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Published on: September 12, 2019
Complications and Recurrence After Pelvic Exenteration for Gynecologic Malignancies: Survival Analysis From the
Nicolò Bizzarri1, Denis Querleu, Giulio Ricotta
1UOC Ginecologia Oncologica, Dipartimento di Scienze Della Salute Della Donna, Del Bambino e di Sanità Pubblica, and the Biostatistics Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, the Unit of Gynecologic Oncology, Istituto Nazionale Tumori-IRCCS Fondazione G. Pascale, Naples, and the Department of Medicine, University of Udine, and the Clinic of Obstetrics and Gynecology, "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; the Department of Surgical Oncology, Department of Surgical Oncology and INSERM CRCT Team 19, Oncogenesis of Sarcomas, and the Department of Surgical Oncology and INSERM CRCT Team 1, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France; the First Obstetrics and Gynecology Clinic, "G. E. Palade" University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania; the Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, the POG Department University of Valencia, and the CEU Cardenal Herrera University, Valencia, Gynecologic Oncology, Universidad de Navarra, Pamplona, and the Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Başkent University Hospital, Ankara, and the Department of Obstetrics and Gynecology, Koc University School of Medicine and VKV American Hospital, and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey; the Department of Gynaecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic; the Department of Gynaecology, National Institute of Oncology, Budapest, Hungary; the Department of Pelvic Cancer and Women's and Children's Health, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden; the Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, Berlin, and the Department of Gynecology and Obstetrics, Florence-Nightingale-Hospital, Düsseldorf, Germany; the Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, United Kingdom; the National Cancer Institute, Kiev, Ukraine; the NN Alexandrov National Cancer Centre of Belarus, Minsk, Belarus; the Department of Gastrointestinal Surgery, University Hospital Ghent, and Human Structure and Repair, Ghent University, Ghent, Belgium; and the National Cancer Institute, Bratislava, Slovakia.
Objective:
To collect data from patients undergoing pelvic exenteration in recent clinical practice. The primary aim was 5-year disease-free survival. Secondary aims were 5-year overall survival, patterns of recurrence, identification of subgroups at higher risk of recurrence and death, survival associated with lymph node metastasis, and development of a prognostic score.
Methods:
This was a retrospective, multicenter, international study conducted in tertiary national gynecologic oncology referral centers. Inclusion criteria included cervical, vaginal, vulvar, or endometrial cancer; anterior or total pelvic exenteration performed between January 2005 and March 2023; curative or palliative intent; and with or without laterally extended endopelvic or pelvic resection. Patients were excluded if they underwent posterior pelvic exenteration only or if preoperative computed tomography (CT), positron emission tomography (PET)-CT, or PET was not performed. A prognostic score was developed that was based on multivariable analysis.
Results:
Eight hundred sixty-two patients were included. Surgical margins were tumor free in 676 (78.4%). In patients treated with curative intent, total pelvic exenteration, positive surgical margins, and presence of lymphovascular space invasion were independently associated with worse disease-free survival. Performance of lymphadenectomy was associated with better disease-free survival. Total pelvic exenteration, positive surgical margins, and presence of lymphovascular space invasion were factors independently associated with decreased overall survival. Performing pelvic exenteration at time of persistent (instead of recurrent) disease negatively affected overall survival. Prognostic score identified four risk groups with a 5-year disease-free survival of 43.7%, 24.9%, 22.2%, and 8.0% ( P <.001). The 5-year overall survival in the four risk groups was 54.3%, 40.4%, 24.0%, and 4.3% ( P <.001). The most frequent sites of recurrence were distant in 166 patients (32.1%). The 5-year disease-free survival and cancer-specific survival in patients with para-aortic lymph node metastasis were significantly worse compared with those in patients with pelvic-only metastatic nodes or with negative nodes ( P =.002 and P <.001, respectively).
Conclusion:
Independent factors associated with worse disease-free survival and overall survival and subgroups of patients at higher risk of recurrence and death were identified. A multivariable prognostic score was developed that can be used for patient counseling and surveillance strategies and for future prospective studies.
