Pelvic exenteration for gynaecological tumours: achievements and unanswered questions

Pelvic exenteration has been used for 60 years to treat cancers of the lower and middle female genital tract in radiated pelves. The mainstay for treatment success in terms of locoregional control and long-term survival is resection of the pelvic tumour with clear margins (R0). New ablative techniques based on developmentally derived surgical anatomy and laterally extended endopelvic resection have raised the number of R0 resections done, even for tumours that extend to the pelvic side wall, which were traditionally judged a contraindication for exenteration. Although mortality has fallen to less than 5%, treatment-related severe morbidity of pelvic exenteration still exceeds 50%, possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. The benefits of exenteration for patients who have advanced primary disease or recurrent tumours after surgery, versus those who have chemoradiotherapy, are not proven by results of controlled trials, but can be assumed from retrospective data. Comparative findings are missing, and arguments are unconvincing to favour pelvic exenteration over less extensive treatments and best supportive care for palliation of cancer symptoms in most patients.     

The changing role for extended resections in an era of advanced radiotherapy techniques and novel therapies in gynaecological malignancy

Pelvic exenteration, first described in 1948 and subsequently refined, may be offered as a last hope of cure to patients with recurrent or locally advanced pelvic tumours, where radiotherapy is not an option. It is a complex, morbid, ultra-radical procedure involving en-bloc resection of the female reproductive organs, lower urinary tract, and a portion of the rectosigmoid.This article discusses the evolution of and current indications for pelvic exenteration in gynaecologic oncology as well as the reasons for its decline: primary and secondary prevention of cervical cancer (the recurrence of which is the most common indication for exenteration); improvements in treatment of cervical, endometrial, vaginal and vulvar cancer in the primary and recurrent setting; and the advent of novel therapies.     

Role of brachytherapy in malignant melanoma: a preliminary report

From August 1979 to May 1986, various brachytherapy techniques were applied at Memorial Sloan Kettering Cancer Center (MSKCC) in an adjuvant setting with/without surgery and external radiation therapy in the management of advanced malignant melanoma. Thirty-three patients underwent brachytherapy procedures. The patients' ages ranged from 35 to 82 years, with a median age of 56 years. Fourteen patients had disease localized to the implant site, whereas 19 patients also had disseminated disease elsewhere. The indications for implant were residual gross disease (21), microscopically positive margins (3), and histologically negative but clinically close margins of resection (9). Local control at the implant site was noted in 80% of patients at 6 months and 42% of patients at 1 year; two patients had reached 54 months and 72 months with no evidence of disease. Local control was 100% (9/9) in patients with histologically negative but clinically close margins of resection, and 48% (11/23) with microscopically positive margins and/or gross residual disease. Complications were seen as follows: delay in wound healing (1), wound infections (4), radiation enteritis (1), small bowel obstruction (1). The present study suggests that brachytherapy combined with surgery can achieve a good local control in patients with negative but clinically close margins of resection. In patients with gross residual disease who are at a high risk for local recurrence, approximately one-half can be locally controlled with this approach. These preliminary results should be tested in a prospective controlled study.     

Surgical treatment of locally advanced and recurrent cervical carcinoma: overview on current standard and new developments

The current standard treatment of locally advanced carcinoma of the uterine cervix is chemoradiation. Whether new developments such as laparoscopic surgical staging or neoadjuvant systemic and regional chemotherapy, preoperative chemoradiation and intraoperative radiation combined with radical hysterectomy will improve recurrence- free and overall survival is yet unproven. Until recently, surgical treatment of locally advanced and recurrent cervical carcinoma was performed only with a central disease location. The required operation, pelvic exenteration, was contraindicated for tumors fixed to the pelvic wall. The laterally extended endopelvic resection (LEER) now allows the exstirpation of a subset of mesenteric pelvic side-wall tumors with clear margins and opens up a 50% chance of long-term survival for the affected patients.     

Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer.

