Recurrent Gynecologic Malignancies Research Articles

Pelvic Exenteration Study: Characteristics and Outcomes of Patients Undergoing Pelvic Exenteration for Recurrent Gynecological Malignancy

Pelvic exenteration is a surgical procedure that requires an en-bloc excision of lower abdominopelvic structures. Although pelvic exenteration is associated with a high level of morbidity and considerable complications may be observed in more than 50% of patients undergoing surgery. Currently, it is the most viable option leading to a cure.

The effect of a CPR decision aid on CPR knowledge and code status preferences in patients with recurrent gynecologic malignancies

Objective: It is imperative to assess and improve CPR literacy in order for patients to make informed decisions regarding end-of-life preferences. We assessed the feasibility of a video CPR decision aid administered in the ambulatory setting and its effect on CPR literacy and code status preferences in patients with recurrent gynecologic cancer.

Role of pelvic exenteration in the treatment of persistent or recurrent gynecological cancers

Objective: Pelvic exenteration has been recognized as potentially curative for selected patients with persistent or recurrent gynecologic malignancies confined in the pelvis. Our main objective is to determine disease-free survival (DFS), overall survival (OS), and factors associated with recurrence.

A digital media attention diversion improves mood and fear in patients receiving chemotherapy for recurrent gynecologic malignancies: results of a randomized trial

BackgroundRecurrent gynecologic cancer patients experience symptoms that affect psychologic, emotional, social, and physical well-being. Chemotherapy can further exacerbate these symptoms. Poor mood, pain, and fatigue are linked and are detrimental...

Real-World Experience with Pembrolizumab Treatment in Patients with Heavily Treated Recurrent Gynecologic Malignancies.

PurposeWe evaluated the efficacy and safety of pembrolizumab in patients with recurrent gynecologic cancers in real-world practice.Materials and MethodsWe conducted a retrospective, single-institution study of patients with recurrent gynecologic malignancies treated with pembrolizumab. The primary endpoints were the objective response rate (ORR) and safety.ResultsThirty-one patients treated with pembrolizumab were included. The primary disease sites were the uterine cervix (n=18), ovaries (n=8), and uterine corpus (n=5). Fifteen of the 31 patients (48%) had an Eastern Cooperative Oncology Group performance status of ≥2. The median number of prior chemotherapy lines was 2 (range, 1–6), and 14 of 31 patients (45%) had received ≥ 3 prior lines of chemotherapy. The overall ORR was 22.6%: specifically, 22.3% (4 of 18 patients), 12.5% (1 of 8 patients), and 40% (2 of 5 patients) for cervical, ovarian, and endometrial cancers, respectively. During a median follow-up of 4.7 months (range, 0.2–35.3), the median time to response was 1.9 months (range, 1.4–5.7). The median duration of response was not reached (range, 8.8-not reached). The median progression-free survival was 2.5 months (95% confidence interval, 1.7-not reached). Adverse events occurred in 20 patients (64.5%), and only 3 (9.7%) were grade ≥3. There was one case of suspicious treatment-related mortality, apart from which most adverse events were manageable.ConclusionIn real-world practice, pembrolizumab was feasible and effective in heavily treated recurrent gynecologic cancer patients with poor performance status who may not be eligible for enrollment in clinical trials.

Phase 2 study of the Exportin 1 inhibitor selinexor in patients with recurrent gynecological malignancies

