Objective
Whereas pelvic exenteration is an established therapy for the treatment of recurrent cervical carcinoma, it is not often performed for primary locally advanced cervical cancer (LACC).
Study Design
This retrospective study analyzed survival data and prognostic factors of 35 patients with LACC who were treated by pelvic exenteration.
Results
After surgery, 33 patients (97%) were macroscopically free of tumor. In 20 patients, pelvic lymph nodes (LN) were involved, and in 6 of these, metastatic tissue had reached the paraaortal nodes. Overall, the patients’ mean 5 year survival was 43%, and the median survival time was 30 months; these values ranged from 15% to 70% and from 15 to 44 months, respectively, depending on LN involvement ( P = .006). Pelvic LN involvement was the only significant factor for overall survival found in the multivariate analysis ( P = .02).
Conclusion
In LACC with free LNs and no distant metastases, pelvic exenteration has good long-term results.
When Brunschwig performed the first exenteration in the 1940s, it was a palliative surgery for the treatment of extended recurrences of genital carcinomas. After several modifications, the perioperative mortality fell to 15% and has been shown to be less than 5% in recent studies. The groups of patients studied were diverse, but these reports described 5 year survival rates that rose from 23% to nearly 50%. New developments such as continent bladder replacement made the procedure more acceptable to patients, and it is now a well-accepted therapy in oncosurgery. However, the indications for exenteration are still discussed as a matter of debate.
Only a few authors favor exenteration when metastatic spread has reached the lymph nodes (LNs) or when a curative result is otherwise doubtful. Moreover, opinions on exenteration as a primary treatment for locally advanced cervical cancer are divided. Whereas in the United States this is rarely an option for gynecooncologists, in Germany, nearly half of the gynecooncologists would consider exenteration as a treatment option in these cases.
The aim of this study was to analyze the prognosis and the factors influencing the prognosis of patients suffering from primary locally advanced cervical cancer who were treated by pelvic exenteration.
Materials and Methods
In a retrospective analysis, we studied the records of all patients who underwent a pelvic exenteration for primary cervical cancer between May 1999 and April 2010. Prior to surgery, performance status (Eastern Cooperative Oncology Group Performance status 0 or 1) and mental capacity had been assessed in all patients to determine their ability to comprehend the complexity, risks, and consequences of the procedure. Informed consent, including the rationale of the procedure and the alternatives (both medical and surgical, as appropriate), was obtained in every case.
Preoperative investigations included examination with cystoscopy and rectoscopy under anesthesia, magnetic resonance imaging of the lower abdomen, and in the case of a urinary tract obstruction, a renal scintigraph to evaluate renal function. Diagnosis was always ensured by biopsy and histological examination.
The operations had been performed exclusively by 2 surgeons (B.L. and D.M.F.), both of whom were highly experienced in both the field of multivisceral and exenterative surgery in the small pelvis and the necessary reconstructive procedures. Both were proficient in intestinal and reconstructive bladder surgery.
Medical records were analyzed with respect to age at the time of surgery, histological tumor type, preceding radio- or chemotherapy, duration of procedure, number of erythrocyte or fresh-frozen plasma transfusions, mode of bladder reconstruction (ileal conduit vs ileocecal pouch), intestinal anastomosis, protective colostomy, and postoperative complications. The surgical results were classified in terms of freedom from tumor using the following categories: not microscopically detectable (R0), microscopically detectable (R1), and macroscopically detectable (R2).
Urinary passage was reestablished by either a continent ileocecal pouch with a catheterizable stoma through the umbilicus or an ileal conduit as described by Wallace. All rectal anastomoses in our patients lay less than 7 cm from the anus and were performed by transanal circular stapler. Protective stomas were fashioned via loop colostomy of the descending colon.
Data were analyzed with the statistics program BIAS for Windows, using the Mann-Whitney U test for data that were not normally distributed and the Fisher-Yates exact test. Univariate comparisons of prognostic factors and survival analyses were made using Kaplan-Meier log-rank statistics.
Discriminant and factor analyses were also done to measure prognostic factors and their impact on overall survival (OS). The level of significance was defined as P < .05. Discriminant analysis helps to identify the independent variables that discriminate a nominally scaled dependent variable of interest. The linear combination of independent variables indicates the discriminating function, showing the large difference that exists in the 2 group means. Factor analysis helps to reduce a vast number of variables to a meaningful, interpretable, and manageable set of factors.
Results
Over a period of 10 years, 35 patients underwent primary exenterative surgery (PE) for locally advanced cervical cancer (LACC) in our department.
The median age of the patients was 52 years (35-71 years), the median operating time for the exenterative and reconstructive procedures was 442 minutes (237-685 minutes), and the median postoperative hospital stay time was 33 days (10-117 days). Patients needed a median of 4 units of packed red blood cells (0-16) and 2 units of fresh-frozen plasma (0-18). Sixteen patients had a total exenteration performed, 17 had an anterior exenteration, and 2 had a posterior procedure ( Table 1 ).
| Characteristic | n or median | Range |
|---|---|---|
| Number of patients | 35 | |
| Age, y | 52 | 35–71 |
| Operation time, min | 442 | 237–685 |
| Hospital stay, d | 33 | 10–117 |
| ICU stay, d | 3 | 1–5 |
| Anterior exenteration | 17 | |
| Posterior exenteration | 2 | |
| Total exenteration | 16 | |
| Squamous cell cancer | 35 | |
| FIGO stage | ||
| T2 | 7 | |
| T3 | 10 | |
| T4 | 18 | |
| Nodal status negative | 15 | |
| Pelvic lymph node metastases | 14 | |
| Pelvic and paraaortal lymph node metastases | 6 | |
| Surgical result | ||
| R0 microscopically free of tumor | 30 | |
| R1 microscopic tumor remnants | 4 | |
| R2 macroscopic tumor remnants | 1 | |
| Grading | ||
| G2 | 10 | |
| G3 | 25 |
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