Pelvic Sidewall Recurrence Research Articles

MILACC study: could undetected lymph node micrometastases have impacted recurrence rate in the LACC trial?

ObjectiveThe etiology of inferior oncologic outcomes associated with minimally invasive surgery for early-stage cervical cancer remains unknown. Manipulation of lymph nodes with previously unrecognized low-volume disease might explain this finding....

Robotic and laparoscopic salvage lateral pelvic node dissection for the treatment of recurrent rectal cancer.

The lateral pelvic sidewall is a major site of local recurrence after radical resection of rectal cancer. Salvage lateral pelvic node dissection (LPND) may be the only way to eliminate recurrent lateral pelvic nodes (LPNs). This study aimed to describe the technical details of robotic and laparoscopic salvage LPND and assess the short-term clinical and oncological outcomes in patients with recurrent LPNs who underwent salvage LPND by a minimally invasive approach for curative intent. Between September 2010 and 2019, 36 patients who underwent salvage surgery for LPN recurrence were retrospectively analyzed from a prospectively maintained database. Patients' characteristics, index operation, MRI findings, and perioperative and pathological outcomes were analyzed. Eleven and 14 patients underwent robotic and laparoscopic salvage LPND, respectively. Eight patients (32.0%) underwent a combined salvage operation for resectable extra-pelvic sidewall metastases. There were four cases of open-conversion during the laparoscopic approach due to uncontrolled bleeding of iliac vessels. In these patients, metastatic LPNs were suspected of iliac vessel invasion and were found to be larger in size (median 15mm; range 12-20) than that in patients who underwent successful LPND using the minimally invasive approach (median 10mm; range 5-20). The median number of metastatic LPNs and harvested LPNs was 1 (range 0-3) and 6 (range 1-16), respectively. Six patients (24.0%) experienced postoperative complications including lymphoceles and voiding difficulties. During the follow-up (median 44.6months; range 24.0-87.7), eight patients developed recurrences, mainly the lung and para-aortic lymph nodes, and one patient developed pelvic sidewall recurrence after laparoscopic salvage LPND. The 3-year disease-free survival and overall survival after salvage LPND were 66.4% and 79.2%, respectively. Robotic and laparoscopic salvage LPND for recurrent LPNs are safe and feasible with favorable short-term surgical outcomes. However, the surgical approach should be carefully chosen in patients with large-sized and invasive recurrent LPNs.

Salvage image-guided freehand interstitial brachytherapy for pelvic sidewall recurrence after hysterectomy for uterine malignancies

Pelvic sidewall recurrence after hysterectomy for uterine malignances has a poor prognosis, and the salvage therapy for this type of recurrence is still challenging. The purpose of this study was to investigate the efficacy of freehand high-dose-rate interstitial brachytherapy (HDR-ISBT) through the perineum using transrectal ultrasonography for this disease. We retrospectively evaluated 42 patients with pelvic sidewall recurrence after hysterectomy for uterine cervical and endometrial cancers. We investigated patients' characteristics, the 2-year local control and survival rates, and late adverse events of the rectum and bladder. The 2-year overall survival, local control, and progression-free survival rates were 73.7% (95% confidence interval [CI], 60.8-89.3%), 69.4% (95% CI, 55.4-80.1%), and 37.3% (95% CI, 24.6-56.5%), respectively. In Cox multivariate analysis, tumor size at recurrence (<45 mm vs.≥45 mm) (p = 0.04) and disease-free periods after hysterectomy (<10 months vs. ≥10 months) (p < 0.01) were significant prognostic factors for overall survival. Lymph node metastasis at recurrence (p < 0.01) was also a significant prognostic factor for progression-free survival. Three patients experienced Grade 3-4 late proctitis (7%). Transperineal freehand salvage HDR-ISBT using transrectal ultrasonography was demonstratedto be a curative treatment option for patients with pelvic sidewall recurrence following hysterectomy. Based on the findings of this study, we emphasize the importance of HDR-ISBT for pelvic sidewall recurrence.

P-280 Can immune checkpoint inhibitors plus surgery cure advanced mismatch repair-deficient cancer?

