Morbidity after pelvic exenteration for gynecological malignancies: a retrospective multicentric study of 230 patients

Patient-Reported Outcomes in Chinese Patients with Locally Advanced or Recurrent Colorectal Cancer After Pelvic Exenteration

BACKGROUND

Pelvic exenteration (PE) is often the only curative treatment option for selected locally advanced and locally recurrent colorectal cancer associated with significant morbidity. Open and laparoscopic approaches were accepted for this procedure.

OBJECTIVE

This study aimed to examine the Chinese patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after PE.

METHODS

A total of 122 enrolled participants were asked to complete PROs at baseline and 1, 3, 6, 9 and 12 months after PE. PROs included seven symptoms from the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). The HRQoL was assessed using the Functional Assessment of Cancer Therapy-Colorectal (FACT-C).

RESULTS

The overall postoperative complication rate was 41.0%. Patients experienced lower physical and functional well-being and FACT-C 1 month after surgery, then gradually recovered. The FACT-C score returned to baseline 9 months after surgery. Social and emotional well-being did not show signs of recovery until 6 months after the surgical procedure, and did not fully return to baseline until 12 months post-surgery. Symptom rates of insomnia, anxiety, discouragement, and sadness (composite score >0) did not improve significantly from baseline until 12 months after surgery.

CONCLUSIONS

PE is a feasible treatment choice for locally advanced primary and recurrent colorectal cancer. Social, psychological, and emotional recovery in the Chinese population after PE tends to be slower compared with the physical condition.

Robotic approach for the treatment of gynecological cancers recurrences: A ten-year single-institution experience

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.

Combined Robotic and Vaginal Surgery for Pelvic Exenteration due to Vaginal Sarcoma Relapse in an Obese Woman

STUDY OBJECTIVE

Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed.

DESIGN

The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM).

SETTING

Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling.

INTERVENTIONS

The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m2), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up.

CONCLUSION

Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.

Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node

Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the preclinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.

Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: a large single-institution experience

OBJECTIVE

To evaluate pre-operative predictors of early (<30 days) severe complications (grade Dindo 3+) in patients with gynecological malignancy submitted to pelvic exenteration (PE).

METHODS

We retrospectively analyzed 129 patients submitted to surgery at Fondazione Policlinico Gemelli between 2010 and 2019. We included patients affected by primary or recurrent/persistent cervical, endometrial, or vulvar/vaginal cancers. Post-operative complications were graded according to the Dindo classification. Logistic regression was used to analyze potential predictors of complications.

RESULTS

We performed 63 anterior PE, 10 posterior PE, and 56 total PE. The incidence of early severe post-operative complications was 27.9% (n=36), and the early mortality rate was 2.3% (n=3). More frequent complications were related to the urinary diversion and intestinal surgery. In univariable analysis, hemoglobin ≤10 g/dL (odds ratio [OR]=4.2; 95% confidence interval [CI]=1.65-10.7; p=0.003), low albumin levels (OR=3.9; 95% CI=1.27-12.11; p=0.025), diabetes (OR=4.15; 95% CI=1.22-14.1; p=0.022), 2+ comorbidities at presentation (OR=5.18; 95% CI=1.49-17.93; p=0.012) were predictors of early severe complications. In multivariable analysis, only low hemoglobin and comorbidities at presentation were independent predictors of complications.

CONCLUSION

Pelvic exenteration is an aggressive surgery characterized by a high rate of post-operative complications. Pre-operative assessment of comorbidities and patient health status are crucial to better select the right candidate for this type of surgery.

Laterally extended endopelvic resection for gynecological malignancies, a comparison between laparoscopic and laparotomic approach

INTRODUCTION

The historical approach to LEER is laparotomic, but recently laparoscopy has been proposed. The objective of this study was to compare surgical and oncological outcomes between the two approaches and to assess the overall quality of life (QoL).

MATERIALS AND METHODS

Women submitted to LEER between October 2012 and March 2020 were retrospectively recruited. Peri-operative data were analyzed and compared. Recurrence-free (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, QLQ-CX24, and QLQ-OV28 questionnaires were administered 6 months after surgery in women with no evidence of recurrence after LEER.

RESULTS

Of the included 41 patients, 20 were submitted to laparoscopic LEER (L-LEER) and 21 to open LEER (O-LEER). Median operating time (442 vs 630 min, p = 0.001), median blood loss (275 vs 800 ml, p < 0.001), and median length of hospital stays (10 vs 16 days, p = 0.002) were shorter in the laparoscopic group, while tumor resection rate and peri-operative complications were similar. After a median follow-up of 27.5 months, no differences, in terms of DFS (p = 0.83) and OS (p = 0.96) were observed between the two approaches. High functional scores and low levels of adverse symptoms were observed on the surviving women.

CONCLUSION

QoL after LEER is acceptable, and laparoscopy provides better surgical and similar oncological outcomes when compared to laparotomy. L-LEER can be considered a further option of treatment for women with gynecological tumors infiltrating the pelvic sidewall.

