OJOG  Vol.3 No.5 A , July 2013
Long term outcome and quality of life after pelvic exenteration for recurrent endometrial and cervical cancers

Introduction: Pelvic exenteration can cure recurrent gynecological malignancies. However, treatment morbidity is over 50% in radiated pelves. We evaluated the outcome, the morbidity and the quality of life after exenteration. Methods: Patients who underwent an exenteration for recurrent cervical or endometrial cancer in our institution between 1999 and 2011 were retrieved. Survival rates were calculated according to Kaplan-Meier method and compared using the logrank test. The EORTC QLQ-C30 and QLQ-CX24 questionnaires were sent to patients alive in January 2012. Results: We identified 25 patients: 17 (68%) had cervical cancer and 8 (32%) endometrial cancer. 92% of them had received radiotherapy previously. All patients had a central pelvic recurrence, within a median time of 30 months [4 - 384] from initial treatment. Early complications requiring a re-laparotomy occurred in 9 patients (36%). Late complications included 2 (8%) fistulas, 2 (8%) occlusion and 1 (4%)

ureteral stenosis. Complete resection was obtained in 92% of patients. Disease Free and Overall survival rates were better in cervical rather than in endometrial cancer (median DFS in months 17 [2 - 145] vs 9.5 [3 - 21], p = 0.064, median OS in months 20 [2 - 145] vs 13 [4 - 42], p = 0.019). 69% of patients answered the quality of life questionnaires. Mean global quality of life score was 45 on a scale of 0 - 100, none of the patients had a sexual activity. Conclusions: Morbidity of exenteration remains high and quality of life is altered. Endometrial cancer is associated with a poorer prognosis. In those patients, exenteration should be put in balance with best supportive care.

Cite this paper
Ngô, C. , Abboud, C. , Meria, P. , Fourchotte, V. , Mariani, P. , Baranger, B. , Sastre, X. , Malhaire, C. , Philippe, A. , Scholl, S. , Rochefordière, A. and Alran, S. (2013) Long term outcome and quality of life after pelvic exenteration for recurrent endometrial and cervical cancers. Open Journal of Obstetrics and Gynecology, 3, 19-27. doi: 10.4236/ojog.2013.35A1005.
[1]   Hockel, M. and Dornhofer, N. (2006) Pelvic exenteration for gynaecological tumours: Achievements and unanswered questions. The Lancet Oncology, 7, 837-847. doi:10.1016/S1470-2045(06)70903-2

[2]   Perez, C.A., Grigsby, P.W., Nene, S.M., Camel, H.M., Galakatos, A., Kao, M.S. and Lockett, M.A. (1992) Effect of tumor size on the prognosis of carcinoma of the uterine cervix treated with irradiation alone. Cancer, 69, 2796-806. doi:10.1002/1097-0142(19920601)69:11<2796::AID-CNCR2820691127> 3.0.CO;2-O

[3]   Resbeut, M., Fondrinier, E., Fervers, B., Haie-Meder, C., Bataillard, A., Lhomme, C., Asselain, B., Basuyau, J.P., Bremond, A., Castaigne, D., Dubois, J.B., Houvenaeghel, G., Lartigau, E., Leblanc, E., Sastre-Garau, X., Sarradet, A., Guastalla, J.P. and Chauvergne, J. (2003) Standards, Options and Recommendations for the management of invasive cervical cancer patients (non metastastic). Bulletin du Cancer, 90, 333-346.

[4]   Peiretti, M., Zapardiel, I., Zanagnolo, V., Landoni, F., Morrow, C.P. and Maggioni, A. (2012) Management of recurrent cervical cancer: A review of the literature. Surgical Oncology, 21, e59-e66. doi:10.1016/j.suronc.2011.12.008

[5]   Burke, T.W., Heller, P.B., Woodward, J.E., Davidson, S.A., Hoskins, W.J. and Park, R.C. (1990) Treatment failure in endometrial carcinoma. Obstetrics & Gynecology, 75, 96-101.

[6]   Berchuck, A., Anspach, C., Evans, A.C., Soper, J.T., Rodriguez, G.C., Dodge, R., Robboy, S. and Clarke-Pearson, D.L. (1995) Postsurgical surveillance of patients with FIGO stage I/II endometrial adenocarcinoma. Gynecologic Oncology, 59, 20-24. doi:10.1006/gyno.1995.1262

[7]   Creutzberg, C.L., van Putten, W.L., Koper, P.C., Lybeert, M.L., Jobsen, J.J., Warlam-Rodenhuis, C.C., De Winter, K.A., Lutgens, L.C., van den Bergh, A.C., van der SteenBanasik, E., Beerman, H. and van Lent, M. (2003) Survival after relapse in patients with endometrial cancer: Results from a randomized trial. Gynecologic Oncology, 89, 201-209. doi:10.1016/S0090-8258(03)00126-4

[8]   Creutzberg, C.L. (2004) GOG-99: Ending the controversy regarding pelvic radiotherapy for endometrial carcinoma? Gynecologic Oncology, 92, 740-743. doi:10.1016/j.ygyno.2004.01.009