AIMS: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer much attention is given to the oncological aspects. In long-term survivors, urogenital morbidity can have a large effect on the quality of life. This study evaluates the functional outcome after multimodality treatment in these patient groups. PATIENTS AND METHODS: Between 1994 and August 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with multimodality treatment: i.e. high-dose preoperative external beam radiation therapy, followed by extended surgery and intraoperative radiotherapy. The medical records of the 121 patients were reviewed. To assess long-term urogenital morbidity, all patients still alive, with a minimum follow-up of 4 months, were asked to fill out a questionnaire about their voiding and sexual function. Seventy-six of the 79 currently living patients (96%) returned the questionnaire (median FU 14 months, range 4-60). RESULTS: The questionnaire revealed identifiable voiding dysfunction as a new problem in 31% of the male and 58% of the female patients. In 42% of patients after locally advanced primary and 48% after locally recurrent rectal cancer treatment bladder dysfunction occurred. The preoperative ability to have an orgasm had disappeared in 50% of the male and 50% of the female patients, and in 45% of patients after locally advanced primary and in 57% after locally recurrent rectal cancer treatment. CONCLUSION: Multimodality treatment for locally advanced primary and recurrent rectal cancer results in acceptable urogenital dysfunction if weighed by the risk of uncontrolled tumour progression. Long-term voiding and sexual function is decreased in half of the patients. Preoperative counselling of these patients on treatment-related urogenital morbidity is important. Copyright Harcourt Publishers Limited.     

Feasibility and first results of multimodality treatment, combining EBRT, extensive surgery, and IOERT in locally advanced primary rectal cancer

PURPOSE: To assess the outcome of aggressive multimodality treatment with preoperative external beam radiation therapy (EBRT), extended circumferential margin excision (ECME) and intraoperative electron beam radiation therapy (IOERT) in patients with locally advanced primary rectal cancer. METHODS AND MATERIALS: Thirty-eight patients with primary locally advanced rectal cancer, but without distant metastases, received multimodality treatment. CT-scan showed extension to other structures in 15 patients (39%) and definite infiltration into the surrounding structures in 23 patients (61%). All patients received preoperative EBRT (dose range 25-61 Gy) and 82% received 50.4 Gy. The resection types were: 12 low anterior resections (31%), 14 abdomino-perineal resections (37%), 6 abdomino-transsacral resections (16%), and 6 pelvic exenterations (16%). The IOERT dose ranged from 10 to 17.5 Gy depending on the completeness of the resection. RESULTS: There was no perioperative mortality. The resection margins were microscopically negative in 31 patients (82%), microscopically positive in 4 (10%), and positive with gross residual disease in 3 patients (8%). Pelvic recurrences were observed in 5 patients (13%) including 3 IOERT infield failures. The overall 3-year local control, disease-free survival (DFS), and survival rates were 82%, 65%, and 72%, respectively. Negative resection margins were the most significant prognostic factor with regard to DFS (p = 0.0003) and distant control (p = 0.002) compared with cancer involved surgical margins. CONCLUSION: A high percentage of curative resections can be achieved in this group of patients with locally advanced rectal cancers. Adding IOERT to preoperative EBRT and ECME achieves high local control rates and possibly improves survival.     

Outcome after the introduction of a multimodality treatment program for locally advanced rectal cancer.

AIM: This prospective study reports the results of a multimodality treatment protocol in patients with locally advanced rectal cancer and assesses outcome after curative vs non-curative surgery and in relation to primary advanced vs locally recurrent cancer. METHODS: Between 1991 and 2002, 122 patients completed the protocol. Fifty-eight had primary advanced and sixty-four had locally recurrent rectal cancer. Median follow up was 82 months (5-143). RESULTS: A potentially curative resection was achieved in 59% of the patients with primary advanced and in 34% of patients with locally recurrent cancer. After curative resection, 53 and 59%, respectively, were free from recurrence during the observation time (median 82 months) and the overall 5-year survival was 34 and 40%. Overall 5-year survival in all patients with primary advanced cancer was 29 and 16% in all patients with locally recurrent rectal cancer. CONCLUSION: Multimodality treatment may cure at least a third of patients with locally advanced rectal cancer provided a radical resection is performed. As the post-operative morbidity is high, an optimised patient selection for neo-adjuvant treatment and surgery is essential. However, palliative surgery may benefit the patient if local control is achieved. Future studies should focus on the problem of distant metastasis.     

