Garcia-Granero E, Garcia-Sabrido J, Gentilini L, George M, Glynn R, Golda T, Griffiths B, Harris D, Evans M, Hagemans J, Harji D, Heriot A, Hohenberger W, Holm T, Jenkins J, Kapur S, Kanemitsu Y, Kelley S, Keller D, Kim H, Koh C, Kok N, Kokelaar R, Kontovounisios C, Kusters M, Larson D, Law W, Laurberg S, Lee P, Lydrup M, Lynch A, Mantyh C, Mathis K, Martling A, Meijerink W, Merkel S, Mehta A, McDermott F, McGrath J, Mirnezami A, Morton J, Mullaney T, Mesquita-Neto J, Nielsen M, Nieuwenhuijzen G, Nilsson P, O'Connell P, Palmer G, Patsouras D, Pellino G, Poggioli G, Quinn M, Quyn A, Radwan R, Rasheed S, Rasmussen P, Regenbogen S, Rocha R, Rothbarth J, Roxburgh C, Rutten H, Ryan É, Sagar P, Saklani A, Schizas A, Schwarzkopf E, Scripcariu V, Shaikh I, Shida D, Simpson A, Smart N, Smith J, Solomon M, Sørensen M, Steele S, Steffens D, Stocchi L, Stylianides N, Tekkis P, Taylor C, Tsarkov P, Tsukamoto S, Turner W, Tuynman J, van Ramshorst G, van Zoggel D, Vasquez-Jimenez W, Verhoef C, Verstegen M, Wakeman C, Warrier S, Wasmuth H, Weiser M, Wheeler J, Wild J, Yip J, Winter D, Sammour T. Palliative pelvic exenteration: A systematic review of patient-centered outcomes. Eur J Surg Oncol 2019; 45:1787-1795. [PMID: 31255441 DOI: 10.1016/j.ejso.2019.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/02/2019] [Accepted: 06/07/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Palliative pelvic exenteration (PPE) is a technically complex operation with high morbidity and mortality rates, considered in patients with limited life expectancy. There is little evidence to guide practice. We performed a systematic review to evaluate the impact of PPE on symptom relief and quality of life (QoL). METHODS A systematic review was conducted according to the PRISMA guidelines using Ovid MEDLINE, EMBASe, and PubMed databases for studies reporting on outcomes of PPE for symptom relief or QoL. Descriptive statistics were used on pooled patient cohorts. RESULTS Twenty-three historical cohorts and case series were included, comprising 509 patients. No comparative studies were found. Most malignancies were of colorectal, gynaecological and urological origin. Common indications for PPE were pain, symptomatic fistula, bleeding, malodour, obstruction and pelvic sepsis. The pooled median postoperative morbidity rate was 53.6% (13-100%), the median in-hospital mortality was 6.3% (0-66.7%), and median OS was 14 months (4-40 months). Some symptom relief was reported in a median of 79% (50-100%) of the patients, although the magnitude of effect was poorly measured. Data for QoL measures were inconclusive. Five studies discouraged performing PPE in any patient, while 18 studies concluded that the procedure can be considered in highly selected patients. CONCLUSION Available evidence on PPE is of low-quality. Morbidity and mortality rates are high with a short median OS interval. While some symptom relief may be afforded by this procedure, evidence for improvement in QoL is limited. A highly selective individualised approach is required to optimise the risk:benefit equation.