There is a strong body of evidence supporting use of immune checkpoint inhibitors (ICI) in unresectable mismatch repair-deficient (MMRd) / microsatellite unstable (MSI) high colorectal cancer (mCRC); anti-PD-1 therapy is the standard of care for first-line treatment of mCRC (Andre, NEJM 2021). Emerging evidence also demonstrates high rates of complete pathological response (pCR) following neoadjuvant ICI in patients with stage I-III MSI colon cancer (Chalabi, Nature 2020) and in MSI gastric cancer (Andre, ASCO GI 2022). This leads to the question of whether ICI with or without surgery could lead to cures in advanced MSI cancers. Herein we describe our single institutional experience of immunotherapy followed by surgery in MSI intestinal cancers. In this retrospective series the institutional electronic health record was reviewed for patients with ICI treated MSI intestinal cancers with subsequent surgical resection. Demographics and clinicopathological characteristics were collected, with ICI therapy details and toxicity, radiological response and operative details. Post-operative histology was reviewed. Overall survival was calculated using the Kaplan-Meier method. Five patients were identified; 5 (100%) female. Mean/median age was 37/46 years (range 22-78). Four (80%) had MLH1/PMS2 deficient cancers, 1 was MSH2/MSH6 deficient. One had germline MLH1 mutation, one germline pending. Two (40%) had concurrent tumour BRAF V600E mutation, two (40%) had KRAS G12D mutation. Four (80%) had colon cancer (1 ascending colon, 1 synchronous ascending colon and hepatic flexure, 1 transverse colon, 1 rectosigmoid); 1 patient jejunal adenocarcinoma. Three colon cancer patients had lymph node metastases distant from the primary, one had local pelvic side wall recurrence, one had direct invasion of liver and pancreas. All patients received ICI with initial palliative intent (1 ascending colon 2nd line nivolumab, 1 synchronous tumours 1st line nivolumab/ipilimumab, 1 rectosigmoid 2nd line nivolumab/ipilimumab, 1 transverse 1st line pembrolizumab, jejunal 1st line nivolumab). Two patients had admissions with ICI related fevers, 1 experienced ICI G3 pneumonitis and 1 experienced G3 hepatitis. All patients had radiological response to ICI. Two patients (transverse colon / jejunal cancer) experienced stricture in responding primary tumour and required surgery. One ascending colon cancer had surgery a symptomatic PET-avid mass, 1 synchronous cancer patient had right total mesocolic excision, partial hepatectomy and Whipples. One recurrent rectosigmoid colon cancer had total pelvic exenteration following ICI and radiotherapy. All patients had R0 resection. Two patients had pCR (ypT0N0) (ascending colon, rectosigmoid colon); both complete responders had experienced ICI related toxicity. Other patients’ stage were transverse colon (ypT3N0), jejunal cancer (ypT0N1) and synchronous tumours (ypT4N0 and ypT2N0). After median follow up of 15 months, no patient has recurrent disease. Median overall survival is not reached. In this series we demonstrate that a combination of ICI and surgery can render patients with advanced MSI cancers disease free by downstaging previously unresectable cancers and eliminating distant metastases. As complete responses were demonstrated in two patients with suspicious pre-operative radiological findings on resection, improved imaging techniques or ctDNA may be helpful in guiding which patients require surgery in future.

Surgery followed by concurrent radiochemotherapy as treatment for patients with locally recurrent cervical cancer.

BackgroundNo standard treatment exists for patients with recurrent cervical cancer. This study aimed to determine the role of surgery, followed by concurrent radiochemotherapy, as a treatment for recurrent pelvic cervical cancer without previous radiotherapy.MethodsThe current study identified patients diagnosed with vaginal and/or pelvic sidewall recurrent cervical cancer after primary surgery without radiotherapy in Zhejiang Cancer Hospital from May 2012 to November 2016. These enrolled patients underwent surgery, followed by concurrent radiochemotherapy and data were analyzed.ResultsThis study enrolled 27 patients, including 11 with central (vaginal) and 16 with noncentral (pelvic sidewall with or without vaginal) recurrences. The median follow-up time after recurrence was 64 months (range, 5–110 months). All patients underwent surgery to resect the tumor as completely as possible and pelvic external beam radiotherapy (EBRT) with a median equivalent dose in 2 Gy fractions (EQD2) of 45.1 Gy (range, 44.3–47.8 Gy) with concurrent weekly cisplatin chemotherapy. The median EQD2 dose for the tumor bed/residual tumor was 51 Gy (range, 44.3–73.4 Gy), including 18 patients with a boost dose by EBRT or vaginal brachytherapy (VBT). The 5-year overall survival (OS) rates were 77.1% (central) and 65.7% (noncentral) without a statistically significant difference (P=0.246). Progression-free survival (PFS) rates were 81.8% (central) and 34.4% (noncentral), respectively, with a statistically significant difference (P=0.047). Three patients with noncentral recurrence experienced grade ≥3 complications associated with surgery.ConclusionsSurgery followed by concurrent radiochemotherapy was a feasible and effective treatment with acceptable complications for locally recurrent cervical cancer, which markedly improved the survival of pelvic sidewall recurrence.

