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Esmailzadeh A, Fakhari MS, Saedi N, Shokouhi N, Almasi-Hashiani A. A systematic review and meta-analysis on mortality rate following total pelvic exenteration in cancer patients. BMC Cancer 2024; 24:593. [PMID: 38750417 PMCID: PMC11095034 DOI: 10.1186/s12885-024-12377-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Total pelvic exenteration (TPE), an en bloc resection is an ultraradical operation for malignancies, and refers to the removal of organs inside the pelvis, including female reproductive organs, lower urological organs and involved parts of the digestive system. The aim of this meta-analysis is to estimate the intra-operative mortality, in-hospital mortality, 30- and 90-day mortality rate and overall mortality rate (MR) following TPE in colorectal, gynecological, urological, and miscellaneous cancers. METHODS This is a systematic review and meta-analysis in which three international databases including Medline through PubMed, Scopus and Web of Science on November 2023 were searched. To screen and select relevant studies, retrieved articles were entered into Endnote software. The required information was extracted from the full text of the retrieved articles by the authors. Effect measures in this study was the intra-operative, in-hospital, and 90-day and overall MR following TPE. All analyzes are performed using Stata software version 16 (Stata Corp, College Station, TX). RESULTS In this systematic review, 1751 primary studies retrieved, of which 98 articles (5343 cases) entered into this systematic review. The overall mortality rate was 30.57% in colorectal cancers, 25.5% in gynecological cancers and 12.42% in Miscellaneous. The highest rate of mortality is related to the overall mortality rate of colorectal cancers. The MR in open surgeries was higher than in minimally invasive surgeries, and also in primary advanced cancers, it was higher than in recurrent cancers. CONCLUSION In conclusion, it can be said that performing TPE in a specialized surgical center with careful patient eligibility evaluation is a viable option for advanced malignancies of the pelvic organs.
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Affiliation(s)
- Arezoo Esmailzadeh
- Department of Obstetrics & Gynecology, Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Nafise Saedi
- Fellowship of Perinatology, Department of Gynecologic Oncology, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Shokouhi
- Fellowship of Female Pelvic Medicine and Reconstructive Surgery, Yas Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Almasi-Hashiani
- Department of Epidemiology, Arak University of Medical Sciences, Arak, Iran.
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran.
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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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Moolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhuijzen LRCW, Mom CH, Zaal A. Clinical outcomes of pelvic exenteration for gynecologic malignancies. Gynecol Oncol 2023; 171:114-120. [PMID: 36870097 DOI: 10.1016/j.ygyno.2023.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES The aim of this study was to analyze morbidity and survival after pelvic exenteration for gynecologic malignancies and evaluate prognostic factors influencing postoperative outcome. METHODS We retrospectively reviewed all patients who underwent a pelvic exenteration at the departments of gynecologic oncology of three tertiary care centers in the Netherlands, the Leiden University Medical Centre, the Amsterdam University Medical Centre, and the Netherlands Cancer Institute, during a 20-year period. We determined postoperative morbidity, 2- and 5-year overall survival (OS) and 2- and 5-year progression free survival (PFS), and investigated parameters influencing these outcomes. RESULTS A total of 90 patients were included. The most common primary tumor was cervical cancer (n = 39, 43.3%). We observed at least one complication in 83 patients (92%). Major complications were seen in 55 patients (61%). Irradiated patients had a higher risk of developing a major complication. Sixty-two (68.9%) required ≥1 readmission. Re-operation was required in 40 patients (44.4%). Median OS was 25 months and median PFS was 14 months. The 2-year OS rate was 51.1% and the 2-year PFS rate was 41.5%. Tumor size, resection margins and pelvic sidewall involvement had a negative impact on OS (HR = 2.159, HR = 2.376, and HR = 1.200, respectively). Positive resection margins and pelvic sidewall involvement resulted in decreased PFS (HR = 2.567 and HR = 3.969, respectively). CONCLUSION Postoperative complications after pelvic exenteration for gynecologic malignancies are common, especially in irradiated patients. In this study, a 2-year OS rate of 51.1% was observed. Positive resections margins, tumor size, and pelvic sidewall involvement were related to poor survival outcomes. Adequate selection of patients who will benefit from pelvic exenteration is important.
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Affiliation(s)
- L R Moolenaar
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E van Rangelrooij
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - M I E van Poelgeest
- Department of Gynecologic Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - M van Beurden
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - W J van Driel
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - L R C W van Lonkhuijzen
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands
| | - C H Mom
- Department of Gynecologic Oncology, Amsterdam University Medical Center, Centre for Gynecologic Oncology Amsterdam, Amsterdam, the Netherlands.
| | - A Zaal
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, the Netherlands
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Xu C, Garda AE, Kumar A. R0 Resection in Recurrent Gynecologic Malignancy: Pelvic Exenteration and Beyond. Curr Treat Options Oncol 2023; 24:262-273. [PMID: 36847987 DOI: 10.1007/s11864-023-01055-6] [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] [Accepted: 01/16/2023] [Indexed: 03/01/2023]
Abstract
OPINION STATEMENT Pelvic exenteration is a radical surgery, but oftentimes, it is the last curative option for patients with recurrent gynecologic malignancies who have exhausted more conservative therapies. Mortality and morbidity outcomes have improved over time, but there are still significant peri-operative risks. Considerations before pursing pelvic exenteration must include the likelihood of oncologic cure and patients' fitness to undergo such a procedure, particularly given the high rate of surgical morbidity. Pelvic sidewall tumors have been a traditional contraindication for pelvic exenteration due to the difficulty in obtaining negative margins, but the use of laterally extended endopelvic resection and intra-operative radiation therapy allows for more radical resection of recurrent disease. We believe that these procedures to achieve R0 resection can expand the use of curative-intent surgery in recurrent gynecologic cancer, but require the surgical expertise of colleagues in orthopedic and vascular surgery and collaboration with plastic surgery for complex reconstruction and optimization of post-operative healing. Surgery of recurrent gynecologic cancer including pelvic exenteration, requires careful patient selection, pre-operative medical optimization and prehabilitation, and thorough counseling to optimize outcomes, both oncologic and peri-operative. We believe the creation of a well-developed team, including surgical teams and supportive care services, can lead to the best patient outcomes and improved professional satisfaction amongst providers.
