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Gynaecology
Published in Andrew Stevens, James Raftery, Gynaecology Health Care Needs Assessment, 2018
Pelvic exenteration is used for cervix, vagina and vulval cancers and in specialist centres five-year survival rates are 50%. Although only about 6% of women treated for cervical cancer will experience a recurrence that is localized solely to the pelvis and are thus potentially curable by ultraradical surgery; few centres manage more than a handful of cases a year and cases should be referred to regional or supraregional oncology centres.258
Central recurrent cervical cancer: The role of exenterative surgery
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
The procedure of pelvic exenteration was first described in its present form by Brunschwig in 1948. Over the years, it has been used mainly in the treatment of advanced and recurrent carcinoma of the cervix (Barber 1969). Its primary role at the present time is the management of the numerous patients who develop recurrent cancer of the cervix following primary radiotherapeutic treatment (Disaia and Creasman 1981). It has also been used for treatment of uterine, ovarian, rectal, bladder and other cancers. It has been estimated that between one-third and one-half of patients with invasive carcinoma of the cervix will have residual or recurrent disease after treatment. Approximately one quarter of these cases will develop a central recurrence which may be amenable to exenterative surgery. However, pelvic exenteration as a therapy for recurrent cancer of the cervix has not been widely performed, and many patients will succumb to their disease having been through the process of radiotherapy followed by chemotherapy and other experimental treatments without being given the formal opportunity of a curative procedure. The published results of exenterative procedures show an acceptable primary mortality of approximately 3% to 4% and an overall survival/cure rate of 30% to 60% (Hockel and Dornhofer 2006). The procedure is also applicable to a wide range of other pelvic cancers including cancer of the vagina, vulva, and rectum, both for primary and secondary diseases. It is less often applicable to ovarian epithelial cancers and melanomas and sarcomas because of their tendency for widespread metastases.
Operative Technique for Pelvic Exenteration
Published in P Ronan O’Connell, Robert D Madoff, Stanley M Goldberg, Michael J Solomon, Norman S Williams, Operative Surgery of the Colon, Rectum and Anus Operative Surgery of the Colon, Rectum and Anus, 2015
Kirk Ks Austin, Michael J Solomon
Pelvic exenteration always involves an abdominal approach, usually with a perineal completion phase that can be done in lithotomy or prone (see Chapter 6.12). The anterior, axial, and lateral compartments are best done through an abdominal combined with a perineal lithotomy approach. Posteriorly, resection of the sacrum from S4 down and the sacrospinous ligaments allows radical excision of posterior pelvic floor that is approached from the abdominal side and is often better visualized than prone. Involvement of S3 and above by nature of the sacroiliac joint attachment requires a prone approach unless only the anterior cortex of the midline bones of L5 and upper sacrum are necessary, which can be done abdominally. Lateral higher sacrum and full vertebral excision of S2 and S3 requires the posterior prone approach.
Radiotherapy for postoperative vaginal recurrences of cervical squamous cell carcinoma: analysis of dosing and prognosis
Published in Journal of Obstetrics and Gynaecology, 2023
Ziye Zheng, Ke Hu, Xiaorong Hou, Lihua Yu, Junfang Yan, Fuquan Zhang
Radical hysterectomy with pelvic lymphadenectomy is the standard recommendation for patients with early-stage cervical cancer (Ramirez et al. 2018); however, the pelvic recurrence rate is 10–20% in patients with this disease after primary treatment, and the disease-free survival rate remains poor at 45% in patients with recurrent locoregional cervical cancer (Thomas et al. 1993). The vagina is the most common site of cervical cancer recurrence (Mahdi et al. 2015). Treatment for recurrent cervical cancer that is confined to the upper vagina can be curative (Cohen et al. 2019) yet remains challenging given the lack of a consistent standard treatment after the primary intervention. Pelvic exenteration is one of the main surgical methods for local recurrence; however, the perioperative mortality rate is relatively high, and the procedure may also reduce the patients’ quality of life (Benn et al. 2011). Salvage radiotherapy (RT) with or without concurrent chemotherapy is currently recommended owing to its effectiveness and tolerable adverse events (Abu-Rustum et al. 2020, S. W. Kim et al. 2017, Kobayashi et al.2019). External beam RT (EBRT) with or without chemotherapy and/or brachytherapy (BT) is conventionally prescribed to patients with cervical cancer who experience local recurrence, especially those without a history of RT.
Chest wall metastasis of endometrial cancer: case report and review of the literature
Published in Acta Chirurgica Belgica, 2019
Osman Nuri Dilek, Emine Özlem Gür, Turan Acar, Serpil Aydoğmuş
After surgery, according to the classification organized by the International Obstetrics and Gynecology (FIGO), 5-year survival in the cases of FIGO I and II is reported to be 80–90% whereas it is 20–25% in the cases of FIGO IV. Besides tumor stage; age of the patient, tumor diameter, histological type and grade of the tumor, depth of myometrial invasion, lymphovascular invasion, and hormone receptor status are also important in the prognosis of endometrial carcinoma. In addition to standard staging surgery, adjuvant radiotherapy and chemotherapy in selected cases are recommended for Stage I and II high-risk groups. In advanced stages, adjuvant chemotherapy and/or radiotherapy is recommended following maximal debulking surgery. Recurrence is seen in 15% of FIGO I and II cases and the majority of recurrences (68–100%) occur within 3 years after the surgery [2,8,9]. In cases of local recurrence, 40–81% of the cases can receive a complete response with the administration of concurrent chemoradiotherapy (CCRT). Pelvic exenteration is suggested for local pelvic recurrence in very few cases. The size of residual tumor tissue in patients undergoing nonexenterative surgery is the most important factor affecting long-term survival [1].
Completion surgery after chemoradiotherapy for cervical cancer – is there a role? UK Cancer Centre experience of hysterectomy post chemo-radiotherapy treatment for cervical cancer
Published in Journal of Obstetrics and Gynaecology, 2019
Sarah L. Platt, Amit Patel, Pauline J. Humphrey, Hoda Al-Booz, Jo Bailey
The standard treatment of patients with locally advanced cervical cancer (FIGO 1B2 to 4A) is chemoradiotherapy (CRT): five weeks of external beam radiotherapy with a concurrent weekly cisplatin and subsequent intrauterine brachytherapy. The presence of a residual disease seems to be directly linked to a relapse and yet there is a debate regarding the role of an adjuvant surgery to excise the residual disease (Touboul et al. 2010). The main concerns are due to the use of multimodality treatments and the associated risks of operating on an irradiated pelvis; namely, the fistulae, lymphocysts and bladder dysfunction. The reliability of magnetic resonance imaging (MRI) performed following CRT is questionable, with one study reporting a 29.2% false positive rate and an 11.1% false negative rate (Hequet et al. 2013). It has been suggested that completion surgery may have a role in certain patients; those who cannot complete CRT and brachytherapy, those with residual disease, and in certain histological types of cervical cancer (Morice et al. 2007; Cetina et al. 2009; Favero et al. 2014). If local disease control can be improved early in the treatment pathway, more extensive salvage therapy with a pelvic exenteration surgery and the associated impact on quality of life could be avoided at the time of a future recurrence