[9]   Creutzberg, C.L., van Putten, W.L., Warlam-Rodenhuis, C.C., van den Bergh, A.C., de Winter, K.A., Koper, P.C., Lybeert, M.L., Slot, A., Lutgens, L.C., Stenfert Kroese, M.C., Beerman, H. and van Lent, M. (2004) Outcome of high-risk stage IC, grade 3, compared with stage I endometrial carcinoma patients: The postoperative radiation therapy in endometrial carcinoma trial. Journal of Clinical Oncology, 22, 1234-1241. doi:10.1200/JCO.2004.08.159

[10]   Campagnutta, E., Giorda, G., De Piero, G., Sopracordevole, F., Visentin, M.C., Martella, L. and Scarabelli, C. (2004) Surgical treatment of recurrent endometrial carcinoma. Cancer, 100, 89-96. doi:10.1002/cncr.11868

[11]   Brunschwig, A. (1948) Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer, 1, 177-183. doi:10.1002/1097-0142(194807)1:2<177::AID-CNCR2820010203>3.0.CO;2-A

[12]   Benn, T., Brooks, R.A., Zhang, Q., Powell, M.A., Thaker, P.H., Mutch, D.G. and Zighelboim, I. (2011) Pelvic exenteration in gynecologic oncology: A single institution study over 20 years. Gynecologic Oncology, 122, 14-18. doi:10.1016/j.ygyno.2011.03.003

[13]   Fleisch, M.C., Pantke, P., Beckmann, M.W., Schnuerch, H.G., Ackermann, R., Grimm, M.O., Bender, H.G. and Dall, P. (2007) Predictors for long-term survival after interdisciplinary salvage surgery for advanced or recurrent gynecologic cancers. Journal of Surgical Oncology, 95, 476-484. doi:10.1002/jso.20686

[14]   Fotopoulou, C., Neumann, U., Kraetschell, R., Schefold, J.C., Weidemann, H., Lichtenegger, W. and Sehouli, J. (2010) Long-term clinical outcome of pelvic exenteration in patients with advanced gynecological malignancies. Journal of Surgical Oncology, 101, 507-512. doi:10.1002/jso.21518

[15]   Maggioni, A., Roviglione, G., Landoni, F., Zanagnolo, V., Peiretti, M., Colombo, N., Bocciolone, L., Biffi, R., Minig, L. and Morrow, C.P. (2009) Pelvic exenteration: Tenyear experience at the European Institute of Oncology in Milan. Gynecologic Oncology, 114, 64-68. doi:10.1016/j.ygyno.2009.03.029

[16]   Marnitz, S., Kohler, C., Muller, M., Behrens, K., Hasenbein, K. and Schneider, A. (2006) Indications for primary and secondary exenterations in patients with cervical cancer. Gynecologic Oncology, 103, 1023-1030. doi:10.1016/j.ygyno.2006.06.027

[17]   McLean, K.A., Zhang, W., Dunsmoor-Su, R.F., Shah, C.A., Gray, H.J., Swensen, R.E. and Goff, B.A. (2011) Pelvic exenteration in the age of modern chemoradiation. Gynecologic Oncology, 121, 131-134. doi:10.1016/j.ygyno.2010.11.044

[18]   Berek, J.S., Howe, C., Lagasse, L.D. and Hacker, N.F. (2005) Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year experience at UCLA. Gynecologic Oncology, 99, 153-159. doi:10.1016/j.ygyno.2005.05.034

[19]   Jurado, M., Alcazar, J.L. and Martinez-Monge, R. (2010) Resectability rates of previously irradiated recurrent cervical cancer (PIRCC) treated with pelvic exenteration: Is still the clinical involvement of the pelvis wall a real contraindication? A twenty-year experience. Gynecologic Oncology, 116, 38-43. doi:10.1016/j.ygyno.2009.09.035

[20]   Sharma, S., Odunsi, K., Driscoll, D. and Lele, S. (2005) Pelvic exenterations for gynecological malignancies: Twenty-year experience at Roswell Park Cancer Institute. International Journal of Gynecological Cancer, 15, 475-482. doi:10.1111/j.1525-1438.2005.15311.x

[21]   Pawlik, T.M., Skibber, J.M. and Rodriguez-Bigas, M.A. (2006) Pelvic exenteration for advanced pelvic malignancies. Annals of Surgical Oncology, 13, 612-623. doi:10.1245/ASO.2006.03.082

[22]   Soper, J.T., Berchuck, A., Creasman, W.T. and ClarkePearson, D.L. (1989) Pelvic exenteration: Factors associated with major surgical morbidity. Gynecologic Oncology, 35, 93-98. doi:10.1016/0090-8258(89)90020-6

[23]   Bladou, F., Houvenaeghel, G., Delpero, J.R. and Guerinel, G. (1995) Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies. Journal of Surgical Oncology, 58, 91-96. doi:10.1002/jso.2930580204

