1. Treatment in Recurrent Cervical Cancer
Surgery – Pelvic exenteration
Prof. Dr. Fuat Demirkıran
Gynecologic Oncology division,
Department of Obstetrics and Gynecology,
Cerrahpasa Medical Faculty,
2010 Antalya

2. Cerrahpaşa Radiation Oncology- Gynecologic Oncology 1978-2002
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
48.4 %(21.6 % central)
28.9 %
22.7 %
Localization of recurrence
pelvic
distant
pelvic + distant

3. 17 retrospective studies
The recurrence ……… 10% to 18% for early stage
62% to 89% detected in 2 years
14% to 57% central
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.

4. Radiotherapy Chemotherapy Surgery Pelvic Pelvic, extrapelvic
Treatment alternatives in Recurrent Cervical Cancer
Radiotherapy
Pelvic
Chemotherapy
Pelvic, extrapelvic
Local extrapelvic
Cervical
Pelvic central
Pelvic side
Surgery
Excisional surgery
TAH Type I
TAH II-III
Exenteration
LEER

5. Excisional Surgery

6. Isolated Cervical Relapse
TAH Type I ??
TAH II-III ?
Ota et al J Br Cancer
35 persistent cervical cancer 13% margin +
12 % fistula 68% 5 years survival.
Coleman et al Gynecol Oncol
50 recurrent cervical cancer, %42 major comp. 30% fistula
72% 5 years survival.

7. Isolated Cervical Relapse
TAH 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 ?

8. Pelvic Exenteration Indication
Recurent Ovarian cancer
Recurrent cervical cancer
Recurrent endometrial cancer 13
Recurrent vulvar-vaginal cancer 6
TOTAL
Cerrahpaşa Gynecologic Oncology

9. 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

10. Central Tumor relapses
Treatment
Prior RT
No Prior RT
Exenteration
Chemotherapy RT
Exenteration

11. First rule of achievement is the selection of convenient patient.
Pelvic Exenteration
Patient selection
First 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 Obesity
Obesity is not an absolute contraindication, but gives difficulty in surgery

12. Pre-operative histologic analysis should been made
Pelvic exenteration
Preoperative search for evidence of distant metastasis.
Chest CT
Abdomen CT-MR
PET-CT
Pre-operative histologic analysis should been made

13. Despite all of these, surgery can’t be made in
Pelvic Exenteration
Patient selection
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

14. 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

15. Even if everything is OK
Patient and her relatives should be informed about
surgical morbidity, mortality
type of exenteration
changing decisions at the operation
possibility of inoperability
stoma
treatment alternatives
success rate

16. Pelvic Exenteration Posterior Exenteration Total Exenteration
Anterior Exenteration

17. Supralevator
Infralevator

18. Distributions of Exenterative Surgery Recurrent Cervical Cancer n:25
Histological disturbition
Squamous cell cancer case (80%)
Adenocancer 4 case (16%)
Malign melanoma case (4%)
Operation type
Anterior exenteration case (32%)
Posterior exenteration 3 case (12%)
Total exenteration case (56%)

19. Pelvic Exenteration
Tumor and surrounding tissue excision

21. Exenterative Operations 1994-2010
Urinary diversions
Ileal conduit
Cophey op
Poch (Mainz I)
Bladder-ileum anastomosis 1
GI diversions
Colostomy
Low rectal anostomosis 8
Cerrahpaşa Gynecologic Oncology

22. Pelvic exenteration
Urinary diversion

23. Pelvic Exenteration
GI diversion

24. Postoperative tumor residuals
None 23 (49%)
Pelvic side wall 13 (27.6%)
Upper abdomen 2 (4.2%)
No complications 14 (29.8%)

26. Pelvic Exenteration Cases
Avarage Min Max
Age
Operation time
(min)
Transfusion
(Unit)
Hospitalization
(days)

27. 20 primary
35 secondary

28. Exenterative Operations 1994-2010
Complications
İleal loop cutenous fistula (4%)
GI fistula (12%)
Infection (16%)
Subileus (12%)
Pulmonary edema (4%)
Thromboemboli (4%)
Wound infection (12%)
Total (64%)
Cerrahpaşa Gynecologic Oncology

29. Postoperative Major Complications and Mortality n:25
Urinary fistula
GI Fistula
Pelvic abscess
Pulmonary embolism
Re-laparotomy (20%)
Mortality (4%)
24%
Cerrahpaşa Gynecologic Oncology

30. 70%

31. Complication rate %
Operative mortality 5%

32. OS at 5 years 52%
OS at 5 years 27%

33. 12 mo
22 mo
4 mo
4 mo

34. Exenterative Operations 1994-2010
Median follow-up month (4- 72)
11 (44 %) in 25 cases died
2 patient died becouse of other conditions
4 patient in 1st year
5 patient in 2nd year
36%
Cerrahpaşa Gynecol Oncol

35. recurrent gynecologic malignancies
The risk factors which predict recurrenceand survival after pelvic exenteration for the treatment of advanced or
recurrent gynecologic malignancies
in the multivariate analysis,
by examining exenteration type, tumor size, lymph vascular
space 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

36. 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.