Treatment in Recurrent Cervical Cancer

Surgery – Pelvic exenteration

Prof. Dr. Fuat DemirkıranGynecologic Oncology division,

Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty,

2010 Antalya

Localization of recurrencepelvicdistantpelvic + distant

48.4 %(21.6 % central)

28.9 %22.7 %

Cerrahpaşa 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

The recurrence ……… 10% to 18% for early stage

62% to 89% detected in 2 years 14% to 57% central

17 retrospective studies

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.

Chemotherapy

SurgeryExcisional surgery

TAH Type ITAH II-III

ExenterationLEER

Radiotherapy Pelvic

Pelvic, extrapelvic

Local extrapelvic

Cervical

Pelvic central

Pelvic side

Treatment alternatives in Recurrent Cervical Cancer

Excisional Surgery

Isolated Cervical Relapse

TAH Type I ??

TAH II-III ?

Ota et al. 2008 J Br Cancer35 persistent cervical cancer 13% margin +

12 % fistula 68% 5 years survival.

Coleman et al. 1994 Gynecol Oncol50 recurrent cervical cancer, %42 major comp. 30% fistula

72% 5 years survival.

Isolated Cervical RelapseTAH II-III ?

Cerrahpaşa 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 ?

Pelvic Exenteration

IndicationRecurent Ovarian cancer 28Recurrent cervical cancer 25Recurrent endometrial cancer 13Recurrent vulvar-vaginal cancer 6

TOTAL 72

Cerrahpaşa Gynecologic Oncology 1994-2010

Central Tumors Recurrences in Cervical Cancer

Isolated cervical recurrence

Isolated vaginal recurrence – bladder invasion.

Vaginal posterior wall recurrence - rectal invasion.

Anterior-posterior vaginal wall recurrence

vaginal cuff recurrence

Central Tumor relapses

Treatment

Prior RT No Prior RT

ExenterationChemotherapy

RTExenteration

Patient selectionFirst 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 ObesityObesity is not an absolute contraindication, but gives difficulty in surgery

Pelvic Exenteration

Pelvic exenteration

Pre-operative histologic analysis should been made

Chest CTAbdomen CT-MR

PET-CT

Preoperative search for evidence of distant metastasis.

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 can’t be made in 25-30 % of patients

Pelvic Exenteration Patient selection

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

Patient and her relatives should be informed about

surgical morbidity, mortalitytype of exenteration

changing decisions at the operationpossibility of inoperability

stoma treatment alternatives

success rate

Even if everything is OK

Total Exenteration

Posterior Exenteration

Anterior Exenteration

Pelvic Exenteration

Supralevator

Infralevator

Distributions of Exenterative Surgery Recurrent Cervical Cancer n:25

Histological disturbitionSquamous 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%)

Pelvic ExenterationTumor and surrounding tissue excision

Cerrahpaşa Gynecologic Oncology

Exenterative Operations1994-2010

Urinary diversions Ileal conduit

17

Cophey op

2

Poch (Mainz I)

2

Bladder-ileum anastomosis

1

Colostomy 9

Low rectal anostomosis 8

GI diversions

Pelvic exenterationUrinary diversion

Pelvic ExenterationGI diversion

Postoperative tumor residuals None 23 (49%)

Pelvic side wall 13 (27.6%) Upper abdomen 2 (4.2%)

No complications 14 (29.8%)

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)

20 primary35 secondary

Complicationsİleal 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%)

Cerrahpaşa Gynecologic Oncology

Exenterative Operations 1994-2010

Postoperative Major Complications and Mortality

n:25 Urinary fistula 1 GI Fistula 3 Pelvic abscess 1 Pulmonary embolism 1 Re-laparotomy 5 (20%) Mortality 1 (4%)

Cerrahpaşa Gynecologic Oncology

24%

70%

Complication rate 57%Operative mortality 5%

OS at 5 years 27%

OS at 5 years 52%

12 mo 4 mo 4 mo

22 mo

Median follow-up 23 month (4- 72)

11 (44 %) in 25 cases died 2 patient died becouse of other conditions 4 patient in 1st year5 patient in 2nd year

Cerrahpaşa Gynecol Oncol

Exenterative Operations1994-2010

36%

The risk factors which predict recurrenceand survival after pelvic exenteration for the

treatment of advanced orrecurrent gynecologic malignancies

in the multivariate analysis, by examining exenteration type, tumor size, lymph vascularspace 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

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.