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PubMed1989

[Extended surgery for advanced colo-rectal carcinoma (stage IV and V)].

Two hundred fifty-five patients with colo-rectal carcinoma underwent operations in our department between January 1980 and December 1988. The five-year survival rate of stage IV patients (30 cases) was 58%, and the three-year survival rate of stage V patients (44 cases) was 8%. The study for the expression of blood group-related cancer-associated antigens (Lea, CA19-9, etc.) in colo-rectal cancers using immunohistological method and a series of mouse monoclonal antibodies revealed that the stromal staining pattern of CA19-9 means high malignancy with poor prognosis. Nineteen patients with locally invading rectal cancer were submitted to total pelvic exenteration with urinary diversion. The operative mortality rate was 5.3%. A determinate 5-year survival rate of 4.5 was achieved. Fourteen patients with local recurrent lesions of rectal cancer following abdominoperineal resection were submitted to pelvic exenteration combined with sacral resection. Two patients are alive disease free for longer than four years at this writing. This operation assures a better quality of life, lessening of symptoms, disease control and, in selected patients, a cure.

Antigens, Tumor-Associated, Carbohydrate↗

PubMed1999

Laterally extended endopelvic resection: surgical treatment of infrailiac pelvic wall recurrences of gynecologic malignancies.

OBJECTIVE: My purpose was to treat infrailiac pelvic wall recurrences of gynecologic malignancies with extended radical surgery. STUDY DESIGN: On the basis of cadaver dissection studies, I developed the laterally extended endopelvic resection techniques. The new operations were offered to patients with infrailiac sidewall disease during a 3-year feasibility study. RESULTS: Laterally extended endopelvic resections extending the lateral resection plane of pelvic exenteration to the medial aspects of the acetabulum, obturator membrane, sacrospinous ligament, and sacral plexus/piriformis muscle were performed in 18 consecutive patients. After this procedure, all patients had tumor-free intraoperative biopsy specimens taken from the remaining pelvic wall structures within the tumor bed area. The final histopathologic report confirmed clean margins in 6 patients and margins with microscopic tumor extensions only in 12 patients. Severe complications occurred in 4 patients (22%), without treatment-related deaths. CONCLUSION: Laterally extended endopelvic resection allows the complete surgical removal of infrailiac pelvic-side-wall tumors, the most frequent local recurrence of lower genital tract cancer, either with free margins or with potential microscopic residual tumor as a prerequisite for combined operative and radiation treatment.

Combined Modality Therapy↗

PubMed1982

Bladder and prostatic tumors in the intergroup Rhabdomyosarcoma study (IRS-I): results of therapy.

Sixty-four children with primary rhabdomyosarcoma of the bladder or prostate were enrolled in the IRS during the initial five years (October 1972-November 1977). Observation of these patients for from 2 1/2-8 years forms the basis of this report. The chemotherapy-radiotherapy regimens employed (IRS) for each Clinical Group were: (1) Group I (completely excised tumor), sequential actinomycin-D (ACD), vincristine (VCN), and cyclophosphamide (CYP), i.e., standard (VAC), with or without radiotherapy (RT); (2) Group II (resected local disease with node involvement, "microscopic" residual, or local extension), RT plus sequential ACD and VCN, or RT plus standard VAC; (3) Group III, (gross residual disease); and (4) Group IV (dissemination), RT and either pulse VAC or pulse VAC plus Adriamycin (ADR). Pulse VAC consisted of VCN (day 1), plus daily intravenous ACD and CYP (days 1-5). Relapse rates were: Group I, 0/8; Group II, 6/23; and the mortality in Group III, 6/23; and in Group IV, 7/10. Among patients with bladder tumors, the rate of relapse was 2/11 following pelvic exenteration (anterior, 10; total 1); 5/12 following partial cystectomy or gross tumor excision; and 3/5 following a primary chemotherapy-radiotherapy (PCR) regimen. In patients with prostatic tumors (Groups I-III), relapse occurred in 0/14 patients treated initially by pelvic exenteration (anterior, 12; total, 2); and in 2/11 patients treated by a PCR regimen.

Adolescent↗

PubMed1997

Extramammary Paget's disease with diffuse involvement of the lower female genito-urinary system.

