treatment in recurrent cervical cancer surgery – pelvic exenteration prof. dr. fuat demirkıran...
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Treatment in Recurrent Cervical Cancer
Surgery – Pelvic exenteration
Prof. Dr. Fuat DemirkıranGynecologic Oncology division,
Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty,
2010 Antalya
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Localization of recurrencepelvicdistantpelvic + distant
48.4 %(21.6 % central)
28.9 %22.7 %
Cerrahpaşa Radiation Oncology- Gynecologic Oncology1978-2002
98 (27.8 %) recurrence seen in 348 patients who had
post operative radiation therapy after surgery.
.Recurrence 52.6 % 1st year
80.4 % 2nd year
93.8 % 3rd year
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The recurrence ……… 10% to 18% for early stage
62% to 89% detected in 2 years 14% to 57% central
17 retrospective studies
The detection rates of asymptomatic recurrence …….,
with physical examination…… median 52% with cytology…………………………..median 6% with CT……………………………………..median 34% with MR……………………………………..median 9%
Follow-up visits should include a complete physical examination whereas, frequent vaginal vault cytology does not add significantly to the detection of early disease recurrence. Patients should return to annual population-based screening after 5 years of recurrence-free follow-up.
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Chemotherapy
SurgeryExcisional surgery
TAH Type ITAH II-III
ExenterationLEER
Radiotherapy Pelvic
Pelvic, extrapelvic
Local extrapelvic
Cervical
Pelvic central
Pelvic side
Treatment alternatives in Recurrent Cervical Cancer
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Excisional Surgery
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Isolated Cervical Relapse
TAH Type I ??
TAH II-III ?
Ota et al. 2008 J Br Cancer35 persistent cervical cancer 13% margin +
12 % fistula 68% 5 years survival.
Coleman et al. 1994 Gynecol Oncol50 recurrent cervical cancer, %42 major comp. 30% fistula
72% 5 years survival.
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Isolated Cervical RelapseTAH II-III ?
Cerrahpaşa Gynecol Oncol 2010 9 persistent-recurrent cervical cancer
22% Major comp, %11 fistula, non margin + 3/9 died in 29 months
Lymphadenectomy inTip I-III TAH ?
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Pelvic Exenteration
IndicationRecurent Ovarian cancer 28Recurrent cervical cancer 25Recurrent endometrial cancer 13Recurrent vulvar-vaginal cancer 6
TOTAL 72
Cerrahpaşa Gynecologic Oncology 1994-2010
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Central Tumors Recurrences in Cervical Cancer
Isolated cervical recurrence
Isolated vaginal recurrence – bladder invasion.
Vaginal posterior wall recurrence - rectal invasion.
Anterior-posterior vaginal wall recurrence
vaginal cuff recurrence
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Central Tumor relapses
Treatment
Prior RT No Prior RT
ExenterationChemotherapy
RTExenteration
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Patient selectionFirst rule of achievement is the selection
of convenient patient.
Biologic behavior of tumor Aggressive tumors which relapse before 1
year, has poor prognosis after exenteration Age
Physiologic age is important not chronologic age ObesityObesity is not an absolute contraindication, but gives difficulty in surgery
Pelvic Exenteration
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Pelvic exenteration
Pre-operative histologic analysis should been made
Chest CTAbdomen CT-MR
PET-CT
Preoperative search for evidence of distant metastasis.
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There will be a psychological devastation if patient found to be inoperable during operation because of introabdominal
metastasis or non operable condition arise So, Fine needle aspiration biopsy should made in
suspicious lesions.
Pelvic, paraaortic lymph node and pelvic wall invasions should carefully evaluated.
Despite all of these, surgery can’t be made in 25-30 % of patients
Pelvic Exenteration Patient selection
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Contraindications for Exenteration
Absolute Relative
Extra pelvic metastasis Obesity
Unilateral leg edema Advanced age
Sciatic pain Systemic diseases
Obstruction of urinary tract
invasion to pelvic wall
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Patient and her relatives should be informed about
surgical morbidity, mortalitytype of exenteration
changing decisions at the operationpossibility of inoperability
stoma treatment alternatives
success rate
Even if everything is OK
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Total Exenteration
Posterior Exenteration
Anterior Exenteration
Pelvic Exenteration
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Supralevator
Infralevator
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Distributions of Exenterative Surgery Recurrent Cervical Cancer n:25
Histological disturbitionSquamous cell cancer 20 case (80%)Adenocancer 4 case (16%)Malign melanoma 1 case (4%)
Operation type
Anterior exenteration 8 case (32%)Posterior exenteration 3 case (12%)Total exenteration 14 case (56%)
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Pelvic ExenterationTumor and surrounding tissue excision
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Cerrahpaşa Gynecologic Oncology
Exenterative Operations1994-2010
Urinary diversions Ileal conduit
17
Cophey op
2
Poch (Mainz I)
2
Bladder-ileum anastomosis
1
Colostomy 9
Low rectal anostomosis 8
GI diversions
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Pelvic exenterationUrinary diversion
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Pelvic ExenterationGI diversion
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Postoperative tumor residuals None 23 (49%)
Pelvic side wall 13 (27.6%) Upper abdomen 2 (4.2%)
No complications 14 (29.8%)
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Pelvic Exenteration Cases Avarage Min Max
Age 43.9 26 62
Operation time 306 181 470 (min)
Transfusion 4.1 2 7
(Unit) Hospitalization 16 8 64 (days)
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20 primary35 secondary
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Complicationsİleal loop cutenous fistula 1 (4%)GI fistula 3 (12%) Infection 4 (16%)Subileus 3 (12%)Pulmonary edema 1 (4%)Thromboemboli 1 (4%)Wound infection 3 (12%)Total 16(64%)
Cerrahpaşa Gynecologic Oncology
Exenterative Operations 1994-2010
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Postoperative Major Complications and Mortality
n:25 Urinary fistula 1 GI Fistula 3 Pelvic abscess 1 Pulmonary embolism 1 Re-laparotomy 5 (20%) Mortality 1 (4%)
Cerrahpaşa Gynecologic Oncology
24%
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70%
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Complication rate 57%Operative mortality 5%
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OS at 5 years 27%
OS at 5 years 52%
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12 mo 4 mo 4 mo
22 mo
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Median follow-up 23 month (4- 72)
11 (44 %) in 25 cases died 2 patient died becouse of other conditions 4 patient in 1st year5 patient in 2nd year
Cerrahpaşa Gynecol Oncol
Exenterative Operations1994-2010
36%
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The risk factors which predict recurrenceand survival after pelvic exenteration for the
treatment of advanced orrecurrent gynecologic malignancies
in the multivariate analysis, by examining exenteration type, tumor size, lymph vascularspace invasion, bladder wall invasion, resection margin status, and age
only the resection margin status was significantly associated with a disease-free
survival.
Park JY, et al. J Surg Oncol 2007
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Conclusions
Surgical therapy due to recurrent cervical cancer
may be associated with a high morbidity. But
complete tumor resection is associated with a
significantly higher overall and PFS.
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