Laterally Extended Endopelvic Resection Versus Chemo or Targeted Therapy Alone for Pelvic Sidewall Recurrence of Cervical Cancer

BackgroundLaterally extended endopelvic resection (LEER) has been introduced for treatment of pelvic sidewall recurrence of cervical cancer (PSRCC), which occurs in only 8% of patients with relapsed cervical cancer. LEER can only be performed by a proficient surgeon due to the high risk of surgical morbidity and mortality, but there is no evidence as to whether LEER is may be more effective than chemo or targeted therapy alone for PSRCC. Thus, we aimed to compare the efficacy and safety between LEER and chemo or targeted therapy alone for treatment of PSRCC.MethodsWe prospectively recruited patients with PSRCC who underwent LEER between December 2016 and December 2019. Moreover, we retrospectively collected data on patients with PSRCC who received chemo or targeted therapy alone between January 2000 and December 2019. We compared treatment-free interval (TFI), progression-free survival (PFS), treatment-free survival (TFS), overall survival (OS), tumor response, neurologic disturbance of the low extremities, and pelvic pain severity in the different patient groups.ResultsAmong 1295 patients with cervical cancer, we included 28 (2.2%) and 31 (2.4%) in the prospective and retrospective cohorts, respectively. When we subdivided all patients into two groups based on the median value of prior TFI (PTFI, 9.2 months), LEER improved TFI, PFS, TRS and OS compared to chemo or targeted therapy alone (median, 2.8 vs. 0.9; 7.4 vs. 4.1; 30.1 vs. 16.9 months; P ≤ 0.05) in patients with PTFI < 9.2 months despite no difference in survival in those with PTFI ≥ 9.2 months, suggesting that LEER may lead to better TFI, PFS, TRS and OS in patients with PTFI < 9.2 months (adjusted hazard ratios, 0.28, 0.27, 0.44 and 0.37; 95% confidence intervals, 0.12-0.68, 0.11-0.66, 0.18-0.83 and 0.15-0.88). Furthermore, LEER markedly reduced the number of morphine milligram equivalents necessary to reduce pelvic pain when compared with chemo or targeted therapy alone.ConclusionCompared to chemo or targeted therapy alone, LEER improved survival in patients with PSRCC and PTFI < 9.2 months, and it was effective at controlling the pelvic pain associated with PSRCC.Trial RegistrationClinicalTrials.gov, identifier NCT02986568.

Laterally extended parametrectomy

ObjectiveTo describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure.MethodsLEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic sidewall. Its initial indications were for lymph node positive Stage Ib (current International Federation of Gynecology and Obstetrics 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic sidewall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic sidewall.ResultsDuring LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic sidewall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic sidewall veins.ConclusionLEP is a feasible technique for removing pelvic sidewall recurrences, aiming to obtain surgical free margins.

Posterior-First Two-Stage Approach to En Bloc Resection of Locally Recurrent Rectal Cancer Involving the Pelvic Sidewall.

Using standard anterior-only or anterior then posterior approaches can make an R0 resection difficult to achieve in patients with pelvic sidewall recurrences because of confined working spaces and poor visibility. Given the limitations of standard approaches, we have used a novel posterior-first then anterior 2-stage approach allowing us to widely expose and secure deep margins and control vessels under direct visualization. We present a technical note describing this approach in patients with recurrent rectal cancer involving the pelvic sidewall with extrapelvic extension. The posterior-first approach may assist in achieving a higher number of R0 resections in patients with locally recurrent rectal cancer involving the pelvic sidewall.

Site-specific risk factors for local recurrence after rectal cancer surgery

BackgroundQuite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites. MethodsLocal recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the “other” type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the “other” type of local recurrence. ResultsUnivariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the “other” type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the “other” type of local recurrence. ConclusionRisk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors. Trial registration numberUMIN000021353.

