The Role of Surgery in Non-Localized Neuroblastoma. Analysis of 59 Cases

The authors considered 59 stage III and IV neuroblastoma cases, which were observed from January 1967 to June 1979. 13 patients (13/59 = 22%) are surviving in complete remission 3 years after surgery: 9/20 (45%) with stage III and 4/39 (10%) with stage IV disease. The children subjected to complete surgical excision are all alive irregardless of age; the children who were not operated on or subjected to a biopsy, have all died. Of the 33 patients who underwent a reductive excision, 6 (all under 2 years of age) are in complete remission (18%). A better prognosis was found in those patients in whom the site of the primary tumor was at the mediastinal level. These data show the importance of the role of the surgeon in the multidisciplinary treatment of stage III and IV neuroblastomas; our experience is also favorable to the practice of second-look surgery.

Postoperative Investigations Resulting in Cost Reduction in Oncological Patients Undergoing Major Abdominal and Pelvic Surgery

AIM

Rising costs in health care are of progressively growing interest and a major factor affecting hospitalization costs is represented by postoperative complications. Complications of Major Abdominal Surgery (MAS) are associated with increased morbidity and mortality. This study estimates the costs of postoperative care associated with complications. Material and Methods: We performed a retrospective study on 254 patients admitted to the 1st General and Oncological Surgery Clinic of the Bucharest Oncology Institute who were submitted to MAS. The total hospitalization, complications and treatment costs were analysed. Results: For a patient undergoing MAS, the average costs for surgery without complications are 5,791.3 RON and reach an average of 20,806 RON after major complications.

CONCLUSION

The results provide insight into the costs of hospitalization for oncology patients submitted to surgical interventions. Complications occur in 20.86% of patients undergoing MAS and account for 50% of total care costs. Establishing and implementing a protocol aimed at early diagnosis and treatment of specific complications could lead to a decrease in morbidity and mortality, as well as of the costs of hospitalization.

How Can We Effectively Address the Medical and Psychological Concerns of Survivors of Pelvic Malignancies?

Sexual and urinary morbidities resulting from treatment of pelvic malignancies are common. These treatment sequelae are significantly bothersome to patients and challenging to address. Awareness of these complications is critical in order to properly counsel patients regarding potential side effects and to facilitate prompt diagnosis and management. Addressing these issues often necessitates a coordinated multidisciplinary approach; however, the effort required often translates into improvement in patient quality of life. Herein we review the sexual and urinary side effects that may arise during or after treatment of pelvic malignancies.

Oncological and surgical outcome after treatment of pelvic sarcomas

Background and objectives

Treatment of pelvic tumors remains challenging due to complex anatomy, poor oncological outcome and high complication rates. We sought to investigate the long-term oncological and surgical outcome of these patients.

Methods

Between 1980 and 2012, 147 patients underwent surgical treatment for pelvic sarcoma. Histological diagnosis was Chondrosarcoma in 54, Ewing’s Sarcoma/PNET in 37, Osterosarcoma in 32 and others in 24 patients. Statistical analysis for the evaluation of oncological and surgical outcome was performed by applying Cox proportional hazards regression and Fine-Gray regression models for competing risk (CR) endpoints.

Results

The estimated overall survival (OS) to death was 80%, 45% and 37% at 1, 5 and 10 years, respectively. Univariate analyses revealed a statistically significant unadjusted influence of age age (p = 0.038; HR = 1.01), margin (p = 0.043; HR = 0.51) and grade (p = 0.001; HR = 2.27) on OS. Considering the multivariable model, grade (p = 0.005; HR = 3.04) and tumor volume (p = 0.014; HR = 1.18) presented themselves as independent prognostic factors on OS. CR analysis showed a cumulative incidence for major complication of 31% at 5 years. Endoprosthetic reconstruction had a higher risk for experiencing a major complication (p<0.0001) and infection (p = 0.001).

Conclusions

Pelvic resections are still associated with a high incidence of complications. Patients with pelvic reconstruction and high volume tumors are especially at risk. Consequently, a cautious decision-making process is necessary when indicating pelvic reconstruction, although a restrictive approach to pelvic reconstruction is not necessarily reasonable when the other option is major amputation.

[Quality of life after extensive pelvic surgery]

INTRODUCTION

Multiorgan resections in the small pelvis are standard procedures in oncosurgery and some indications have no alternative. In advanced pelvic cancer, pelvic exenteration with en bloc resection of the involved organs and structures, including portions of the bony pelvis, is indicated. The 5-year survival rate is fairly good, around 50%, but little is known about the long-term quality of life. The aim was to describe the quality of life of long-term total pelvic exenteration survivors.

METHOD

In total, 63 pelvic exenterations were performed between 2000 to 2015 at the Department of Surgery, Thomayer Hospital, First Faculty of Medicine, Charles University in Prague, mostly for primary or relapsed rectal cancer. In this retrospective cohort study, the quality of life was assessed using the EORTC QLQ-C30 (version 3.0) and the EORTC QLQ-CR29 questionnaires. The completed questionnaires were scored according to EORTC instructions.

RESULTS

At the time of this survey, 24 patients after TPE were surviving longer than one year after the surgery. The five-year survival of all patients was 49%, median survival 4.6 years, and median follow-up 15 months. Most of our patients reported a good level of their physical, emotional, cognitive and social functions. Some patients reported a worse body image, and of course a worsening in their sexual life. Regarding symptom-oriented questions, some patients evaluated the necessity of more frequent care of the stomia as slightly problematic; most patients reported impotence (men) or painful sexual intercourse (women).

CONCLUSION

Long-term quality of life in survivors of pelvic exenteration for rectal cancer is comparable with reported results following primary rectal cancer resection with the exception of the sexual function. The quality of life gradually improves in the course of weeks to months from the surgery.

KEY WORDS

pelvic exenteration quality of life.

Optimal Extent of Prophylactic Irradiation of Paraaortic Lymph Nodes in Patients with Uterine Cervical Cancer

Purpose

The purpose of this study was to determine optimal extent of prophylactic irradiation of paraaortic lymph nodes (PALN) in patients with uterine cervical cancer who had metastatic pelvic LNs.

Methods and Materials

We retrospectively evaluated 103 patients with cervical cancer and pelvic lymph node metastasis who were treated with prophylactic semi-extended field radiotherapy (SEFRT) between 1990 and 2012. The semi-extended field included PALN below the second lumbar spine with prescribed doses of 45 to 50 Gy. Survival outcomes were calculated using the Kaplan-Meier method, and acute and late toxicities were scored using the Radiation Therapy Oncology Group and European Organisation for Research and Treatment of Cancer toxicity criteria.

Results

The median follow-up after SEFRT was 61 (range 5–296) months. Overall, 28 patients (27.2%) experienced treatment failures, which were classified as local in 8 patients (7.8%), regional in 8 patients (7.8%), and distant in 13 patients (12.6%). Of the regional failures, only two involved PALN failure around the renal artery or the renal hilum area at the upper margin of the semi-extended field. At 5 years, the overall survival was 82%. Grade 3 or higher acute gastrointestinal and genitourinary toxicities occurred in one and two patients, respectively. As a late toxicity, one patient developed grade 3 small bowel obstruction.

Conclusion

Prophylactic SEFRT provided favorable outcomes with little acute or late gastrointestinal toxicity. For prophylaxis of PALN recurrences, upper part of PALN might not need to be included in patients with uterine cervical cancer and metastatic pelvic LNs.

Impact of Pelvic and Para-aortic Lymphadenectomy in Advanced Ovarian Cancer After Neoadjuvant Chemotherapy

AIM

The aim of our study was to evaluate the impact of systemic pelvic and para-aortic lymphadenectomy on survival in patients with advanced ovarian cancer after neoadjuvant chemotherapy.

PATIENTS AND METHODS

This multi-centric descriptive study included patients with initially inoperable advanced ovarian cancer, undergoing neoadjuvant chemotherapy followed by cytoreductive surgery with no residual tumor between 1998 and 2012. They were distributed into two groups depending on if they underwent lymphadenectomy or not during the interval surgery.