Extramammary Paget's disease of the lower female genito-urinary system is an uncommon neoplasm with a high rate of recurrence. A 52-year-old white female with a history of extramammary Paget's disease, originally excised in 1985 by skinning vulvectomy and who had multiple recurrences, including two in a vaginal graft and with extension to the urethra and the uterine cervix, in 1992 underwent an anterior pelvic exenteration for control of the disease process. Standard surgical management for extramammary Paget's disease without invasion or without an underlying adenocarcinoma is simple or skinning vulvectomy. However, because the disease commonly recurs, diffuse involvement may require more extensive surgery including pelvic exenteration in extraordinary cases.

Journal Article↗

PubMed2006

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction.

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.

Algorithms↗

PubMed2004

Treatment outcomes in locally advanced colorectal carcinoma.

BACKGROUND: Locally advanced colorectal cancers form a distinct subgroup where contiguous organs could be involved without distant metastases and so may be amenable to curative surgical resection. It was our objective to report our experience in treating six such patients with operable locally advanced colorectal carcinomas. METHODS: We retrospectively reviewed the case notes of 47 patients who were diagnosed with colorectal cancers at M S Ramaiah Medical Teaching Hospital between the years 1996 - 2001. Six patients were identified with T4 lesions, adjacent organ involvement and with no nodal involvement. The treatments and outcomes for these patients were then reviewed. RESULTS: Two of three patients with rectal malignancies who underwent pelvic exenteration succumbed to disease recurrence within the first 18 months. One of the three patients with colonic cancers died of non malignant causes. The other two are disease free till date. CONCLUSIONS: Aggressive multivisceral resections for locally advanced colonic cancers might be appropriate. Rectal cancers when locally advanced may be considered for pelvic exenteration, but a more guarded prognosis may apply.

Journal Article↗

PubMed1988

Vaginal neoplasms in infancy: the combined role of chemotherapy and conservative surgical resection.

This retrospective review of nine infants treated for vaginal tumors between 1964 and 1986 identifies the spectrum of lesions and examines the trend toward more conservative surgical therapy. Our patients' ages ranged from 1 to 30 months. Symptoms of vaginal bleeding or protruding tissue prompted examination under general anesthesia in all cases. Two children had benign protruding polypoid masses treated by simple excision. Seven had malignant tumors, two with endodermal sinus lesions and five with embryonal rhabdomyosarcoma. Early in this series, surgical therapy for embryonal rhabdomyosarcoma consisted of either anterior or complete pelvic exenteration, with adjuvant chemotherapy given in two of the three patients. One patient was operated on prior to the development of effective chemotherapy, and died of recurrent tumor 14 months after surgery. A second patient died from cardiac failure secondary to adriamycin toxicity 6 years after initial therapy. A third patient underwent total pelvic exenteration followed by successful reanastomosis of the colon to the anal verge. This patient, a female, is the oldest survivor and is free of disease 14 years after therapy. The most recent therapeutic approach used in two patients with embryonal rhabdomyosarcoma consisted of local tumor excision followed by postoperative chemotherapy. Both patients are alive and disease-free 9 and 11 years after therapy. Two patients with endodermal sinus tumor were treated with chemotherapy after simple excisional biopsy. They were then followed with serial vaginal biopsies at 3-month intervals. One required a partial vaginectomy for local recurrence 21 months after initial presentation. Both patients are alive and disease-free 18 months and 4 years after surgery.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1990

Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap.

Poor perineal healing is a major complication of total or partial pelvic exenteration especially when the pelvis and perineum have previously been irradiated. Perineal, vulval or vaginoperineal reconstruction was performed in five women using the inferiorly based rectus abdominis myocutaneous flap. Primary perineal wound healing occurred in all patients and no flap-related complications developed. Primary healing of abdominal wall wounds occurred in all patients without incisional hernia. Three of the patients had an anterior or total pelvic exenteration with continent urinary diversion by the Mitrofanoff technique. Two of the patients had complete vaginal reconstruction and one patient had after-loading catheters inserted for postoperative interstitial irradiation. The patients were in hospital for 42, 28, 21, 17 and 15 days respectively. The longest stays were associated with training for self-catheterization of the continent urinary diversion. Median follow-up was 9 months. One patient developed two perineal recurrences at 16 months which were resected, and she remains disease-free 6 months later.

Abdominal Muscles↗

PubMed1980

Intestinal fistula following pelvic exenterative surgery: predisposing causes and treatment.

An interest fistula is a life-threatening complication when associated with the treatment of pelvic cancer. Such fistulae arise in 10% of patients treated by the combination of aggressive surgery and radiation therapy. Nineteen such occurrences developing in 245 patients who had pelvic exenterations are used to demonstrate the need for directing immediate attention toward correcting the physiologic and metabolic abnormalities created by the fistulae. Local control of the fistulae is facilitated by techniques for identifying its cause and precise location.