Value of tube combined with real-time ultrasound-guided accurate interstitial high-dose-rate brachytherapy for post-operative pelvic side-wall recurrences of cervical cancer.

PurposeTreatment of post-operative pelvic side-wall relapses of cervical cancer has always been a therapeutic challenge for radiation oncologists. Radiation dose boost to recurrent tumor by brachytherapy is necessary, but difficult to achieve. Our treatment center has successfully achieved precise transvaginal insertion of a pelvic side-wall mass, using a metal tube with real-time ultrasound guidance. This study investigates the efficacy and safety of image-guided high-dose-rate (HDR) interstitial brachytherapy (IBT) for patients with post-operative pelvic side-wall relapses.Material and methodsBetween 2018 and 2020, 36 post-operative pelvic side-wall relapses of cervical cancer patients receiving external beam radiotherapy (EBRT) combined with HDR-IBT were analyzed retrospectively. Doses per fraction ranged from 6.0 to 7.0 Gy, whereas cumulative equivalent doses in 2 Gy fractions ranged from 80 to 100 Gy. Effects of prognostic factors on local control (LC) and progression-free survival (PFS) were analyzed, and late toxicity data were evaluated.ResultsA total of thirty-six patients were included, with a median follow-up of 19.3 months. The tumor response was obtained for all patients, with radiological complete remission in 20 (55.6%) patients. Two-years LC and PFS rates were 72.2% and 47.2%, respectively. Grade II rectal toxicity was observed in 5 patients (13.9%). Multivariate analyses for LC and PFS using proportional regression model were performed, in which shape of exophytic tumor was associated with a significantly better prognosis for both LC and PFS (HR = 0.071, 0.128, p = 0.005, 0.002). Clinical target volume (CTV) D90 remained associated with a significantly better prognosis for PFS (HR = 0.056, p = 0.000).ConclusionsA metal tube placed in the vagina, under the guidance of real-time ultrasound in transvaginal IBT for pelvis masses can be accurately achieved. The shape of exophytic tumor and CTV D90 were associated with a significantly better prognosis for PFS, and the shape of exophytic tumor was also associated with a better prognosis for LC. Therefore, radiation dose boost using IBT can improve the prognosis of patients with post-operative pelvic side-wall recurrences of cervical cancer.

Metal tube combined with ultrasound-guided accurate interstitial brachytherapy for postoperative pelvic side-wall recurrences of cervical cancers: Technique and outcome

Objective: Our goal was to describe and evaluate the metal tube-assisted ultrasound-guided accurate interstitial brachytherapy technique (TUG-ISBT) and the clinical outcome of a transvaginal treatment without anesthesia modality for the treatment of women with postoperative pelvic sidewall recurrences of cervical cancer.

Intraoperative radiotherapy for resectable advanced lower rectal cancer-final results of a randomized controlled trial (UMIN000021353).

Pelvic autonomic nerve preservation (PANP) is useful to preserve voiding and sexual function after rectal cancer surgery. The aim of this study was to investigate the benefit of intraoperative radiotherapy (IORT) to have complete PANP without affecting oncological outcomes. Patients undergoing potentially curative resection of the rectum were included. They were randomized to intraoperative radiotherapy of the completely preserved bilateral pelvic nerve plexuses (IORT group) or the control group without IORT, but with limited nerve preservation. The primary endpoint was pelvic sidewall recurrence. Moreover, patients' clinicopathologic parameters, postoperative complications, voiding function, and other oncologic outcomes were compared. From 79 patients, three were excluded from analysis, resulting in 38 patients in each group. Patients' demographic and pathological parameters were well balanced between the two groups. The trial was terminated prematurely in July 2017, because distant metastasis-free survivals were found to be significantly worse in the IORT group compared to the control group (odds ratio 2.554; 95% CI, 1.041 ~ 6.269; p= 0.041). Neither overall survival nor pelvic sidewall recurrence did differ between the two groups (overall survival: odds ratio 1.264; 95% CI, 0.523~3.051; p= 0.603/pelvic sidewall recurrence; odds ratio 1.350; 95% CI, 0.302~6.034; p= 0.694). Postoperative complications did not differ between the groups; however, the urinary function was significantly better in the IORT group in the short and long term. With the aid of IORT, complete PANP can be done without increase of pelvic sidewall recurrence; however, IORT may increase the incidence of distant metastases. Therefore, IORT cannot be recommended as a standard therapy to compensate less radical resection for advanced lower rectal cancer.

