Risk factors for pelvic and distant recurrence in locally advanced cervical cancer.

OBJECTIVE: Despite the benefits of concomitant radiotherapy and cisplatin for locally advanced cervical cancer, recurrence rates remain high. New treatment strategies such as consolidation chemotherapy and different concomitant chemotherapy combinations have been tested in recent years. Identification of the best candidates for each treatment strategy could optimize results. STUDY DESIGN: A retrospective review of data from 127 patients with locally advanced cervical cancer (International Federation of Gynecology and Obstetrics Stages IIB-IVA), treated at a single institution from 2005 to 2014. Risk factors for loco-regional and systemic recurrence, and prognostic factors for overall survival (OS) were analysed using Cox regression. Survival of patients treated with consolidation chemotherapy was compared with survival of patients not treated with consolidation chemotherapy in the role cohort and in a propensity-score-matched cohort. RESULTS: With a median follow-up time of 48.7 months, loco-regional-recurrence-free survival (LRFS), distant-metastasis-free survival (DMFS) and OS at 5 years were 76.6%, 54.0% and 63.0%, respectively. On multivariate analysis, tumour size ≥6 cm was associated with shorter LRFS [hazard ratio (HR) 5.18; 95% confidence interval (CI) 1.45-18.45; p = 0.011], and adenocarcinoma (HR 2.48; 95% CI 1.10-5.57; p = 0.028) and positive lymph nodes (HR 2.21; 95% CI 1.303-4.72; p = 0.041) were associated with shorter DMFS. Tumour size ≥6 cm was associated with shorter OS (HR 2.64; 95% CI 1.09-6.35; p = 0.031). Twenty-two patients were treated with consolidation chemotherapy; on univariate analysis, these patients had longer OS compared with patients who were not treated with consolidation chemotherapy (p = 0.043). In a propensity-score-matched cohort, patients treated with consolidation chemotherapy had longer DMFS and OS compared with patients who were not treated with consolidation chemotherapy, although the difference was not significant. CONCLUSIONS: Different risk factors are associated with loco-regional and distant metastases in patients with locally advanced cervical cancer, and could potentially lead to particular therapeutic strategies. Although the number of patients treated with consolidation chemotherapy in the study cohort was small, they seemed to live longer and to have better control of distant relapse then patients who were not treated with consolidation chemotherapy.

Prognostic factors in pelvic exenteration for gynecological malignancies.

OBJECTIVES: Analyze morbidity, mortality and prognostic factors after pelvic exenteration (PE) for gynecological malignancies. METHODS: We reviewed a series of 107 individuals who underwent PE at A.C. Camargo Cancer Hospital from August 1982 to September 2010. RESULTS: Median age was 56.4 years. Primary tumor sites were uterine cervix in 73 cases (68.2%); vaginal, 10 (9.3%); endometrial, 14 (13.1%); vulvar, 7 (6.5%); and uterine sarcomas, 3 (2.8%). Median tumor size was 5.5 cm. Total PE was performed in 56 cases (52.3%), anterior in 31 (29.9%), posterior in 10 (9.3%) and lateral extended in 10. Median operation time, blood transfusion and hospital stay length were 420 min (range: 180-780), 900 ml (range: 300-4500) and 13 days (range: 4-79), respectively. There was no intra-operative death. Fifty-seven (53.3%) and 48 (44.8%) patients had early and late complications, respectively. Five-year progression free survival (PFS), overall survival (OS) and cancer specific survival (CSS) were 35.8%, 27.4% and 41.1%, respectively. Endometrial cancer had better 5-year OS (64.3%) than cervical cancer (23.1%). Lymph node metastasis negatively impacted PFS, CSS and OS. Presence of perineural invasion negatively impacted PFS and CSS. No variable retained the risk of recurrence or death in the multivariate analysis. CONCLUSIONS: PE has acceptable morbidity and mortality and may be the only method that can offer long-term survival in highly selected patients.

Class II radical hysterectomy for stage I-IIA cervix cancer: prognostic factors associated to recurrence and survival in a northeast Brazil experience.