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Affiliation(s)
- Conway Xu
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amanika Kumar
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
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5
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Zanini LAG, Reis RJ, Laporte GA, Vieira SC, Zanella JDF, Machado GM. Analysis of the surgical management of patients with recurrent cervical cancer after radiotherapy and chemotherapy. Rev Col Bras Cir 2020; 47:e20202443. [PMID: 32555966 DOI: 10.1590/0100-6991e-20202443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/02/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze the results of morbidity and survival after curative and palliative surgery in recurrent cervical cancer patients who underwent chemoradiation as their primary treatment. Another goal was to assess the factors associated with curative and non-curative procedures. METHODS This was a retrospective cohort consisting of patients undergoing surgery curative and palliative from January 2011 to December 2017 at a high complexity oncology center. Outcome of morbidity was reported according to the Clavien-Dindo classification, and survival analysis was carried out using the Kaplan-Meir method. To assess the factors associated with the procedures, a univariate analysis using the Mann-Whitney U test was performed. RESULTS Two radical hysterectomies, three pelvic exenterations with curative intent, and five palliatives pelvic exenterations were performed. In the curative group, there were major complications in 40% of the cases, and the median survival time was 16 months. In the palliative group, there were major complications in 60% of the cases, and the median survival time was 5 months. Advanced staging (p-value= 0.02), symptoms (p-value=0.04), tumor size greater than five centimeters (p-value=0.04), and more than three organs involved (p-value=0.003) were factors significantly associated with non-curative surgery. CONCLUSIONS The morbidity rates of this study were higher in palliative group, and the median survival time was lower in the palliative group than the curative group, but this difference in survival was not statistically significant. Advanced stage, symptoms, tumor size and number of organs involved are factors that should be taken into consideration when indicating surgical salvage.
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Affiliation(s)
| | - Rosilene Jara Reis
- Santa Casa de Misericórdia of Porto Alegre, Cirurgia oncológica - Porto Alegre - RS - Brasil
| | | | | | - Janice de Fátima Zanella
- Universidade de Cruz Alta, Programa de Pós Graduação em Atenção Integral à Saúde - Cruz Alta - RS - Brasil
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Kiiski J, Räikkönen K, Vuento MH, Hyöty MK, Kallio J, Kuokkanen HO, Kaartinen IS. Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:1632-1637. [DOI: 10.1016/j.ejso.2019.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/03/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
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The effect of preoperative nutritional status on postoperative complications and overall survival in patients undergoing pelvic exenteration: A multi-disciplinary, multi-institutional cohort study. Am J Surg 2019; 218:275-280. [PMID: 30982571 DOI: 10.1016/j.amjsurg.2019.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Optimization of preoperative nutritional status has been recommended and associated with improved outcomes for other oncologic procedures, but has not been studied in patients undergoing pelvic exenteration. METHODS A retrospective chart review of 199 patients was conducted. Overall survival (OS) was calculated using the Kaplan-Meier method and multivariate analysis was performed with Cox proportional hazards. RESULTS 199 patients underwent PE with 61 (31%), 78 (40%) and 58 (29%) patients having colorectal, gynecologic and urologic histological diagnoses, respectively. Median OS following PE was 25 months. Preoperative serum albumin <3.5 g/dL was associated with worsened OS (HR 1.661; 95% CI 1.052-2.624) as well as increased incidence of any postoperative complication (85.9% vs 72.3%, p = 0.034), but was not associated with 90-day mortality (11.3% vs 7.9%, p = 0.457). CONCLUSION Poor preoperative nutritional status is associated with increased complications and decreased OS. Surgeons should maximize preoperative nutritional status to improve perioperative outcomes and long-term survival.
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8
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Karmaniolou I, Arkadopoulos N, Vassiliou P, Nastos C, Dellaportas D, Siatelis A, Theodosopoulos T, Vezakis A, Parasyris S, Polydorou A, Smyrniotis V. Pelvic Exenteration Put into Therapeutical and Palliative Perspective: It Is Worth to Try. Indian J Surg Oncol 2018; 9:552-557. [PMID: 30538387 DOI: 10.1007/s13193-018-0792-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/13/2018] [Indexed: 12/27/2022] Open
Abstract
Pelvic exenteration (PE) is one of the most drastic operations in surgical oncology, associated with severe morbidity and mortality. The objective of our study was to review our experience of PE in terms of surgical characteristics, complications, and overall survival. All patients who had PE surgery between January 1999 and December 2015 were identified. Patients with verified distant metastatic disease were excluded. Patients with advanced pelvic tumors experiencing incapacitating postradiation severe damages were included. The following parameters were recorded: age, sex, indication for surgery, tumor histology, type of exenteration, urinary tract and colon reconstruction methods, operative time, blood transfusion, intensive care unit admissions, length of hospital stay and readmissions, and characteristics of perioperative morbidity and mortality. A total of 25 patients were submitted to PE by our surgical team. Most of the patients suffered from cervical cancer followed by bowel cancer. There was no perioperative mortality. Early postoperative complications ensued in 56% of the patients. Most complications involved the urinary system. Five years survival was estimated at 38%. Most patients (n = 9, 36%) died due to their primary disease, 5 (20%) died because of complications following operation, and 2 (8%) died because they denied oral feeding, which was associated with depression. Patients with a variety of malignancies can benefit from PE. Meticulous surgical technique, perioperative care, counseling, and nutritional support play an important role.