Female↗

PubMed1992

Sphincter-preserving extended resection for locally advanced rectosigmoid carcinoma involving the urinary bladder.

Radical en bloc resection has gained acceptance in the management of locally advanced colorectal carcinoma. Total pelvic exenteration has been advocated as treatment for rectosigmoid cancers involving adjacent genitourinary structures. We report a series of 10 patients who underwent total cystectomy with en bloc segmental colorectal resection and restoration of intestinal continuity. All margins, including the distal colorectal margin of resection, were pathologically uninvolved by tumor. The median follow-up on these patients was 44 months and the mean survival was 42.5 months. The local recurrence rate (20%) and survival rates are comparable to those in reports describing pelvic exenteration for colorectal cancer. Our patients had normal postoperative bowel function. An extended colorectal resection, including a total cystectomy with rectal sphincter preservation, is occasionally possible when tumor-negative resection margins can be achieved. By restoring intestinal continuity, such an operation provides an improved quality of life, and more importantly, fulfills the criteria for an oncologically sound operation.

Colorectal Neoplasms↗

PubMed1998

Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group.

PURPOSE: To determine the feasibility of using preoperative chemoradiotherapy to avert the need for more radical surgery for patients with T3 primary tumors, or the need for pelvic exenteration for patients with T4 primary tumors, not amenable to resection by standard radical vulvectomy. METHODS AND MATERIALS: Seventy-three evaluable patients with clinical Stage III-IV squamous cell vulvar carcinoma were enrolled in this prospective, multi-institutional trial. Treatment consisted of a planned split course of concurrent cisplatin/5-fluorouracil and radiation therapy followed by surgical excision of the residual primary tumor plus bilateral inguinal-femoral lymph node dissection. Radiation therapy was delivered to the primary tumor volume via anterior-posterior-posterior-anterior (AP-PA) fields in 170-cGy fractions to a dose of 4760 cGy. Patients with inoperable groin nodes received chemoradiation to the primary vulvar tumor, inguinal-femoral and lower pelvic lymph nodes. RESULTS: Seven patients did not undergo a post-treatment surgical procedure: deteriorating medical condition (2 patients); other medical condition (1 patient); unresectable residual tumor (2 patients); patient refusal (2 patients). Following chemoradiotherapy, 33/71 (46.5%) patients had no visible vulvar cancer at the time of planned surgery and 38/71 (53.5%) had gross residual cancer at the time of operation. Five of the latter 38 patients had positive resection margins and underwent: further radiation therapy to the vulva (3 patients); wide local excision and vaginectomy necessitating colostomy (1 patient); no further therapy (1 patient). Using this strategy of preoperative, split-course, twice-daily radiation combined with cisplatin plus 5-fluorouracil chemotherapy, only 2/71 (2.8%) had residual unresectable disease. In only three patients was it not possible to preserve urinary and/or gastrointestinal continence. Toxicity was acceptable, with acute cutaneous reactions to chemoradiotherapy and surgical wound complications being the most common adverse effects. CONCLUSION: Preoperative chemoradiotherapy in advanced squamous cell carcinoma of the vulva is feasible, and may reduce the need for more radical surgery including primary pelvic exenteration.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1992

Sacral resection for control of pelvic tumors.

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.

Bone Neoplasms↗

PubMed1998

Squamous-cell carcinoma of the pelvis in a giant condyloma acuminatum: use of neoadjuvant chemoradiation and surgical resection: report of a case.

A 60-year-old bisexual male was referred to our institution for management of an unresectable squamous-cell carcinoma of the pelvis arising in a giant condyloma acuminatum. He received neoadjuvant chemoradiation consisting of 5-fluorouracil and mitomycin C with concurrent external beam radiation, followed by posterior pelvic exenteration. The surgical specimen had no residual cancer. In situ hybridization was performed using a human papilloma virus omniprobe for human papilloma virus subtypes 6, 11, 16, 18, 31, 33, and 35. Two years after diagnosis the patient is doing well with no evidence of recurrent disease.

Antibiotics, Antineoplastic↗

PubMed1995

Laparoscopically assisted transvaginal radical cystectomy.