RESULTS

Among the 101 included patients, 54 underwent lymphadenectomy and 47 did not. The multivariate analysis for overall survival showed no significant difference between the two groups [hazard ratio (HR)=1.88, confidence interval (CI)=0.89-3.94; p=0.08]. The multivariate analysis for progression-free survival showed no significant difference (HR=1.43, 95% CI=0.86-2.39; p=0.17).

CONCLUSION

In patients with advanced ovarian cancer, treated by neoadjuvant chemotherapy and interval surgery with no residual tumor, lymphadenectomy does not seem to improve the survival rate.

[Modern aspects of surgical treatment of locally advanced pelvic cancer]

The aim of investigation is to improve surgical treatment of patients with locally advanced pelvic cancer. The basis of investigation is 186 patients with locally advanced pelvic cancer. The average age of patients is 65.2 ± 5.2 years (from 43.7 to 88.4 years). Among them are 112 women and 74 men. In the period from 2007 to 2015 they were carried out combined (101 patients) and expanded (85 patients) surgical intervention in the department of naval surgery of the Military medical academy after S.M.Kirov. Pelvic evisceration was performed in 63 cases. Both patients were performed isolated vascular hyperthermic chemical pelvic perfusion. Indications for plastic surgery of peritoneum pelvic were: total infralitoral pelvic evisceration (9 patients), dorsal infralitoral pelvic evisceration (11 cases) and expanded abdominoperineal rectum extirpation (34 patients). Plastic surgery with autogenouse tissues was performed to 43 patients, with reticulate explants--to 11 patients. The rate of postoperative complications was 40.2%. The rate of postoperative lethality was 8%. Expanded and combined operations of pelvic at patients with locally advanced cancer without absolute contra-indications can be performed irrespective of age. Plastic surgery of peritoneum pelvic after total and dorsal infralitoral pelvic evisceration and expanded abdominoperineal rectum extirpation indicated in all cases. The easiest method is plastic surgery with greater omentum or peritoneum pelvic. Plastic surgery with reticulate explants is performed when autoplastic is impossible.

Multimodal treatment of abdominal and pelvic desmoplastic small round cell tumor with relative good prognosis

OBJECTIVE

To investigate the clinicopathologic features and survival outcomes of desmoplastic small round cell tumor (DSCRT).

METHODS

The retrospective cohort study was performed on clinical and pathological data of 18 DSCRT patients. Among them, two subgroups were classified according to treatment modalities. 10 cases underwent operation and adjuvant chemotherapy (group 1, 10/18, 55.6%) and 8 cases were diagnosed by fine needle aspiration biopsy without surgical intervention (group 2, 8/18, 44.4%). All cases received six courses of multiple agents chemotherapy.

RESULTS

All cases were histologically confirmed as DSRCT and Cox regression revealed that sex, tumor localization and treatment modality affected patient outcomes. Kaplan-Meier analysis revealed that the median survival time was 22.0 ± 4.0 mo in group 1 versus 9.0 ± 0.7 mo in group 2.

CONCLUSION

DSRCT is highly aggressive malignance with poor prognosis, surgical excision with combination of chemotherapy can significantly improve the survival outcomes.

Phase II trial evaluating the feasibility of interdigitating folfox with chemoradiotherapy in locally advanced and metastatic rectal cancer

BACKGROUND

Patients (pts) with metastatic rectal cancer and symptomatic primary, require local and systemic control. Chemotherapy used during chemoradiotherapy (CRT) is adequate for radiosensitisation, but suboptimal for systemic control. The aim of this phase II study was to assess tolerability, local/systemic benefits, of a novel regimen delivering interdigitating intensive chemotherapy with radical CRT.

METHODS

Eligible pts had untreated synchronous symptomatic primary/metastatic rectal cancer. A total of 12 weeks of treatment with split-course pelvic CRT (total 50.4 Gy with concurrent oxaliplatin and 5-FU infusion) alternating with FOLFOX chemotherapy. All pts staged with CT, MRI and FDG-PET pre and post treatment.

RESULTS

Twenty-six pts were treated. Rectal primary MRI stage: T3 81% and T4 15%. Liver metastases in 81%. Twenty-four pts (92%) completed the 12-week regimen. All patients received planned RT dose, and for both agents over 88% of patients achieved a relative dose intensity of >75%. Grade 3 toxicities: neutropenia 23%, diarrhoea 15%, and radiation skin reaction 12%. Grade 4 toxicity: neutropenia 15%. FDG-PET metabolic response rate for rectal primary 96%, and for metastatic disease 60%.

CONCLUSIONS

Delivery of interdigitating chemotherapy with radical CRT was feasible to treat both primary and metastatic rectal cancer. High completion and response rates were encouraging.

Multifactorial, site-specific recurrence models after radical cystectomy for urothelial carcinoma: external validation in a cohort of Korean patients

Purpose

The aim of this study was to evaluate the accuracy of site-specific recurrence models after radical cystectomy in the Korean population.

Materials and Methods

We conducted a review of an electronic medical record of 572 patients who underwent radical cystectomy for urothelial carcinoma of the bladder. Primary end point was the site-specific recurrence after radical cystectomy.

Results

The median follow-up in the validation cohort was 42.3 months (interquartile range: 23.0–89.3 months). During the follow-up period, there were 165 patients (28.8%), 85 (14.9%), 31 (5.4%), and 78 (13.6%) who recurred in abdomen/pelvis, thoracic region, upper urinary tract, and bone, respectively. The c-indices of abdomen/pelvis, thoracic region, upper urinary tract, and bone models 3 years after radical cystectomy were 0.69 (95% confidence interval [CI], 0.65–0.73), 0.69 (95% CI, 0.64–0.75), 0.61 (95% CI, 0.52–0.69), and 0.65 (95% CI, 0.59–0.71), respectively. Kaplan-Meier curves demonstrated that models discriminated well and log-rank test were all highly significant (all p<0.001), except upper urinary tract model (p = 0.366). Decision curve analysis revealed that the use of prediction models for abdomen/pelvis, thoracic region, and bone recurrence was associated with net benefit gains relative to the treat-all strategy, but not the model for upper urinary tract recurrence.

Conclusions

Abdomen/pelvis, thoracic region, and bone models demonstrate moderate discrimination, adequate calibration, and meaningful net benefit gains, whereas upper urinary tract model does not seem applicable to patients from Asia because it has suboptimal accuracy.

Long-term results of reconstruction with pelvic allografts after wide resection of pelvic sarcomas

Reconstruction after the resection of a pelvic tumor is a challenging procedure in orthopedic oncology. The main advantage of allograft reconstruction is restoration of the bony architecture of the complex pelvic region. However, high complication rates such as infection and allograft resorption had been reported in the literature. In this study, we aimed to retrospectively review nine patients treated with pelvic resection and structural pelvic allograft reconstruction. Functional results, complications, and survival of the patients and the allografts were evaluated. At a mean follow-up of 79 months, three patients were dead. Major complications were detected in eight of the nine patients. Infection (four of the nine patients) and allograft resorption (three of the nine patients) were the most common causes of failure. The cumulative survival of the patients was 66.7 percent at 70 months. However, allograft survival was only 26.7 percent at 60 months. Mean MSTS score was 69. In conclusion, we suggest that other reconstruction options should be preferred after pelvic resections because of the high complication rates associated with massive allograft reconstruction.

Postoperative radiotherapy for uterine cervical cancer: impact of lymph node and histological type on survival

AIM

To retrospectively analyze the treatment results of postoperative radiotherapy (PORT) in patients with early-stage uterine cervical cancer.

PATIENTS AND METHODS

Records of 141 patients with stage IB-IIB uterine cervical cancer treated with PORT from 1985 to 2004 were retrospectively reviewed. The majority of patients received whole-pelvic radiotherapy with antero-posterior fields, and the total radiation doses ranged from 10.8-60 Gy (median: 50.4 Gy). The median follow-up of all 141 patients was 106 months (range: 0.8-273.7 months).