Pelvic exenteration for vulvar cancer: Postoperative morbidity and oncologic outcome - A single center retrospective analysis

BACKGROUND

Pelvic exenteration may be the only curative treatment for some patients with primary advanced or recurrent vulvar cancer but is associated with high morbidity. This study evaluated the clinical outcome of patients treated at a centralized service in Norway.

METHODOLOGY

This retrospective study included patients treated with pelvic exenteration for primary locally advanced or recurrent vulvar cancer between 1996 and 2019 at Oslo University Hospital, Norway. Complications were coded according to the contracted Accordion classification. Relapse free survival (RFS), cancer specific survival (CSS) and overall survival (OS) were estimated with the Kaplan Meier method.

RESULTS

The 30 patients were followed for a median of 4.94 years (95%CI: 3.37-NR). Exenteration due to primary vulvar cancer was carried out in 16 (53%) patients, 14 (47%) had recurrent vulvar cancer. Free histopathological margins were achieved in 28 (93%) patients. The 90 days morbidity for grade 3 complications was 63%, predominantly wound/surgical flap infections, 7% had no complications. 90 days mortality was 3%. Five-year RFS was 26% (95% CI 8-48%), OS was 50% (95%CI: 29-69%) and CSS was 64% (95% CI 43-79%). There was no significant difference in survival between patients with primary vs recurrent disease. The 3-year CSS for patients with negative lymph nodes and positive lymph nodes was 70% (95% CI 47-84%) and 30% (95% CI 1-72%), respectively.

CONCLUSIONS

Acceptable oncologic outcomes after pelvic exenteration for primary and recurrent vulvar cancer can be achieved if surgery is centralized. Careful patient selection is imperative due to significant postoperative morbidity and considerable risk of relapse.

A giant primary vaginal sarcoma: A report case and literature review

Primary vaginal sarcoma is a rare disease entity, reported in less than 3% of cases of vaginal cancers. We report the observation of a patient treated at the regional oncology center of Oujda in Morocco who is presented with a non-metastatic primary vaginal leiomyosarcoma of 20 cm. The treatment consisted of neoadjuvant chemotherapy, followed by hemostatic surgery with tumor resection limits, reinforced by radiotherapy and then a surgical resection with a tumor resection taking away the infiltrated part of the anterior face of the lower rectum and the realization of a left iliac colostomy whose resected tumor part limits were healthy. At present, the patient is 4 years of follow-up without locoregional or distant recurrence.

Clinical outcomes of pelvic exenteration for gynecologic malignancies

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.

Minimally invasive versus open pelvic exenteration in gynecological malignancies: a propensity-matched survival analysis

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.

Primary vaginal sarcoma in a single center

Objectives

To investigate the clinical characteristics and prognosis of primary vaginal sarcoma.

Methods

A retrospective analysis of patients with primary vaginal sarcoma treated at our center from 2000 to 2020 was conducted.

Results

Fifteen patients were identified, among which 9 (60.0 %) patients had leiomyosarcoma, 2 (13.3 %) patients had Ewing's sarcoma, 2 (13.3 %) patients had rhabdomyosarcoma, 1 (6.7 %) patient had undifferentiated sarcoma, and 1 (6.7 %) patient had malignant peripheral schwannoma. Nine patients presented with vaginal mass that was the most common primary symptoms. Eleven patients received their primary surgery, and 7 of them received postoperative adjuvant chemotherapy or radiation therapy. The remaining 4 patients received initial chemotherapy and/or radiotherapy because of advanced stage. The distribution by stage was as follows: stage I in 10 patients, stage II in 1 patient, stage III in 2 patients and stage IV in 2 patients. The median follow-up was 43.7 months (10.1-137.5 months). Thirteen patients (86.7 %) had disease extent during follow-up, and among them, 11 patients (11/13, 84.6 %) developed local relapse or adjacent organ metastases, 1 patient (1/13, 7.7 %) developed liver metastases, and the remaining 1 patient (1/13, 7.7 %) developed lung metastases and local relapse during follow-up. Ten (10/13, 76.9 %) patients relapsed within 2 years after diagnosis. Eight patients (8/11, 72.7 %) with local recurrence or adjacent organ metastases received a secondary surgery treatment, and only 2 of them relapsed again. Two-year overall survival (OS) and 5-year OS were 80.0 % and 66.7 %, respectively. Patients with leiomyosarcoma had a tendency toward a better 5-year OS than those with other sarcomas (74.1 % vs 66.7 %, P = 0.307).

Conclusions

Primary vaginal sarcomas are aggressive neoplasms with different presenting characteristics. Surgery is the main treatment for primary vaginal sarcoma and for local relapse vaginal sarcoma.

Primary vaginal sarcoma in a single center

Objectives

To investigate the clinical characteristics and prognosis of primary vaginal sarcoma.

Methods

A retrospective analysis of patients with primary vaginal sarcoma treated at our center from 2000 to 2020 was conducted.