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Affiliation(s)
- Iosifina Karmaniolou
- 1Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Rd, Lambeth, London, SE1 7EH UK
| | - Nikolaos Arkadopoulos
- 22nd Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini Str, 124 10 Chaidari, Greece
| | - Pantelis Vassiliou
- 22nd Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini Str, 124 10 Chaidari, Greece
| | - Constantinos Nastos
- 32nd Department of Surgery, Aretaieion Hospital, University of Athens Medical School, 76 Vasilisis Sofias Avenue, 115 28 Athens, Greece
| | - Dionysios Dellaportas
- 32nd Department of Surgery, Aretaieion Hospital, University of Athens Medical School, 76 Vasilisis Sofias Avenue, 115 28 Athens, Greece
| | - Argyris Siatelis
- 22nd Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini Str, 124 10 Chaidari, Greece
| | - Theodosis Theodosopoulos
- 32nd Department of Surgery, Aretaieion Hospital, University of Athens Medical School, 76 Vasilisis Sofias Avenue, 115 28 Athens, Greece
| | - Antonios Vezakis
- 32nd Department of Surgery, Aretaieion Hospital, University of Athens Medical School, 76 Vasilisis Sofias Avenue, 115 28 Athens, Greece
| | - Stavros Parasyris
- 22nd Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini Str, 124 10 Chaidari, Greece
| | - Andreas Polydorou
- 32nd Department of Surgery, Aretaieion Hospital, University of Athens Medical School, 76 Vasilisis Sofias Avenue, 115 28 Athens, Greece
| | - Vassilios Smyrniotis
- 22nd Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini Str, 124 10 Chaidari, Greece
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Nelson AM, Albizu-Jacob A, Fenech AL, Chon HS, Wenham RM, Donovan KA. Quality of life after pelvic exenteration for gynecologic cancer: Findings from a qualitative study. Psychooncology 2018; 27:2357-2362. [DOI: 10.1002/pon.4832] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 06/08/2018] [Accepted: 06/21/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Ashley M. Nelson
- Department of Health Outcomes and Behavior; Moffitt Cancer Center; Tampa FL USA
- Department of Psychology; University of South Florida; Tampa FL USA
| | | | - Alyssa L. Fenech
- Department of Health Outcomes and Behavior; Moffitt Cancer Center; Tampa FL USA
- Department of Supportive Care Medicine; Moffitt Cancer Center; Tampa FL USA
| | - Hye Sook Chon
- Department of Gynecologic Oncology; Moffitt Cancer Center; Tampa FL USA
| | - Robert M. Wenham
- Department of Gynecologic Oncology; Moffitt Cancer Center; Tampa FL USA
| | - Kristine A. Donovan
- Department of Health Outcomes and Behavior; Moffitt Cancer Center; Tampa FL USA
- Department of Supportive Care Medicine; Moffitt Cancer Center; Tampa FL USA
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Margolis B, Kim SW, Chi DS. Long-term survival after anterior pelvic exenteration and total vaginectomy for recurrent endometrial carcinoma with metastatic inguinal nodes at the time of surgery. Gynecol Oncol Rep 2016; 19:39-41. [PMID: 28070552 PMCID: PMC5219612 DOI: 10.1016/j.gore.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 11/05/2022] Open
Abstract
Pelvic exenteration can be used in patients with multifocal recurrence. Ability to achieve negative margins remains a necessity for pelvic exenteration. Individualized treatments are essential for those with recurrent malignancy.
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Affiliation(s)
- Benjamin Margolis
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA; New York Presbyterian Hospital, 622 W 168th St, New York, NY 10032, USA
| | - Sun Woo Kim
- New York Presbyterian Hospital, 622 W 168th St, New York, NY 10032, USA; Weill Cornell Medical College, Cornell University, 1300 York Ave, New York, NY 10065, USA
| | - Dennis S Chi
- Weill Cornell Medical College, Cornell University, 1300 York Ave, New York, NY 10065, USA; Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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11
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Macrì A, Fleres F, Arcoraci V, Alibrandi A, Mandolfino T, Cucinotta E, Saladino E. Evaluation of the Short- and Long-Term Outcome Predictors in Patients Undergoing Posterior Pelvic Exenteration: A Single-Center Experience. J Gynecol Surg 2016. [DOI: 10.1089/gyn.2015.0081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Antonio Macrì
- Department of Human Pathology, University of Messina, Messina, Sicily, Italy
| | - Francesco Fleres
- Department of Human Pathology, University of Messina, Messina, Sicily, Italy
| | - Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Sicily, Italy
| | - Angela Alibrandi
- Department of Statistics, University of Messina, Messina, Sicily, Italy
| | - Tommaso Mandolfino
- Anesthesiology and Neuroreanimation Unit, University of Messina, Messina, Sicily, Italy
| | - Eugenio Cucinotta
- Department of Human Pathology, University of Messina, Messina, Sicily, Italy
| | - Edoardo Saladino
- Department of Human Pathology, University of Messina, Messina, Sicily, Italy
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Hannes S, Nijboer JM, Reinisch A, Bechstein WO, Habbe N. Abdominoperineal Excisions in the Treatment Regimen for Advanced and Recurrent Vulvar Cancers-Analysis of a Single-Centre Experience. Indian J Surg 2016; 77:1270-4. [PMID: 27011549 DOI: 10.1007/s12262-015-1273-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 04/14/2015] [Indexed: 11/25/2022] Open
Abstract
Vulva cancer is the fourth leading gynaecological malignancy, accounting for approximately 4 % of all gynaecological cancers. Surgery represents the treatment of choice, and cases of advanced or recurrent vulvar cancers are to date a major challenge to multidisciplinary teams. Abdominoperineal excision (APE) in combination with vulvectomy and inguinal lymphadenectomy is the only curative treatment option. Patients' files of all women with squamous cell carcinoma of the vulva who underwent abdominoperineal resection were retrospectively reviewed with special regards to technical challenges the general surgeon will face. Seven women were enrolled in this retrospective study with a median age of 71 years (range 56-79 years). In six patients, the pelvic floor after abdominoperineal excision could be closed by direct suture of the levator muscles. One woman underwent abdominoperineal resection with closure of the defect using a vertical rectus abdominis myocutaneous (VRAM) flap. All women underwent radical vulvectomy, in five patients in combination with bilateral inguinal lymph node dissection. Operation time was 377 min (range 130-505 min). The median overall survival after surgery was 27 months (range 4-84 months), with a calculated 5-year survival rate of 42 %. Women with negative lymph nodes revealed a longer survival time after surgery compared to women with lymph node metastases (15.5 vs. 72 months; p = 0.09). Abdominoperineal excisions represent a powerful tool in the multidisciplinary treatment regimen of advanced or recurrent vulvar cancer. Reconstruction of the pelvic floor usually does not require myocutaneous flaps, even when facing large tumours. Despite high complication rates, radical surgery was a feasible treatment with long-term survival potential without mortality.