BACKGROUND: The main aim of this study was describe the author's experience with class II radical hysterectomy and pelvic lymphadenectomy to treat stage I-IIA cervix cancer and reexamine some prognostic factors associated with disease recurrence and patient survival in this data from northeast Brazil. METHODS: A cross-sectional study was carried out on patients treated at our Centers from January 2001 to December 2008. Statistical analyses were performed using conventional methods. RESULTS: Eighty-eight patients were selected to analysis. Over the 7.3-year follow-up, 80 (91%) patients were alive and 8 (9%) disease recurrences were observed. Overall 1-, 2-, and 5-year patients survival was 96.5%, 95.3%, and 84%, respectively. Recurrence was associated to tumor size ≥1 cm (P = 0.021) and compromised vaginal margin (P = 0.020). Lower survivals were associated to tumor size ≥1 cm (P = 0.038), compromised vaginal margin (P < 0.001), and lymph node metastasis (P = 0.024). Postoperative complications (n = 11) included wound infection (5.7%), partial wound dehiscence (3.4%), and bladder atony (3.4%). CONCLUSIONS: Class II radical hysterectomy has provided appropriated disease control of cervix cancer with low morbidity in our experience. Furthermore, tumor size and compromised vaginal margin were significantly associated to recurrence. These factors and lymph node metastasis were also associated to lower 5-year survival according to our analysis.

Hemipelvectomias: tratamento, avaliação funcional e prognóstica dos tumores pélvicos / Hemipelvectomies: treatment, functional outcome and prognostic of the pelvic tumors

OBJETIVO: Demonstrar a experiência de uma única instituição em hemipelvectomias internas sem reconstrução. Avaliar as cirurgias pélvicas preservadoras e as amputações interílio-abdominais e seu prognóstico. MÉTODOS: 21 pacientes com tumores primitivos pélvicos submetidos à hemipelvectomia com ou sem preservação de membro. Sete foram tratados com hemipelvectomias externas (amputação) e 14 com internas, entre junho de 2004 e julho de 2009. A classificação cirúrgica utilizada foi a de Enneking para tumores pélvicos. O método de avaliação funcional foi o escore de ISOLS/MSTS. RESULTADOS: A sobrevida dos pacientes em dois anos foi de 63,9 por cento. A média de sobrevida do grupo todo foi de 43 meses. A avaliação funcional demonstrou que as hemipelvectomias preservadoras com ressecção do osso inominado obtiveram 12,5 por cento, 62,5 por cento e 25 por cento de resultados ruins, bons e excelentes, respectivamente. Nos casos em que o osso inominado foi preservado, os resultados foram 16,7 por cento e 83,3 por cento bons e excelentes, respectivamente. CONCLUSÕES: A hemipelvectomia é procedimento pouco usual e causador de importante limitação funcional e comorbidades. A alternativa de ressecar a hemipelve sem reconstrução tem demonstrado resultados tão bons quanto a não-reconstrução. Os elevados custos médicos, além das possíveis complicações com uso de enxerto e próteses justificam a técnica empregada neste artigo. Nível de Evidência IV, Estudo de caso-controle.

OBJECTIVE: To describe the experience of one single institution in internal hemipelvectomies without reconstruction and external hemipelvectomies. METHODS: Twenty-one patients with primary tumors of the pelvic region underwent total hemipelvectomy, at Barretos Cancer Hospital, São Paulo, Brazil, between 2004 and July 2009. Of these, seven were treated with external hemipelvectomy (classic) and 14 with internal hemipelvectomy. Evaluation was done based on Enneking's surgical classification for internal hemipelvectomy. RESULTS: Overal survival in two years was 63,9 percent. Median survival of 43 months. Functional outcomes demonstrated that procedures with inominate bone ressection reached 12,5 percent, 62,5 percent and 25 percent of bad, good and excellent results, respectively. When inominate bone was preserved the results were 16,7 percent and 83,3 percent good and excellent, respectively. No endoprosthesis or bone graft reconstructions were done. CONCLUSIONS: Hemipelvectomy is an unusual procedure that is rarely performed because it is infrequently indicated and because of its high morbidity rate. In some reports, the morbidity rate has reached 77 percent of the cases. We did not perform any type of reconstruction or arthrodesis based on complications and the experience of good results with this method. Our results are similar to the main reports and are still subject of discussion by the oncologic surgeons. Level of evidence IV, Case-control study.

Pelvic exenteration and sphincter preservation: an analysis of 96 cases.

BACKGROUND: Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results. METHODS: Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed. RESULTS: Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival. CONCLUSIONS: The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.

Caso de angiosarcoma de pelvis asociado a angiomatosis de columna / Case report of angiosarcoma of the pelvis associated to angiomatosis of the spine

El angiosarcoma primario de hueso es una lesión infrecuente que se asocia raramente con lesiones óseas, v. gr. solamente en dos casos se ha informado asociación con agiomatosis ósea. El caso que se presenta corresponde al de una mujer de 62 años con padecimiento de 11 meses de evolución caracterizado por incapacidad para la deambulación y la presencia de una masa en región glútea. En la autopsia se encontró un angiosarcoma originado en los huesos de la pelvis, con destrucción de la cresta ilíaca, del acetábulo y con extensión a tejidos blandos de la región glútea y del retroperitoneo; además mostró metástasis en cápsula renal izquierda y angiomatosis en cuerpos vertebrales