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Nougaret S, Lambregts DMJ, Beets GL, Beets-Tan RGH, Blomqvist L, Burling D, Denost Q, Gambacorta MA, Gui B, Klopp A, Lakhman Y, Maturen KE, Manfredi R, Petkovska I, Russo L, Shinagare AB, Stephenson JA, Tolan D, Venkatesan AM, Quyn AJ, Forstner R. Imaging in pelvic exenteration-a multidisciplinary practice guide from the ESGAR-SAR-ESUR-PelvEx collaborative group. Eur Radiol 2024:10.1007/s00330-024-10940-z. [PMID: 39181949 DOI: 10.1007/s00330-024-10940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/04/2024] [Accepted: 06/16/2024] [Indexed: 08/27/2024]
Abstract
Pelvic exenteration (PE) is a radical surgical approach designed for the curative treatment of advanced pelvic malignancies, requiring en-bloc resection of multiple pelvic organs. While the procedure is radical, it has shown promise in enhancing long-term survival and is now comparable in surgical mortality to elective resections for primary pelvic cancers. Imaging plays a crucial role in preoperative planning, with MRI, CT, and PET/CT being pivotal in assessing the extent of cancer and formulating a surgical roadmap. This paper presents clinical practice guidelines for imaging in the context of PE, developed jointly by ESGAR, SAR, ESUR, and the PelvEx Collaborative. These guidelines aim to standardize imaging protocols and reporting to improve the preoperative assessment and facilitate decision-making in the multidisciplinary treatment of pelvic cancers. Our recommendations underscore the importance of a multidisciplinary approach and the need for clear and precise imaging reports to optimize patient care. CLINICAL RELEVANCE STATEMENT: Our recommendations underscore the importance of a multidisciplinary approach and the need for clear and precise imaging reports to optimize patient care. KEY POINTS: MRI is mandatory for local staging in pelvic exenteration. Structured reporting (using the template provided in this guide) is recommended. Multidisciplinary review of imaging is critical for surgical planning.
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Affiliation(s)
- Stephanie Nougaret
- Department of Radiology, PINKCC lab, U1194, Montpellier Cancer Center, Montpellier, France.
| | - Doenja M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lennart Blomqvist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Sweden & Department of Radiation Physics/Nuclear Medicine, Karolinska University Hospital, Solna, Sweden
| | - David Burling
- Intestinal Imaging Centre, St Mark's Hospital, London North West University Healthcare NHS, London, UK
| | - Quentin Denost
- Bordeaux ColoRectal institute, Clinique Tivoli, Bordeaux, France
| | - Maria A Gambacorta
- Department of Radiation Oncology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - Benedetta Gui
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ann Klopp
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Yulia Lakhman
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate E Maturen
- Departments of Radiology and Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Riccardo Manfredi
- Department of Bioimaging, Radiation Oncology and Hematology, UOC of Radiodiagnostica Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luca Russo
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Atul B Shinagare
- Department of Radiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - James A Stephenson
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Damian Tolan
- Department of Radiology, St James's University Hospital, Leeds, UK
| | - Aradhana M Venkatesan
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Aaron J Quyn
- John Goligher Colorectal Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Huepenbecker SP, Soliman PT, Meyer LA, Iniesta MD, Chisholm GB, Taylor JS, Wilke RN, Fleming ND. Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program. Gynecol Oncol 2024; 189:80-87. [PMID: 39042957 DOI: 10.1016/j.ygyno.2024.07.674] [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: 06/25/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols. METHODS We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006-12/30/2014) and after (1/1/2015-6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system. RESULTS Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%. CONCLUSIONS Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary B Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roni Nitecki Wilke
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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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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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [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: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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