Management Of Pelvic Malignancies Research Articles

Interim 18FDG PET/CT during radiochemotherapy in the management of pelvic malignancies: A systematic review.

18F-fluorodeoxyglucose PET/CT (18F-FDG-PET/CT) is widely applied in oncology for disease staging, assessment of therapy response, relapse diagnosis, follow-up and target volume delineation. In particular, it can detect early response during chemoradiotherapy (interim) because functional modifications usually precede morphological ones. This ability is crucial to the radiation oncologist for the management of patients, to avoid persisting with ineffective therapy - often leading toxicity - and to shift to potentially more effective alternatives. Interim 18F FDG-PET imaging in rectal and cervical cancer, the main malignancies of the pelvic district, has been applied and a broad literature is available, although some results are discordant. This systematic review summarizes the application of 18F FDG-PET/CT during the chemoradiotherapy of locally advanced pelvic malignancies in order to clarify its capability to predict response and prognosis and its potential role to tailor therapy, which seems to be validated in rectal cancer, whilst less conclusive in cervical cancer.

1 RECONSTRUCTION OF URETHRAL STRICTURES FOLLOWING PELVIC RADIATION THERAPY: COMPARISON OF RECONSTRUCTION TECHNIQUES

INTRODUCTION AND OBJECTIVES: Radiation based treatments have proven useful in the management of pelvic malignancy. Urethral stricture is one of the complications of such treatment. The objective of this study is to report outcomes of urethral reconstruction for radiation induced urethral strictures. METHODS: A retrospective review of urethral reconstructions performed by a single surgeon (KR) at the University of Alberta from August 2003 to November 2010 was performed. Patients who underwent reconstruction for urethral strictures after radiation treatment in the form of External Beam Radiation Therapy (EBRT) or prostate Brachytherapy were identified. The primary outcome was urethral patency with secondary outcomes being incontinence and 90-day complication rates. Outcomes were compared between two reconstructive techniques (Excision and Primary Anastomosis versus Tissue Transfer) using the Fisher’s exact test and mean stricture length was compared using the unpaired t-test. RESULTS: During the study period, 507 urethral reconstructions were performed. Of these, 18 met our inclusion criteria including 11 and 7 reconstructions following EBRT and Brachytherapy, respectively. Reconstruction was performed by Excision and Primary Anastomosis (EPA) in 8 (44.4%) of the cases. The remaining patients required Tissue Transfer as either buccal mucosa graft (33.3%) or penile island flap (22.2%). Seventeen patients (94.4%) achieved cystoscopic patency with similar patency rates between the reconstructive techniques (EPA 100%; Tissue Transfer 90%; Not Significant). A 90-day complication rate of 22.2% was reported with 25% and 20% complication rates in the EPA and Tissue Transfer groups respectively (Not Significant). All the complications were Clavien Grade I-II. New onset or adverse change in incontinence occurred in 16.7% of patients. A significant difference was found between the reconstructive techniques with 25% of the EPA reconstructions versus 10% of the Tissue Transfer patients deemed incontinent at 6 months (p 0.013). The overall mean stricture length was 4.3cm. A significantly longer mean stricture length was found in the Tissue Transfer group (EPA 2.13cm vs. Tissue Transfer 6cm; p 0.0001). Mean follow-up was 41.1 months. CONCLUSIONS: Reconstruction of radiation induced urethral strictures yields satisfying rates of success in the outcomes measured. There are no differences in reconstructive technique with regard to urethral patency and 90-day complications. Anastomotic repairs are found to have significantly higher postoperative incontinence rates.

Anovulatory Bleeding in a 12-Year-Old as Presenting Sign for Rare Undifferentiated Sarcoma

BackgroundAbnormal uterine bleeding is a common phenomenon in perimenarchal females. Though most cases of abnormal bleeding are due to anovulatory bleeding or bleeding disorders, rare cases are attributable to underlying malignancy. CaseHere we report a 12-year-old female patient who presented with abnormal uterine bleeding three months after menarche. She was ultimately diagnosed with a pelvic sarcoma of unknown primary origin. She was subsequently treated with chemotherapy, whole pelvic radiation, and hysterectomy with bilateral salpingo-oophorectomy. SummaryAbnormal uterine bleeding unresponsive to conventional temporizing measures should be thoroughly evaluated. Management of pelvic malignancies in the pediatric population requires cooperation amongst specialists from an array of disciplines.

