Pelvic Exenteration for Primary or Recurrent Gynecologic Malignancy

Öz

Introduction: Pelvic exenteration is often the only curative treatment option for selected locally advanced tumors, and especially for recurrent cancers. The primary aim of this study is to assess the clinical features, types and frequency of operative and postoperative complications of patients who underwent pelvic exenteration operation by our clinic. Material and Methods: Retrospectively, between 2019 and 2023, 14 patients with primary and recurrent gynecologic tumors who underwent pelvic exenteration were assessed in our clinic. Findings: All patients treated with anterior, posterior and total exenteration. Mean age was 56 (range, 26-71 years). The most primary tumors were cervical cancer (n=5, 35.7%) and ovarian cancer (n=5, 35.7%). 28.5% of patients received neoadjuvant chemotheraphy before exenteration, 35.7% of patients were treated with primary chemo-radiotheraphy and 3 patients didn't receive preoperative treatment. Urinary diversion was ileum conduit (64.2%). Mean operation time, estimated blood loss and hospital stay were 420 minutes, 2 units and 25 days. There were no intraoperative complications. Total morbidity rate was 28.5%; 7.1% of patients had early complications (<30 days after surgery) whereas 3 patients (21.4%) had late complications. Re-operation was not required in any patients. Disease recurrence occurred in 50% patients. There were no post-operative deaths (<30 days from surgery) nor intra-operative mortality. Eight patients died from recurrent malignancy. In our study survival was not assessed because of the short follow-up time. Results and conclusion: Pelvic exenteration is the only curative surgical method in locally invasive or recurrent gynecological tumors, with high complication rates and hospital stays.

Anahtar Kelimeler

• Pelvic exenteration
• Recurrence
• Gynecologic cancer
• Prognosis
• Cervical cancer

Primer ve nüks jinekolojik vakalarda pelvik egzenterasyon

Öz

Giriş: Pelvik ekzenterasyon, seçilmiş lokal ileri ever tümörler ve özellikle tekrarlayan kanserler için genellikle tek küratif tedavi seçeneğidir. Bu çalışmanın primer amacı, kliniğimizde pelvik ekzenterasyon operasyonu geçiren hastaların klinik özelliklerini, tiplerini ve operatif ve postoperatif komplikasyon sıklığını değerlendirmektir. Gereç ve Yöntem: Kliniğimizde 2019-2023 yılları arasında primer ve nüks jinekolojik tümör nedeniyle pelvik ekzenterasyon yapılan 14 hasta retrospektif olarak değerlendirildi. Bulgular: Tüm hastalara anterior, posterior ve total ekzenterasyon uygulandı. Ortalama yaş 56 (26-71 yaş arası) idi. Pelvik ekzenterasyonun en sık nedenleri servikal kanser (n=5, %35,7) ve over kanseriydi (n=5, %35,7). Ekzenterasyon öncesi hastaların %28,5'ine neoadjuvan kemoterapi, %35,7'sine primer kemo- radyoterapi ve 3 hastaya preoperatif tedavi verilmemiştir. Üriner diversiyon şekli ileum konduit (%64,2) idi. Ortalama operasyon süresi, tahmini kan kaybı ve hastanede kalış süresi 420 dakika, 2 ünite ve 25 gündü. Hiçbir intraoperatif komplikasyon görülmedi. Toplam morbidite oranı %28,5; hastaların %7,1'inde erken komplikasyon (ameliyattan <30 gün sonra), 3 hastada (% 21,4) geç komplikasyon görüldü. Hiçbir hastada reoperasyon gerekmedi. Hastaların %50'sinde nüks gelişti. Postoperatif (ameliyattan <30 gün sonra) veya intraoperative ölüm olmadı. Sekiz hasta maligniteden ötürü vefat etti. Çalışmamızda kısa takip süresi nedeniyle sağkalım değerlendirilemedi. Sonuç: Lokal invaziv veya nüks jinekolojik tümörler için pelvik ekzenterasyon, yüksek komplikasyon oranları ve hastanede kalış süresi olan, tek küratif cerrahi yöntemdir.

Anahtar Kelimeler

• pelvik egzenterasyon
• rekürrens
• jinekolojik kanser
• prognoz

Kaynakça

1. 1. Diver EJ, Rauh-Hain JA, Del Carmen MG. Total Pel- vic Exenteration for Gynecologic Malignancies. Int J Surg Oncol. 2012;2012:693535.
2. 2. Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol. 2006 Oct;7(10):837-47.
3. 3. Brunschwig A. Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominop- erineal operation with end colostomy and bilateral ureteral implantation into the colon above the co- lostomy. Cancer 1948; 1: 177-83.
4. 4. Lakhman Y, Nougaret S, Miccò M, Scelzo C, Var- gas HA, Sosa RE, et al. Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Pa- tients Treated with Pelvic Exenteration for Gy- necologic Malignancies. Radiographics. 2015 Jul- Aug;35(4):1295-313.
5. 5. Lambrou NC, Pearson JM, Averette HE. Pelvic ex- enteration of gynecologic malignancy: indications, and technical and reconstructive considerations. Surg Oncol Clin N Am 2005; 14: 289-300.
6. 6. Seebacher V, Sturdza A, Bergmeister B, Polterauer CamScanner ile tarandı Pelvic Exenteration For Primary and Recurrent Gynecologic Malignancy ⚫ 31 S, Grimm C, Reinthaller A, et al. Factors associated with post-relapse survival in patients with recur- rent cervical cancer: the value of the inflammation- based Glasgow prognostic score. Arch Gynecol Obstet 2019; 299: 1055-62.
7. 7. Yoshida K, Kajiyama H, Utsumi F, Niimi K, Sakata J, Suzuki S, et al. A post-recurrence survival-pre- dicting indicator for cervical cancer from the analy- sis of 165 patients who developed recurrence. Mol Clin Oncol 2018; 8: 281-5.
8. 8. Kolomainen DF, Barton DPJ. Pelvic exenteration for recurrent gynaecological cancer after radiotherapy. Obstet Gynecol 2017; 19: 109-18.