RESULTS

Multivariate analysis revealed that positive lymph node status (p=0.001) and histological type (p=0.015) were independent prognostic factors for overall survival. The group with three or more involved lymph nodes was significantly more likely to have extra-pelvic recurrence when compared with the groups with no (p=0.006) and up to two lymph nodes (p=0.024), respectively.

CONCLUSION

PORT yielded excellent pelvic control rates for early-stage uterine cervical cancer. Lymph node status and histological type were significant prognostic factors for overall survival of patients with these tumors.

Outcome and clinical-biological characteristics of patients with advanced breast cancer undergoing removal of ovarian/pelvic metastases

BACKGROUND

Patients with metastatic breast cancer to the ovary, without tumor debulking and after systemic therapy, have a 5-year survival rate < 10%.

PATIENTS AND METHODS

We analyzed a series of 37 patients, operated in one institution over 10 years, for both the primary tumor (PT) and ovarian/pelvic metastases (OPM). Estrogen receptors (ER), progesterone receptors (PgR), HER-2 and Ki-67 were determined.

RESULTS

Patients were predominantly young: 27 (73%) patients were < 50 years. Average ER/PgR expression did not change significantly between PT (mean ER = 66%, PgR = 35%) and OPM (mean ER = 67%, PgR = 28%). Median time to OPM was 42 months (range 0-176); 5-year OS after OPM was 51% (95% confidence interval 32% to 67%). When combining ER and PgR status, patients with ER > 50% on both PT and OPM and with PgR > 50% on PT and/or OPM (good prognosis, 11 patients) had a better outcome versus0 patients with ER and PgR ≤ 50% on both PT and OPM (bad prognosis, eight patients) and also versus the remaining patients (intermediate prognosis, 18 patients), P value = 0.010.

CONCLUSION

Patients with OPM from breast cancer show a favorable prognosis after tumor debulking, whether it was radical or not, especially when a high expression of ER and PgR is present in both PT and OPM.

Analysis of failures in patients with FIGO stage IIIc1-IIIc2 endometrial cancer

AIM

To assess the pattern of failures in patients with FIGO stage IIIc(1)-IIIc(2) endometrial cancer.

PATIENTS AND METHODS

Data were retrospectively analyzed for 34 patients with this malignancy who underwent extra-fascial total hysterectomy, bilateral salpingo-oophorectomy and pelvic/para-aortic node dissection. Postoperative treatment consisted of radiotherapy in 5 patients, 6 cycles of chemotherapy in 9, and 3-4 cycles of chemotherapy followed by radiotherapy in 20. The median follow-up of survivors was 33 months (range, 6 to 133 months).

RESULTS

Tumour relapsed in 14 out of 34 patients (41.2%). Median time to recurrence was 17 months (range, 9.5-42 months). Vaginal recurrence developed in 2 patients (5.9%), distant recurrence in 5 (14.7%), pelvic node recurrence in 3 (8.8%) and para-aortic recurrence in 7 (20.6%). Two patients had multiple sites of recurrence. Distant failure occurred in 11.1% of the patients who received 6 cycles of chemotherapy versus 20.0% of those who had 3-4 cycles of chemotherapy followed by radiotherapy. Five-year overall survival was 60.5%, and, in particular, it was 62.5% for stage IIIc(1) and 57.0% for stage IIIc(2).

CONCLUSION

FIGO stage IIIc(1)-IIIc(2) endometrial cancer relapses in approximately 40% of cases, and distant sites and para-aortic nodes represent the most common sites of failure.

A single-institution approach to total pelvic exenteration

The objective of this study was to describe in detail the technique of total pelvic exenteration. Total pelvic exenteration (TPE) was first described in 1948 by Brunschwig. Since its description, complications of the procedure and surgical innovations have changed the approach to this radical surgery. We have described our institutional approach and outcomes of TPE. Fifty-four patients underwent TPE between 2004 and 2010 by the Division of Surgical Oncology at the Ohio State University Medical Center. Fifty-three patients have complete medical records available for review. Outcomes are described and have shaped these techniques. Patients were divided into various groups based on their histology: colorectal (n = 36), gynecologic (n = 6), urologic (n = 5), squamous cell (n = 2), sarcomatous disease (n = 3), and severe infections (n = 1). These were divided into two groups-colorectal (n = 36) and noncolorectal (n = 17)-for analysis. Demographics, operative time, length of stay, and complication rates were similar between the two groups. The median survival was 21.4 months for the colorectal group and 6.9 months for the noncolorectal group. Total pelvic exenteration for colorectal tumors has improved survival when compared with patients undergoing exenteration for pelvic malignancies of other origins. Total pelvic exenteration continues to be associated with high morbidity; however, with appropriate patient selection and proper operative technique, a perioperative mortality of 0 per cent can be achieved.

Vaginal and pelvic recurrences in stage I and II endometrial carcinoma--survival and prognostic factors

AIM OF THE STUDY

The analysis of prognostic factors and treatment outcomes in 106 patients with Stage I and II endometrial carcinoma (EC) treated between 1980 and 2005 in the Center of Oncology, Maria Skłodowska-Curie Memorial Institute, Kracow, Poland, who developed vaginal or pelvic recurrences.

MATERIAL AND METHODS

The median age of patients was 61. Stage IB and IC of EC was diagnosed in 48 (45.3%) patients and Stage IIA and IIB in 58 (54.7%) patients. All patients were treated previously with surgery (TAH-BSO) and postoperative radiotherapy. There were 17 (16%) patients with vaginal vault recurrences, 30 (28.3%) with lower one-third vaginal recurrences, and 59 (55.7%) with pelvic recurrences. Palliative treatment (chemo- or hormonotherapy) or best supportive care only was undertaken in 53 (50.0%) patients. Radical treatment was conducted in 70.6% (12/17) of vault recurrences, 86.7% (26/30) of lower one-third vagina recurrences, and 25.4% (15/59) of pelvic recurrences, with surgery (4 patients), brachytherapy +/- chemotherapy (34 patients), and teleradiotherapy +/- chemotherapy (15 patients).

RESULTS

The 5-year overall survival rate in the observed group was 17%. Five-year survival was 23.3% (14/60) for patients with KPS 60-70 vs 8.7% (4/46) with KPS 40-50, 25% (12/48) patients with Stage I EC vs 10.3% (6/58) with Stage II EC, and 34% (16/47) patients with vaginal recurrence vs 3.4% (2/59) with pelvic recurrences.

CONCLUSIONS

In the analyzed group of 106 patients with Stage I and II EC, treated previously with surgery and postoperative radiotherapy, 5-year overall survival rate was low; in radically treated patients it was 42.1%, and 13.3% for vaginal and pelvis recurrences, respectively. Univariate analysis showed a statistically significant, unfavorable impact of KPS < 60, Stage II and recurrence pelvic. Cox multivariate analysis demonstrated that the only independent prognostic factor for 5-year overall survival was the site of recurrence.

[Current status and perspective of heavy ion beam therapy for patients with pelvic recurrence after primarily resected rectal cancer]

PURPOSE

To evaluate the tolerance for and effectiveness of carbon ion radiotherapy in patients with locally recurrent rectal cancer.

PATIENTS AND METHODS

We conducted a phase I / II dose escalation of carbon ion radiotherapy. One hundred twelve patients with 117 sites of locally recurrent cancer receiving carbon ion radiotherapy were analyzed.

RESULTS

None of 112 patients experienced National Cancer Institute-Common Toxicity Criteria grade 3 to 5 acute reactions. The local control rate in patients treated with 67.2 GyE, 70.4 GyE and 73.6 GyE in the present study was 70%, 89% and 97% at 5 years, respectively. The overall survival rates in patients treated with 73.6 GyE were 72% at 3 years and 40% at 5 years.

CONCLUSION

Carbon ion radiotherapy seems to be a safe and effective modality in the management of locally recurrent rectal cancer, providing good local control and offering a survival advantage without unacceptable morbidity.

