Archives of Gynecology and Obstetrics (2019) 300:161–168 https://doi.org/10.1007/s00404-019-05154-4 GYNECOLOGIC ONCOLOGY Pelvic exenteration as ultimate ratio for gynecologic cancers: single‑center analyses of 37 cases N. de Gregorio1 · A. de Gregorio1 · F. Ebner2 · T. W. P. Friedl1 · J. Huober1 · R. Hefty3 · M. Wittau4 · W. Janni1 · P. Widschwendter1 Received: 5 February 2019 / Accepted: 5 April 2019 / Published online: 22 April 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract Background Pelvic exenterations are a last resort procedure for advanced gynecologic malignancies with elevated risks in terms of patients’ morbidity. Methods This single-center analysis reports surgical details, outcome and survival of all patients treated with exenteration for non-ovarian gynecologic malignancies at our university hospital during a 13-year time period. We collected data regarding patients and tumor characteristics, surgical procedures, peri- and postoperative management, transfusions, complications, and analyzed the impact on survival outcomes. Results We identifed 37 patients between 2005 and 2013 with primary or relapsed cervical cancer (59.5%), vulvar cancer (24.3%) or endometrial cancer (16.2%). Median age was 60 years and most patients (73%) had squamous cell carcinomas. Median progression-free survival was 26.2 months and median overall survival was 49.9 months. The 5-year survival rates were 34.4% for progression-free survival and 46.4% for overall survival. There were no signifcant diferences in progres- sion-free survival and overall survival with regard to disease entity. Patients with tumor at the resection margins (R1) had a nearly signifcantly worse progression-free survival (median: 28.5 vs. 7.3 months, HR 2.59, 95% CI 0.98–6.88, p = 0.056) and a signifcantly worse overall survival (median: not reached vs. 10.9 months, HR 4.04, 95% CI 1.40–11.64, p = 0.010) compared to patients with complete tumor resection (R0). In addition, patients without lymphovascular space invasion had a signifcantly better progression-free survival (p = 0.017) and overall survival (p = 0.034) then patients with lymphovascular space invasion. We observed complications in 14 patients (37.8%), 10 of those were classifed as Clavien–Dindo 3 or 4. There was a trend to worse progression-free survival in patients that sufered complications (p = 0.052). Median total amount of transfused blood products was 4 (range 0–20). Conclusion Pelvic exenteration is a procedure that provides substantial progression-free survival and overall survival improvement and—in selected patients—can even achieve cure in otherwise hopeless clinical situations. Patients need to be ofered earnest counseling for sufcient informed consent with realistic expectations what to expect. Keywords Pelvic exenteration · Advanced gynecologic malignancy · Cervical cancer · Endometrial cancer · Vulvar cancer Introduction * N. de Gregorio For almost 50 years, pelvic exenteration has been used as a [email protected] last resort for patients with advanced or relapsed gyneco- logic malignancies. Depending on the surgical extend an 1 Department of Obstetrics and Gynecology, University anterior, posterior or complete exenteration is diferentiated. of Ulm, Prittwitzstr. 43, 89075 Ulm, Germany The anterior exenteration is defned as the removal of the 2 Department of Obstetrics and Gynecology, Amper Hospital uterus, tubes, ovaries, parametrium, vagina, urinary bladder Dachau, Dachau, Germany and urethra. In case of a posterior exenteration, the bladder 3 Department of Urology, Klinikum Heidenheim, and urethrae are spared and the rectum is removed instead. Heidenheim an der Brenz, Germany A complete exenteration comprises all of those organs. A 4 Department of General Surgery, University of Ulm, Ulm, further variation is the removal of the perineal compartment, Germany Vol.:(0123456789)1 3 162 Archives of Gynecology and Obstetrics (2019) 300:161–168 mostly performed in cases of a relapsed vulvar or vaginal Data regarding age, weight, body height, initial tumor carcinoma. Here, myocutaneus skin faps are used to recon- stage, tumor type and subtype, grade, time interval since last struct pelvic foor defects in the perineal region. treatment and staging procedures were collected; in addition, Survival rates after exenteration tend to be poor due to the the histological factors tumor size, vascular and lymphovas- often advanced stages of the diseases, but sometimes even cular space invasion and resection margin (negative/posi- cure can be achieved in case of a complete resection with tive and location of residual tumor) were documented. To be tumor-free margins. Ultraradical surgical concepts like the able to comprehensively assess the surgical procedures, we