Exenterative pelvic surgery—eleven year experience of the Swansea Pelvic Oncology Group

AIMS: To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group. PATIENTS AND METHODS: Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery. RESULTS: Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis. CONCLUSION: With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.     

Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer

PURPOSE: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed. METHODS AND MATERIALS: Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months). RESULTS: The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients. CONCLUSIONS: As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.     

Preoperative radiation with concurrent 5-fluorouracil continuous infusion for locally advanced unresectable rectal cancer

Background and Purpose: To determine the percentage of complete responders and the resectability rate for patients with locally advanced carcinoma of the rectum treated by 5-fluorouracil (5-FU) infusional chemotherapy and pelvic radiation.Materials and Methods: Between October 1992 and June 1996, 29 patients with a diagnosis of locally advanced unresectable rectal cancer received preoperative 5 FU by continuous intravenous infusion at a dose of 225 mg/m²/day concurrent with pelvic radiation (median 54 Gy/28 fractions). All patients were clinical stage T4 on the bases of organ invasion or tumor fixation. Median time for surgical resection was 6 weeks.Results: Median follow-up for the group was 28 months (range 5–57 months). Six patients were felt to be persistently unresectable or developed distant metastases and did not undergo surgical resection. Of the 29 patients, 23 proceeded to surgery, 18 were resectable for cure, 13 by abdominoperineal resection, 3 by anterior resection and 2 by local excision. Of the 29 patients, 4 (13%) had a complete response, and 90% were clinically downstaged. Of the 18 resected patients, 1 has died of his disease, 17 are alive, and 15 disease-free. The regimen was well tolerated; there was only one treatment-related complication, a wound dehiscence.Conclusion: The combination of 5 FU infusion and pelvic radiation in the management of locally advanced rectal cancer is well tolerated and provides a baseline for comparison purposes with future combinations of newer systemic agents and radiation.     

Neoadjuvant and adjuvant therapy with imatinib for locally advanced gastrointestinal stromal tumors in eastern Indian patients

Background: Imatinib mesylate is able to at least modify the course of gastrointestinal stromal tumours (GISTs). Neoadjuvant use for locally advanced lesions is evolving as a new treatment paradigm in this hitherto universally fatal disease. Methods and Results: The study patients with locally advanced GIST received neoadjuvant and adjuvant imatinib mesylate. Response was noted as per the RECIST protocol and overall progression free survival was reported. Of 19 patients (mean age 38.5 years, range 26 yrs to 64 yrs) studied, 13 achieved partial response (PR) and 6 a stationary disease (SD) on preoperative imatinib. Histopathological evaluation and grading of responses revealed only moderate and low grade pathological response after imatinib. R0 resection was possible in 13/19 and R1 in 6/19. Imatinib was well tolerated and adverse reactions were minimal. Post operative complications of surgery were not out of the ordinary for a surgical series featuring extensive abdominal surgery. Conclusion: Preoperative imatinib in locally advanced GIST seems to be a reasonable option for locally advanced GIST patients and enough downstaging to allow a resection with microscopically negative margins can be expected in a fairly good proportion of patients.     

Treatment of locally advanced rectal cancer with external beam radiation, surgical resection, and intraoperative radiation therapy

To try to improve the local control and survival of patients with locally advanced rectal cancer we have used a combination of high-dose pre-operative radiation therapy to 5,040 cGy followed by surgical resection and intraoperative electron beam radiation therapy (IORT) when there was visible or palpable residual disease, microscopically positive surgical margins, or persisting tumor adherence. A total of 75 patients were taken to surgery for resection +/- IORT who did not have distant metastases. Of the 49 patients with primary tumors, 11 did not have IORT as the tumor was thought to be completely resected. Of these 11, there were two local recurrences and a 3-year survival of 71%. Thirty-six patients with primary tumors had resection (20 complete, 16 partial) plus IORT, with a 3-year survival of 58% and three local failures. Twenty-six additional patients were treated for locally advanced recurrence of whom four could not receive IORT because of pelvic size or the extent of tumor. Of the 22 who received IORT, 7/9 with complete resection, 2/8 with partial resection, and 1/5 with no resection had local control with an overall 3-year actuarial survival of 32%. The local control and survival results in the primary tumors appear favorable compared to other series in the literature and suggest benefit to the use of IORT. For patients treated for local recurrence, local control and long-term survival can be obtained, but the results are not as encouraging as for the primary tumors.     