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Affiliation(s)
- Sabine Hannes
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Johanna M Nijboer
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Alexander Reinisch
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Wolf O Bechstein
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Nils Habbe
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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13
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Petruzziello A, Kondo W, Hatschback SB, Guerreiro JA, Filho FP, Vendrame C, Luz M, Ribeiro R. Surgical results of pelvic exenteration in the treatment of gynecologic cancer. World J Surg Oncol 2014; 12:279. [PMID: 25200866 PMCID: PMC4167277 DOI: 10.1186/1477-7819-12-279] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 08/23/2014] [Indexed: 11/23/2022] Open
Abstract
Background Our aim in the present study was to evaluate surgical outcomes and complications of pelvic exenteration in the treatment of gynecologic malignancy and to compare surgery-related complications associated with different types of exenteration. Methods We performed a retrospective analysis of patients who underwent pelvic exenteration for the treatment of gynecologic cancer between January 2008 and August 2011. Patients were divided into two groups for comparison: total pelvic exenteration (TPE) and nontotal pelvic exenteration (NTE, including anterior pelvic exenteration (APE) posterior pelvic exenteration (PPE)). Outcomes are reported according to the modified Clavien-Dindo Classification of Surgical Complications. Results Twenty-eight patients were included in the analysis. Eighteen had cervical cancer (64.3%). The prevalence of stage IIIB cervical cancer was 55%. Primary treatment with radiotherapy was performed in 53.3% of patients. Fifty percent of patients underwent TPE, 25% had APE and 25% underwent PPE. Patients who underwent TPE had worse outcomes, with a mean operative time of 367 minutes, use of blood transfusion in 93% of patients, ICU stay of 4.3 days and total hospital stay of 9.4 days. The overall mortality rate was 14.3%, and the surgical site infection rate was 25%. In the TPE group, 78.6% of patients experienced surgical complications. One-fourth of the total patient sample required reoperation, and the leading cause was urinary fistula (57.1%). Urinary leakage occurred in 22.7% of urinary reconstruction patients. Wet colostomy was the most common form of reconstruction with 10% of leakage. Conclusions Postoperative urinary and infectious complications accounted for 75% of all causes of morbidity and mortality after pelvic exenteration. TPE is a more complex and morbid procedure than NTE.
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Affiliation(s)
- Andrea Petruzziello
- Surgical Oncology, Department of Surgery, Erasto Gaertner Hospital, Curitiba, Brazil.
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Vargas HA, Burger IA, Donati OF, Andikyan V, Lakhman Y, Goldman DA, Schöder H, Chi DS, Sala E, Hricak H. Magnetic resonance imaging/positron emission tomography provides a roadmap for surgical planning and serves as a predictive biomarker in patients with recurrent gynecological cancers undergoing pelvic exenteration. Int J Gynecol Cancer 2014; 23:1512-9. [PMID: 24257566 DOI: 10.1097/igc.0b013e3182a41e61] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) is the modality of choice for staging gynecological cancers owing to its superb soft tissue resolution, whereas F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) allows the assessment of glycolytic activity within the tumor microenvironment. In this study, we evaluated the incremental value of fused MRI/PET over MRI or fluorodeoxyglucose PET/CT alone for assessing local disease extent in patients with recurrent gynecological cancers undergoing pelvic exenteration and determined the associations between imaging findings and clinical outcomes in this patient population. MATERIALS AND METHODS The institutional review board approved this retrospective, Health Insurance Portability and Accountability Act (HIPAA)-compliant study of 31 patients who underwent pelvic MRI and PET/CT 3 months or less before pelvic exenteration for recurrent cancers of the uterine cervix, corpus, or vulva/vagina. Using a 1 to 5 scale (1, definitely not present; 5, definitely present), 2 readers independently evaluated MRI, PET/CT, and fused MRI/PET images for the presence of bladder, rectum, and pelvic sidewall invasion. Surgical pathology constituted the reference standard. Measurements of diagnostic accuracy, interreader agreement, and associations between imaging findings and progression-free survival and overall survival were calculated. RESULTS Compared with MRI or PET/CT, fused MRI/PET correctly improved readers' diagnostic confidence in detecting bladder, rectum, or pelvic sidewall invasion in up to 52% of patients. Interreader agreement was consistently in the highest ("almost perfect") range only for MRI/PET (κ = 0.84-1.0). The highest sensitivities (0.82-1.0), specificities (0.91-1.0), and predictive values (0.80-1.0) were consistently achieved with fused MRI/PET (although the differences were not statistically significant [P > 0.05]). Pelvic sidewall invasion on MRI/PET was the only finding significantly associated with both progression-free and overall survival for both readers (P = 0.0067-0.0440). CONCLUSIONS In patients with recurrent gynecological cancers undergoing pelvic exenteration, fused MRI/PET served as a predictive biomarker and yielded greater diagnostic confidence and interreader agreement than either MRI or PET/CT.
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Affiliation(s)
- Hebert Alberto Vargas
- Departments of *Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY; †Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland; and ‡Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Ang C, Bryant A, Barton DPJ, Pomel C, Naik R. Exenterative surgery for recurrent gynaecological malignancies. Cochrane Database Syst Rev 2014; 2014:CD010449. [PMID: 24497188 PMCID: PMC6457731 DOI: 10.1002/14651858.cd010449.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common cancers in women. Unfortunately, given the nature of the disease, cancer can recur or progress in some patients. Although the management of early-stage cancers is relatively straightforward, with lower associated morbidity and mortality, the surgical management of advanced and recurrent cancers (including persistent or progressive cancers) is significantly more complicated, often requiring very extensive procedures. Pelvic exenterative surgery involves removal of some or all of the pelvic organs. Exenterative surgery for persistent or recurrent cancer after initial treatment is difficult and is usually associated with significant perioperative morbidity and mortality. However, it provides women with a chance of cure that otherwise may not be possible. In carefully selected patients, it may also have a place in palliation of symptoms. The biology of recurrent ovarian cancer differs from that of other gynaecological cancers; it is often responsive to chemotherapy and is not included in this review. OBJECTIVES To evaluate the effectiveness and safety of exenterative surgery versus other treatment modalities for women with recurrent gynaecological cancer, excluding recurrent ovarian cancer (this is covered in a separate review). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of clinical guidelines and review articles and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) or non-randomised studies with concurrent comparison groups that included multivariate analyses of exenterative surgery versus medical management in women with recurrent gynaecological malignancies. DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No studies were found; therefore no data were analysed. MAIN RESULTS The search strategy identified 1311 unique references, of which seven were retrieved in full, as they appeared to be potentially relevant on the basis of title and abstract. However, all were excluded, as they did not meet the inclusion criteria of the review. AUTHORS' CONCLUSIONS We found no evidence to inform decisions about exenterative surgery for women with recurrent cervical, endometrial, vaginal or vulvar malignancies. Ideally, a large RCT or, at the very least, well-designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances are needed to compare exenterative surgery versus medical management, including palliative care.