Results

Fifteen patients were identified, among which 9 (60.0 %) patients had leiomyosarcoma, 2 (13.3 %) patients had Ewing's sarcoma, 2 (13.3 %) patients had rhabdomyosarcoma, 1 (6.7 %) patient had undifferentiated sarcoma, and 1 (6.7 %) patient had malignant peripheral schwannoma. Nine patients presented with vaginal mass that was the most common primary symptoms. Eleven patients received their primary surgery, and 7 of them received postoperative adjuvant chemotherapy or radiation therapy. The remaining 4 patients received initial chemotherapy and/or radiotherapy because of advanced stage. The distribution by stage was as follows: stage I in 10 patients, stage II in 1 patient, stage III in 2 patients and stage IV in 2 patients. The median follow-up was 43.7 months (10.1-137.5 months). Thirteen patients (86.7 %) had disease extent during follow-up, and among them, 11 patients (11/13, 84.6 %) developed local relapse or adjacent organ metastases, 1 patient (1/13, 7.7 %) developed liver metastases, and the remaining 1 patient (1/13, 7.7 %) developed lung metastases and local relapse during follow-up. Ten (10/13, 76.9 %) patients relapsed within 2 years after diagnosis. Eight patients (8/11, 72.7 %) with local recurrence or adjacent organ metastases received a secondary surgery treatment, and only 2 of them relapsed again. Two-year overall survival (OS) and 5-year OS were 80.0 % and 66.7 %, respectively. Patients with leiomyosarcoma had a tendency toward a better 5-year OS than those with other sarcomas (74.1 % vs 66.7 %, P = 0.307).

Conclusions

Primary vaginal sarcomas are aggressive neoplasms with different presenting characteristics. Surgery is the main treatment for primary vaginal sarcoma and for local relapse vaginal sarcoma.

The changing role for extended resections in an era of advanced radiotherapy techniques and novel therapies in gynaecological malignancy

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.

Re-Irradiation for Recurrent Cervical Cancer: A State-of-the-Art Review

The recurrence rate of cervical cancer after primary treatment can reach 60%, and a poor prognosis is reported in most cases. Treatment options for the recurrence of cervical cancer mainly depend on the prior treatment regimen and the location of recurrent lesions. Re-irradiation is still considered as a clinical challenge, owing to a high incidence of toxicity, especially in in-field recurrence within a short period of time. Recent advances in radiotherapy have preliminarily revealed encouraging outcomes of re-irradiation. Several centers have concentrasted on stereotactic body radiation therapy (SBRT) for the treatment of well-selected cases. Meanwhile, as the image-guiding techniques become more precise, a better dose profile can also be achieved in brachytherapy, including high-dose-rate interstitial brachytherapy (HDR-ISBT) and permanent radioactive seed implantation (PRSI). These treatment modalities have shown promising efficacy with a tolerable toxicity, providing further treatment options for recurrent cervical cancer. However, it is highly unlikely to draw a definite conclusion from all of those studies due to the large heterogeneity among them and the lack of large-scale prospective studies. This study mainly reviews and summarizes the progress of re-irradiation for recurrent cervical cancer in recent years, in order to provide potential treatment regimens for the management of re-irradiation.

Gynecologic Oncology: Pelvic Exenteration for Advanced or Recurring Cervical Cancer - A Single Center Analysis

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.

Indocyanine Green to Assess Vascularity of Ileal Conduit Anastomosis During Pelvic Exenteration for Recurrent/Persistent Gynecological Cancer: A Pilot Study

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.

High-intensity focused ultrasound ablation in the treatment of recurrent ovary cancer and metastatic pelvic tumors: a feasibility study

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.

Pelvic exenteration for recurrent or advanced gynecologic malignancies - Analysis of outcome and complications

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Overall survival was 25.5% with a median follow-up of 47 months.

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Positive resection margins had a negative impact on survival.

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Neoadjuvant treatment correlated with achieving negative margins.

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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.

Laparoscopic assessment improves case selection for exenterative surgery in recurrent cervical and endometrial cancer

The objective of this study is to evaluate the role of laparoscopy in the case selection of patients for pelvic exenteration to treat recurrent cervical or endometrial cancer. Pelvic exenteration is a rare surgical procedure performed by specialised multidisciplinary surgical teams. We performed a review of 55 consecutive laparoscopies for patients being evaluated for possible exenterative surgery for recurrent cervical or endometrial cancer at a single centre in the UK with a significant exenterative surgical practice. All patients had no evidence of metastatic disease on imaging prior to the laparoscopy. Despite thorough radiological assessment laparoscopy detected peritoneal, nodal or extrapelvic metastases in 20.8% of cases. 5.6% of the patients who underwent exenterative surgery were found to have unresectable pelvic disease intraoperatively. In these cases, the extent of disease was not determined radiologically or during the initial exploratory laparotomy. In our view, laparoscopic assessment is an essential component of the pre-operative work up of patients with recurrent cervical or endometrial cancer being considered for exenterative surgery.Impact statementWhat is already known on this subject? Pelvic exenteration is potentially curative in cases of recurrent pelvic malignancy. Case selection is essential to determine those patients without metastases and with resectable pelvic disease - this will improve patient outcomes, avoid the unnecessary morbidity of major surgery, as well as the psychological consequences of abandoned procedures. The only two previous studies, published in 1998 (Plante and Roy 1998) and 2002 (Köhler et al. 2002) have shown laparoscopic assessment to be safe and improve case selection.What do the results of this study add? This study provides evidence that in the context of modern imaging modalities, including PET-CT scans, laparoscopic assessment continues to improve case selection for exenterative surgery.What are the implications of these findings for clinical practice and/or further research? This study provides further evidence of the benefit of laparoscopy in the assessment of patients being considered for exenterative surgery for recurrent pelvic cancer. Routine laparoscopy improves case selection and will enhance patient experiences and outcomes.

