Elsevier

Gynecologic Oncology

Volume 91, Issue 2, November 2003, Pages 369-377
Gynecologic Oncology

Regular article
Laterally extended endopelvic resection: Novel surgical treatment of locally recurrent cervical carcinoma involving the pelvic side wall

https://doi.org/10.1016/S0090-8258(03)00502-XGet rights and content

Abstract

Objectives

To demonstrate the therapeutic potential of the laterally extended endopelvic resection (LEER) especially for patients with recurrent cervical carcinomas involving the side wall of an irradiated pelvis. These patients, suffering from the most common situation of local failure, have so far no longer been considered for curative therapy.

Methods

Extending the lateral resection plane of pelvic exenteration to the medial aspects of the lumbosacral plexus, sacrospinous ligament, acetabulum, and obturator membrane enables the complete removal of a subset of locally advanced and recurrent tumors of the lower female genital tract fixed to the pelvic wall with free margins (R0). Patients selected for LEER were accrued to a prospective outcome trial.

Results

Thirty-six patients with recurrent (n = 29) or primary advanced (n = 7) gynecologic malignancies involving the side wall of the lesser pelvis underwent LEER from July 1996 until October 2002. The majority of the patients suffered from cervical carcinoma (n = 29) and had received previous pelvic irradiation (n = 24). Tumor-free (R0) lateral margins were obtained in 34 patients. Severe postoperative complications occurred in 14 patients with one treatment-related death. Five-year survival probability is 49% for the whole group and 46% for those patients considered only for palliation with current treatment options. Most patients without evidence of disease at least 1 year after LEER achieved good quality of life.

Conclusion

LEER can be offered as novel surgical salvage therapy to a selected subset of patients with locally advanced and recurrent cervical carcinoma involving the pelvic wall.

Introduction

In a global perspective carcinoma of the uterine cervix is still an epidemiologically important malignant disease of the female population with a yearly incidence of almost half a million new cases and a mortality rate of about 50% [1]. In the developed countries more than 90,000 women are diagnosed with cervical carcinoma and almost 40,000 die from their neoplasm per year [1]. Complications of persistent or recurrent tumor in the pelvis is the leading cause of death. The standard treatment is radical hysterectomy for early disease and (chemo)radiation both for early and more advanced carcinomas [2]. There is now evidence that adjuvant (chemo)radiation improves local control and survival in patients with early clinical stages exhibiting histopathological risk factors treated with standard radical hysterectomy [3], [4]. As a consequence, approximately half of the patients treated surgically will also receive (chemo)radiotherapy and thus the majority of patients have been irradiated when their treatment is terminated.

Tumor persistence or local recurrence in an irradiated pelvis indicates a very dismal prognosis [5], [6]. Up to now salvage was only possible in selected patients with central disease who underwent pelvic exenteration, the en bloc resection of bladder, genital tract, and rectum, first described by Brunschwig [7] in 1948. Patients with a pelvic side wall component representing the most common situation of local failure are no longer regarded eligible for curative therapy according to current treatment guidelines [6].

I have developed the laterally extended endopelvic resection (LEER), which is characterized by the resection of the viscera en bloc with the side wall muscles and major vessels in the lesser pelvis of the female, as a new surgical treatment of gynecologic cancers involving the pelvic wall and reported its feasibility [8]. Herein I show that LEER enabled complete remissions and long-term survival with good quality of life for selected patients with side wall disease even when previously irradiated. Moreover, the logic of this surgical approach is confirmed by the histopathological demonstration that locally recurrent (as well as advanced primary) cancer of the lower genital tract fixed at the pelvic wall usually does not infiltrate the adjacent striated muscle. Inclusion of the pelvic floor and side wall muscles in the surgical specimen therefore provides tumor-free (R0) margins.

Section snippets

Surgical technique

LEER is characterized by the inclusion of the internal iliac vessel system, endopelvic part of the obturator internus muscle, coccygeus, iliococcygeus, and pubococcygeus muscles at the side of tumor fixation into the exenteration specimen. Both abdominal and abdominoperineal exenteration as well as total, anterior, and posterior exenteration can be laterally extended.

The step-by-step surgical techniques of LEER have been described in detail previously [8]. It is important to perform a

Results

From July 1996 until October 2002, 36 patients with gynecologic malignancies fixed to the wall of the lesser pelvis, having given informed consent to LEER treatment, entered the prospective outcome study. No planned LEER procedure was abandoned intraoperatively due to unexpected findings or complications. The patient, tumor, and pretreatment data are summarized in Table 1.

Twenty-four patients suffered from recurrent cervical carcinoma after surgical treatment with (n = 14) or without (n = 10)

Discussion

For recurrent cervical carcinoma with side wall involvement of an irradiated pelvis affecting more than 20% of the treated patients current therapeutic options are limited to palliation. Selected patients with central relapses, which occur in less than 10%, can be salvaged by pelvic exenteration. However, the clinical demonstration of tumor fixation at the pelvic side wall and/or any of the symptoms of the “triad of trouble,” i.e., hydronephrosis, leg edema, and sciatic pain indicating tumor

Acknowledgements

The author is indebted to several individuals for important contributions to the development of LEER, conductance of the outcome trial, and writing of this report. The urologists Prof. Dr. Rudolf Hohenfellner and Dr. Jens-Uwe Stolzenburg performed all urinary diversions. The histopathological investigations were carried out by Priv.-Doz. Dr. Lars-Christian Horn. All statistical calculations were provided by Dipl. Math. Bettina Hentschel. Quality of life evaluation was supported by Katja Schmidt

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