Patient selection criteria

CRS/HIPEC was recommended according to the patient’s history, CT scan findings, and evaluation of our senior surgeon, who considered that a potential complete cytoreduction (CC-0) could be achieved. Additional selection criteria included patients without evidence of extraabdominal disease, with good functional status to undergo a major surgical procedure.

The CRS/HIPEC surgical technique implemented was previously described by Sardi and colleagues. Doxorubicin (7 mg/m ² ) plus cisplatin (50 mg/m ² ), or melphalan (50 mg/m ² ) was used as chemotherapeutic agents during HIPEC.

Follow-up for disease progression was carried out at 3 weeks, 3 months, and every 6 months thereafter. A CT scan of the chest, abdomen, and pelvis were performed 1 month postoperatively, at 6 month intervals for 5 years, and yearly thereafter. Systemic chemotherapy was started if indicated. Clinical descriptive analysis was reported.

Patient 1 clinical description

A 39 year old obese African-American female, G0P0A0, was referred with a complaint of abdominal distention and shortness of breath. Physical examination revealed a large pelvic mass with ascites. A CT scan of the chest, abdomen, and pelvis identified bilateral pleural effusion, mediastinal lymphadenopathy, a large confluent mass in the abdomen extending from the pelvis to the undersurface of the liver with marked displacement of the bowel, ascites, and an umbilical mass. Fine-needle aspiration for cytology of the right axillary lymph nodes, diagnostic thoracocenthesis, and abdominal paracenthesis was benign. A biopsy of the intraabdominal mass was suggestive of a low-grade LMS of the uterus. Relevant family history included maternal uterine and breast cancers and paternal prostate cancer.

The patient underwent an exploratory laparotomy with CRS (TAH, BSO, segmental small bowel resection [jejunum], omentectomy, lymphadenectomy, biopsy of the left/right parietal peritoneum, resection of the umbilicus with hernia sac, biopsy of multiple peritoneal implants) followed by HIPEC using doxorubicin (7 mg/m ² ) and cisplatin (50 mg/m ² ). CC-0 was achieved, with a peritoneal carcinomatosis index (PCI) of 16/0.

The postoperative histopathological diagnosis was a high-grade LMS (T2, N0, M1, grade IV). Her postoperative course was uncomplicated. An individualized tumor response testing assay was carried out on the pathological tissue sample to determine tumor chemotherapeutic response. The tumor phenotype was seen to demonstrate an intermediate drug resistance to cytoxan, vincristine, and doxorubicin, with extreme drug resistance to etoposide, ifosfamide, dacarbazine, and cisplatin. As a result, systemic chemotherapy was withheld.

On follow-up at 20 months, an enlarging mass within the right lobe of the liver was identified. The patient subsequently underwent a right partial hepatectomy (12 × 9 × 5 cm), cholecystectomy, and diaphragmatic resection. Histopathology revealed metastatic high-grade sarcoma. No adjuvant chemotherapy was given.

Seven months later the patient complained of left nipple discharge, at which time a left breast ductoscopy and lumpectomy were performed, revealing a benign histopathology. The patient progressively gained weight, ultimately reaching 312 lbs 130 months after CRS/HIPEC. Follow-up chest positron emission tomography/CT scan 115 months after CRS/HIPEC showed a left upper lobe pulmonary metastasis (LMS) measuring 1 cm, and a thoracoscopic left upper lobe wedge resection was performed.

Three months later, she presented again with left bloody nipple discharge. A mammogram revealed a 2 cm upper-outer-quadrant left breast mass, which was removed by a wide excision. Pathology confirmed metastasic LMS and clear margins.

Because all tumors were reported as estrogen and progesterone positive, letrazol, an aromatase inhibitor, was prescribed. The patient is currently stable without disease progression. She is now without any evidence of disease 142 months after initial CRS/HIPEC and 24 months after her last surgical procedure.

Patient 2 clinical description

A 38 year old white female, G7P0C1A6, was referred complaining of severe menorrhagia for 1 week associated with postcoital bleeding. Past medical history was relevant for hysteroscopy because of multiple previous miscarriages, cesarean section, and morbid obesity (body mass index of 51 mg/m ² ). Family history includes endometrial hyperplasia (mother) and breast cancer (paternal grandmother in her 50s), renal cancer (paternal grandfather), diabetes, hypertension, and heart disease.

An ultrasound showed an enlarged uterus (14.0 × 4.2 × 5.4 cm) with multiloculated cystic endometrium. Hysteroscopy, dilation, and curettage revealed high-grade undifferentiated sarcoma. A CT scan of the abdomen and pelvis showed findings worrisome for endometrial malignancy of the lower uterine segment extending outside the confines of the uterus ( Figure 1 , Ai and Aii). There were no distal metastases. She underwent TAH/BSO and extensive tumor debulking. A tumor was found to be invading the left parametria. Pathology evidenced high-grade sarcoma arising from adenosarcoma with sarcomatous overgrowth with invasion through the full thickness of the myometrium into subserosal tissue and extension to the pelvis. The endocervix, ovaries, fallopian tubes, and cervix were all negative for a tumor. Margins were clear. There were no complications in her postoperative recovery, and she was discharged 3 days later.

CT scan evidence of disease

Ai and Aii, Two pelvic endometrial malignancies outside the uterus, 23 × 23 mm and 41 × 33 mm (yellow measurements) (Sept. 9, 2008). B, First recurrence to anterior pelvis, 71 × 41 mm (yellow measurement) (Nov. 9, 2009). C, Second recurrence at lower quadrant abdomen, 24 × 21 mm (yellow measurement) (Oct. 21, 2010). D, Third recurrence at the level of pelvic brim, 57 × 47 mm (yellow measurement) (Oct. 14, 2011). Ei and Eii, Two recurrent masses: 1 in the right ileal vessels, 47 × 33 mm, and 1 in the bowel on the right side , 39 × 34 mm (yellow measurement) (June 22, 2012).