Urinary diversion after pelvic exenteration for gynecologic malignancies

Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B12 deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.

Cold Atmospheric Pressure Plasma (CAP) as a New Tool for the Management of Vulva Cancer and Vulvar Premalignant Lesions in Gynaecological Oncology

Vulvar cancer (VC) is a specific form of malignancy accounting for 5–6% of all gynaecologic malignancies. Although VC occurs most commonly in women after 60 years of age, disease incidence has risen progressively in premenopausal women in recent decades. VC demonstrates particular features requiring well-adapted therapeutic approaches to avoid potential treatment-related complications. Significant improvements in disease-free survival and overall survival rates for patients diagnosed with post-stage I disease have been achieved by implementing a combination therapy consisting of radical surgical resection, systemic chemotherapy and/or radiotherapy. Achieving local control remains challenging. However, mostly due to specific anatomical conditions, the need for comprehensive surgical reconstruction and frequent post-operative healing complications. Novel therapeutic tools better adapted to VC particularities are essential for improving individual outcomes. To this end, cold atmospheric plasma (CAP) treatment is a promising option for VC, and is particularly appropriate for the local treatment of dysplastic lesions, early intraepithelial cancer, and invasive tumours. In addition, CAP also helps reduce inflammatory complications and improve wound healing. The application of CAP may realise either directly or indirectly utilising nanoparticle technologies. CAP has demonstrated remarkable treatment benefits for several malignant conditions, and has created new medical fields, such as “plasma medicine” and “plasma oncology”. This article highlights the benefits of CAP for the treatment of VC, VC pre-stages, and postsurgical wound complications. There has not yet been a published report of CAP on vulvar cancer cells, and so this review summarises the progress made in gynaecological oncology and in other cancers, and promotes an important, understudied area for future research. The paradigm shift from reactive to predictive, preventive and personalised medical approaches in overall VC management is also considered.

Is a Vaginectomy Enough or is a Pelvic Exenteration Always Required for Surgical Treatment of Recurrent Cervical Cancer? A Propensity-Matched Study

PURPOSE

Reporting the perioperative and survival outcomes of vaginectomy with respect to a matched series of pelvic exenteration (PE) in women with isolated recurrent cervical cancer.

METHODS

The records of vaginal recurrent cervical cancer patients admitted at Fondazione Policlinico "Agostino Gemelli" IRCCS in Rome from January 2010 to June 2019 were retrospectively analyzed. A propensity-matched score analysis was performed by age, clinical stage, disease-free interval, and R0 resection. Postsurgical complications and survival rates were evaluated.

RESULTS

Fifteen women underwent vaginectomy, and 30 patients were submitted to PE. No statistical differences were observed between the two groups at baseline characteristics. The vaginectomy procedures were successfully performed in all women, and no case required conversion to PE. Moreover, a higher rate of major postoperative complications after PE with respect to vaginectomy (p = 0.027) was recorded. Among them, three women required reoperation within 30 postoperative days, and four experienced two or more complications. Twenty-five (55.6%) women experienced recurrence: 8 of 25 (32.0%) in the vaginectomy group, and 17 of 25 (68%) in the PE group, with a median progression-free survival of 20 months and 13 months, respectively (p = 0.169). In total, 5 of 15 (33.3%) died of disease in the vaginectomy group and 13/30 (43.3%) in the PE group, with a median overall survival of 39 and 18 months for vaginectomy and PE, respectively (p = 0.161).

CONCLUSIONS

The vaginectomy seems to allow for salvage treatment, such as radiotherapy and/or PE, but with a minimal impact on the quality of life in appropriately selected women with local recurrent cervical cancer.

Stereotactic Ablative Radiotherapy for Recurrent or Metastatic Gynecological Cancer: Extending Lives?

OPINION STATEMENT

Recent phase II clinical trials suggest that stereotactic ablative radiation therapy (SABR) can potentially improve survival for patients with oligometastatic cancer. However, these studies have mostly enrolled primaries other than gynecologic malignancies. While level I evidence is limited, recent publications exploring the use of SABR for oligometastatic gynecologic cancers have indicated a potential role for this treatment in para-aortic lymph node recurrences, and in visceral and brain metastases. The use of SABR for recurrences in the pelvis presents a number of challenges as these patients have often received previous radiation treatment. In these settings, care must be taken to avoid trespassing normal tissue tolerance with SABR leading to toxicity, especially as the potential benefit of SABR in this setting is not based on high-level evidence. Although SABR is feasible and in general safe for oligometastatic gynecologic malignancies, insufficient data are available to indicate whether it is associated with improved survival. Clinical judgment that incorporates patient and tumor factors is needed to determine if SABR is appropriate for selecting patients. Future directions include combining SABR with novel systemic therapies, determining optimal sequencing of treatments, and generating more robust randomized data pertaining to the use of SABR for oligometastatic gynecologic cancers.