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Affiliation(s)
- Christine Ang
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalSheriff HillGatesheadUKNE9 6SX
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Desmond PJ Barton
- Royal Marsden HospitalDivision of Gynaecological OncologyFulham RoadLondonUKSW3 6JJ
| | - Christophe Pomel
- Jean Perrin Comprehensive Cancer Centre of AuvergneSurgical OncologyClermont‐FerrandFrance
| | - Raj Naik
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalSheriff HillGatesheadUKNE9 6SX
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Pelvic exenteration for recurrent gynecologic malignancy: a study of 28 consecutive patients at a single institution. Int J Gynecol Cancer 2014; 23:755-62. [PMID: 23407096 DOI: 10.1097/igc.0b013e318287a874] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the outcomes of patients undergoing pelvic exenteration (PE) for recurrent gynecologic malignancy. METHODS A retrospective review using all medical records of 28 consecutive patients who underwent PE between January 2002 and December 2011 at a single institution was conducted. Complications were graded according to Clavien-Dindo. Overall survival (OS) and disease-free survival (DFS) were estimated by the method of Kaplan-Meier. RESULTS Pelvic exenteration was performed for recurrent cancer in all patients. Distribution of primaries was as follows: cervix (n = 10), vagina (n = 5), ovary (n = 5), uterus (n = 4), tube (n = 2), Bartholin gland (n = 1), and vulva (n = 1). In all but 1 case, PE was performed with curative intent. Pelvic exenteration was total (n = 11), anterior (n = 2), or posterior (n = 15). Reconstructive procedures included urinary tract (n = 13), gastrointestinal tract (n = 26), pelvic floor (n = 6), and vagina (n = 5). There was no postoperative mortality within 30 days. All patients developed 1 or several early complications of various grades, and 22 patients (79%) developed late complications. Twelve patients (43%) underwent reoperation because of complications to PE, and 2 patients died within follow-up as a consequence of their PE. A complete tumor resection (R0) was obtained in 23 patients (82%). With a median follow-up of 27 months (range, 2-110 months), the 5-year OS and DFS rates were 70% and 41%, respectively. R0 resection was associated with increased OS (P < 0.001) and DFS (P = 0.015). CONCLUSIONS Pelvic exenteration for recurrent gynecologic malignancies can be associated with long-term survival in selected patients. However, postoperative complications are common and can be lethal.
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Landoni F, Zanagnolo V, Rosenberg P, Lopes A, Radice D, Bocciolone L, Aletti G, Parma G, Colombo N, Maggioni A. Neoadjuvant chemotherapy prior to pelvic exenteration in patients with recurrent cervical cancer: Single institution experience. Gynecol Oncol 2013; 130:69-74. [DOI: 10.1016/j.ygyno.2013.02.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 02/24/2013] [Accepted: 02/27/2013] [Indexed: 10/27/2022]
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Oranratanaphan S, Termrungruanglert W, Sirisabya N. Characteristics of gynecologic oncology patients in King Chulalongkorn Memorial Hospital - complications and outcome of pelvic exenteration. Asian Pac J Cancer Prev 2013; 14:2529-32. [PMID: 23725169 DOI: 10.7314/apjcp.2013.14.4.2529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pelvic exenteration is a procedure which includes enbloc resection of pelvic organs followed by surgical reconstruction. Aims include both cure and palliation but data for pelvic exenteration in Thailand are very limited. OBJECTIVE This study was conducted to evaluate characteristics of patients, operative procedure outcomes and complications. MATERIALS AND METHODS This retrospective review covered all of the charts of exenteration patients during January 2002 to December 2011. Baseline characteristic of the patients were collected as well as details of clinical results. RESULTS A total of 13 cases of pelvic exenteration were included. Most underwent total pelvic exenteration (9 cases) and the remainder posterior and anterior exenteration. Their primary cancers were ovarian, cervical and vulva. Mean operative time was 532 minutes (SD 160.2, range 270- 750) and estimated blood loss was 2830 ml (1850, 1000-8000). Mean tumor size was 7.33 cm (3.75, 4-15). Mean hospital stay was 35.2 days (29.8, 13-109). The most common post operative complication was urinary tract infection. Overall disease free survival with a negative surgical margin was significantly better than in positive surgical margin patients (p=0.014). CONCLUSIONS Surgical margin was the most significant prognostic factor for disease free survival, in line with earlier studies.
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Affiliation(s)
- Shina Oranratanaphan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn Memorial Hospital, Bangkok, Thailand.