Management of extrinsic malignant ureteral obstruction with urinary diversion

OBJECTIVE

The effectiveness of urinary diversion for patients with renal insufficiency due to extrinsic ureteral obstruction was assessed.

METHODS

Between 1990 and 2003, 30 males and 45 females, ranging 36-90 years of age (average, 62.7) who had secondary ureteral obstruction due to either a retroperitoneal or pelvic invasion of malignant disease, underwent nephrostomy or ureteral stenting using a double-J stent without side holes.

RESULTS

Ureteral stenting was attempted as an initial procedure in 51 of the 75 cases. The remaining 24 cases had a nephrostomy at the first step. Of 51, 37 cases were successfully stented, while internal stenting was unsuccessful in the remaining 14 cases. These 14 cases were treated with nephrostomy at the second step following the unsuccessful internal stenting. Eight cases of the 37 successfully stented cases were eventually changed to a nephrostomy because of catheter trouble. As a result, 29 cases could be managed by internal ureteral stenting up until the end of their life. The follow-up period for the 75 cases who underwent urinary diversion ranged from 5 days to 19 months, averaging 5.7 months. The average period from diversion to death was 5.6 months in the internally stented group and 5.9 months in the nephrostomy group.

CONCLUSION

The high patency rate of the internal ureteral stent in our cases might be due to our use of a stent without shaft vent holes.

Long-term cure in surgery for extrarectal pelvic recurrence of rectal cancer

PURPOSE

Survival benefit of radical surgery for locally recurrent rectal cancer depends on whether disease is cured rather than whether death is delayed. Cured patients gain decades of life and are spared from sufferings with recurrence. Unfortunately, the majority of patients undergoing surgery, particularly those with extrarectal pelvic recurrence, have poor outcomes with occult disseminated disease. This study was designed to identify which of these patients are curable.

METHODS

Of 61 patients with pelvic recurrence treated by radical reexcision more than nine years before, 36 patients whose initial surgery was abdominoperineal resection were examined retrospectively. We used the logistic regression and Gamel-Boag regression models to estimate curability and identify predictors of cure.

RESULTS

Ten patients survived five years and seven survived ten years. The cumulative disease-specific mortality curve leveled off 6.5 years after reexcision and remained at 74 percent (95 percent confidence interval, 60-89), indicating that the remaining 26 percent are curable. This value is comparable with the 23 percent curability estimated by the Gamel-Boag model, which also found that the disease-free interval from the initial surgery to the first recurrence is the best predictor of cure (P = 0.005). Of 11 patients with disease-free interval three years or more, 6 survived ten years, whereas 8 of 9 patients with disease-free interval less than one year died of second recurrence within three years of reexcision.

CONCLUSIONS

Even patients with extrarectal pelvic recurrence may have isolated disease that is amenable to complete eradication. As a biologic marker, the disease-free interval serves to predict curability and may distinguish isolated disease from occult disseminated disease.

Clinicopathological significance of fibrous tissue around fixed recurrent rectal cancer in the pelvis

Background

Fibrous tissue around a locally recurrent rectal tumour is an interesting histological feature, but its clinicopathological significance has not been investigated.

Methods

This retrospective study examined clinicopathological findings in 48 patients who underwent curative total pelvic exenteration with distal sacrectomy (TPES) between 1992 and 2004. Data were analysed with respect to fibrosis around the recurrent tumour, categorized into one of three groups: no fibrosis (f0), partial fibrosis (f1) or circumferential fibrosis (f2).

Results

Ten, 17 and 21 patients had f0, f1 and f2 fibrosis respectively, with 5-year survival of none, four and eight patients respectively. The overall survival of patients with circumferential fibrosis was significantly better than that in patients with no fibrosis (P = 0·003). Univariable analysis showed that a high level of sacrectomy (P = 0·036), absence of lymphatic invasion (P = 0·031) and circumferential fibrosis (P = 0·039) were significantly associated with better overall survival. In multivariable analysis, circumferential fibrosis (P = 0·031) and low serum carcinoembryonic antigen levels (P = 0·044) were independent factors for a favourable outcome.

Conclusion

The outcome of patients with locally recurrent rectal cancer after curative TPES appears to be better when circumferential fibrosis is present around the tumour.

Survival of patients with transitional cell carcinoma of the ureter and renal pelvis in Balkan endemic nephropathy and non-endemic areas of Serbia

OBJECTIVE

To evaluate the characteristics and survival of patients with upper urinary tract (UUT) transitional cell carcinoma (TCC) in Serbia, followed for >/=5 years or until death.

PATIENTS AND METHODS

From 1998 to 2005 we analysed 114 cases of pathologically confirmed UUT TCC, divided into two groups according to topographical characteristics, and compared their demographic, clinical and pathological characteristics. The influence of various factors on overall 5-year survival of patients with UUT TCC was also tested. The prognostic value of different variables was assessed by univariate and multivariate Cox proportional-hazard models.

RESULTS

The most important change in demographic characteristics of the patients with UUT TCC in Serbia was a similar proportion of patients residing in areas of Balkan endemic nephropathy (BEN) and non-endemic areas. The median (range) follow-up was 67 (46-88) months. The 5-year probability of survival was 51.2 +/- 5.8%. There was a significantly lower probability of 5-year survival for patients with a higher histological grade (P = 0.001), higher T stage (P < 0.001) and tumour size >3 cm (P = 0.001) at diagnosis. In this cohort of patients the independent predictors of a poorer outcome of the disease were being female (hazard ratio, HR, 2.2, P = 0.010), tumour size >3 cm (HR 2.8, P = 0.001) and T3 or T4 stages (HR 3.1, P = 0.001).

CONCLUSION

Comparative analysis of the characteristics of UUT TCC between patients from BEN and non-endemic areas of Serbia showed similarities in demographic, clinical and pathological features. Factors that significantly influenced survival of patients with UUT TCC were being female, tumour size and tumour grade and stage.

Does the molecular staging in pelvic lymph nodes improve the detection of relevant prostate cancer metastases? An assessment after 6 years

OBJECTIVE

To assess the course of cancer-free survival and thus determine how reliably reverse transcriptase-polymerase chain reaction (RT-PCR) can detect prostate-specific antigen (PSA)-expressing cells, as patients with untreated lymph node-positive prostate cancer tend to have a poor prognosis, whereas those treated with radical prostatectomy (RP) and immediate adjuvant hormonal therapy show excellent local disease control and a disease-free survival comparable with that of patients with negative lymph nodes, but the detection of micrometastatic disease in pelvic lymph nodes remains a major challenge.

PATIENTS AND METHODS

Quantitative RT-PCR was used to detect PSA mRNA expression in total RNA of 457 pelvic lymph nodes from 70 patients who had RP (53 patients) or laparoscopic lymphadenectomy (17) at our clinic in 1999/2000. For this purpose, alternate sections of lymph node tissue were either snap-frozen for later RNA isolation or examined by standard histopathological methods. Clinicopathological data, adjuvant treatments and follow-up data were recorded for all patients.

RESULTS

After January 2006 (6-year observation period), 13 patients had no follow-up data, while 27 had biochemical (PSA) recurrence or other evidence of clinical progression (two died from prostate cancer), and 30 had no signs of recurrence. Compared to the 'reference' standard (histopathology), the PCR method had a sensitivity of 83% and a specificity of 66%. The method had a positive predictive value of 52% and a negative predictive value of 57%.

CONCLUSION

Considered alone, pelvic lymph node PSA RT-PCR does not predict the clinical course better than a histopathological assessment of lymph nodes. However, it also identifies some patients with negative histology who later show progression. When added to the pathological classification, PSA RT-PCR improves the detection rate of primary lymphatic dissemination.