Palliative treatment with electrochemotherapy in recurrent or metastatic vaginal cancer

OBJECTIVE

Vaginal metastases are very rare events with a poor prognosis. To improve the quality of life, local treatments should be considered. The aim of this study was to evaluate the role of electrochemotherapy as palliative treatment in vaginal cancer not amenable to standard treatments due to poor performance status, previous treatments, or advanced disease.

METHODS

This is a prospective observational study on patients diagnosed with vaginal cancer and treated from January 2017 to December 2018 with palliative electrochemotherapy. We collected data on patients with vaginal cancer treated by electrochemotherapy with the aim of local control. Data regarding electrochemotherapy, hospital stay, adverse events, and patient outcomes were analyzed. Intravenous bleomycin was injected as a bolus in 2-3 min at a dose of 15 000 UI/m² and electrical pulses started 8 min after chemotherapy. Electrochemotherapy response was defined according to the Response Evaluation Criteria in Solid Tumors.

RESULTS

Five patients with vaginal recurrence (two squamous, two melanomas, and one leiomyosarcoma) and one with vaginal metastasis from intestinal adenocarcinoma received one treatment and two patients were re-treated. Imaging reported nodal metastasis (inguinal or pelvic) in two patients, distant metastases in two, and both node and distant metastasis in two patients, respectively. Response Evaluation Criteria in Solid Tumors showed a complete response in one patient, partial response in three patients, stable disease in one patient, and progressive disease in one patient, with an overall response rate of 67% and a clinical benefit rate (complete response, partial response, stable disease) of 83%. Two patients were re-treated and had a new response (partial response and stable disease, respectively). At last follow-up, two patients had died of the disease, two were alive with stable disease, one was alive with progressive disease, and one was alive without disease. Median post-electrochemotherapy overall survival was 12.9 months (range 1.6-26.9) and 1-year overall survival was 66.7%.

CONCLUSIONS

This preliminary experience showed a tumor response or stabilization in 83% of patients requiring palliative management for vaginal cancer. Further studies are needed to evaluate treatment outcome in larger and prospective series.

Laparoscopic laterally extended endopelvic resection procedure for gynecological malignancies

Objectives

Pelvic side wall infiltration by gynecological malignancies has been considered for a long time an absolute contraindication to curative resection. The development of the laterally extended endopelvic resection (LEER) has challenged this surgical paradigm. Although the LEER has been standardized in open surgery, only small studies have been published about its endoscopic feasibility. The objective of this study is to analyze the safety of LEER in patients with gynecological malignancies involving the pelvic side wall.

Methods

We retrospectively evaluated a consecutive series of patients who underwent a laparoscopically modified LEER between July 2014 and November 2018. This indicated gynecological tumors involving the pelvic sidewall and surgeries were conducted in two Italian institutions. All patients underwent pre-operative CT scan or PET to evaluate for distant metastases. Patients without suspicioun of distant metastasis underwent pelvic MRI and examination under anesthesia to establish the resectability of the disease and concomitant diagnostic laparoscopy to exclude intraperitoneal dissemination. All women with disease-free interval <6 months, and/or performance status >2 ECOG were excluded. Type of resection was defined based on the status of the pathologic margins: R0, microscopically negative (free margin <5 mm); R1, microscopically positive; and R2, macroscopically (grossly) positive. Disease-free survival was calculated from the date of primary surgery to the time of recurrence. Overall survival was defined as the time from primary surgery to death.

Results

Overall, 39 patients underwent a laparoscopic LEER and 18 (46.2%) patients were eligible for a laparoscopic approach. Laparoscopic LEER was performed as primary treatment for newly diagnosed tumors in eight patients (44.4%), and for recurrences in the other 10 patients (55.6%). No laparotomic conversions were registered. R0 resection was achieved with negative margins in all patients. The median operative time was 415 min (range, 285–615), median estimated blood loss was 285 mL (range, 100–600), and the median length of hospital stay was 10 days (range; 4–22). Only four patients (22.2%) needed blood intraoperative transfusion. In seven patients (38.9%), post-operative admission to intensive care unit was required. There were three (16.7%) intraoperative complications, all managed laparoscopically. In total there were six (33.3%) major postoperative complications: three patients (16.7%) experienced moderate hydronephrosis with normal renal function, which required temporary placement of nephrostomy; one patient (5.6%) had permanent urinary retention; and two patients (11.1%) had a reoperation, one for post-operative hemoperitoneum and another for complete vaginal cuff dehiscence.

Discussion

Laparoscopic LEER can be safely performed by experienced laparoscopic surgeons, in carefully selected patients with gynecological malignancies involving the lateral pelvic side wall, even for those in which a bladder and rectum sparing surgery appears possible. Further larger prospective trials are needed to evaluate the oncological and the long-term functional outcomes.

Pelvic exenteration as ultimate ratio for gynecologic cancers: single-center analyses of 37 cases

BACKGROUND

Pelvic exenterations are a last resort procedure for advanced gynecologic malignancies with elevated risks in terms of patients' morbidity.