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Role of preoperative MR imaging in the evaluation of patients with persistent or recurrent gynaecological malignancies before pelvic exenteration. Eur Radiol 2013; 23:2906-15. [DOI: 10.1007/s00330-013-2875-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/18/2013] [Accepted: 03/20/2013] [Indexed: 10/26/2022]
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Burger IA, Vargas HA, Donati OF, Andikyan V, Sala E, Gonen M, Goldman DA, Chi DS, Schöder H, Hricak H. The value of 18F-FDG PET/CT in recurrent gynecologic malignancies prior to pelvic exenteration. Gynecol Oncol 2013; 129:586-592. [PMID: 23369941 DOI: 10.1016/j.ygyno.2013.01.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 01/15/2013] [Accepted: 01/17/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE In patients undergoing pelvic exenteration for recurrent gynecological malignancies, we assessed the performance of [(18)F]-FDG PET/CT for delineating disease extent and evaluated the association between quantitative FDG uptake metrics (SUVmax, total lesion glycolysis [TLG] and metabolic tumor volume [MTV]) and progression-free survival (PFS) and overall survival (OS). METHODS Retrospective study of patients undergoing pelvic exenteration for gynecologic malignancies between January 2002 and November 2011 who had FDG PET/CT within 90days before surgery. Two readers (R1, R2) independently determined the presence of bladder, rectum, vagina, cervix and pelvic side wall invasion and measured SUVmax, TLG and MTV in each patient. Areas under the curve (AUCs), for detecting organ invasion were calculated. Kaplan-Meier graphs were used to determine associations between FDG uptake and PFS/OS. Inter-reader agreement was assessed. RESULTS 33 patients (mean age 56years, range: 28-81) were included; primary sites of disease were the cervix (n=18), uterus (n=8) and vagina/vulva (n=7). AUCs for organ invasion ranged from 0.74 to 0.96. There was a significant association between FDG uptake metrics incorporating tumor volume (TLG and MTV) and OS (p≤0.001) as well as between MTV and PFS (p=0.001). No significant association was identified between SUVmax and OS/PFS (p=0.604/0.652). Inter-reader agreement for organ invasion was fair to substantial (k=0.36-0.74) and almost perfect for FDG quantification (ICC=0.97-0.99). CONCLUSION In patients undergoing pelvic exenteration for recurrent gynecological malignancies, (18)F-FDG PET/CT is useful for preoperative assessment of disease extent. Furthermore, quantitative metrics of FDG uptake incorporating MTV serve as predictive biomarkers of progression-free and overall survival in this population.
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Affiliation(s)
- Irene A Burger
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Hebert Alberto Vargas
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Olivio F Donati
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Vaagn Andikyan
- Department of Gynecology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Evis Sala
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Mithat Gonen
- Department of Epidemiology-Biostatistics, Memorial Sloan-Kettering Cancer Center, 307 E 63rd Street, New York, NY 10065, USA
| | - Debra A Goldman
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Dennis S Chi
- Department of Gynecology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Heiko Schöder
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
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Tsubamoto H, Maeda H, Kanazawa R, Ito Y, Ohama N, Hori M, Ikeda Y, Kato T, Sakane R, Hirota S. Phase II trial on neoadjuvant intravenous and trans-uterine arterial chemotherapy for locally advanced bulky cervical adenocarcinoma. Gynecol Oncol 2013; 129:129-34. [PMID: 23333929 DOI: 10.1016/j.ygyno.2013.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/09/2013] [Accepted: 01/09/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A phase II trial on neoadjuvant trans-uterine arterial chemotherapy (TUAC) followed by type III radical hysterectomy (RH) was conducted for patients with bulky cervical adenocarcinoma (AC). METHODS Tumors of >4 cm were eligible. The neoadjuvant regimen comprised paclitaxel (60 mg/m(2) intravenously on days 1, 8, and 15) and cisplatin (70 mg/m(2) TUAC followed by transcatheter embolization with gelatin sponge particles on day 2) repeated every 3 weeks for 3 cycles. The primary endpoints were clinical and pathological responses. RESULTS Twenty-two patients (median age, 51 years; range, 33-75 years) were enrolled. The International Federation of Gynecology and Obstetrics stages were IB2 (9 patients), IIA-IIB (8), IIIB (3), and IVA (2). The adeno/adenosquamous ratio was 16/6. The overall clinical response rate was 95.4% (95% confidence interval [CI], 86.7-100%). RH was completed in 19 patients (86%), including 2 stage IVA patients who underwent anterior or posterior pelvic exenteration. Of the 19 patients, no residual malignant cells were found pathologically in 4; thus, the pathological complete response rate was 18% (4/22). No patients experienced grade 4 thrombocytopenia or febrile neutropenia or required platelet transfusions. The 5-year progression-free survival and overall survival rates in stages IB2-IIB were 70.0% (95%CI, 48.1-92.1%) and 69.5% (95%CI, 47.0-92.0%), respectively. The 2 patients with stage IVA tumors were alive without recurrence for 72 and 84 months after enrollment. CONCLUSIONS TUAC showed high clinical and pathological response rates. TUAC is promising for stage IB2-IIB and IVA bulky AC.
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Affiliation(s)
- Hiroshi Tsubamoto
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Japan.
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Baiocchi G, Guimaraes G, Rosa Oliveira R, Kumagai L, Faloppa C, Aguiar S, Begnami M, Soares F, Lopes A. Prognostic factors in pelvic exenteration for gynecological malignancies. Eur J Surg Oncol 2012; 38:948-54. [DOI: 10.1016/j.ejso.2012.07.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/30/2012] [Accepted: 07/02/2012] [Indexed: 10/28/2022] Open
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Yoo HJ, Lim MC, Seo SS, Kang S, Yoo CW, Kim JY, Park SY. Pelvic exenteration for recurrent cervical cancer: ten-year experience at National Cancer Center in Korea. J Gynecol Oncol 2012; 23:242-50. [PMID: 23094127 PMCID: PMC3469859 DOI: 10.3802/jgo.2012.23.4.242] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 07/02/2012] [Accepted: 07/03/2012] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate survival and morbidity after pelvic exenteration (PE) for the curative management of recurrent cervical cancer. Methods We retrospectively evaluated patients with recurrent cervical cancer who underwent PE from January 2001 to April 2011. Patients were identified from the registry of our institution. The clinical status and demographic information was obtained by reviewing the medical records. Results Sixty-one recurrent cervical cancer patients underwent PE. Patients who received radiotherapy, operation, chemotherapy before PE were 98%, 41%, and 23%, respectively. The total morbidity rate was 44%; 10 (16%) patients had early complications (30 days or less after PE), whereas 22 (36%) patients had late complications. Wound problems were common early complications (7/18), and bowel fistulas were common late complications (9/30). The five-year overall survival and five-year disease-free survival were 56% and 49%, respectively. Median follow-up was 22 months (range, 1.8 to 60 months). Affecting factors for overall survival were resection margin status, pelvic wall and rectal involvement. Conclusion Our overall 5-year survival is encouraging. Although the morbidity rate is still high, PE is a potentially curative opportunity in gynecological malignancies with no other treatment options. The most important factors for overall survival after PE are the resection margin status, pelvic wall involvement and rectal involvement.