[Total pelvic exenteration in the treatment of advanced pelvic cancer]

Total pelvic exenteration (TPE) is a radical and aggressive procedure performed in the local advanced pelvic cancer started from any pelvic organ. The experience of 73 TPE performed for local invasive cancer and centro-pelvic recurrences with initial malignancy at the cervix (45 cases), rectum (19 cases), vagina (5 cases), endometrial (3 cases) and urinary bladder (1 case), in 61 females and 12 males with age range 27-78 years, are analysed. The procedures were performed for advanced pelvic cancer in 24 cases and also for invasive centro-pelvic recurrences in 49 cases (67.5%). In 5 cases, TPE was extended laterally. In 42 patients reconstructive procedures were added. All patients survived to surgery but 5 postoperative deaths (6.8%) were recorded. Complications occurred in 52% of cases, 38 from 73 patients had one or more than one complication with an average of 1.5 per patient. 22 among these patients (30%) requiring operative treatment. The average survival was 49.07 months, the median survival of 55 months and the estimated survival at 11 and 78 months was 66%, respectively 50%. The procedure is indicated in the absence of pelvic wall invasion and secondary distant dissemination and lengthens significantly the life span and increase the quality of life.

A single institution experience of combined modality management of extra skeletal Ewings sarcoma

Background

Extraskeletal Ewings sarcoma are rare tumors for which there is no consensus on optimal management.

Methods

A retrospective review of the clinical features, treatment and outcome of patients with extraskeletal Ewings sarcoma who reported to a single institution between January 1992 – December 2003 is reported.

Results

A total of 19 patients with extraskeletal Ewings sarcoma were identified. Of these, 4 patients had metastatic disease at presentation and 15 patients with non-metastatic disease received combined modality treatment with primary combination chemotherapy followed by local treatment with radiotherapy or surgery. Disease free survival and overall survival for patients with non metastatic disease after combined modality treatment were 60% and 30% respectively. The significant predictors for prolonged disease free survival and overall survival were high haemoglobin(p = 0.002), low lactate dehydrogenase (p = 0.028), chemotherapy with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide and Etoposide regime (p = 0.008) and complete response to chemotherapy (p = 0.001).

Conclusion

Aggressive combination chemotherapy followed by complete surgery or radiotherapy to a dose of more than 50 Gy is essential to confer optimal outcome for patients with extraskeletal ewings sarcoma.

[Use of combined surgery for locally-advanced tumors of the small pelvis]

Two-hundred and six operations were carried out at the Hospital (radical surgery - 184, combined excision of tumor and metastases - 22) (1995-2004). Complication was in 43 patients (20.9%), lethality - 8.7%. Five-year survival after radical surgery was 49.1% (rectal cancer) and 52.6% (cancer of female genitals). Four out of 22 patients survived for 5 years.

Phase II trial of pemetrexed as second-line therapy in patients with metastatic urothelial carcinoma

PURPOSE

The purpose of this single-center phase II study was to determine the activity of pemetrexed administered as second-line therapy in patients with advanced urothelial carcinoma.

METHODS

Patients with advanced urothelial carcinoma that had relapsed after receiving perioperative chemotherapy, or progressed on first-line chemotherapy for metastatic disease, were eligible for enrollment. Patients received pemetrexed 500 mg/m(2) every 21 days along with folic acid and vitamin B12 supplementation.

RESULTS

A total of 13 patients were enrolled. An objective response was achieved in 1/12 evaluable patients for an overall response rate of 8% (90% upper limit 29%). This level of activity did not meet criteria for expansion based on the pre-defined optimal 2-stage Simon design and the trial was concluded. Treatment was generally well tolerated, however, 2/13 patients developed febrile neutropenia. Non-hematologic grade > or = 3 toxicity was rare.

CONCLUSIONS

Pemetrexed as second-line therapy in advanced urothelial carcinoma is associated with modest activity. The role of this novel antifolate in chemotherapy-naïve patients warrants further investigation.

Aggressive angiomyxoma of the female pelvis and perineum: a case series

Aggressive angiomyxoma (AA) was first described in 1983, and fewer than 150 cases have been reported in the world medical literature. These tumors are benign, locally infiltrative mesenchymal neoplasms with a predilection for the female pelvis and perineum and a tendency to recur. The size of AAs at presentation varies considerably; however, these tumors often achieve large dimensions before becoming clinically symptomatic. Surgical excision remains the mainstay of treatment, but whether clear, tumor-free surgical margins are necessary is controversial. We report a cohort of six patients treated surgically during the past 20 years for primary or recurrent AA. Treatment, surgical margin status, estrogen and progesterone receptor status, and outcomes are reviewed.

Exenterative pelvic surgery—eleven year experience of the Swansea Pelvic Oncology Group

AIMS

To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group.

PATIENTS AND METHODS

Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery.

RESULTS

Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis.

CONCLUSION

With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.

On the apparent failure of adjuvant pelvic radiotherapy to improve survival for women with uterine sarcomas confined to the uterus

Despite numerous studies documenting reduction of pelvic relapses after adjuvant pelvic radiotherapy stage I and II uterine sarcomas, improved survival remains unproven. This retrospective report analyzes patterns of failure, survival, and toxicity in 42 women with stage I and 7 patients with stage II uterine sarcomas treated from 1972 through 1998 to identify patients likely to benefit from pelvic or abdominal radiotherapy and chemotherapy. Four of these patients also received adjuvant chemotherapy. There were 20 leiomyosarcomas, 18 homologous mixed mullerian tumors, and 11 heterologous mixed mullerian tumors. Disease-free survivals for mixed mullerian tumors were 65% at 5 years and 61% at 15 years. Disease-free survivals for leiomyosarcomas were 40% at 5 years and 40% at 15 years. There were 14 distant only, 5 distant and abdominal, 1 abdominal, 1 distant and pelvic, and 2 unknown initial sites of failure. Acute toxicity was acceptable as measured by a median 1-kg weight loss from radiotherapy and a 2% rate of failure to complete therapy. Chronic toxicity consisted of 3 small bowel obstructions and 1 sigmoid colon obstruction. In conclusion, the efficacy of adjuvant pelvic radiation is demonstrated by the absence of any isolated pelvic failures. Although the frequent occurrence of peritoneal failures suggests a role for prophylactic abdominal radiation for mixed mullerian tumors, more effective systemic therapy is necessary to substantially increase the chance of cure for women with early-stage uterine sarcomas.

Feasibility and Early Results of Interstitial Intensity-Modulated HDR/PDR Brachytherapy (IMBT) with/without Complementary External-Beam Radiotherapy and Extended Surgery in Recurrent Pelvic Colorectal Cancer

BACKGROUND

A new multimodality treatment concept consisting of extended resection and postoperative fractionated intensity-modulated interstitial brachytherapy (IMBT) was introduced for pelvic recurrence of colorectal carcinoma.

PATIENTS AND METHODS

46 patients received extended resection and single plastic tubes were sutured directly onto the tumor bed. IMBT was started within 2 weeks postoperatively with a median dose of 24.5 Gy (5-35 Gy). Patients were treated either with high-dose-rate brachytherapy (HDR; n = 23) or with pulsed-dose-rate brachytherapy (PDR; n = 23). 25 patients received complementary 45-Gy external-beam irradiation (EBRT) to the pelvic region after explanting the plastic tubes.

RESULTS

Median follow-up was 20.6 months (7-107 months) and mean patient survival 25.7 +/- 25.8 months (median 17, range 1-107 months). After 5 years overall survival, disease-free survival and local control rate were 23%, 20% and 33%, significantly influenced by the resectional state. There was a trend in favor of PDR compared to HDR, which reached statistical significance in patients who had not received additional EBRT.

CONCLUSION

The combination of extended surgery and postoperative interstitial IMBT is feasible and offers effective interdisciplinary treatment of recurrent colorectal cancer. In this small and inhomogeneous cohort of patients PDR seems to be more effective than HDR, particularly when application of complementary EBRT is not possible. None of the patients who required resection of distant metastasis survived > 2 years in this study.

Radiotherapy for pelvic recurrence after radical hysterectomy for cervical cancer

PURPOSE

To evaluate outcomes in patients treated with irradiation for recurrent cervical cancer after hysterectomy.