Outcomes ofpreoperative chemoradiotherapy followed bysurgery inpatients withunresectable locally advanced sigmoid colon cancer

Background:Complete resection of locally advanced sigmoid colon cancer (LASCC) is sometimes diffcult. Patients with LASCC have a dismal prognosis and poor quality of life, which has encouraged the evaluation of alternative multimodality treatments. This prospective study aimed to assess the feasibility and effcacy of neoadjuvant chemora?diotherapy (neoCRT) followed by surgery as treatment of selected patients with unresectable LASCC.
Methods:We studied the patients with unresectable LASCC who received neoCRT followed by surgery between October 2010 and December 2012. The neoadjuvant regimen consisted of external?beam radiotherapy to 50Gy and capecitabine?based chemotherapy every 3weeks. Surgery was scheduled 6–8weeks after radiotherapy.
Results:Twenty?one patients were included in this study. The median follow?up was 42months (range, 17–57months). All patients completed neoCRT and surgery. Resection with microscopically negative margins (R0 resection) was achieved in 20 patients (95.2%). Pathologic complete response was observed in 8 patients (38.1%). Multivisceral resection was necessary in only 7 patients (33.3%). Two patients (9.5%) experienced grade 2 postopera?tive complications. No patients died within 30days after surgery. For 18 patients with pathologic M0 (ypM0) disease, the cumulative probability of 3?year local recurrence?free survival, disease?free survival and overall survival was 100.0%, 88.9% and 100.0%, respectively. For all 21 patients, the cumulative probability of 3?year overall survival was 95.2% and bladder function was well preserved.
Conclusion:For patients with unresectable LASCC, preoperative chemoradiotherapy and surgery can be performed safely and may result in an increased survival rate.     

Postoperative chemoradiotherapy for high-risk head-and-neck squamous cell carcinoma

PURPOSE: To describe the use of postoperative concurrent chemoradiotherapy, with either weekly cisplatin or carboplatin, for high-risk head-and-neck squamous cell carcinoma (HNSCC) in a single institutional setting. METHODS AND MATERIALS: Between July 1999 and January 2003, 47 patients were treated with postoperative chemoradiotherapy. RESULTS: Of the 47 patients, 41 (87%) had Stage III-IV disease. The predominant primary site was the oral cavity in 24 patients (51%), 27 had nodal disease with extracapsular extension, and 26 had positive or close mucosal margins (<5 mm). Ten patients had undergone resection of recurrent disease after previous surgery. Twenty-seven (57%) were treated with cisplatin, and the remaining patients received carboplatin because of contraindications to cisplatin. The median radiotherapy dose was 60 Gy (range, 50-66 Gy). Of the 47 patients, 45 (96%) completed at least four of the six planned doses of chemotherapy and 45 (96%) completed the planned course of radiotherapy. Nineteen patients (40%) had confluent mucositis, eight (17%) had Grade 3-4 hematologic toxicity, and four (9%) had febrile neutropenia. No treatment-related deaths occurred. The estimated 2-year locoregional control, progression-free survival, and overall survival rate was 73%, 56%, and 62%, respectively. Excluding the 10 patients with recurrence after previous surgery, the locoregional control, progression-free survival, and overall survival rate was 81%, 64%, and 71%, respectively. Five cases of Grade 3-4 late treatment-related sequelae developed. CONCLUSION: Treatment with postoperative concurrent weekly cisplatin or carboplatin and radiotherapy was reasonably well tolerated. Acute and late toxicity was acceptable. The overall results achieved are comparable with the preliminary results of recent randomized trials. Patients treated after resection of recurrent disease (after previous surgery alone) fared worse than those treated at the initial resection.     