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Affiliation(s)
- Heon Jong Yoo
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Creagh TA, Dixon L, Frizelle FA. Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy. J Plast Reconstr Aesthet Surg 2012; 65:791-7. [DOI: 10.1016/j.bjps.2011.11.063] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 09/15/2011] [Accepted: 11/10/2011] [Indexed: 01/06/2023]
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Iglesias DA, Westin SN, Rallapalli V, Huang M, Fellman B, Urbauer D, Frumovitz M, Ramirez PT, Soliman PT. The effect of body mass index on surgical outcomes and survival following pelvic exenteration. Gynecol Oncol 2012; 125:336-42. [PMID: 22261299 DOI: 10.1016/j.ygyno.2012.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/05/2012] [Accepted: 01/08/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE We sought to evaluate whether preoperative body mass index (BMI) impacts surgical outcomes, complication rates, and/or recurrence rates in women undergoing pelvic exenteration. METHODS All women who underwent pelvic exenteration for gynecologic indications at our institution from 1993 through 2010 were included. Women were stratified into 3 groups based on BMI. Baseline characteristics, surgical outcomes, early (<60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were collected. Multivariate logistic regression analyses were performed. Kaplan-Meier survival curves were compared using log-rank test. RESULTS 161 patients were included (59 normal weight, 44 overweight, 58 obese). Median follow-up times were 22, 29, and 25 months. Most patients underwent total pelvic exenteration (68%); 64.6% had a vaginal reconstruction. On multivariate analysis, both overweight and obese patients had a higher risk of early superficial wound separation compared to normal weight patients - OR 10.74 (3.33-34.62, p<0.001) and OR 4.35 (1.40-13.52, p=0.011), respectively. Length of surgery was significantly longer for overweight (9.6h, OR 1.26, 1.02-1.55, p=0.032) and obese (10.1h, OR 1.24, 1.04-1.47, p=0.014) patients than for normal weight patients (8.7h). Late postoperative complications for patients in the normal weight, overweight, and obese groups were 47.5%, 45.5%, and 43.1% (p=0.144). There were no differences in time to recurrence (p=0.752) or overall survival (p=0.103) between groups. CONCLUSION Although operative times were longer and risk for superficial wound separation was significantly higher, pelvic exenteration appears to be feasible and safe in overweight and obese women with overall complication rates and survival outcomes comparable to normal weight women.
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Affiliation(s)
- David A Iglesias
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas, M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
Surgical management for cervical carcinoma uses a wide variety of procedures for all stages of disease, ranging from the most conservative excisional biopsy to aggressive extirpative surgery with sophisticated reconstruction. Innovative surgical procedures have given fertility-sparing treatment options to women of reproductive age, and refinement and use of minimally invasive surgical approaches have minimized operative morbidity without sacrificing outcomes. Conservative staging procedures are being evaluated to improve survival in locally advanced disease. There have been many breakthroughs in the treatment of cervical carcinoma over recent years, which have improved not only survival but also the quality of ensuing life for women afflicted by this disease.
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Affiliation(s)
- Jessica L Berger
- Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, Phoenix, AZ 85006, USA.
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Forner DM, Lampe B. Exenteration as a primary treatment for locally advanced cervical cancer: long-term results and prognostic factors. Am J Obstet Gynecol 2011; 205:148.e1-6. [PMID: 21640963 DOI: 10.1016/j.ajog.2011.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 02/04/2011] [Accepted: 03/29/2011] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Whereas pelvic exenteration is an established therapy for the treatment of recurrent cervical carcinoma, it is not often performed for primary locally advanced cervical cancer (LACC). STUDY DESIGN This retrospective study analyzed survival data and prognostic factors of 35 patients with LACC who were treated by pelvic exenteration. RESULTS After surgery, 33 patients (97%) were macroscopically free of tumor. In 20 patients, pelvic lymph nodes (LN) were involved, and in 6 of these, metastatic tissue had reached the paraaortal nodes. Overall, the patients' mean 5 year survival was 43%, and the median survival time was 30 months; these values ranged from 15% to 70% and from 15 to 44 months, respectively, depending on LN involvement (P=.006). Pelvic LN involvement was the only significant factor for overall survival found in the multivariate analysis (P=.02). CONCLUSION In LACC with free LNs and no distant metastases, pelvic exenteration has good long-term results.
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MÄENPÄÄ JOHANNAU, KANGASNIEMI KATRI, LUUKKAALA TIINA. Pelvic exenteration for gynecological malignancies: an analysis of 15 cases operated on at a single institution. Acta Obstet Gynecol Scand 2010; 89:279-83. [DOI: 10.3109/00016340903370122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- JOHANNA U MÄENPÄÄ
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University Hospital of Tampere
- Medical School, University of Tampere
| | | | - TIINA LUUKKAALA
- Science Center, Pirkanmaa Hospital District, and Tampere School of Public Health, University of Tampere, Tampere, Finland
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Fotopoulou C, Neumann U, Kraetschell R, Schefold JC, Weidemann H, Lichtenegger W, Sehouli J. Long-term clinical outcome of pelvic exenteration in patients with advanced gynecological malignancies. J Surg Oncol 2010; 101:507-12. [PMID: 20401918 DOI: 10.1002/jso.21518] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES We evaluated the outcome of pelvic exenteration in women with locally advanced primary or recurrent gynecological malignancies. METHODS All pelvic exenteration procedures performed between 01/2003 and 06/2009 were evaluated. Extent of surgical radicality, operative techniques, and outcome were evaluated. Kaplan-Meier curves were calculated for Overall (OS) and progression-free survival (PFS). RESULTS Forty-seven patients (median age: 52.5 years) were evaluated. Ten of 47 patients (21.3%) had a primary and 37(78.7%) a relapsed cancer. Most common (80.8%) site of origin was the cervix. Patients (80.8%) had undergone previous pelvic irradiation. A total exenteration was performed in 32/47 patients (68%). A complete tumor resection was obtained in 23 patients (49%). Thirty-three patients (70.2%) had at least one major complication, including ileus (8.5%), intestinal-fistula (29.8%), ureteral anastomotic insufficiency (6.4%), abscess (6.4%), and cardiothrombotic events (23.4%). At a median follow-up of 7 months (range: 1-42), 22/47 patients (46.8%) died and 22/47 (46.8%) experienced a relapse. Median OS was 4 months (range: 0.1-16) and 22 months (range: 6-42) for patients with versus without postoperative tumor residuals, respectively (P = 0.0006), while median PFS was 4 months (range:0.1-16) versus 12 months (range: 6-42) (P < 0.0001). CONCLUSIONS Radical pelvic exenteration due to advanced pelvic malignancies may be associated with a high morbidity. Complete tumor resection is associated with a significantly higher overall and PFS.