A , anterior; CT , computed tomography; L , left; P , posterior; R , right.

Jimenez. CRS/HIPEC in recurrent high-grade uterine sarcomas with peritoneal dissemination. Am J Obstet Gynecol 2014 .

She received 6 cycles of adjuvant paclitaxel and carboplatin over 3 months, followed by 3 cycles of ifosfamide, which was stopped because of intolerance. A follow-up positron emission tomography/CT scan at 14 months demonstrated a 7 × 4 cm mass in the anterior pelvis ( Figure 1 , B). She underwent a CRS (resection of abdominal wall, total omentectomy, sigmoid resection, primary side-to-side functional stapled anastomosis, and resection of multiple peritoneal implants) and HIPEC using melphalan (50 mg/m ² ). CC-0 was achieved with a PCI score of 7/0. She was discharged on postoperative day 7 without complications.

A follow-up CT scan 12 months later identified a 2 cm right-lower quadrant lesion close to the cecum ( Figure 1 , C). She had a second CRS (resection of abdominal wall, partial cecectomy, appendectomy, resection of pelvic tumor of 4.5 cm diameter) and HIPEC using melphalan (50 mg/m ² ). CC-0 was achieved with a PCI of 3/0. A superficial surgical site infection and urinary tract infection were successfully treated with antibiotics, and she was discharged on postoperative day 6.

A follow-up CT scan at 11 months after the second CRS/HIPEC revealed a left abdominal mass at the level of the pelvic brim of 5.5 × 4.6 × 4.8 cm, con-sidered a disease recurrence ( Figure 1 , D). She then underwent a third CRS (small bowel resection with side-to-side anastomosis, resection of sigmoid colon, takedown of the splenic flexure), HIPEC with melphalan (50 mg/m ² ). She had a PCI score of 3/0 and again, CC-0 was achieved. Pathology revealed a high-grade sarcoma that was highly estrogen receptor and progesterone receptor positive.

Against medical advice she did not take tamoxifen postoperatively. She has also refused systemic chemotherapy. Eight months after her last CRS/HIPEC, a follow-up CT scan showed 2 lesions: 1 at the right ileal vessels and 1 in the bowel on the right side, considered disease recurrence ( Figure 1 , E). She then underwent a fourth CRS (resection of abdominal wall, resection of distal jejunum and proximal side-to-side stapled anastomosis, resection of pelvic tumor, and right uterolysis). There was an incomplete cytoreduction in the tumor foci because of circumferential involvement of the right ureter and right iliac vessels (CC-2). No HIPEC was performed at this time. Radiotherapy was administered over 3 days (cyberknife) to a total dose of 3000 cGy, without complications.

At last follow-up, a CT scan revealed right hydronephrosis with a 3 × 2 cm tumor at the right common iliac region, difficult to separate from the right common iliac vein and right ureter, and a left common iliac lymph node 1.4 × 1.1 cm. She is now tolerating tamoxifen well with stable disease and is followed up every 3 months.

She is alive with disease at 55, 44, and 9 months since diagnosis, first CRS/HIPEC, and last CRS/HIPEC, respectively. She is working full time and has no restriction in her physical activity or quality of life.

Patient 3 clinical description

A 50 year old female, G2P2A0, with a history of recurrent high-grade LMS referred with complaints of lower abdominal pain radiating to the lower extremities, occasional constipation, and urinary frequency with occasional pressure-like symptoms. Her symptoms worsened after a routing follow-up CT scan (Feb. 9, 2011) of the chest, abdomen, and pelvis for her high-grade uterine LMS. Relevant past medical history included a primary surgery (TAH/BSO on April 29, 2010) and 6 courses of gemicitabine and docetaxel. She had a recurrence 7 months after her primary surgery while receiving chemotherapy and underwent another cytoreductive surgery with resection of 20 cm soft friable cystic mass arising from pelvis, adherent to rectosigmoid, posterior bladder, bilateral sidewalls, and cul-de sac. The tumor was excised completely.

Two months after CRS, an abdominopelvic magnetic resonance imaging (MRI) identified 2 masses: 1 measured approximately 6 cm in diameter, originating from the vaginal cuff and extending superiorly, closely abutting the posterior wall of the bladder, the pelvic side wall bilaterally, and the rectosigmoid colon; the second mass measured 4 cm in diameter abutting the superior aspect of the bladder wall ( Figure 2 , B).

Follow-up imaging of recurrent rapidly growing LMS

Ai and Aii, Axial and coronal CT scan of Dec. 21, 2010, showing no clear images suggesting masses. B, MRI of Jan. 28, 2011, showing 2 pelvic masses, the first located between the posterior wall of the bladder and the rectosigmoid colon (65 × 60 mm: yellow measurement); the second abutting the superior aspect of the bladder extending to the right side (38 × 23 mm: yellow measurement). Ci and Cii, Axial and coronal CT scan views of Feb. 24, 2011, showing the increased size masses in less than 4 weeks after MRI (yellow measurements).

A , anterior; CT , computed tomography; L , left; LMS , leiomyosarcoma; MRI , magnetic resonance imaging; P , posterior; R , right.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. The health disparities of uterine fibroid tumors for African American women: a public health issue
2. Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial
3. Serum leptin levels and reproductive function during the menstrual cycle
4. Ultrasound assessment of uterine cavity remodeling after surgical correction of subseptations

Stay updated, free articles. Join our Telegram channel

Join