Rho kinase signalling mediates radiation-induced inflammation and intestinal barrier dysfunction

Radiotherapy is important in the management of pelvic malignancies, but radiation-induced intestinal damage is a dose-limiting factor. Microvascular injury and epithelial barrier dysfunction are considered to be rate-limiting aspects in radiation-induced enteropathy. This study investigated the role of Rho kinase signalling in radiation-induced inflammation and intestinal barrier dysfunction. The specific Rho kinase inhibitor Y-27632 (1 and 10 mg/kg) was given to C57BL/6J mice before challenge with 20 Gy radiation. Leucocyte- and platelet-endothelium interactions in the colonic microcirculation were assessed by intravital microscopy. Levels of myeloperoxidase (MPO) and CXC chemokines (macrophage inflammatory protein 2 and cytokine-induced neutrophil chemoattractant), and intestinal leakage were quantified after 16 h. Radiation increased leucocyte and platelet recruitment, MPO activity, CXC chemokine production and intestinal leakage. Y-27632 significantly reduced radiation-induced leucocyte rolling and abolished adhesion; it also decreased platelet rolling and adhesion by 55 and 74 per cent respectively (P < 0·050). Inhibition of Rho kinase signalling significantly decreased radiation-provoked formation of CXC chemokines, MPO activity by 52 per cent, and intestinal leakage by 67 per cent (P < 0·050). Rho kinase activity constitutes an important signalling mechanism in radiation-induced inflammation and intestinal barrier dysfunction.

Laparoscopic pelvic sling placement facilitates optimum therapeutic radiotherapy delivery in the management of pelvic malignancy

Background Radiotherapy has a significant role in the management of pelvic malignancies. However, the small intestine represents the main dose limiting organ. Invasive and non-invasive mechanical methods have been described to displace bowel out of the radiation field. We herein report a case series of laparoscopic placement of an absorbable pelvic sling in patients requiring pelvic radiotherapy. Methods Six patients were referred to our minimally invasive unit. Four patients required radical radiotherapy for localised prostate cancer, one was scheduled for salvage localised radiotherapy for post-prostatectomy PSA progression and one patient required adjuvant radiotherapy post-cystoprostatectomy for bladder carcinoma. All patients had excessive small intestine within the radiation fields despite the use of non-invasive displacement methods. Results All patients underwent laparoscopic mesh placement, allowing for an elevation of small bowel from the pelvis. The presence of an ileal conduit or previous surgery did not prevent mesh placement. Post-operative planning radiotherapy CT scans confirmed displacement of the small intestine allowing all patients to receive safely the planned radiotherapy in terms of both volume and radiation schedule. Conclusion Laparoscopic mesh placement represents a safe and efficient procedure in patients requiring high-dose pelvic radiation, presenting with unacceptable small intestine volume in the radiation field. This procedure is also feasible in those that have undergone previous major abdominal surgery.

Laparoscopic surgery and gynaecological cancers

The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the late 80's and the first reports were published in the early 90's. The issue has been initially most controversial, and is still debated, with some justification considering the possible adverse consequences of surgical mismanagement of gynaecologic malignancy. Since then, a number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, including major exenterative surgery. The use of extraperitoneal technique for aortic dissections is emerging as a new tool. New indications, such as radical vaginal trachelectomy (Dargent operation), radical parametrectomy, pelvic sentinel node identification, decisional laparoscopy in adnexal malignancies, or the use of pretherapeutic surgical staging of uterine cancers, have been developed in direct relation with the use of laparoscopic techniques. Worldwide interest clearly demonstrates that laparoscopic techniques must now be part of the armamentarium of the gynaecologic oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay and recovery time, particularly in obese patients. Combined training in gynaecologic oncology and in laparoscopic and/or vaginal surgery is more than ever mandatory to reduce the operating time, which is becoming similar to laparotomy in experiences hands, and avoid the risk of inadequate staging or management of pelvic malignancies.

Laparoscopic surgery in gynaecological oncology

Aims The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the late 1980s and the first reports were published in the early 1990s. The issue has been initially most controversial, and is still debated, with some justification considering the possible adverse consequences of surgical mismanagement of gynaecologic malignancy. Methods The current literature has been reviewed and updated, concentrating on long-term, and/or comparative studies. Large observational studies have also been included. Recent papers concerning new developments have been selected. Findings A number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, including major exenterative surgery. The use of extraperitoneal technique for aortic dissections is emerging as a new tool. New indications, such as radical vaginal trachelectomy, radical parametrectomy, pelvic sentinel node identification, interval debulking surgery of adnexal malignancies, or the use of pretherapeutic surgical staging of uterine cancers, have been developed in direct relation with the use of laparoscopic techniques. Conclusions Current available data and worldwide interest clearly demonstrate that laparoscopic techniques must now be part of the armamentarium of the gynaecologic oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay and recovery time, although operating room time is increased in some procedures. Combined training in gynaecologic oncology and in laparoscopic and/or vaginal surgery is more than ever mandatory to avoid the risk of inadequate staging or management of pelvic malignancies.

Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures. We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed--the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Clinical Implementation of Intensity-Modulated Radiotherapy (IMRT) in the Management of Pelvic Malignancies

Clinical Implementation of Intensity-Modulated Radiotherapy (IMRT) in the Management of Pelvic Malignancies

The value of computed tomography in the radiotherapy management of pelvic malignancy

The value of computed tomography in the radiotherapy management of pelvic malignancy