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Kiiski J, Räikkönen K, Vuento MH, Hyöty MK, Kallio J, Kuokkanen HO, Kaartinen IS. Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:1632-1637. [DOI: 10.1016/j.ejso.2019.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/03/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
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Application of robot-assisted laparoscopic pelvic exenteration in treating gynecologic malignancies. Chin Med J (Engl) 2019; 132:976-979. [PMID: 30958440 PMCID: PMC6595759 DOI: 10.1097/cm9.0000000000000202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Germanova A, Raspagliesi F, Chiva L, Dusek L, Arvas M, Leblanc E, Lengeyl T, Di Donato V, Zaal A, Dursun P, Zapardiel I, Turan T, Triginelli SA, Kim SW, Jurado M, Sehouli J, Sehnal B, Masak L, Ioanid N, Dreyer G, Jach R, Mlynček M, Chiappa V, Martinelli F, Slama J, Kocian R, Bogani G, Cibula D. Oncological outcome of surgical management in patients with recurrent uterine cancer—a multicenter retrospective cohort study—CEEGOG EX01 Trial. Int J Gynecol Cancer 2019; 29:711-720. [DOI: 10.1136/ijgc-2019-000292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 11/04/2022] Open
Abstract
ObjectivesTo assess the survival of patients who have received an operation for recurrent cervical and endometrial cancer and to determine prognostic variables for improved oncologic outcome.MethodsA retrospective multicenter analysis of the medical records of 518 patients with cervical (N = 288) or endometrial cancer (N = 230) who underwent surgery for disease recurrence and who had completed at least 1 year of follow-up.ResultsThe median survival reached 57 months for patients with cervical cancer and 113 months for patients with endometrial cancer after surgical treatment of recurrence (p = 0.036). Histological sub-type had a significant impact on overall survival, with the best outcome in endometrial endometrioid cancer (121 months), followed by cervical squamous cell carcinoma, cervical adenocarcinoma, or other types of endometrial cancer (81 vs 35 vs 35 months; p<0.001). The site of recurrence did not significantly influence survival in cervical or in endometrial cancer. Cancer stage at first diagnosis, tumor grade, lymph node status at recurrence, progression-free interval after first diagnosis, and free resection margins were associated with improved overall survival on univariate analysis. On multivariate analysis, the stage at first diagnosis and resection margins were significant independent predictive parameters of an improved oncologic outcome.ConclusionLong-term survival can be achieved via secondary cytoreductive surgery in selected patients with recurrent cervical and endometrial cancer. An excellent outcome is possible even if the recurrence site is located in the lymph nodes. The possibility of achieving complete resection should be the main criterion for patient selection.
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Factors Predictive of 90-Day Morbidity, Readmission, and Costs in Patients Undergoing Pelvic Exenteration. Int J Gynecol Cancer 2019; 28:975-982. [PMID: 29683876 DOI: 10.1097/igc.0000000000001251] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Pelvic exenteration for recurrent gynecological malignancies is characterized by a high rate of severe complications. Factors predictive of morbidity, readmission, and cost were analyzed. METHODS Data of consecutive patients undergoing pelvic exenteration between January 2007 and December 2016 were prospectively evaluated. RESULTS Fifty-eight patients were included in the analysis. Anterior, posterior, and total exenterations were executed in 39 (67%), 9 (16%), and 10 (17%) patients, respectively. Ten (15.5%) severe complications occurred: 8 (20.5%), 0 (0%), and 1 (10%) after anterior, posterior, and total exenterations, respectively. Radiotherapy dosage, time between radiotherapy and surgery, and previous administration of chemotherapy did not influence 90-day complications and readmission. At multivariable analysis, albumin levels less than 3.5 g/dL (odds ratio, 16.2 [95% confidence interval, 2.85-92.8]; P = 0.002) and history of deep vein thrombosis (odds ratio, 9.6 [95% confidence interval, 0.93-98.2]; P = 0.057) were associated with 90-day morbidity. Low albumin levels independently correlated with readmission (P = 0.011). The occurrence of 90-day postoperative complications and readmission increased costs of a median of +12,500 and +6000 euros, respectively (P < 0.05). CONCLUSIONS Preoperative patient selection is a key point for the reduction of postoperative complications after pelvic exenteration. Further prospective studies are warranted to improve patient selection.