lateral extended endopelvine resection (LEER) have been collected data on all previous lines of treatment, time in the introduced to improve complete resection rates in the last operating theater, methods of bowel and bladder reconstruc- years [1]. A LEER procedure extends the resection margin tion, intra- and postoperative complications (classifed after to the osseous pelvic side wall which includes a resection Clavien–Dindo) [6], progression-free and overall survival, of the internal iliac vessels and their branches. Even in very estimated blood loss, number of transfused blood product experienced centers, those procedures still tend to be risky (thrombocytes, frozen–fresh plasma, packed red blood cells), with high rates of perioperative morbidity (> 50%) and even total length of hospital stay and any adjuvant treatment. mortality (up to 5%) [2]. In addition, the patients’ quality of All data were extracted from the available archived patient’s life has been reported to be signifcantly reduced within the documents and subsequently anonymized. All procedures frst 3 months after the procedure [3]. performed in this study involving human participants were In spite of an overall decreasing incidence, relapsed cer- in accordance with the ethical standards of the institutional vical cancer accounts for the majority of cases in recently committee. Ethical approval of the ethics committee of the published studies regarding exenterative surgery, followed University Ulm was given (73/18). by endometrial cancer and infrequently vulvar or vaginal carcinomas [4]. Even for colorectal carcinomas, exentera- Statistical analysis tion is used as a salvage procedure, with lower morbidity compared to gynecologic malignomas (50% vs. 75%) and at Categorical variables are summarized and described using the same time signifcantly improved 5 year overall survival absolute and relative frequencies, while ordinal and continu- (92.9% vs. 58%) [5]. ous variables are described using medians, interquartile ranges Widely accepted patient selection criteria for an exen- and ranges. As the data distribution of most of the continuous teration are the possibility of complete resection, no dis- variables was signifcantly diferent from normal distribu- tant metastases, unavailability of less radical alternatives, tion (Shapiro–Wilk test), non-parametric statistical tests were willingness of the patient to accept the drastic body modi- used for all analyses presented here. Correlation tests were fcations and patients’ general condition that allow a proce- performed using Spearman’s rank correlation coefcient r. dure of this magnitude. While a multidisciplinary approach Progression-free survival (without deaths) and overall survival (including lower GI surgeons and urologists) is mandatory, data were analyzed using the Kaplan–Meier method and sum- this procedure also requires a very experienced gynecologic marized using medians, 95% confdence limits (95% CI) and surgeon and an adequate institutional infrastructure in terms Kaplan–Meier survival plots. All time-to-event intervals were of a blood bank and an intensive care unit. measured from the date of surgery to the date of the event. If This study reports the institutional experience of the no event was documented, the data were censored at the date department of obstetrics and gynecology of the University of the last adequate follow-up. Between group comparisons Hospital Ulm with the conduction of exenterations over a of progression-free survival and overall survival were per- 12-year time interval. formed with the log-rank test and hazard ratios (HR) were calculated based on univariable cox regression models. All statistical analyses were performed using the SPSS statistical software package, version 24 (IBM, New York, NY, USA). All Materials and methods statistical tests were two-sided, and p values below 0.05 were considered signifcant (no adjustment of signifcance levels Patient characteristics and variable selection for multiple testing). Data from all patients having the documented procedures “Exenteration” and/or “LEER” at our Department of Gynecology and Obstetrics at the University Hospital Ulm between January 1st, 2005 and February 28 th, 2018 were ret- rospectively reviewed. We identifed 37 cases with complete datasets for further analysis. 1 3 Archives of Gynecology and Obstetrics (2019) 300:161–168 163 Results Table 1 Baseline characteristics of 37 women with exenteration or LEER Patient characteristics Variable Age (years) The median age in the patients’ collective was 60 years, Median 60 ranging from 24 to 83 years, and median BMI was 23.9 kg/ Interquartile range 47.5–67.5 2 2 m (range 16.2–46.7 kg/m ). 59.5% of patients had a cervical Range 24–83 carcinoma, followed