METHODS

This single-center analysis reports surgical details, outcome and survival of all patients treated with exenteration for non-ovarian gynecologic malignancies at our university hospital during a 13-year time period. We collected data regarding patients and tumor characteristics, surgical procedures, peri- and postoperative management, transfusions, complications, and analyzed the impact on survival outcomes.

RESULTS

We identified 37 patients between 2005 and 2013 with primary or relapsed cervical cancer (59.5%), vulvar cancer (24.3%) or endometrial cancer (16.2%). Median age was 60 years and most patients (73%) had squamous cell carcinomas. Median progression-free survival was 26.2 months and median overall survival was 49.9 months. The 5-year survival rates were 34.4% for progression-free survival and 46.4% for overall survival. There were no significant differences in progression-free survival and overall survival with regard to disease entity. Patients with tumor at the resection margins (R1) had a nearly significantly worse progression-free survival (median: 28.5 vs. 7.3 months, HR 2.59, 95% CI 0.98-6.88, p = 0.056) and a significantly worse overall survival (median: not reached vs. 10.9 months, HR 4.04, 95% CI 1.40-11.64, p = 0.010) compared to patients with complete tumor resection (R0). In addition, patients without lymphovascular space invasion had a significantly better progression-free survival (p = 0.017) and overall survival (p = 0.034) then patients with lymphovascular space invasion. We observed complications in 14 patients (37.8%), 10 of those were classified as Clavien-Dindo 3 or 4. There was a trend to worse progression-free survival in patients that suffered complications (p = 0.052). Median total amount of transfused blood products was 4 (range 0-20).

CONCLUSION

Pelvic exenteration is a procedure that provides substantial progression-free survival and overall survival improvement and-in selected patients-can even achieve cure in otherwise hopeless clinical situations. Patients need to be offered earnest counseling for sufficient informed consent with realistic expectations what to expect.

Factors Predictive of 90-Day Morbidity, Readmission, and Costs in Patients Undergoing Pelvic Exenteration

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.

The effect of preoperative nutritional status on postoperative complications and overall survival in patients undergoing pelvic exenteration: A multi-disciplinary, multi-institutional cohort study

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.

Laterally Extended Pelvic Resection for Gynaecological Malignancies: A Multicentric Experience with Out-of-the-Box Surgery

PURPOSE

To evaluate morbidity and oncological outcome in a multicentre series of women with gynaecological malignancies infiltrating pelvic side wall (PSW) that received laterally extended pelvic resection (LEPR).

METHODS

Patients operated between 2007 and 2017 at three institutions were included. LEPR was defined as an en bloc lateral resection of a pelvic tumour involving sidewall muscle, and/or bone, and/or major nerve, and/or major vascular structure. Postsurgical complications and survivals were evaluated.

RESULTS

Sixty-three women with gynaecological tumours involving PSW were treated with LEPR. Five women underwent primary LEPR, whereas 58 (92%) patients needed LEPR because of recurrence. Twenty-four women (38%) received previous radiation therapy before the surgery. R0 resection was achieved in 54 patients (85.7%), whereas the pathologic margins were microscopically and macroscopically positive in 8 (12.7%) patients and 1 (1.6%) patient, respectively. There was one perioperative death, whereas major postoperative complications occurred in 17 patients (27.7%). Thirty (47.5%) women experienced recurrences: 24/54 (44.4%) were in the R0 group, and 6/9 (66.6%) were in the R1 group, with a median PFS of 15 months and 7 months, respectively (p = 0.024). In total, 11 of 54 (20.3%) patients died of disease in the R0 group and 5 of 9 (55.5%) in the R1 group; a median OS was not reached and was 32 months for R0 and R1 groups, respectively (p = 0.033).

CONCLUSIONS

Involvement of the PSW should not prevent obtaining R0 resection. Although the LEPR is associated with considerable morbidity (≈ 30%), a long-term survival seems to be achieved in those women with complete resection.

Disease-free survival after robotic-assisted laparoscopic total pelvic exenteration for recurrent cervical adenocarcinoma: A case report

RATIONALE

Pelvic exenteration is considered a method to treat central recurrent or persistent gynecologic malignancy after the initial therapy. The postoperative survival rate has been greatly increased by the improvement in the surgical technology and the perioperative management. Yet various complications are still impacting the quality of life. New technologies such as robotic surgery system made it possible to approach radical surgical resection by using a minimally invasive method.

PATIENT CONCERNS

The patient is a 53-year-old female with the cervical adenocarcinoma pelvic recurrence who had undergone the adjuvant chemo-radiotherapy and the laparoscopic radical hysterectomy in our hospital 2 years ago. She still expected her life to be prolonged through surgery therapy.

DIAGNOSES

Locoregional recurrence of cervical adenocarcinoma.

INTERVENTIONS

A robotic total pelvic exenteration with ileal neobladder was performed.

OUTCOMES

The postoperative results were excellent and after 17-month follow-up, the patient is alive and satisfied without any recurrence or distant metastasis.

