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.

Endocytoscopy can identify dysplasia in aberrant crypt foci of the colorectum: a prospective in vivo study

BACKGROUND AND STUDY AIM

A catheter-type endocytoscope has recently been developed that is able to provide in vivo cellular images of gastrointestinal mucosa. Aberrant crypt foci (ACF) represent the earliest precursor of colorectal cancer featuring the dysplasia-carcinoma sequence. The aim of the current study was to assess the potential of the endocytoscopy system (ECS) in the "in vivo" detection of dysplasia in colorectal ACF.

PATIENTS AND METHODS

Consecutive patients with colorectal ACF were studied with endocytoscopy. Blinded endoscopic and histological assessments were obtained. Lesions were excised en bloc for histology.

RESULTS

A total of 48 colorectal lesions were examined in 41 patients. The mean duration of the ECS procedure was 44 +/- 12 minutes (range 31 - 62 minutes). The quality of ECS images was rated as good in 39/48, medium in six, and poor in three (6.2 %). It was possible to observe lesions at the cellular level and evaluate both cellular and structural atypia in vivo. In normal mucosa, crypts had preserved individuality and round-shaped contours. Nuclei were located at the basal third of the crypt in a single line, and the lumen was circular. In dysplastic ACF, crypt contours were polygonal, cell nuclei were elongated with pseudostratification toward the luminal half of the crypt and irregularly arranged, and the lumen was linear. In all, 23 endocytoscopic images were labeled as dysplastic and 25 as nondysplastic. Histology confirmed low-grade dysplasia in 21/23 cases (91.4 % sensitivity). Absence of dysplasia was confirmed in the remaining 25 cases (100 % specificity). Interobserver agreement between trained endoscopist and pathologist was good (wK 0.68; 95 % CI 0.59 - 0.78).

CONCLUSIONS

Endocytoscopy provides real-time histological images in vivo, with clear visualization of cellular details and features of dysplasia in colorectal ACF.

Predictive value of magnification chromoendoscopy for diagnosing invasive neoplasia in nonpolypoid colorectal lesions and stratifying patients for endoscopic resection or surgery

BACKGROUND AND STUDY AIMS

In nonpolypoid colorectal lesions, the presence of irregular, distorted glands in the colon (a disrupted crypt pattern) on magnification chromoendoscopy (MCE) is strongly associated with submucosal invasive cancer. The aim of the present study was to evaluate the ability of MCE to differentiate between an invasive crypt pattern and a noninvasive crypt pattern, including nonneoplastic lesions, and to assess the ability of this MCE classification to predict invasiveness and allow patients to be selected for endoscopic resection or surgical resection.

PATIENTS AND METHODS

In a prospective study including 1560 colonoscopies, 153 flat or depressed colorectal lesions were evaluated with MCE among 534 colorectal lesions; the remainder had a polypoid appearance. The pit pattern was classified as nonneoplastic (type II) or neoplastic (types III - V), and the latter was subdivided into noninvasive (types III or IV) or submucosally invasive (type V). Lesions with a nonneoplastic and noninvasive neoplastic appearance were resected endoscopically if technically feasible, whereas those with a type V pattern were resected surgically. The resection specimens were analyzed histologically in relation to the Vienna classification.

RESULTS

Using this management strategy based on the pit pattern, 86 % (n = 70) of the type II lesions were hyperplastic; the remaining 11 had low-grade intraepithelial neoplasia. Type III and IV lesions (n = 58) represented either low-grade or high-grade intraepithelial neoplasia in 95 % of the cases. Three patients had sm1 (n = 2) or sm2/3 invasive cancers. Among the patients with type V lesions (n = 14), 11 had invasive cancers (four sm1 and seven sm2/3). Endoscopic differentiation based on the pit pattern thus had a positive predictive value (PPV) of 86 % and a negative predictive value of 96 % for distinguishing between nonneoplastic and neoplastic lesions. The pit pattern criteria for distinguishing between invasive and noninvasive neoplasia (including nonneoplastic lesions), and hence the choice between endoscopic and surgical resection, had a PPV of 79 % and a NPV of 98 %. Excluding nonneoplastic lesions, the NPV would be 95 %.

CONCLUSIONS

The endoscopic pit pattern on MCE has only a moderate predictive value for nonneoplastic lesions, so that leaving these flat hyperplastic lesions in place on the basis of the endoscopic magnification appearance alone cannot be generally recommended. However, MCE has a good predictive value for guiding management toward either endoscopic resection (if technically feasible) or surgical resection.