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PubMedDate not supplied

The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma.

From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.

Adenocarcinoma↗
PubMed1989

Extended resection of fixed rectal cancer.

Between 1980 and 1987, we operated on 23 patients (16 men and 7 women) with fixed rectal cancer. Two patients had primary tumours. Twenty-one patients had recurrent disease (anterior resection, 8; abdominoperineal resection, 13). Eighteen patients had prior irradiation (40 Gy to 120 Gy). Resection was possible in 20 patients (16 for cure and 4 for palliation). Operations included extended proctectomy (n = 4), standard pelvic exenteration (n = 4), and sacropelvic exenteration (n = 12). One (5%) patient died postoperatively and five (25%) others had significant postoperative complications. With a follow-up time of 1 to 48+ months (median, 18 months), nine patients are dead of disease (operative death included), four are living with disease, two are dead free of disease, and eight (50% of those undergoing curative resection) are living free of disease. The results suggest that resection of fixed rectal cancer is feasible in many patients and of potential long-term benefit to approximately 50% of those in whom curative resection is possible.

Adenocarcinoma↗
PubMed2002

Long-term results of reirradiation for patients with recurrent rectal carcinoma.

BACKGROUND: The current study was conducted to assess the long-term results of reirradiation in patients with recurrent rectal carcinoma. METHODS: One hundred and three patients with recurrent adenocarcinoma of the rectum underwent reirradiation with concurrent 5-fluorouracil-based chemotherapy. The initial radiation dose to the pelvis ranged from 3000 to 7400 centigrays (cGy) with a median dose of 5040 cGy. The median time from initial treatment to recurrence was 19 months. Irradiation techniques consisted of two lateral fields with/without a posterior pelvic field to include recurrent tumor with a margin of 2-4 cm only. The reirradiation doses ranged from 1500 to 4920 cGy with a median dose of 3480 cGy. Total cumulative doses ranged from 7060 to 1080 cGy with a median total dose of 8580 cGy. After the reirradiation, 34 patients also underwent surgical resection for residual disease. Fourteen patients underwent pelvic exenteration, 11 patients underwent abdominoperineal resection, 4 patients underwent transanal transabdominal proctosigmoidectomy, 2 patients underwent full thickness local excision, and 3 patients underwent a Hartmann resection. RESULTS: Follow-up ranged from 3 84 months with a median follow-up of 2 years. The median survival for the whole group was 26 months and the 5-year actuarial survival rate was 19%. The median interval and 5-year survival rate of patients undergoing surgical resection after reirradiation was 44 months and 22% compared with 14 months and 15% for patients treated with reirradiation only (P = 0.001). Treatment was generally well tolerated. Fifteen patients required a treatment break and early termination of treatment for Grade 3 and higher diarrhea, moist desquamation, or mucositis. Late complications were seen in 22 patients, including persistent severe diarrhea in 18 patients with 10 patients requiring long-term parental support, small bowel obstruction was seen in 15 patients, fistula formation in 4 patients, and coloanal stricture in 2 patients. There was no difference in incidence of acute or long-term complications by the total radiation dose delivered. CONCLUSIONS: In patients with recurrent rectal carcinoma, high doses of reirradiation can be delivered with acceptable risks without prohibitive long-term side effects. Surgical salvage and long-term survival of patients are possible.

Adenocarcinoma↗
PubMed2001

Psychosocial issues: pelvic exenterative surgery.

This review of the literature describes the psychosocial consequences of all the elements associated with Pelvis Exenterative Surgery (PES): a diagnosis of cancer and/or its recurrence, impact of procedures such as simple or radical hysterectomy, prostatectomy, or colostomy. All studies report a high incidence of anxiety, depression, self-image insult, sexual dysfunction, social isolation, and dysfunction. There are few studies of the consequences of PES itself. Their consensus is that its psychosocial impact is not as catastrophic as one would expect. However, their methodological drawbacks do not yet permit a definitive conclusion. The interaction of the patients with their surgeon and treatment team during the preoperative period is examined with special attention to potential pitfalls. Acute psychiatric syndromes that may occur during the postoperative period (delirium, anxiety, depression, brief reactive psychosis) and their management is discussed. So are sexual dysfunctions. General principles of intervention in preparing patients for invasive procedures and facilitating favorable outcomes are described. J. Surg. Oncol. 2001;76:224-236.