METHODS

This is a retrospective chart review of 36 patients initially treated with a radical hysterectomy and lymph node dissection who developed a pelvic recurrence and were subsequently treated with irradiation. None received chemotherapy.

RESULTS

The overall 5- and 10-year survivals were 74% and 50%, respectively. Ten patients developed recurrent disease after irradiation. The sites of failure in these 10 patients were pelvis only in two, pelvis and distant metastases in five, and distant metastases only in three. Severe complications occurred in four patients. One patient developed a hip fracture, one developed a bowel obstruction requiring a colostomy, and two developed fistulae.

CONCLUSION

Pelvic irradiation and brachytherapy resulted in a 74% overall 5-year survival. Distant metastases were the most common site of failure. Systemic chemotherapy should be considered as adjunctive therapy for these patients.

Hydronephrosis as a prognostic factor in pelvic recurrence from rectal and colon carcinomas

BACKGROUND

After multimodal treatment estimated 5-year survival of locally recurrent rectal cancer is about 25%. Hydronephrosis secondary to pelvic recurrence of colorectal cancer is a condition claimed to represent a contraindication to surgery due to a dismal prognosis.

METHODS

Prospective registration of 193 consecutive patients operated for pelvic recurrence in rectal or colon cancer from January 1991 until March 2002 at a tertiary referral hospital, 121 men and 72 women, median age 67 years, all given irradiation preoperatively. Twenty-three of 193 had hydronephrosis prior to preoperative irradiation for recurrent disease.

RESULTS

R-0 stage resection was obtained in 22% of patients with hydronephrosis and in 41% without. The median survival times in patients without metastasis were 27 and 32 months, respectively, and 5-year survival rates were 11% and 25%.

CONCLUSIONS

An aggressive surgical approach offers patients with pelvic recurrence from rectal and colon cancer the best potential for survival. The presence of hydronephrosis probably indicates a lower chance for complete surgical resection of the recurrence, but local control and improved survival may still be achieved, and about two thirds of patients may benefit from the operation.

Pelvic perfusion for locally recurrent unresectable rectal tumors

BACKGROUND/AIMS

Pelvic perfusion evolved as a palliative and curative treatment modality for advanced pelvic tumors and literature data support its use in different steps of the disease.

METHODOLOGY

15 patients with recurrent rectal tumor, without any systemic metastases were included in the study. Mean age was 49.7 years, 12 males, 3 females. Mean survival was 18 months.

RESULTS

15 unresectable rectal cancer patients were included in this study. Three (20%) complete response, 6 (40%) partial response, 2 stable disease (13.3%) and 4 (26.7%) progression were seen after pelvic perfusion. Mean survival is 26.54 months after perfusion (median=10). In multivariate analysis response rate to isolated perfusion and tumor size are significant factors effecting survival (p<0.05). The patients who did not receive chemotherapy after detection of pelvic recurrence did better (p=0.0086). Response to isolated pelvic perfusion (IPP) is an important factor for survival of locally advanced rectal tumors in log-rank test (p=0.0001).

CONCLUSIONS

Isolated pelvic perfusion is a good alternative for non-resectable pelvic malignancies and should be considered as an important part of the multidisciplinary approach for these tumors.

The role of pelvic exenteration for treatment of pelvic malignancy--a nine-year experience

Pelvic exenteration offers the last chance for some women with gynecological and rectal malignancy. A series of 23 patients who underwent pelvic exenteration for local advanced gynecological and rectal malignancies between 1996 and 2004 were retrospectively reviewed. The exenteration was performed because of vulvar cancer in 14 patients and other pelvic malignancies in nine cases: rectal cancer in four cases, in three cases cervical cancer, in one case ovarian cancer and in one case uterine sarcoma. Nine patients developed major complications of the operative field involving the urinary tract or the wound. Early complications included massive bleeding from the sacral plexus in two cases (one patient died during surgery), acute respiratory distress syndrome (ARDS) in one case and thrombophlebitis in one case. Urinary incontinence was observed in two women as a late complication. Only one patient had a complication connected with the gastrointestinal tract. Twenty-two patients were followed-up. In the group of patients with vulvar cancer five women died after 4-29 months because of recurrence of disease. The nine surviving patients are still being followed-up and are without disease; survival time ranges from 6-74 months. In the group of patients with other malignancies four women died.

Establishing long-term survival and cure in young patients with Ewing's sarcoma

This paper investigates the potential for long-term survivorship for young patients diagnosed with Ewing's sarcoma. Data are examined from two successive UKCCSG Ewing's Tumour studies (ET-1 and ET-2). Patients have been followed for up to 20 years. These studies had suggested that better 5-year survival with ET-2 over the earlier ET-1 was achieved by replacing cyclophosphamide by ifosfamide and increasing the dose of doxorubicin in a four-drug chemotherapy regimen. The updated hazard ratio, stratified for metastatic status at diagnosis, of 0.39 (95% confidence interval 0.12–0.61) confirmed the advantage of the ET-2 regimen in terms of overall survival. Cure models, based on the Weibull distribution, suggested that factors for long-term survival in addition to presence of metastases were age, primary site of tumour and study. Modelling identified the proportion cured with the ET-2 protocol as best at 70% in those who are under 10 years with a nonpelvic primary site and without metastatic disease. This contrasts to only 13% cure in those with the corresponding adverse prognostic indicators. Additionally, the risk of death remains greatest but relatively constant over the first 2 years postdiagnosis, and then declines to a lower but constant value for the next 3 years before reaching the ‘cure plateau’ at about 5 years. This investigation suggests that ‘cure’ is possible for patients with Ewing's sarcoma. This is established at approximately 5 years post diagnosis and the proportion cured depends on the presence of metastases, pelvic site and age at diagnosis.

Malignant tumors of the pelvis: an outcome study

This is a report of outcomes after a review of the demographic, diagnostic, therapeutic, and survival data for patients with pelvic primary and secondary tumors treated during the past 28 years. Using a computerized system it has been possible to assess the results for 206 patients with bone and soft tissue sarcomas and metastatic carcinomas to define the variation in outcome and the factors which statistically show an effect on survival. The data were compared with data for other anatomic sites. Based on our study, it is apparent that the outcome for all the tumors was approximately 50% survival with only soft tissue sarcomas having a poorer result. There were only minimal to moderate differences in outcome on the basis of gender, age, type of surgery, or adjunctive therapy. Patients who had intralesional surgery did less well as did patients with higher Musculoskeletal Tumor Society stages. Comparing the results for these patients with results for patients with the same stage and diagnosis but with tumors located in other sites showed significant differences. Results for patients with pelvic allograft compared with results of patients who had femoral allografts for the same diagnoses showed a poorer outcome for the patients who had pelvic allografts. Several possible explanations are provided for these variations in results.

Results of treatment of fifty-six patients with localized retroperitoneal and pelvic rhabdomyosarcoma: a report from The Intergroup Rhabdomyosarcoma Study-IV, 1991-1997

BACKGROUND

We reviewed 56 IRS-IV patients with localized rhabdomyosarcoma [RMS] of the retroperitoneum/pelvis to assess outcome and prognostic factors, including the value of initially excising >or=50% of the tumor (debulking) before chemotherapy.

METHODS

Patients had embryonal RMS [N=38], alveolar RMS [N = 7], RMS not otherwise specified [NOS, N = 7], or undifferentiated sarcoma [N = 4]. Fifteen patients were debulked; 41 patients were biopsied. All received VAC; most received radiotherapy.

RESULTS

Estimated 5-year failure-free survival [FFS] and overall survival rates were 70 and 75%, respectively. FFS rates were better for patients <10 years old and those with embryonal RMS compared to alveolar RMS/undifferentiated sarcoma. After adjusting for age and histological differences, FFS was better for patients whose tumor was debulked prior to beginning therapy [P = 0.02].

CONCLUSIONS

These results are superior to those of previous protocols for patients with RMS of the retroperitoneum/pelvis. Initial excision of >or=50% of the tumor may be associated with increased FFS.

Pelvic exenteration and sphincter preservation: An analysis of 96 cases

BACKGROUND

Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results.

