Slayt 1

1
Treatment in Recurrent Cervical Cancer Surgery
Pelvic exenteration
Prof. Dr. Fuat Demirkiran Gynecologic Oncology
division, Department of Obstetrics and
Gynecology, Cerrahpasa Medical Faculty, 2010
Antalya
2
Cerrahpasa 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

48.4 (21.6 central) 28.9 22.7
Localization of recurrence pelvic distant pelv
ic distant
3
17 retrospective studies
The recurrence 10 to 18 for early stage
62 to 89
detected in 2 years
14 to 57 central
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.
4
Treatment alternatives in Recurrent Cervical
Cancer
Radiotherapy
Pelvic
Chemotherapy
Pelvic, extrapelvic
Local extrapelvic Cervical Pelvic
central Pelvic side
Surgery
Excisional surgery TAH Type I TAH
II-III Exenteration LEER
5
Excisional Surgery
6
Isolated Cervical Relapse
TAH Type I ?? TAH II-III ?
Ota et al. 2008 J Br Cancer 35 persistent
cervical cancer 13 margin 12 fistula 68 5
years survival.
Coleman et al. 1994 Gynecol Oncol 50 recurrent
cervical cancer, 42 major comp. 30 fistula 72
5 years survival.
7
Isolated Cervical Relapse
TAH II-III ?
Cerrahpasa 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 ?
8
Pelvic Exenteration Indication

• Recurent Ovarian cancer 28
• Recurrent cervical cancer 25
• Recurrent endometrial cancer 13
• Recurrent vulvar-vaginal cancer 6
• TOTAL 72

Cerrahpasa Gynecologic Oncology 1994-2010
9
Central Tumors Recurrences in Cervical Cancer
Isolated cervical recurrence Isolated vaginal
recurrence bladder invasion. Vaginal posterior
wall recurrence - rectal invasion. Anterior-poste
rior vaginal wall recurrence vaginal cuff
recurrence
10
Central Tumor relapses
Treatment
No Prior RT
Prior RT
Exenteration Chemotherapy
RT Exenteration
11
Pelvic Exenteration

• Patient selection
• First 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
  Obesity
• Obesity is not an absolute contraindication, but
  gives difficulty in surgery

12
Pelvic exenteration
Preoperative search for evidence of distant
metastasis.
Chest CT Abdomen CT-MR PET-CT
Pre-operative histologic analysis should been made
13
Pelvic Exenteration
Patient selection

• 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 cant be made
  in
• 25-30 of patients

14
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
15
Even if everything is OK
Patient and her relatives should be informed
about surgical morbidity, mortality type
of exenteration changing decisions at the
operation possibility of inoperability stoma
treatment alternatives success rate

16
Pelvic Exenteration
Posterior Exenteration
Total Exenteration
Anterior Exenteration
17
Supralevator
Infralevator
18
Distributions of Exenterative Surgery Recurrent
Cervical Cancer n25
Histological disturbition
Squamous 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)
19
Pelvic Exenteration
Tumor and surrounding tissue excision
20
(No Transcript)
21
Exenterative Operations1994-2010
Urinary diversions

• Ileal conduit 17
• Cophey op 2
• Poch (Mainz I) 2
• Bladder-ileum anastomosis 1

GI diversions
Colostomy 9 Low rectal
anostomosis 8
Cerrahpasa Gynecologic Oncology
22
Pelvic exenteration Urinary diversion
23
Pelvic Exenteration GI diversion
24
Postoperative tumor residuals None 23
(49) Pelvic side wall 13 (27.6)
Upper abdomen 2 (4.2) No complications 14
(29.8)
25
(No Transcript)
26
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)

27
20 primary 35 secondary
28
Exenterative Operations 1994-2010
Complications Ileal 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)
Cerrahpasa Gynecologic Oncology
29
Postoperative Major Complications and
Mortalityn25

• 
  
• Urinary fistula 1
• GI Fistula 3
• Pelvic abscess 1
• Pulmonary embolism 1
• Re-laparotomy 5 (20)
• Mortality 1 (4)

24
Cerrahpasa Gynecologic Oncology
30
70
31
Complication rate 57 Operative mortality
5
32
OS at 5 years 52
OS at 5 years 27
33
12 mo
22 mo
4 mo
4 mo
34
Exenterative Operations1994-2010

• Median follow-up 23 month (4- 72)
• 11 (44 ) in 25 cases died
• 2 patient died becouse of other conditions
• 4 patient in 1st year
• 5 patient in 2nd year

36
Cerrahpasa Gynecol Oncol
35
The risk factors which predict recurrenceand
survival after pelvic exenteration for the
treatment of advanced or recurrent gynecologic
malignancies in the multivariate analysis, by
examining exenteration type, tumor size, lymph
vascular space 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
36
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.
37
(No Transcript)