9. 9. Andikyan V, Khoury-Collado F, Sonoda Y, Gerst SR, Alektiar KM, Sandhu JS, et al. Extended pelvic resections for recurrent or persistent uterine and cervical malignancies: an update on out of the box surgery. Gynecol Oncol 2012; 125: 404-8.
10. 10. Sagebiel TL, Viswanathan C, Patnana M, Devine CE, Frumovitz M, Bhosale PR. Overview of the role of imaging in pelvic exenteration. Radiograph- ics 2015; 35: 1286-94.
11. 11. Maggioni A, Roviglione G, Landoni F, Zanagnolo V, Peiretti M, Colombo N, et al. Pelvic exentera- tion: Ten-year experience at the European Insti- tute of Oncology in Milan. Gynecol Oncol. 2009 Jul;114(1):64-8.
12. 12. Van Wijk FH, Van den Burg MEL, Burger CW, Ver- gote I, van Doorn HC. Management of recurrent endometrioid endometrial cancer. An overview. Int J Gynecol Cancer. 2009;19:314Y320.
13. 13. Fleisch MC, Pantke P, Beckmann MW, Schnuerch HG, Ackermann R, Grimm MO, et al. Predictors for long-term survival after interdisciplinary salvage surgery for advanced or recurrent gynecologic can- cers. J Surg Oncol 2007;95:476-84.
14. 14. Hatch KD, Berek JS. Pelvic exenteration. In: Berek JS, Hacker NF, editors. Practical Gynecologic On- cology. 4th ed. Philadelphia' Lippincott Williams and Wilkins; 2005. p. 801-16.
15. 15. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year ex- perience at UCLA. Gynecol Oncol 2005;99:153-9.
16. 16. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exen- teration: The Albert Einstein College of Medicine/ Montefiore Medical Center Experience (1987 to 2003). Gynecol. Oncol 2006. 101, 261–268.
17. 17. Chiantera V, Rossi M, De Iaco P, Koehler C, Marnitz S, Fagotti A, et al. Morbidity after pelvic exentera- tion for gynecological malignancies: A retrospec- tive multicentric study of 230 patients. Int. J. Gy- necol 2014. Cancer 24, 156-164.
18. 18. Urh A, Soliman PT, Schmeler KM, Westin S, Fru- movitz M, Nick AM, et al. 2013. Postoperative out- comes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies. Gynecol. Oncol. 129, 580-585.
19. 19. Matsuo K, Mandelbaum RS, Adams CL, Roman LD, Wright JD. Performance and outcome of pel- vic exenteration for gynecologic malignancies: a population-based study, Gynecol. Oncol. 153 (2) (2019) 368-375.
20. 20. Chiantera V, Rossi M, De Iaco P, Koehler C, Mar- nitz S, Ferrandina G, et al. Survival after curative pelvic exenteration for primary or recurrent cer- vical cancer: a retrospective multicentric study of 167 patients, Int. J. Gynecol. Cancer 24 (5) (2014) 916-922.
21. 21. Westin SN, Rallapalli V, Fellman B, Urbauer DL, Pal N, Frumovitz MM, et al. Overall survival after pel- vic exenteration for gynecologic malignancy, Gy- necol. Oncol. 134 (3) (2014) 546-551.
22. 22. Lee RK, Abol-Enein H, Artibani W, Bochner B, Dalbagni G, Daneshmand S, et al. Urinary diver- sion after radical cystectomy for bladder cancer: options, patient selection, and outcomes. BJU Int. 2014 Jan;113(1):11-23.
23. 23. ter Glane L, Hegele A, Wagner U, Boekhoff J. Pel- vic exenteration for recurrent or advanced gy- necologic malignancies - Analysis of outcome and complications. Gynecol Oncol Rep. 2021 Mar 31;36:100757.
24. 24. Moolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhui- jzen LRCW et al. Clinical outcomes of pelvic ex- enteration for gynecologic malignancies. Gynecol Oncol. 2023 Apr;171:114-120.
25. 25. Kaur M, Joniau S, D'Hoore A, Van Calster B, Van Limbergen E, Leunen K, et al. Pelvic Exenterations for Gynecological Malignancies A Study of 36 Cas- es. Int J Gynecol Cancer. 2012 Jun;22(5):889-96.
26. 26. Jäger L, Nilsson PJ, Rådestad AF Pelvic exentera- tion for recurrent gynecologic malignancy: a study of 28 consecutive patients at a single institution. Int J Gynecol Cancer. 2013 May;23(4):755-62.
27. 27. Nielsen CKP, Sørensen MM, Christensen HK, Jonas Amstrup Funder. Complications and survival after total pelvic exenteration. Eur J Surg Oncol. 2022 Jun;48(6):1362-1367