Imen Bouraoui The first author was a medical student that finish his general medical cursus and then she was specialized in oncologic surgery. She spent five years in the department of oncologic surgery, she assisted in several operations as an observator or operating assistant and she made many operations especially in breast cancer. She is preparing to pass her final exam this year.
Background The purpose of this work was to identify the results of pelvic exenteration for recurrent, persistent or locally advanced cervical cancer in terms of survival performed for 41 patients in Salah Azaiez Institute.
Patients and Methods We conducted a retrospective unicentric study. The association between PE and OS was estimated using the method of Kaplan–Meier using SPSS ver 24.
Results Median age at the time of intervention was 53.9 years old. FIGO stage IIB was the most frequent (46.3%). Eighteen patients had pelvic exenteration after neoadjuvant treatment. Resection margins were free of tumor in 83.3% of cases. Twenty-three patients underwent pelvic exenteration for recurrence of cervical cancer treated. The median time of recurrence was 23.4 months. Free resection margins were obtained in 69.5% of cases. Postoperative complications were noted in 61% of patients. Two deaths were seen in the early postoperative period. After a median follow-up of 40.5 months, 24.4% of recurrences were noted. Overall survival at 5 years was 51% and recurrence-free survival at one year was 39%. Prognostic factors which impact overall and recurrence-free survival were the size of recurrence and resection margins after exenteration. The time between the end of initial treatment and recurrence was the only predictive factor of recurrence after pelvic exenteration.
Conclusion Pelvic exenteration remains a curative treatment of cervical cancer in certain indications despite high morbidity. A rigorous preoperative selection of candidate may reduce the morbidity and improve the survival of patients.
Keywords : Cervical cancer · Locally advanced · Recurrence · Pelvic exenteration · Survival
Cervical cancer still represents an important health problem worldwide. It is the fourth leading cause of cancer death in the world [1]. Squamous cell carcinoma is the most common histological type [2]. After positive diagnosis of cervical cancer, this latter must be staged according to the International Federation of Gynecology and Obstetrics (FIGO 2018) classification. For locally advanced cervical cancer classification as FIGO stage IVA which involves the bladder and/or the rectum, the only therapeutic surgical procedure after neoadjuvant chemoradiation is pelvic exenteration [3]. Although radical surgery and radiotherapy represent effective treatment modalities, up to one-third of patients, all stages combined, will develop progressive or recurrent tumors, the pelvis being the most common site of recurrence [3]. The relapse rate of cervical cancer ranges between 11 and 22% in FIGO stages Ib-IIa and between 28 and 64% in FIGO stages IIb-Iva [3].
For recurrent cervical cancer, repeated radiotherapy for the same anatomical sites is contraindicated and chemotherapy is no longer effective due to a lack of vascularization [4]. The only lifesaving therapeutic weapon remains pelvic exenteration. In 1948, Brunchwing published the first pelvic exenteration series with high morbidity and mortality [5].
Pelvic exenteration (PE) is a radical surgical procedure in which pelvic organs are removed. It has made significant progress over the past 20 years with favorable survival outcomes although at cost of high-morbidity rates [6]. In this background, we decided to look into our own experience with pelvic exenteration for locally advanced, persistent or pelvic recurrent cervical cancer. The aim of this study was to identify the expected results of pelvic exenteration in terms of overall survival and disease- free survival.
We reviewed the cases of a total of 41 women who underwent PE between February 2000 and May 2017. Among them, twenty-three women (56.1%) underwent pelvic exenteration after persistent or recurrent cervical cancer. The remaining cases underwent pelvic exenteration after neoadjuvant treatment.
Their median age at diagnosis was 52 years (range, 33–70 years). At the time of pelvic exenteration, their median age was 55 years (range, 32–78 years). Forty patients presented with symptoms at time of initial cancer diagnosis. The most common symptoms reported were vaginal bleeding (84.4%) followed by pelvic pain (14.6%).
Preoperative gynecological examination under general anesthesia was performed in 33 patients (80.48%). Pretherapeutic pelvic MRI was practiced in only 12 patients (29.2%) as part of locoregional extension assessment. The mean radiological tumor size was 53 mm. Cystoscopy was performed in 33 patients (80.48%). It was abnormal with positive biopsy in 4 cases. Nine patients (21.9%) were evaluated with CT scan and no distant metastases were found.
Conflict of interest The authors declare that they have no conflict of interest.
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