Pelvic Exenteration in Advanced, Recurrent or Synchronous Cancers-Last Resort or Therapeutic Option?

Overview

Journal Diagnostics (Basel)

Specialty Radiology

Date 2024 Aug 29

PMID 39202196

Authors

Vlad Rotaru

Elena Chitoran

Daniela-Luminita Zob

Sinziana-Octavia Ionescu

Gelal Aisa

Prie Andra-Delia

Dragos Serban

Daniela-Cristina Stefan

Laurentiu Simion

Affiliations

Soon will be listed here.

Abstract

First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology "Prof. Dr. Al. Trestioreanu" in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits.

References

Brown K, Solomon M, Lau Y, Steffens D, Austin K, Lee P . Sciatic and Femoral Nerve Resection During Extended Radical Surgery for Advanced Pelvic Tumours: Long-term Survival, Functional, and Quality-of-life Outcomes. Ann Surg. 2019; 273(5):982-988. DOI: 10.1097/SLA.0000000000003390. View

de Gregorio N, De Gregorio A, Ebner F, Friedl T, Huober J, Hefty R . Pelvic exenteration as ultimate ratio for gynecologic cancers: single-center analyses of 37 cases. Arch Gynecol Obstet. 2019; 300(1):161-168. DOI: 10.1007/s00404-019-05154-4. View

Burns E, Quyn A . The 'Pelvic exenteration lexicon': Creating a common language for complex pelvic cancer surgery. Colorectal Dis. 2023; 25(5):888-896. DOI: 10.1111/codi.16476. View

Rottoli M, Vallicelli C, Boschi L, Poggioli G . Outcomes of pelvic exenteration for recurrent and primary locally advanced rectal cancer. Int J Surg. 2017; 48:69-73. DOI: 10.1016/j.ijsu.2017.09.069. View

Nielsen M, Rasmussen P, Lindegaard J, Laurberg S . A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database. Colorectal Dis. 2011; 14(9):1076-83. DOI: 10.1111/j.1463-1318.2011.02893.x. View

BRICKER E . Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950; 30(5):1511-21. DOI: 10.1016/s0039-6109(16)33147-4. View

Hockel M, Dornhofer N . Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol. 2006; 7(10):837-47. DOI: 10.1016/S1470-2045(06)70903-2. View

McKigney N, Houston F, Ross E, Velikova G, Brown J, Harji D . Systematic Review of Patient-Reported Outcome Measures in Locally Recurrent Rectal Cancer. Ann Surg Oncol. 2023; 30(7):3969-3986. PMC: 10250265. DOI: 10.1245/s10434-023-13388-5. View

. Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc. 2018; 32(12):4707-4715. DOI: 10.1007/s00464-018-6299-5. View

10.

Spratt Jr J, Watson F, Pratt J . Characteristics of variants of colorectal carcinoma that do not metastasize to lymph nodes. Dis Colon Rectum. 1970; 13(3):243-6. DOI: 10.1007/BF02617216. View

11.

Wong C, Cummings B, Brierley J, Catton C, McLean M, Catton P . Treatment of locally recurrent rectal carcinoma--results and prognostic factors. Int J Radiat Oncol Biol Phys. 1998; 40(2):427-35. DOI: 10.1016/s0360-3016(97)00737-2. View

12.

Bhangu A, Mohammed Ali S, Brown G, Nicholls R, Tekkis P . Indications and outcome of pelvic exenteration for locally advanced primary and recurrent rectal cancer. Ann Surg. 2013; 259(2):315-22. DOI: 10.1097/SLA.0b013e31828a0d22. View

13.

Clavien P, Barkun J, De Oliveira M, Vauthey J, Dindo D, Schulick R . The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009; 250(2):187-96. DOI: 10.1097/SLA.0b013e3181b13ca2. View

14.

Gerard J, Romestaing P, Chapet O . Radiotherapy alone in the curative treatment of rectal carcinoma. Lancet Oncol. 2003; 4(3):158-66. DOI: 10.1016/s1470-2045(03)01020-9. View

15.

Gannon C, Zager J, Chang G, Feig B, Wood C, Skibber J . Pelvic exenteration affords safe and durable treatment for locally advanced rectal carcinoma. Ann Surg Oncol. 2007; 14(6):1870-7. DOI: 10.1245/s10434-007-9385-9. View

16.

BRUNSCHWIG A . Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer. 1948; 1(2):177-83. DOI: 10.1002/1097-0142(194807)1:2<177::aid-cncr2820010203>3.0.co;2-a. View

17.

Voinea S, Bordea C, Chitoran E, Rotaru V, Andrei R, Ionescu S . Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?. Cancers (Basel). 2024; 16(2). PMC: 10813912. DOI: 10.3390/cancers16020425. View

18.

. Changing outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer. BJS Open. 2019; 3(4):516-520. PMC: 6677093. DOI: 10.1002/bjs5.50153. View

19.

. Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. Br J Surg. 2018; 105(6):650-657. DOI: 10.1002/bjs.10734. View

20.

Simion L, Rotaru V, Cirimbei C, Gales L, Stefan D, Ionescu S . Inequities in Screening and HPV Vaccination Programs and Their Impact on Cervical Cancer Statistics in Romania. Diagnostics (Basel). 2023; 13(17). PMC: 10486539. DOI: 10.3390/diagnostics13172776. View