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The effect of preoperative nutritional status on postoperative complications and overall survival in patients undergoing pelvic exenteration: A multi-disciplinary, multi-institutional cohort study. Am J Surg 2019; 218:275-280. [PMID: 30982571 DOI: 10.1016/j.amjsurg.2019.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Optimization of preoperative nutritional status has been recommended and associated with improved outcomes for other oncologic procedures, but has not been studied in patients undergoing pelvic exenteration. METHODS A retrospective chart review of 199 patients was conducted. Overall survival (OS) was calculated using the Kaplan-Meier method and multivariate analysis was performed with Cox proportional hazards. RESULTS 199 patients underwent PE with 61 (31%), 78 (40%) and 58 (29%) patients having colorectal, gynecologic and urologic histological diagnoses, respectively. Median OS following PE was 25 months. Preoperative serum albumin <3.5 g/dL was associated with worsened OS (HR 1.661; 95% CI 1.052-2.624) as well as increased incidence of any postoperative complication (85.9% vs 72.3%, p = 0.034), but was not associated with 90-day mortality (11.3% vs 7.9%, p = 0.457). CONCLUSION Poor preoperative nutritional status is associated with increased complications and decreased OS. Surgeons should maximize preoperative nutritional status to improve perioperative outcomes and long-term survival.
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Lin AJ, Ma S, Markovina S, Schwarz J, Mutch DG, Powell MA, Grigsby PW. Clinical outcomes after isolated pelvic failure in cervical cancer patients treated with definitive radiation. Gynecol Oncol 2019; 153:530-534. [PMID: 30905434 DOI: 10.1016/j.ygyno.2019.03.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/11/2019] [Accepted: 03/14/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To describe clinical outcomes in patients with isolated pelvic failures after definitive radiation treatment for cervical cancer. METHODS AND MATERIALS Cervical cancer patients with isolated pelvic failure after definitive radiation with brachytherapy boost were identified in a tertiary academic center database from 1997 to 2016. All patients received an FDG-PET scan prior to their initial treatment and at the time of their first recurrence. Isolated failures in the cervix or pelvic nodes were biopsy-proven. Distant failure and overall survival (OS) were censored outcomes. RESULTS Isolated pelvic failure was detected in 67(11%) out of 607 consecutive patients treated with external beam pelvic radiation and brachytherapy boost. The median time to isolated pelvic recurrence was 9 months (range 3-198). Median follow-up time for patients alive after isolated pelvic recurrence was 40 months (range 0.6-183). Of these 67 patients, 28(42%) received salvage surgery, 17(25%) received chemotherapy alone, and 22(33%) received neither surgery nor chemotherapy. The median time to distant failure after isolated pelvic failure was 20 months (95% CI 3-37), with no significant difference between patients treated surgically vs. non-surgically. FDG-avid pelvic and para-aortic nodes at initial presentation were associated with worse distant control after isolated pelvic failure (HR = 3.4, 95% CI 1.0-12). Median OS for patients treated with surgery, chemotherapy alone, and neither surgery nor chemotherapy was 29 months (95% CI 16-41), 12 months (95% CI 3-21), and 3 months (95% CI 1-5), respectively. CONCLUSIONS Patients who have pelvic and para-aortic nodal disease at initial presentation are at higher risk of failing distantly after isolated pelvic failure, which should be considered when counseling patients on aggressive surgical salvage. Surgical salvage was associated with prolonged survival after isolated pelvic failure.
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Affiliation(s)
- Alexander J Lin
- Department of Radiation Oncology, Washington University School of Medicine, United States of America
| | - Sirui Ma
- Department of Radiation Oncology, Washington University School of Medicine, United States of America
| | - Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, United States of America
| | - Julie Schwarz
- Department of Radiation Oncology, Washington University School of Medicine, United States of America
| | - David G Mutch
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, United States of America
| | - Matthew A Powell
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, United States of America
| | - Perry W Grigsby
- Department of Radiation Oncology, Washington University School of Medicine, United States of America.
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