Anxiety↗
PubMed2001

Soft tissue sarcomas involving the pelvis.

BACKGROUND AND OBJECTIVES: Soft tissue sarcomas (STS) of the true pelvis are rare tumors and there is little information in the literature related to pelvic STS. The purposes of this review were to understand the anatomic extension of these tumors to better plan surgical treatment and to determine the outcome of these patients. METHODS: Eighteen consecutive patients presenting between 1987 and 1995 with soft tissue sarcomas involving the true pelvis were retrospectively reviewed at minimum follow-up of 18 months. Cross-sectional imaging was reviewed for each patient to determine the anatomical location of the lesions. RESULTS: The tumors were confined to the true pelvis in 4 patients, extended to the retroperitoneum in three cases, and extended to the thigh in 11 patients. Adjuvant radiation was administered to all but 2 patients who had received radiation to the region in the past and all patients underwent surgical resection (local resection in 13 patients and hindquarter amputation in 5 patients). Surgical resection had a high rate of morbidity and complications including positive resection margins in nine individuals. Of the 18 patients, 11 died at a mean time of 15.5 (2-58) months from surgery, 4 were alive with evidence of disease at a mean time of 44.3 (18-68) months, and 3 were alive with no evidence of disease at a mean time of 57 (43-71) months. CONCLUSIONS: Soft tissue sarcoma of the pelvis is fortunately a rare disease with a high risk of local and systemic disease progression despite treatment with irradiation and surgical resection.

Adult↗
PubMed1983

Myosarcomas of the small and large intestine: a clinicopathologic study.

A retrospective study was made of 38 myosarcomas of the small and large intestines (34 leiomyosarcomas and 4 malignant leiomyoblastomas). Endoenteric, small, and noninvasive tumors were successfully treated by simple wedge excision, cautery snare removal, or segmental bowel resection with a high 5-yr cure rate of 86% (12/14). Exo-enteric tumors often invaded adjacent structures or perforated into the peritoneal cavity. Extensive resection procedures, including pancreaticoduodenectomy, abdominoperineal resection, and pelvic exenteration salvaged only 13% (2/16) of these patients. Three clinicopathologic factors adversely affected prognosis: i) tumor size greater than 5 cm in diameter, ii) extra-intestinal invasion or free perforation, and iii) high histopathologic grade of malignancy. The presence of none, one, two, or three of these adverse factors gave decreasing 5-yr survival rates of 100, 44, 31, and 0%, respectively. These observations suggest use of a multimodal treatment program that may minimize treatment failure from local as well as distant disease.

Adolescent↗
PubMed2004

Adenocarcinoma of the cervix and vagina in pediatric patients.

Here we report our combined analysis of vaginal mesonephric adenocarcinoma (MA) in a 13 years old treated at our institution and of reported vaginal or cervical MA and clear-cell adenocarcinoma in 37 patients 18 years old or younger. Tumors in 27 patients arose in the vagina; 8 (21%) had metastases at diagnosis. The predominant symptom was vaginal bleeding; 62% of patients were exposed to diethylstilbestrol in utero. The 3-year survival estimate was 71% +/- 11%. Surgical treatment and metastasis at diagnosis were significant predictors of survival. The association between tumor excision and excellent outcome suggests that radical hysterectomy or pelvic exenteration is unnecessary. Radiotherapy as an adjunct may have contributed to this outcome.

Adenocarcinoma↗
PubMed1994

Post-radical vulvectomy reconstruction using the inferiorly based transverse rectus abdominis (TRAM) flap: a preliminary experience.

The rectus abdominis myocutaneous flap has been reported for pelvic floor and neovaginal reconstruction following pelvic exenteration but not for neovulvar reconstruction following radical vulvectomy. The present report describes our preliminary experience with the inferiorly based transverse rectus abdominis muscle (TRAM) flap in five patients who underwent radical vulvectomy for invasive squamous cell carcinoma of the vulva.

Aged↗
PubMed1995

Perineal reconstruction using single gracilis myocutaneous flaps.