LESSONS

For the patients with advanced or recurrent cervical cancer who are willing to receive surgical therapy and not sensitive to chemo-radiotherapy, robotic-assisted laparoscopic total pelvic exenteration is technically a feasible surgical method for recurrent pelvic malignancies. Yet the operation time should be further controlled to reduce complications which include pressure sore and thrombus. Moreover, appropriate assessment is required in the selection of the methods for reconstruction.

Pelvic exenteration by robotically-assisted laparoscopy: A feasibility series of 6 cases

After concomitant chemo-radiation therapy, 20 to 30% of advanced cervical cancers recur in irradiated territory. Pelvic exenteration remains a therapeutic option for selected patients. However, this procedure remains complex because of tissue fragility after radiotherapy and their associated co-morbidities. Minimally invasive surgery such as robotically assisted laparoscopy may overcome these surgical challenges. The objective of this study was to evaluate the feasibility of pelvic exenteration with robotically assisted laparoscopy.

Patients who underwent this procedure between 2015 and 2016 were included. Patients characteristics, treatment indication, intraoperative events, immediate and late complications, and histological outcomes were recorded.

The data of 6 patients were analyzed. The primary cancer staging ranged from IB1 to IIB. All cases were loco-regional recurrence and 2 cases presented with with vesico-vaginal fistula. All patients had a history of pelvic irradiation. The mean operative time was 6.7 h. No complications occurred during surgery. The average hospital stay was 11.5 days. Immediate complications were mostly represented by urinary tract infections (4/5). Histological margins were clear in 67% (4/6), and a focal involvement was found in 33% (2/6) of cases. Late complications occurred within 82 days on average and included stenosis of ileal anastomosis, wound infection, acute renal failure, and pulmonary embolism. Revision surgery was necessary in 2 cases. There were 3 local recurrences occurring within an average of 215 days.

In the light of these results, pelvic exenteration by robotically assisted laparoscopy may represent a valuable treatment modality of recurrent cervical cancer with low immediate postoperative morbidity.

•

Robotic-assisted laparoscopy improve surgical performance in pelvic exenterations.

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Robotic-assisted laparoscopy is associated with good post-operative results.

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Robotic-assisted laparoscopy is associated with good histological results.

•

This series described 6 real pelvic exenterations contrary to other smaller series.

Survival After Pelvic Exenteration for Cervical Cancer: A National Cancer Database Study

OBJECTIVE

To determine overall survival (OS) and factors associated with OS after pelvic exenteration for cervical cancer.

METHODS

Women with cervical cancer who underwent exenteration (n = 517) were identified from the 1998 to 2011 National Cancer Database. Kaplan-Meier and multivariate Cox proportional-hazards survival analyses were performed to test for associations of potential explanatory variables with OS. Analyzed confounders included age, insurance status, income, distance from home to treatment center, stage, exenteration type, surgical margin status, and treatment with adjuvant radiation and/or chemotherapy.

RESULTS

Among the entire cohort with clinical follow-up (n = 313), median OS was 24 months. Stage (P = 2.5 × 10), lymph node status (P = 1.3 × 10), insurance status (P = 1.5 × 10), and histologic type (P = 0.04) were significantly associated with OS by the log-rank test. Unadjusted median OS was 24.2 and 61.8 months for women with squamous and adenocarcinoma histologies, respectively. By multivariate Cox regression, age, insurance status, stage, margin status, and adjuvant radiation were associated with OS. Histology was not independently associated with OS on multivariate regression. Among women with node-negative disease, median OS was 73.2 months.

CONCLUSIONS

Exenteration may be curative for more than half of women with node-negative cervical cancer. Stage, insurance status, lymph node status, and surgical margin are independently associated with differential OS after exenteration.

Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study

OBJECTIVES

Radical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team.

METHOD

A retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model.

RESULTS

Thirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years.

CONCLUSION

Long-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.

Role of robotic surgery in ovarian malignancy

As part of minimally invasive surgery, robotic-assisted approach is becoming increasingly popular in gynecologic oncology. It has been shown to be effective and feasible for staging and treating endometrial and cervical cancer, but its role in the context of primary and recurrent ovarian cancers is presently debated. Scanty data are available in the literature, and the level of evidence supporting its use in ovarian cancer is quite low. However, from a retrospective case-control series, robotic surgery seems to be safe and feasible for early-stage ovarian cancer. Its use in treating patients with advanced-stage or relapsed ovarian cancer is still highly controversial, suggesting the choice of robotic approach in a highly selected population.

Out-of-the-box pelvic surgery including iliopsoas resection for recurrent gynecological malignancies: Does that make sense? A single-institution case-series

OBJECTIVE

To report morbidity and oncological outcomes in a consecutive series of lateral isolated recurrent gynecological cancer involving the pelvic side wall (PSW) including the iliopsoas muscle.

MATERIAL AND METHODS

We retrospectively evaluated a consecutive series between 6/2013 and 12/2015 of lateral isolated recurrent gynecological malignancies treated with a lateral endopelvic resection (LEPR). LEPR was defined as an en-bloc lateral resection of a pelvic tumor with sidewall muscle, and/or bone, and/or major nerve, and/or major vascular structure. Post-surgical complications, quality of life (QoL) and survivals were computed.