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Affiliation(s)
- Christina Fotopoulou
- Department of Gynecology and Obstetrics, Charité, Campus Virchow Clinic, University Hospital, Berlin, Germany.
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Forner DM, Meyer A, Lampe B. Preoperative assessment of complete tumour resection by magnetic resonance imaging in patients undergoing pelvic exenteration. Eur J Obstet Gynecol Reprod Biol 2010; 148:182-5. [DOI: 10.1016/j.ejogrb.2009.10.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 08/17/2009] [Accepted: 10/19/2009] [Indexed: 12/17/2022]
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Bansal N, Roberts WS, Apte SM, Lancaster JM, Wenham RM. Electrothermal bipolar coagulation decreases the rate of red blood cell transfusions for pelvic exenterations. J Surg Oncol 2009; 100:511-4. [PMID: 19697350 DOI: 10.1002/jso.21372] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND We evaluated whether electrothermal bipolar coagulation (Ligasure) for pelvic exenterations decreases operative morbidity. METHODS All cases of pelvic exenterations, for all malignancies, performed at Moffitt Cancer Center from 1999 to 2008, were identified through retrospective review of medical records. Estimated blood loss (EBL), transfusion, operative time, hospital stay, and complications were compared between Ligasure cases and non-Ligasure cases. RESULTS Seventy-five patients underwent identified. Ligasure was used in 29/75 (39%) cases and standard techniques in 46/75 (61%) cases. Primary malignancy was gynecologic in 31/75(40%) cases (18/29, 62% Ligasure cases, 13/46, 26% non-Ligasure cases). Patients undergoing gynecologic exenteration received fewer intraoperative packed red blood cell (PRBC) transfusions in the Ligasure group (mean = 2.8 U), compared to the non-Ligasure group (mean = 3.8 U; P < 0.0001). The EBL was less for Ligasure cases (1,815 ml vs. 2,205 ml; P = 0.4). For all patients, Ligasure cases had lower mean transfusion (2.7 U vs. 3.2 U; P = 0.32), and EBL (1,662 ml vs. 1,843 ml; P = 0.5). The mean operating time was similar (492 min vs. 502 min). There were no cases of re-operation for hemorrhage in either group. CONCLUSIONS Use of electrothermal bipolar coagulation for gynecologic exenterative surgery is associated with significantly lower blood transfusions, and may decrease blood loss and transfusion in non-gynecologic exenterative surgery.
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Affiliation(s)
- Nisha Bansal
- Division of Gynecological Oncology, Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, Florida 33612, USA
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Maggioni A, Roviglione G, Landoni F, Zanagnolo V, Peiretti M, Colombo N, Bocciolone L, Biffi R, Minig L, Morrow CP. Pelvic exenteration: ten-year experience at the European Institute of Oncology in Milan. Gynecol Oncol 2009; 114:64-8. [PMID: 19411097 DOI: 10.1016/j.ygyno.2009.03.029] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/16/2009] [Accepted: 03/21/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Analyze morbidity and survival after pelvic exenteration (PE) of gynecological malignancies. METHODS We reviewed 106 consecutive patients with gynecologic malignancies who underwent PE from June 1996 to April 2007 at the Division of Gynecology, European Institute of Oncology (IEO), Milan. RESULTS PE was performed for cancer of the cervix (62 patients), vagina (21 patients), vulva (9 patients), endometrium (9 patients), ovary (4 patients) and 1 uterine sarcoma. Mean age was 53.6 (30-78) years. 97% of the patients received radiotherapy before PE and 3 patients had PE as primary treatment. We performed 53 anterior, 48 total and 5 posterior PE. Median operation time, estimated blood loss and hospital stay were respectively 490 (200-780) minutes, 1240 (300-6500) ml and 21.6 (11-55) days. No residual tumor was left in 93% of the patients. Median follow-up was 22.3 (1.6-117) months. There were no post-operative deaths (<30 days from surgery) nor intra-operative mortality. Total morbidity rate was 66%; 48% of patients had early complications (<30 days after PE) whereas 52 patients (48.5%) had late complications; 70% of these occurred to the urinary tract and 25% were due to bowel occlusions or fistulas. Overall survival was 52%, 35%, 19% and 16% respectively for cervical, endometrial, vaginal and vulvar cancer. CONCLUSIONS PE is a feasible technique with no post-operative mortality and high percentage of long-survivors, although the morbidity rate still remains significantly high. Careful patient selection, pre- and post-operative care and optimal surgical skills in a Gynecologic Oncologic Center are the cornerstones to further improve quality of life and survival for these patients.
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Affiliation(s)
- Angelo Maggioni
- Division of Gynecologic Oncology, European Institute of Oncology, Via Ripamonti 435-20141, Milan, Italy
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Current World Literature. Curr Opin Obstet Gynecol 2009; 21:101-9. [DOI: 10.1097/gco.0b013e3283240745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park SY. Diagnosis and Treatment of Recurrent Cervical Cancer. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2007. [DOI: 10.5124/jkma.2007.50.9.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sang Yoon Park
- Department of Obstetrics and Gynecology, National Cancer Center, Korea.
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