[24]   Moutardier, V., Houvenaeghel, G., Lelong, B., Mokart, D. and Delpero, J.R. (2003) Colorectal function preservation in posterior and total supralevator exenteration for gynecologic malignancies: An 89-patient series. Gynecologic Oncology, 89, 155-159. doi:10.1016/S0090-8258(03)00069-6

[25]   Schmidt, A.M., Imesch, P., Fink, D. and Egger, H. (2012) Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecologic Oncology, 125, 604-609. doi:10.1016/j.ygyno.2012.03.001

[26]   Barakat, R.R., Goldman, N.A., Patel, D.A., Venkatraman, E.S. and Curtin, J.P. (1999) Pelvic exenteration for recurrent endometrial cancer. Gynecologic Oncology, 75, 99-102. doi:10.1006/gyno.1999.5536

[27]   Morris, M., Alvarez, R.D., Kinney, W.K. and Wilson, T.O. (1996) Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecologic Oncology, 60, 288-291. doi:10.1006/gyno.1996.0040

[28]   Forner, D.M., Lampe, B. (2011) Exenteration as a primary treatment for locally advanced cervical cancer: Long-term results and prognostic factors. American Journal of Obstetrics & Gynecology, 205, 148e1-e6.

[29]   Park, S.Y., Bae, D.S., Nam, J.H., Park, C.T., Cho, C.H., Lee, J.M., Lee, M.K., Kim, S.H., Park, S.M. and Yun, Y.H. (2007) Quality of life and sexual problems in disease-free survivors of cervical cancer compared with the general population. Cancer, 110, 2716-2725. doi:10.1002/cncr.23094

[30]   Distefano, M., Riccardi, S., Capelli, G., Costantini, B., Petrillo, M., Ricci, C., Scambia, G. and Ferrandina, G. (2008) Quality of life and psychological distress in locally advanced cervical cancer patients administered preoperative chemoradiotherapy. Gynecologic Oncology, 111, 144-150. doi:10.1016/j.ygyno.2008.06.034

[31]   Hawighorst-Knapstein, S., Fusshoeller, C., Franz, C., Trautmann, K., Schmidt, M., Pilch, H., Schoenefuss, G., Knapstein, P.G., Koelbl, H., Kelleher, D.K. and Vaupel, P. (2004) The impact of treatment for genital cancer on quality of life and body image—Results of a prospective longitudinal 10-year study. Gynecologic Oncology, 94, 398-403. doi:10.1016/j.ygyno.2004.04.025

[32]   Ferrandina, G., Mantegna, G., Petrillo, M., Fuoco, G., Venditti, L., Terzano, S., Moruzzi, C., Lorusso, D., Marcellusi, A. and Scambia, G. (2012) Quality of life and emotional distress in early stage and locally advanced cervical cancer patients: A prospective, longitudinal study. Gynecologic Oncology, 124, 389-394. doi:10.1016/j.ygyno.2011.09.041

[33]   Rezk, Y.A., Hurley, K.E., Carter, J., Dao, F., Bochner, B.H., Aubey, J.J., Caceres, A., Einstein, M.H., AbuRustum, N.R., Barakat, R.R., Makker, V. and Chi, D.S. (2013) A prospective study of quality of life in patients undergoing pelvic exenteration: Interim results. Gynecologic Oncology, 128, 191-197. doi:10.1016/j.ygyno.2012.09.030

[34]   Roos, E.J., de Graeff, A., van Eijkeren, M.A., Boon, T.A. and Heintz, A.P. (2004) Quality of life after pelvic exenteration. Gynecologic Oncology, 93, 610-614. doi:10.1016/j.ygyno.2004.03.008

[35]   Fayers, P.W.S. and Curran, D. (1998) EORTC QLQ-C30. Reference values. European Organisation for Research and Treatment of Cancer.

[36]   Magrina, J.F., Stanhope, C.R. and Weaver, A.L. (1997) Pelvic exenterations: Supralevator, infralevator, and with vulvectomy. Gynecologic Oncology, 64, 130-135. doi:10.1006/gyno.1996.4532

[37]   Ratliff, C.R., Gershenson, D.M., Morris, M., Burke, T.W., Levenback, C., Schover, L.R., Mitchell, M.F., Atkinson, E.N. and Wharton, J.T. (1996) Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration. Cancer, 78, 2229-2235. doi:10.1002/(SICI)1097-0142(19961115)78:10<2229::AID-CNCR27>3.0.CO;2-#

[38]   Martinez, A.F.T., Filleron, T., Rouanet, P., Meeus, P., Houvenaeghel, G. and Classe, J.M. Quality of life after exenteration. Gynecologic Oncology, in Press.

[39]   Bonvalot, S., de Baere, T., Mendiboure, J., Paci, A., Farace, F., Drouard-Troalen, L., Bonnet, L., Hakime, A., Bonniaud, G., Raynard, B., Israel, P., Le Cesne, A., Eggermont, A.M., Laplanche, A. and Muret, J. (2012) Hyperthermic pelvic perfusion with tumor necrosis factoralpha for locally advanced cancers: Encouraging results of a phase II study. Annals of Surgery, 255, 281-286. doi:10.1097/SLA.0b013e318242ebe7