Elsevier

Gynecologic Oncology

Volume 103, Issue 3, December 2006, Pages 1023-1030
Gynecologic Oncology

Indications for primary and secondary exenterations in patients with cervical cancer

https://doi.org/10.1016/j.ygyno.2006.06.027Get rights and content

Abstract

Objective.

Fifty years after the introduction of exenterative surgery in gynecologic oncology, the indication for primary and secondary exenteration is controversially discussed in cervical cancer patients. In addition, the term “palliative exenteration” is not precisely defined. We evaluate the role of primary exenteration in patients with stage IVA cervical cancer and the role of secondary palliative exenteration.

Methods.

The study retrospectively analyzed surgical and oncologic data of 55 patients who underwent exenterative surgery in the Department of Gynecology at the University of Jena between February 1998 and January 2004. Primary surgery was performed in 20 patients with laparoscopically confirmed stage IVA cervical cancer, while 35 patients with recurrent cervical cancer underwent secondary exenteration. Fifty-one had total, 3 posterior and 1 anterior exenteration. Survival was analyzed in relation to the patient's age, indication (primary versus secondary, curative versus palliative), previous therapy (operation, radiation, chemotherapy, radiochemotherapy), histology, resection margins, pelvic nodal involvement, time interval from primary therapy to recurrence, type of exenteration and adjuvant therapy. Early and late postoperative complications as well as perioperative mortality were reviewed.

Results.

The overall cumulative survival of all patients after exenteration was 36.8% at 5 years with 52.5% in the primary group and 26.7% in the recurrent one (p = 0.0472). Complications were noted in 56.9% of patients, most commonly fistulas or gastrointestinal complications. Operative mortality was 5.5%. Survival correlated significantly with the time interval between primary treatment and recurrence (within 1–2 years 16.8% five-year survival, 2–5 years 28%, > 5 years 83.2%, p = 0.0105) as well as with curative or palliative intention (2-year survival rate of 60% in patients with curative intent, 10.5% in those with palliative intent, p = 0.0001) and with tumor-free resection margins (2-year survival of 10.2% for positive margins, 5-year survival of 55.2% for negatives ones, p = 0.0057). The age, the type of exenteration, the histologic type and the metastatic spread to pelvic lymph nodes had no significant influence on long-term survival.

Conclusion.

In patients with histopathologically confirmed stage IVA cervical cancer primary, exenteration is a valid alternative to primary chemoradiation. In patients with persistent or recurrent tumor limited to the pelvis, secondary exenteration should be offered in the absence of other therapeutic options. Palliative and curative attempts can best be differentiated by the resection margin status.

Introduction

In 1948, Brunschwig published the first case series of 22 patients who underwent pelvic exenterations; the perioperative mortality rate was 23%. The indications for this innovative radical approach were advanced cancer in the pelvis associated with pain, fistulas or infection in patients, who did not respond to radiotherapy [3]. A number of case series published since that time focus either on aspects of surgical technique or on indications. During the last 50 years, valid concepts have been developed for the two major surgical challenges of exenterative surgery — management of the empty pelvis and deviation of feces and urine [2], [17], [19], [21], [36]. Combining antibiotic therapy, intensive care monitoring and thromboembolic prophylaxis reduced the perioperative mortality to 2–14% [1], [4], [5], [6], [13], [14], [16], [17], [21], [23], [26], [30], [31], [34], [41], [42], [44], [47], [48], [49], [50], [51], [53] and increased the 5-year survival rate to 20–60% [1], [4], [5], [10], [11], [13], [14], [16], [23], [25], [26], [30], [31], [34], [42], [44], [46], [48], [49], [50], [51], [53] with a good quality of life [6], [15], [43], [47]. Recently, even laparoscopic and laparoscopic assisted exenteration procedures have been described [27], [40].

The spectrum of indications for exenteration has also changed over the years. Primary exenteration is only performed in patients with tumor- or treatment-associated urogenital or genitointestinal fistulas, though this restrictive approach is not justified by data [13], [25], [43], [51], [53]. This is surprising since very little data are available on primary chemoradiation in patients with stage IVA: only 50 patients (3–20% of patients in randomized trials) have been treated and their survival data are not separately analyzed [18], [35], [39], [52], [57]. Indication criteria for secondary exenteration vary considerably: intraperitoneal tumor spread and distant metastases regarded as the only exclusion criteria by some authors [11], [48]. Others consider exenteration to be contraindicated in the presence of positive lymph nodes, a large tumor size, tumor infiltration of the pelvic side wall and clinical symptoms such as lymphedema of the leg, obstructive uropathy or sciatic nerve pain [4], [10], [13], [14], [16], [20], [23], [25], [30], [42], [46], [47], [49], [53]. Barber describes a number of tumor-associated medical and psychosocial prerequisites for performing secondary exenteration [1]. Moreover, the indication criteria for “palliative exenteration” have not yet been defined [51].

A number of retrospective studies compare the mortality, complication rate and oncologic outcome in patients following exenteration. The results of these studies are difficult to compare due to the inhomogeneous patient groups with gynecologic and non-gynecologic malignancies [3], [4], [11], [12], [13], [16], [17], [19], [21], [26], [30], [31], [34], [36], [38], [41], [42], [44], [46], [48], [50], [51], [53]. Only 5 series analyze exclusively patients with cervical cancer [10], [14], [20], [23], [49].

Indications for primary and secondary and for curative or palliative exenteration will be discussed on the basis of exenteration results obtained in cervical cancer patients in the Department of Gynecology at the University of Jena.

Section snippets

Materials and methods

Between February 1998 and June 2004, fifty-five patients with histologically confirmed cervical cancer underwent pelvic exenteration in the Department of Gynecology at the Friedrich-Schiller-University of Jena, Germany. Twenty primary and thirty-five secondary exenterations were performed.

All patients underwent preoperative imaging to exclude distant metastases. In addition, all patients had a pelvic MRI and an abdominal CT in order to evaluate operability. Prior to exenteration, the data of

Results

The median age of the 55 patients was 49.8 years (28–74). Thirty-five patients were treated for recurrent or persistent carcinoma, while twenty had a primary exenteration (Table 1). Histological examination identified 51 squamous cell carcinomas and 4 adenocarcinomas. Histopathological examination of operative specimens showed that margins were negative in 42 and positive in 13. There were nineteen patients with positive lymph nodes and thirteen with more than one positive node. Lymph nodes

Discussion

Exenterations are major surgery with an operating time of 5 to 14 h [4], [14], [16], [23], [31], [34], [38], [48], a mean blood loss of 2300 to 4000 cm3 [4], [14], [16], [31], [34], [38], [41], [48], [50] and a mean hospital stay of 19 to 37 days [4], [14], [31], [34], [41], [42], [48], [51]. The quality of life of patients following exenteration may be comparable to that of healthy women, but they tend to have more physical, sexual and social problems and a worse body image [15], [43]. Despite

Acknowledgment

We thank Marc Possover M.D., for support with his surgical skills.

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