Primary and recurrent retroperitoneal soft tissue sarcoma: prognostic factors affecting survival

BACKGROUND AND OBJECTIVES: To analyze treatment and survival in 34 patients (28 resected) with primary or recurrent retroperitoneal sarcoma (RPS). METHODS: Between July 1994 and January 2001, 34 patients (15M, 19F; mean age: 56 years, range: 25-77) were evaluated. Complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. RESULTS: Twenty-eight out of 34 patients (82%) (15 were affected by primary RPS, and 13 by recurrent RPS), underwent surgical exploration. Twenty-three patients had a grossly and microscopically complete resection, (3 having a grossly incomplete resection and 2 patients with a grossly complete resection having histologically involved resection margins). Twenty-one out of 28 patients (75%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil, and morbidity occurred in six cases only (21%). High tumor grade results a significant variable for a worse survival in all 28 patients (100% 5 years survival for low grade vs. 0% for high grade; P = 0.0004). Amongst completely resected patients, only histologic grade and peroperative blood transfusions affected disease-free survival (P = 0.04 and P = 0.05, respectively). CONCLUSIONS: An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.     

Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer

BackgroundThe incidence of rectal cancer recurrence after surgery is 5–45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer.AimTo evaluate the surgical and oncological outcome of such treatment.Patients and methodsBetween 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2–3 interface in 10 patients, at S3–4 in 15 patients and S4–5 in 3 patients.ResultsForty patients, male to female ratio 1.7:1, median age 45 years (range 25–65 years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%.ConclusionExtended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.     

外科多专业合作胸壁切除与重建术在乳腺癌侵犯胸壁患者治疗中的地位

目的探讨由切除外科及重建外科医师合作完成的胸壁切除与重建术（CWRR）在乳腺癌侵犯胸壁患者治疗中的地位。方法由切除外科和重建外科合作完成CWRR44例,切除后胸壁软组织缺损35～800cm^2;同时切除骨性胸壁15例,骨性胸壁缺损5～320cm^2。切除后立即重建43例,因伤口原因延迟重建1例。根治切除36例,姑息切除8例。进行以电话及门诊复查为主的随访,随访时间为5．0～285．0个月。结果全组无手术后30d死亡者。CWRR术后,根治性切除患者术后中位生存时间〉36．0个月,1、3、5年生存率分别为71．5％、65．7％和65．7％;姑息性切除患者术后中位生存时间为15．1个月,1、3、5年生存率分别为35．1％、23．4％和7．8％。根治性切除患者的生存率高于姑息性切除患者（P=0．018）。原发乳腺癌患者术后中位生存时间为44．7个月,1、3、5年生存率分别为78．4％、78．4％和39．2％。复发乳腺癌患者术后中位生存时间为36．0个月,1、3、5年生存率均为70．9％。有转移者术后中位生存时间为16．0个月,1、3、5年生存率分别为30．0％、15．0％和0。原发性乳腺癌患者与复发性乳腺癌患者术后生存率差异无统计学意义（P=0．752）,而有转移者术后生存率明显低于原发乳腺癌患者（P=0．003）或复发乳腺癌患者（P=0．018）。结论只有切除外科和重建外科同时参与才能完成符合肿瘤治疗原则的复杂CWRR。在完成乳腺癌全盘治疗计划、全身和局部疾病得到良好控制的前提下,根治性CWRR能改善侵及胸壁乳腺癌患者的生存,适当的姑息性CWRR可改善患者的生活质量。     

Role of Pelvic Exenteration in the Management of Locally Advanced Primary and Recurrent Rectal Cancer

Aim

A review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed.

Materials & Methods

Patients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan–Meier Method (Fig. 1).

Results

Pelvic exenterations were performed in 13 patients with a median age of 59 (range 26–81). The rate of major post-operative complications was 8 % (n?=?1), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70 %). The DFS was 19.4 and the OS was 22.5 months.

Conclusion

An aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.     