Bilateral gracilis myocutaneous flaps were originally used as part of a technique for creating a neovagina following total pelvic exenteration. Based upon this experience, we began using single flaps for primary repair and closure of large surgical defects in the perineal area that require alternate tissue sources to replace lost skin, mucosa, or adjacent deep tissues. Eighteen single gracilis flaps were used for major vulvovaginal reconstructions in 17 women during the past 5 years. Women undergoing unilateral flap reconstructions included 6 with anorectal cancers and 11 with vulvovaginal tumors. Most patients were being treated for recurrence after failed primary therapy (n = 7) or were receiving multimodal treatment for advanced local disease (n = 7). All cases involved complex resections followed by simultaneous reconstruction: mean total operative time was 377 min with a mean estimated blood loss of 1010 cc. Reconstruction involved external flap placement on the vulva or perineum in 7 cases and internal placement to replace excised portions of the vagina in the other 11. Mean flap size was 6.6 x 11.4 cm. Necrosis of flap skin occurred in 3 patients; minor wound separations or flap edge necrosis was seen in 5 cases. Hospital stay averaged 18.4 days. Nine women had recurrent disease and died over 4-30 months; the remaining 8 are alive and disease free with a median follow-up of 25 months. The single gracilis flap provides a versatile method for providing anatomic reconstruction of large perineal defects in women who have undergone extensive resection.

Adult↗
PubMed1996

Massive pelvic hemorrhage during gynecologic cancer surgery: "pack and go back".

Over a 13-year period, intraabdominal packing has been used to control massive hemorrhage during surgery for gynecologic malignancy in six patients. Five patients had undergone total pelvic exenteration and one total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. Massive hemorrhage was defined as infusion of more than 10 units of blood and replacement of more than one total blood volume. Tamponade was performed using continuous Kerlex rolls (Kendall Co., Boston, MA) in a bowel bag with directed pressure over the hemorrhaging site with abdominal closure. The packs were removed in 48 to 72 hr in the operating room, transabdominally in five patients and transvaginally in one. One postoperative death occurred within 8 hr of surgery. The packing was ultimately successful in the five remaining patients. In five of six patients, tumors were removed before the packing, whereas in one, the tumor was removed concurrently with the pack. In one patient, immediate repacking was required after pack removal, with ultimate hemostasis. Morbidity included "empty pelvis syndrome" in four patients, neuropathy in three (obturator in 1, sciatic in 2), and small bowel obstruction in one. In patients with severe intraoperative hemorrhage, intraabdominal packing has been successful as a mode of treatment.

Adult↗
PubMed1997

A simplified method for detubularization in the construction of a continent ileocolic reservoir (Miami pouch).

The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient's colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients.

Aged↗
PubMed1997

The inferior gluteal flap in the difficult vulvar and perineal reconstruction.

OBJECTIVE: The objective was to study the feasibility and complications of the use of the inferior gluteal flap in the difficult vaginal, perineal, and vulvar reconstruction among women treated for gynecologic cancers. METHODS: A prospective pilot study is reported. Between October 1994 and May 1996, seven patients underwent either unilateral (n = 3) or bilateral (n = 4) inferior gluteal flaps for primary reconstruction of extensive vulvar, perineal, and vaginal defects. RESULTS: The median age of the patients was 59 years (range, 40-70). The indications for the construction of the flaps were radical resection of recurrent vulvar cancer (n = 2), radical resection of stage IV vulvar cancer (n = 2), resection of recurrent Paget's disease of the vulva (n = 1), resection of perineal recurrence of cancer of the cervix (n = 1), and resection of enteroperineal fistula following total pelvic exenteration (n = 1). The median surface area of the vulvar and perineal defect was 113 cm2 (range, 10.5-448 cm2). The median operative time for both the extirpative and the reconstructive procedures was 270 min (95-685 min) and the median estimated blood loss was 200 mL (50-950 mL). The median postoperative hospital stay was 15 days (9-29). None of the patients experienced complete graft loss. Two patients suffered necrosis of the tip of the flap that resulted in minimal wound dehiscence which healed by secondary intention, and one patient suffered graft separation which required graft revision and reconstruction. The patients were followed for a median of 11 months (3-26 months). No late complications of the reconstructive surgery were recorded. CONCLUSIONS: The inferior gluteal flap can be safely used for the reconstruction of the difficult and extensive vulvar, perineal, and vaginal defects with excellent results.

Adult↗