METHODS

Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed.

RESULTS

Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival.

CONCLUSIONS

The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.

Hemipelvectomy: a changing perspective for a rare procedure

OBJECTIVE

To compare the prognosis of patients undergoing a hemipelvectomy (HP) in the treatment of pelvic sarcomas and carcinomas and to review the morbidity and mortality associated with HP.

DESIGN

Retrospective chart review.

SETTING

The Foothills Hospital, University of Calgary, Calgary, Alberta.

PATIENTS

Thirteen patients with clinically and radiographically isolated malignancies involving the bony pelvis and adjacent structures.

INTERVENTIONS

Patients were treated with either an external HP (9 patients) or internal HP (4) in 1983-2001.

OUTCOME MEASURES

Survival and recurrence rates for patients in 2 histopathologic groups (sarcoma v. carcinoma); morbidity and mortality associated with HP.

RESULTS

Hemipelvectomy was performed for 7 sarcomas (4 primary bone and 3 soft tissue) and 6 carcinomas (5 genital tract and 1 unknown primary). Seven of the 9 external HPs involved composite resection of other pelvic structures, including other pelvic viscera (3 patients), sacrum (3) and portions of lumbar vertebrae and nerves (1). There were no additional resections among the 4 internal HPs, but 3 patients had allograft reconstruction. Length of stay averaged 30 days (range 14-70 d). At least 1 complication occurred in 10 of 13 cases. The most common complication was flap necrosis occurring in 5 patients (38%). There was 1 perioperative death (8%). The survival of patients treated for sarcomas was better than for carcinomas, which were primarily of the genital tract. Only 1 of the patients with a pelvic sarcoma died of disease (86% disease-specific survival), with a median follow-up of 12 months (range 9-108 mo). Of the 7 sarcoma patients 5 were disease-free at last follow-up. One of 6 pelvic carcinoma patients died perioperatively, with another dying of unknown causes 4 months after surgery. Of the 4 remaining patients 3 died of disease, resulting in a median survival of 9 months (range 4-20 mo). Four of 6 patients with pelvic carcinomas developed recurrent disease, none local.

CONCLUSIONS

HP has considerable morbidity but is a viable and potentially curative treatment for patients with pelvic sarcomas. With pelvic carcinomas HP was not curative, but did provide short-term local disease control. Future improvements in imaging techniques and quality-of-life studies may help with patient selection. The role of HP in recurrent carcinoma remains to be determined.

Management of advanced pelvic cancer by exenteration

AIM

To describe our results in managing locally advanced primary or recurrent pelvic malignancies.

METHOD

Investigations included: clinical, laboratory, endoscopic (rectoscopy and colonoscopy) examinations, ultrasound scan, and CT scan or MRI of the abdomen and pelvis, to determine the extent of the pelvic malignancy. A careful explorative laparatomy of abdomen and pelvis was performed, followed by anterior, posterior or total pelvic exenteration.

RESULTS

In the period June 1995-Jan 2002, 7 anterior, 2 posterior and 51 total pelvic exenterations were performed in 60 patients, distributed as follows: 28 for rectal cancer (12 primary, 16 recurrent), 20 for cervical cancer (9 primary, 11 recurrent) and 12 for other pelvic malignancies. The median survival time and overall 5-year survival rates were as follows: primary rectal cancer--50 months and 32%; recurrent rectal cancer--31 months and 17%; primary cervical cancer--46.4 months and 41% and recurrent cervical cancer--23.4 months and 16%. During the same period, 559 of our patients were treated for primary or recurrent rectal cancer by different types of straightforward resection.

CONCLUSION

Pelvic exenteration is justifiable in cases of locally advanced primary and recurrent malignancies of rectum, cervical cancer and possibly in cases of other pelvic malignancies.

Pelvic relapses in ovarian cancer. Role of CA-125, transvaginal ultrasound and color Doppler

From January 1995 to January 2001, 40 patients with epithelial ovarian cancer were treated at our Institution. Fourteen of these, with a clinical CR after surgery and platinum-based chemotherapy, were evaluated monthly by gynecological examination, Ca-125 RIA assay, pelvic ultrasound with transabdominal and transvaginal probe and color Doppler. Six pelvic relapses, from 1.5 to 3.0 cm, were detected by transvaginal ultrasound (US). They showed a rich neovascularization with low resistance, high flow, PI from 0.3 to 1.0 and RI < 0.5 in all cases. US did not reveal any sign of relapse in the remaining eight patients. In all cases of pelvic relapses ultrasonic signs of recurrence preceded the increase of Ca-125 by one to six months (average 3.8).

Reconstruction of the pelvis after resection of tumors about the acetabulum

Periacetabular resections for primary malignancies and metastatic disease require reconstruction to restore weightbearing along anatomic axes. Without reconstruction, patients are unable to ambulate independently, and are left with a disfigured pelvis and shortened limb. The current authors describe a reconstruction technique using Steinmann pins augmented with methylmethacrylate reconstruction, and autoclaved autografting, in combination with total hip arthroplasty, after resection of primary sarcomas of the pelvis. For this study, the results of 15 patients at two institutions who had surgery by the same surgeons were retrospectively reviewed. The patients had primary malignant tumors of the pelvis, and had limb-sparing resections between 1985 and 2000. Three measures of outcome were evaluated: survival, function, and pain. The surgical method uses Steinmann pins with bone cement to fill in areas of bone loss that cannot be reconstructed with autoclaved autograft. A constrained polyethylene acetabular component is cemented into this bed. Twelve patients had chondrosarcoma and one patient had osteosarcoma. The remaining two patients had alveolar sarcoma of soft parts. Six patients died of disease. Seven patients were alive with no evidence of disease, and two were alive with disease at the most recent followup. Early return to ambulation without assistive devices occurred in nine of 15 patients. The functional outcome of this technique compares favorably with others reported. Sixty percent of patients ambulated independently without assistive devices, compared with 0% to 10% in other studies reviewed. The time required for independent gait is similar to recovery from a total hip arthroplasty. Moreover, this method minimized leg length discrepancy, while also producing a favorable cosmetic result.

Transureteroureterostomy: an adjunct to the management of advanced primary and recurrent pelvic malignancy

BACKGROUND AND AIMS

The surgical management of advanced primary or recurrent rectal cancer may involve the lower ureter or ureterovesical junction. With unilateral involvement, reconstruction of the ureters with salvage of the ipsilateral renal function should be considered.

PATIENTS AND METHODS

With optimal exposure both ureters are visualized. The crossed ureter is incised perpendicularly and then longitudinally on its medial aspect. An anterolateral ureterotomy is made on the recipient ureter. A mucosa-to-mucosa anastomosis is completed. Stents are used selectively.

RESULTS

Eleven patients with advanced pelvic malignancy underwent this procedure. There was one major complication requiring ureteronephrectomy of the crossed system.

CONCLUSION

Transureteroureterostomy should be considered as a treatment option in patients with unilateral ureteral obstruction.

MIB-1, p53, bcl-2, and WAF-1 expression in pelvic lymph nodes and primary tumors in early stage cervical carcinomas: correlation with clinical outcome

A complete series of 40 cervical carcinomas with pelvic lymph node metastases were analysed immunohistochemically for prognostic markers. The aims of this study were to examine whether the detection of MIB-1, p53, bcl-2, and WAF-1 could be used as a prognostic marker for tumor recurrence and survival rate. During the period of observation (mean 222, range 72-360 months) 22 (55%) recurrences were encountered and 20 patients died of the disease. There were 35 squamous cell carcinomas (87.5%), 2 adenosquamous carcinomas (5.0%), and 3 pure adenocarcinomas (7.5%). One tumor (2.5%) was well differentiated, 12 tumors (30%) were moderately differentiated, and 27 tumors (67.5%) were poorly differentiated. The primary tumor grade (P=0.037) and radicality of the surgical margins (P=0.021) were significant prognostic factors with regard to tumor recurrence. The site and number of lymph nodes with metastases had no prognostic value. P53, bcl-2, and WAF-1 were not predictive factors for recurrences or the cancer-specific survival rate. The concordant expression of WAF-1 in the primary tumor and in lymph node metastases was lower than for p53 and bcl-2. The proliferative activity (MIB-1) seemed to be lower in tumor cells metastasized to the pelvic lymph nodes than in cells of the primary tumor. Expression of MIB-1 in lymph nodes was predictive of disease-free survival in both univariate and multivariate proportional hazard Cox analyses.