Herein we describe 5 cases of anterior pelvic exenteration in females through a combined transvaginal and laparoscopic approach for bladder cancer. In 4 cases hysterectomy and bilateral ovariectomy were performed. As far as urinary diversion is concerned, a bilateral cutaneous ureterostomy was performed in the 1st case, and in the remaining 4 an ileal conduit was accomplished through a minilaparotomy at the stoma site. The surgical specimen was withdrawn 'en bloc' transvaginally in all cases except 1, in whom vaginal atrophy forced us to perform a midline minilaparotomy. Total operative time ranged between 6 and 9 h, and 4 patients were discharged after 7-11 days with no complications. One patient was discharged only after 18 days due to obesity and diabetic problems. A larger series is needed to confirm the advantages of the combined transvaginal and videolaparoscopic approach for anterior pelvic exenteration as compared to the conventional procedure, with special regard given to the oncological outcome. Our initial experience is surely encouraging.

Aged↗

PubMed1984

Preoperative radiation therapy for locally advanced vulvar cancer.

Eight patients with locally advanced vulvar cancer that would have necessitated pelvic exenteration to encompass the primary tumor were given preoperative radiation therapy in an attempt to shrink the primary tumor and allow more conservative surgery. From 4400 to 5400 rad of external radiation were delivered to the primary tumor, and one patient received an additional 2400 rad from intracavitary therapy. Satisfactory shrinkage of tumor occurred in seven of the eight patients (87.5%), thus allowing conservative surgical excision. In four patients (50%), there was no viable tumor in the surgical specimen. Moist desquamation of the vulva occurred in all patients and was of sufficient severity to require temporary cessation of radiation in four patients (50%). Five received groin radiation, and one (20%) subsequently developed bilateral hip fractures. No other major morbidity occurred. Five of the eight patients (62.5%) are alive without evidence of disease at intervals ranging from 15 months to 10 years. Preoperative radiation in this group obviated the need for pelvic exenteration, resulting in significantly less morbidity without compromising survival.

Adenocarcinoma↗

PubMed1983

The multidisciplinary team approach to exenteration of the pelvis.

The experience of a newly formed, multidisciplinary, pelvic exenteration team is presented which consists of a gynecologic oncologist, a general surgeon and a urologist. The first 20 exenterations performed by this team are reviewed. Nine patients had no postoperative problems, and of the 11 patients who did have complications, all but two, which resulted in death, were corrected without resultant debilitation. Fourteen of the 18 patients who survived the operation are tumor-free for as long as three years postoperatively. Operative proficiency as well as operative mortality and morbidity have certainly improved quite significantly as the team has gained experience.

Adult↗

PubMed1998

[Retrovesical liposarcoma: a case report].

A case of retrovesical liposarcoma is reported. The patient was a 41-year-old man who complained of left scrotal pain and of hip discomfort. Digital rectal examination revealed a hen's egg-sized mass with an elastic hard consistency at the left side of the normal prostate. Pelvic CT and MRI showed a heterogeneous tumor in the retrovesical region. Transperineal biopsy revealed liposarcoma. Pelvic exenteration, colostomy and ileal conduit were performed. The resected weight was 1,680 grams, and the histopathological diagnosis was myxoid type of liposarcoma, grade II. Postoperatively, a metastatic lesion to vertebrae thoracicae I developed causing radiculoneuropathy of the left superior limb. Spot radiation (50 Gy) was administered to the lesion, but there was no response. Currently, the patient is being treated with combination chemotherapy consisting of dacarbazine, vincristine, adriamycin, and cyclophosphamide. Cases of retrovesical liposarcomas reported in Japan are reviewed and discussed.

Adult↗

PubMed1994

[Reliability of imaging procedures in multi-visceral gynecologic operations of the pelvis].

Between March 1989 and December 1992, a total of 85 pelvic exenterations were performed in the Department of Gynaecology and Obstetrics of the University of Mainz. To assess the accuracy of preoperative Magnetic Resonance Imaging (MRI) and Computer Tomography (CT) with regard to tumour localisation and spread, the results of 28 MRI and 14 CT examinations were compared with the postoperative histological findings. For this widely varying patient group that had undergone a broad range of previous treatments, MRI produced an accurate forecast in 56% of cases (CT, 36%). In 33% of the patients tested, the diagnosis based on MRI was partially correct (CT, 43%), whereas the MRI results fundamentally disagreed with the actual findings in 11% of cases (CT, 21%). We conclude that both MRI and CT are of great value in the planning of operations and for informing patients about their condition; however, in individual cases, an intraoperative quick-section diagnosis is necessary to provide details of tumour spread. If the extent of tumour spread is uncertain, the results of CT and/or MRI should not deter the surgeon from the radicality of the planned operative intervention.

Adult↗