High-dose-rate interstitial brachytherapy with hypoxic radiosensitizer KORTUC II for unresectable pelvic sidewall recurrence of uterine cervical cancer: a case report

In order to improve oncologic outcomes in radiotherapy treatments of patients with unresectable pelvic sidewall recurrences of uterine cervical cancer, we combined high-dose-rate interstitial brachytherapy (HDR-ISBT) with newly tested hypoxic radiosensitizer Kochi oxydol-radiation therapy for unresectable carcinomas (KORTUC II), an enzyme-targeting radiosensitization treatment involving intra-tumoral injection of sodium hyaluronate mixed with hydrogen peroxide. We report on a 63-year-old patient referred to our department with an extensive pelvic sidewall recurrence of uterine cervical cancer after initial hysterectomy. The tumor size was 55 × 25 × 80 mm, with a calculated volume of 89.7 cc. Whole pelvic irradiation of 50 Gy in 25 fractions was administered, combined with weekly cisplatin injections. KORTUC II injections were given two times: at day 21 (42 Gy) and at day 24 (48 Gy). After finishing whole pelvic irradiation, HDR-ISBT of 25 Gy in 5 fractions b.i.d. over 3 days was administered. KORTUC II was also injected at the time of implantation. Dose-volume histogram (DVH) values for clinical target volume were D90, D98, and D100 of 6.0, 5.0, and 3.5 Gy per fraction, respectively. D2cc values were 2.1, 4.1, 3.2, and 2.0 Gy per fraction for the bladder, rectum, sigmoid colon, and small bowel, respectively. No acute adverse events ≥ grade 3 were observed. Repeated grade 3 pyelonephritis occurred as a late complication at 11, 24, and 26 months after the treatment, and was successfully resolved with antibiotics. Moreover, grade 2 late toxicity was documented, including sciatic neuralgia, lower limb lymphedema, and urinary incontinence. At present, 32 months after HDR-ISBT, the patient remains free of disease, with no toxicity-related deterioration in physical condition.

Pelvic side wall recurrence in locally advanced cervical carcinoma treated with definitive chemoradiation-clinical impact of pelvic wall dose.

Pelvic side wall dose in locally advanced cervical carcinoma treated with definitive chemoradiation has been debated. The present study investigated relationship of disease recurrence with dose for the pelvic side wall. It also attempted to identify minimal dose that significantly reduced recurrence. Pelvic side wall recurrence at median 24 months was assessed clinically and radiologically across three groups of patients receiving variable pelvic wall doses using no parametrial boost, external beam or interstitial boost, or dose escalated combined external beam with interstitial boost. At 24 months, recurrence occurred in 3/155 boost vs 40/130 no boost patients. (p < 0.0001). Receiver operating characteristic curve analysis demonstrated cut-off pelvic wall dose to be 58.9 Gy (p < 0.0001). Dose escalated combined boost showed no significant benefit compared to single modality parametrial boost (p = 0. 0.553). Mean pelvic wall dose of at least 58.9 Gy offers clinically significant benefit in pelvic wall control. Doses recommended by guidelines should be adhered to in the patients' best interests. This preliminary study determined a relationship between recurrence rates and dose to the pelvic side wall and also a cut-off dose that significantly improved pelvic wall control in locally advanced cervical cancer.

How to simplify out-of-the-box surgery in recurrent gynecologic malignancies compromising iliac vessels: preoperative femorofemoral crossover bypass.

Pelvic side wall recurrences represent a challenge for oncologic surgeons, especially in cases requiring major vascular resections. Until the description of the out-of-the-box lateral resection surgical technique, lateral pelvic wall involvement was considered a contraindication for surgery.[1 2][1

WITHDRAWN: Image Guided HDR Brachytherapy for Pelvic Sidewall Recurrence of Endometrial Cancer

WITHDRAWN: Image Guided HDR Brachytherapy for Pelvic Sidewall Recurrence of Endometrial Cancer

Impact of sentinel lymph node mapping on recurrence patterns in endometrial cancer