Locoregional control in infants with neuroblastoma: role of radiation therapy and late toxicity

PURPOSE

To review patterns of failure in infants with neuroblastoma and determine late toxicity and efficacy of radiotherapy (RT) on locoregional control.

MATERIALS AND METHODS

From 1955 to 1998, 53 children (35 males and 18 females) <1 year old with neuroblastoma were seen at our institution. Twenty-one (40%) were </=1 month of age (neonates). Seven congenital anomalies were seen in 4 children (atrial septal defect, pulmonary valve stenosis, and absent corpus callosum were seen in 1 patient each; the other child had atrial and ventricular septal defect, aortic arch hypoplasia, and mitral valve stenosis). Primary tumor was located in the adrenal gland in 26 (49%), abdomen/nonadrenal in 14 (26%), thorax in 9 (17%), neck in 2 (4%), and pelvis in 2 (4%). All infants were retrospectively staged according to the International Neuroblastoma Staging System (INSS); 8 had Stage 1, 7 Stage 2A, 6 Stage 2B, 15 Stage 3, 6 Stage 4, and 11 Stage 4S. All patients, except 11 with Stage 4S and 4 with Stage 4, had resection of the primary tumor. Sixteen infants had pathologic involvement of regional lymph nodes (LN+). Twenty patients received RT. Kilovoltage beams were used in 10, megavoltage photons in 9, and electrons in 1 child. Fifteen received RT to the primary site and regional nodes (postoperative 8, preoperative 7). Postoperative doses ranged from 15 to 25 Gy whereas preoperative doses ranged from 12 to 31 Gy using a median fraction size of 1.5 Gy. Chemotherapy was employed in 22 of 53 patients (42%) with the most common agents being cyclophosphamide in 22 and doxorubicin in 11. Median follow-up was 13.1 years (range, 2-41 years).

RESULTS

Tumor control: The 5-year overall and freedom from progression rates were 79 +/- 9% and 81 +/- 11%; the locoregional control rate was 88 +/- 9%. INSS Stage was a prognostic factor for overall survival (p = 0.03) and freedom from progression (p = 0.035). Gender, age (</=1 month vs. >1 month), and primary site were not found to impact on survival or progression. None of the Stage 1, 2A, or 2B patients recurred. One of 15 Stage 3 and 5 of 6 Stage 4 children recurred (6 distant metastases, 4 local failure). Four of 6 (67%) LN+ patients treated with locoregional RT and 8 of 10 (80%) LN+ patients treated without RT were locally controlled. There was no isolated locoregional relapse. Two Stage 4S patients died of respiratory compromise secondary to hepatomegaly. RT toxicity: For the 20 infants who received RT, 13 are alive with long-term follow-up ranging from 9.3 to 41 years, median 23 years. The 10 and 15-year musculoskeletal toxicity rates were 38.5% and 47.3% for those receiving RT and 3.3% for no RT (p = 0.02, log-rank test). Five of 6 infants <6 months of age and 1 of 7 >/=6 months developed musculoskeletal toxicity. Musculoskeletal effects were seen in 6 RT patients and included bony hypoplasia in 6, scoliosis in 5, soft tissue hypoplasia in 3, slipped capital femoral epiphysis in 2, kyphosis in 1, and osteochondroma in 1. Three required orthopedic intervention, all receiving >/=20 Gy. One child developed bowel obstruction at 21 months and another developed a leiomyosarcoma in the treatment field 34 years after RT.

CONCLUSION

Our study shows that most LN+ infants achieve locoregional control without RT. Infants <6 months receiving RT were the most susceptible to musculoskeletal abnormalities. Further studies are needed to determine if cardiovascular anomalies are more frequently seen in children with neuroblastoma.

[Orthopedic/visceral surgery cooperation in pelvic tumors]

Co-operation between orthopaedic surgeons and visceral surgeons is required in the treatment of malignant tumours of the pelvis when the rectum or the iliac vessels are infiltrated. Such infiltration can be expected in malignancies which originate in the sacrum. Most frequently, chordomas are found in this area, that should be resected with wide surgical margins even in advanced tumours to reduce the risk of local recurrence. When resecting the sacrum, the stability of the vertebral column and the pelvis is compromised only at levels above S2. After unilateral resection of the sacral nerve roots S2-S5, there are only minor impairments of the anal and bladder sphincter control. In the case of tumour infiltration of the rectum and simultaneous resection of the sacral nerve roots, abdominoperineal extirpation of the rectum is required even when a safe margin is left between the tumour and the anal sphincter. In different studies, the 5-year survival in patients with a malignancy of the sacrum varies between 52% and 84%. In view of the rarity of these tumours, treatment should be performed only at specialized centers where co-operation is ensured.

Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis?

BACKGROUND

The prognosis for patients with recurrent rectal adenocarcinoma is not uniformly fatal if one can safely and selectively reoperate on a subset of patients with resectable disease. Even with careful selection, many patients undergo exploratory laparotomy and do not have resectable disease. We have reported that the presence of hydronephrosis in the setting of recurrent rectal carcinoma portends a poor outcome because of invariable association with unresectable disease. The purpose of this study was to update our experience of patients presenting with unilateral or bilateral hydronephrosis and recurrent rectal cancer.

METHODS

A retrospective chart review of 142 patients with recurrent rectal cancer evaluated at our institution from January 1989 to December 1999 was performed.

RESULTS

Twenty-seven of 142 patients referred for the management of recurrent rectal cancer had unilateral or bilateral hydronephrosis. Fifteen (55%) of these patients had distant metastatic disease. Twelve patients (45%) with hydronephrosis and local recurrent disease on evaluation were analyzed. Six of the 12 patients underwent exploratory laparotomy, with none found to have resectable disease. Their mean survival after diagnosis of recurrent disease was 14 months.

CONCLUSIONS

Based on our results, the presence of hydronephrosis (unilateral or bilateral) in recurrent rectal adenocarcinoma portends a survival equivalent to the presence of distant metastasis. Therefore, we do not believe potential curative surgery has a role for patients with locally recurrent rectal adenocarcinoma in the presence of hydronephrosis.

Survival after induction chemotherapy and surgical resection for high-grade soft tissue sarcoma. Is radiation necessary?

BACKGROUND

Induction chemotherapy can produce dramatic necrosis in sarcomas-raising the question of whether or not radiation is necessary. This study reviews the clinical outcome of a subset of patients with high-grade extremity soft tissue sarcomas (STS) who were treated with induction chemotherapy and surgical resection but without radiation.

METHODS

Nonmetastatic, large, high-grade STS of the pelvis and extremities were treated with intra-arterial cisplatin, adriamycin, and, after 1995, ifosfamide. After induction, oncologic resection and histologic evaluation were performed. Good responders with good surgical margins were not treated with radiation.

RESULTS

Thirty-three patients, with a median follow-up of 5 years, were included. Limb salvage rate was 94%. Median tumor necrosis was 95%. Four patients developed metastatic disease with three subsequent deaths. Two local recurrences occurred; both patients were salvaged with reresection and adjuvant external beam radiotherapy, although one died of metastatic disease 10 years later. Relapse-free and overall survival is 80% and 88% at 5 and 10 years by Kaplan-Meier analysis.

CONCLUSIONS

Intensive induction chemotherapy can be extremely effective for high-grade STS, permitting limb-sparing surgery in lieu of amputation. Radiation may not be necessary if a good response to induction chemotherapy and negative wide margins are achieved. All patients with large, deep, high-grade STS of the extremities should be considered candidates for induction chemotherapy.