RESULTS

Seventy-four women with pelvic isolated relapse were admitted for surgery during the study period. Among them, 8 cases (10.8%) showed lateral isolated relapse involving the iliopsoas muscle and were treated with LEPR. R0 resection was achieved in 6/8 patients (75.0%), while the pathologic margins were microscopically and macroscopically positive in 1 patient (12.5%), respectively. There were no perioperative mortalities. Major postoperative complications occurred in 3 patients (37.5%) through peripheral neuropathies, thrombosis of the vascular graft and compartment syndrome of the leg. Median follow-up time was 21 months (range, 12-28). The 2-year overall survival (OS) was 88% improving up to 100% if R0 resection was achieved. In patients with positive pathologic margins (n = 2), the 2-year OS was 50%. All women showed an improved QoL after surgery.

CONCLUSION

LEPR with iliopsoas resection can be safely performed in selected cases with lateral isolated gynecological relapse involving the PSW and was associated with improved QoL and prolonged survival when an R0 resection was achieved.

A surgical multi-layer technique for pelvic reconstruction after total exenteration using a combination of pedicled omental flap, human acellular dermal matrix and autologous adipose derived cells

•A multi-layer technique for reconstruction after pelvic exenteration is proposed.•Human acellular dermal matrix used in reconstruction after total pelvic exenteration.•A reconstructive technique based on human dermis, omental flap and fat is proposed.

Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals. Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Patients Treated with Pelvic Exenteration for Gynecologic Malignancies

Pelvic exenteration (PE) is a radical surgical procedure used for the past 6 decades to treat locally advanced malignant diseases confined to the pelvis, particularly persistent or recurrent gynecologic cancers in the irradiated pelvis. The traditional surgical technique known as total PE consists of resection of all pelvic viscera followed by reconstruction. Depending on the tumor extent, the procedure can be tailored to remove only anterior or posterior structures, including the bladder (anterior exenteration) or rectum (posterior exenteration). Conversely, more extended pelvic resection can be performed if the pelvic sidewall is invaded by cancer. Preoperative imaging evaluation with magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is central to establishing tumor resectability and therefore patient eligibility for the procedure. These imaging modalities complement each other in diagnosis of tumor recurrence and differentiation of persistent disease from posttreatment changes. MR imaging can accurately demonstrate local tumor extent and show adjacent organ invasion. FDG PET/CT is useful in excluding nodal and distant metastases. In addition, FDG PET/CT metrics may serve as predictive biomarkers for overall and disease-free survival. This pictorial review describes different types of exenterative surgical procedures and illustrates the central role of imaging in accurate patient selection, treatment planning, and postsurgical surveillance.

Pelvic Exenteration in Gynecologic Cancer: La Paz University Hospital Experience

BACKGROUND

Pelvic exenteration is an ultraradical surgery involving the en bloc resection of the pelvic organs, including the internal reproductive organs, the distal urinary tract (ureters, bladder, urethra), and/or anorectum. It is mainly applied as a salvage surgery for recurrent gynecologic tumors of any origin (vulva, vagina, cervix, uterine, and also ovary). Our aim was to establish the most favorable cases for this type of surgery by means of a review of our institution experience.

METHODS

Retrospective analyses of all patients treated with pelvic exenteration for recurrent gynecologic cancer from 2008 to 2014 at La Paz University Hospital.

RESULTS

Ten patients underwent pelvic exenteration for recurrent gynecologic cancers including uterine, cervical, vaginal, vulvar, and ovarian cancer. All patients had received prior treatment: surgery, radiotherapy, and/or chemotherapy. Eight patients underwent total pelvic exenteration, one anterior and one posterior pelvic exenteration. Urinary diversions technique consisted of ileal conduits in all cases. Permanent colostomy was performed in all cases. Postoperative complications were related to the urinary diversion in 50% of the cases, to the reconstructive technique in 30%, and to systemic or pelvic infections in 20%.

CONCLUSIONS

Despite the high morbidity and mortality rates, pelvic exenteration is feasible, and in selected cases of cancer recurrence is the last possible treatment.

[Curative pelvic exenteration for recurrent cervical carcinoma in the era of concurrent chemotherapy and radiation therapy. A systematic review]

OBJECTIVE

The purpose of this review is to assess the preoperative management in case of recurrent cervical cancer, to assess patients for a surgical curative treatment.

METHODS

English publications were searched using PubMed and Cochrane Library.

RESULTS

In the purpose of curative surgery, pelvic exenteration required clear margins. Today, only half of pelvic exenteration procedures showed postoperative clear margins. Modern imaging (RMI and Pet-CT) does not allow defining local extension of microcopic disease, and thus postoperative clear margins. Despite the same generic term of pelvic exenteration, there is a wide heterogeneity in surgical procedures in published cohorts.

CONCLUSION

Because clear margins are required for curative pelvic exenteration, but are not predictable by preoperative assessment. The larger surgery, i.e. the infra-elevator exenteration with vulvectomy, could be the logical surgical choice to increase the rate of clear margins and therefore, recurrent cervical carcinoma patient survival.