BackgroundSentinel lymph node (SLN) mapping has emerged as a promising solution to the ongoing debate regarding lymphadenectomy in the initial surgical management of endometrial cancer. Currently, little is known about its possible impact on location of disease recurrence compared to systematic lymphadenectomy. MethodsIn this retrospective study, 472 consecutive patients with endometrial cancer who underwent either SLN mapping (SLN cohort, n=275) or systematic lymphadenectomy (LND cohort, n=197) from sequential, non-overlapping historical time points were compared. Clinical characteristics were extracted from a prospectively gathered electronic database. Both overall and pelvic sidewall recurrence free survival (RFS) were evaluated at 48-month post-operative follow-up. ResultsNo significant difference in overall RFS could be identified between the cohorts at 48months (HR 0.74, 95% CI 0.43–1.28, p=0.29). However, the SLN cohort had improved pelvic sidewall RFS compared to the LND cohort (HR 0.32, 95% CI 0.14–0.74, p=0.007). The pelvic sidewall recurrences accounted for 30% of recurrences in the SLN cohort (8 out of 26 recurrences) compared to 71.4% in the LND cohort (20 out of 28 recurrences). ConclusionsSLN mapping may enable more efficient detection of the LNs at greatest risk of metastasis and help to guide adjuvant therapy, which in turn seems to decrease the risk of pelvic sidewall recurrences.

Salvage stereotactic body radiotherapy for locally recurrent uterine cervix cancer at the pelvic sidewall: Feasibility and complication.

To determine the feasibility of stereotactic body radiotherapy (SBRT) in patients with pelvic sidewall recurrence of uterine cervical cancer after radical hysterectomy or definitive radiotherapy. We retrospectively reviewed 23 patients with locally recurrent uterine cervical cancer limited to the pelvic sidewall who were treated with SBRT at our institution between January 2003 and May 2010. The SBRT dose ranged from 27 to 45 Gy (median, 39 Gy) in three fractions, and the fractional SBRT dose ranged from 9 to 15 Gy (median, 13 Gy). The 2-year overall survival, local progression-free survival and disease progression-free survival rates were 43%, 65% and 52%, respectively. Patients with small tumors (gross tumor volume <30 cm(3) ) had a significantly longer 2-year overall survival rate and 2-year local progression-free survival rate than did patients with large tumors (overall survival rate: 89% vs 12%; P = 0.0001 and local progression-free survival: 85% vs 0%; P = 0.0199). There were three cases (13%) of severe toxicities (rectovaginal fistula). Pelvic pain relief was achieved in all patients. In particular, 10 of 14 patients (71%) achieved analgesic (nonsteroidal anti-inflammatory drug or narcotic) reduction of 50% or more from baseline. SBRT is a feasible treatment option for women with pelvic sidewall tumors from recurrent uterine cervical cancer, especially for small recurrent tumors. However, SBRT should be used carefully in the treatment of large tumors, as the incidence of severe late toxicity increases with the size of the tumor.

The Role of Intraoperative Radiation Therapy in the Management of Recurrent and Locally Advanced Gynecologic Cancers

For patients with locally advanced primary or recurrent gynecologic cancers, prognosis is poor. Doses of external beam radiation therapy required to treat either gross or microscopic disease in patients previously irradiated or treated surgically exceed doses that are tolerated by normal anatomic structures. Intraoperative radiation therapy allows maximal tumor control achievable with radiation while minimizing radiation exposure of dose-limiting surrounding structures. Intraoperative radiation therapy is a unique treatment modality, allowing direct visualization of the target volume during a planned surgical procedure. Intraoperative radiation therapy has the potential to improve both long-term local control and overall survival especially in patients with para-aortic and/or pelvic sidewall recurrences.

Arterial Thrombosis After Surgery of Pelvic Side Wall Recurrence of a Villoglandular Adenocarcinoma of the Cervix

Abstract Background: Villoglandular adenocarcinoma of the cervix is a rare condition that appears in young women and is characterized by its low aggressiveness. The most common treatment is surgery, consisting of either a conization or hysterectomy. Ovaries may be preserved depending upon the patient's reproductive desires. Case: The case reported here involves the recurrence of a stage IB1 villoglandular adenocarcinoma of the cervix. This may be the first case report of the recurrence of a villoglandular adenocarcinoma of the cervix with no lymph node metastasis following a radical hysterectomy, and the first case of a laterally extended endopelvic resection being complicated by an arterial thrombosis. Results: Resection was performed, leaving part of the residual tumor. The patient experienced a postoperative thrombosis of the left common iliac artery. A fasciotomy of the tibia and calf was performed, followed by a femoro-femoral crossover bypass. The patient is still undergoing rehabilitation, as well ...