Sacropelvic resection and intraoperative radiation therapy: feasibility, technical description and early clinical results

Sarcomas and locally recurrent colorectal carcinomas are disease entities in which sacral resection is an effective alternative for meaningful palliation with a limited cure expectation. To provide local control, pain palliation and a marginal expectation of definitive cure, a multimodality approach including external beam radiation therapy, surgical resection, and intraoperative radiation therapy (IORT), has been developed for patients with locally recurrent rectal cancers and primary sarcomas of the sacro-pelvic región. Seven consecutive patients (5 females; 2 males; ages, 40–75) underwent surgical exploration, sacrectomy, and IORT, between 1997 and 2000. IORT doses ranged from 10 to 12.5 Gy. External beam irradiation (EBRT) was used in six patients not previously irradiated (85%). Only 1 patient (14.2%) had received postoperative chemotherapy. Level of sacral resection: S2–S3 in 3 patients and S3–S4 in 2 patients. One patient with osteosarcoma underwent a posterior approach only, requiring removal of the posterior sacral table exclusively. An exclusively anterior approach was used in another patient with recurrent rectal cancer involving uterus, vagina and presacral fascia, requiring selective removal of the anterior sacral table. Margins: clear in 5 and microscopically involved in 2 patients. Postoperative mortality rate: 1 patient (14.2%). Three patients (42%) suffered major postoperative complications. Follow-up was available on six patients: time from surgery ranging from 1 to 36 (median 12.5) months. At the time of analysis, 5 out of 6 patients were alive without recurrent symptoms. Intensified local radiosurgical treatment with sacropelvic resection in conjunction with IORT provides palliation and offers potential for cure in patients with locally recurrent rectal cancer and sacropelvic sarcomas.     

Recurrent vulvar cancer

Opinion statement Recurrent vulvar cancer occurs in an average of 24% of cases after primary treatment after surgery with or without radiation. The relatively few primary vulvar cancers, combined with the low proportion of recurrences, has made it difficult to perform randomized studies to document the most appropriate therapeutic modalities. Most reports are small retrospective studies and anecdotal reviews that have emphasized the importance of surgery and have led to new approaches with respect to chemoradiation. Traditionally, the most accepted treatment of vulvar cancer has been and continues to be surgery. Recently, radiation and chemotherapy have been combined with very encouraging results. The therapeutic modality used depends on the location and extent of the recurrence. Most recurrences occur locally near the original resection margins or at the ipsilateral inguinal or pelvic lymph nodes. Lateralized local vulvar recurrences treated with a wide radical local excision with inguinal lymphadectomy results in an excellent cure rate of 70%. With a central pelvic recurrence with antecedent radiotherapy involving the urethra, upper vagina, and rectum, total pelvic exenteration is indicated in a select group of patients with curative intent. Radiotherapy or chemoradiation concomitantly with wide radical local excision of an advanced vulvar has proven successful in avoiding an exenteration, with improved survival and less morbidity. Prospective and retrospective studies have shown excellent results using radiation or chemoradiation with wide radical local excision in patients with locally advanced disease in whom adequate resection margins are difficult to achieve (with a central lesion requiring exenteration) or with debilitating medical conditions that preclude surgery. In these patients, chemoradiation has shown favorable results when used before a wide local resection. In patients with advanced local disease, external beam and interstitial radiation has been used for palliative and curative intent with encouraging results. Regional recurrences to the inguinal and pelvic lymph nodes have been shown to have a poor prognosis with a high mortality rate. We recommend that inguinal recurrences without prior radiation therapy undergo excision followed by radiotherapy with chemosensitization. In patients with previous radiation to the inguinal lymph nodes, we try to avoid any excisional procedures because of the high rate of complications. We offer these patients brachytherapy for palliation. With pelvic recurrences, we recommended chemoradiation as the treatment modality. In the subset of patients with distant metastasis, chemotherapy may be offered; however, few studies have been performed to advocate any single combination. The literature supports the use of 5-fluorouracil or cisplatin as single agents or in combination to have sensitivity against squamous cells. There are few studies revealing improvement in 5-year survival, thus these patients may benefit from recruitment into research protocols.