BackgroundSelinexor is an oral inhibitor of the nuclear export protein Exportin 1 (XPO1) with demonstrated antitumor activity in solid and hematological malignancies. We evaluated the efficacy and safety of selinexor in heavily pretreated, recurrent gynecological malignancies. MethodsIn this phase 2 trial, patients received selinexor (35 or 50 mg/m2 twice-weekly [BIW] or 50 mg/m2 once-weekly [QW]) in 4-week cycles. Primary endpoint was disease control rate (DCR) including complete response (CR), partial response (PR) or stable disease (SD) ≥12 weeks. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and safety. Results114 patients with ovarian (N = 66), endometrial (N = 23) or cervical (N = 25) cancer were enrolled. Median number of prior regimens for ovarian, endometrial and cervical cancer was 6 (1–11), 2 (1–5), and 3 (1–6) respectively. DCR was 30% (ovarian 30%; endometrial 35%; cervical 24%), which included confirmed PRs in 8%, 9%, and 4% of patients with ovarian, endometrial, and cervical cancer respectively. Median PFS and OS for patients with ovarian, endometrial and cervical cancer were 2.6, 2.8 and 1.4 months, and 7.3, 7.0, and 5.0 months, respectively. Common Grade 3/4 adverse events (AEs) were thrombocytopenia (17%), fatigue (14%), anemia (10%), nausea (9%) and hyponatremia (9%). Patients with ovarian cancer receiving 50 mg/m2 QW had fewer high-grade AEs with similar efficacy as BIW treatment. ConclusionsSelinexor demonstrated single-agent activity and disease control in patients with heavily pretreated ovarian and endometrial cancers. Side effects were a function of dose level and treatment frequency, similar to previous reports, reversible and mitigated with supportive care.

Comparison of postoperative complications and quality of life between patients undergoing continent versus non-continent urinary diversion after pelvic exenteration for gynecologic malignancies

BackgroundPelvic exenteration and its reconstructive techniques have been associated with high postoperative morbidity and a negative impact on patient quality of life. The aim of our study was to compare...

Creation of a Y-shaped ileal orthotopic neobladder after an anterior pelvic exenteration in 10 logical steps

Anterior pelvic exenteration is a salvage procedure for patients presenting with recurrent or persistent gynecological malignancies involving the bladder after prior radiotherapy. The goals of urinary reconstruction have evolved from...

1948 Robotic Type II B Posterior Exenteration for Recurrent Vaginal Cancer

Video Objective To demonstrate a surgical video where-in a robotic-assisted posterior pelvic exenteration was performed in a case of recurrent vaginal cancer. Setting A tertiary referral center. Interventions We present a case of a 55 year-old Hispanic female with a history of stage II squamous cell vaginal carcinoma. She was initially treated with concurrent chemotherapy (cisplatin) and radiation (pelvic and vaginal) in 2016. She had a biopsy proven isolated recurrence located in posterior aspect of upper third of the vagina. A robotic type II B posterior pelvic exenteration is demonstrated step by step in this video. Besides the technical aspects of the procedure, pelvic anatomic landmarks have also been emphasized. Conclusion Robotic approach to highly morbid pelvic exenteration procedures should be considered in selected patients with recurrent gynecologic malignancies, who present without evidence of distant metastatic disease.

MRI of surgical flaps in pelvic reconstructive surgery: a pictorial review of normal and abnormal findings.

Surgical flaps are commonly used for pelvic reconstruction in a subgroup of patients with locally advanced or recurrent anorectal and gynecologic malignancies and following complications of pelvic irradiation. Surgical scenarios where flaps may be placed include (but are not limited to) extended or radical abdominal perineal resection (APR) and total pelvic exenteration (PE). Surgical flaps in pelvic reconstruction serve several functions, including reducing dead space and providing structural support, facilitating wound closure and cosmetic appearance, enhancing the postsurgical healing process, protecting anastomosesand helping to prevent adhesions of organs and viscera to adjacent structures and the pelvic side wall. The most commonly used surgical flaps in pelvic reconstruction surgery include the VRAM (Vertical Rectus Abdominis Muscle), MRAM (Modified Rectus Abdominis Myocutaneous flap), gracilis, sartoriusand omental flaps. Surgical flaps can be mistaken for recurrent or residual tumor by radiologists who are not familiar with the appearance or surgical methods of flap placement, since flaps may have a mass-like appearance on cross sectional imaging, including CT and MRI. Recurrent neoplasm may be difficult to differentiate from postoperative changes of flap placement and associated postsurgical anatomic distortion. This review article focuses on understanding the nuances of surgically placed pelvic flaps and identifying their normal and abnormal appearances on magnetic resonance imaging (MRI) along a time continuum. Postsurgical complications, including hematoma, postoperative fluid collections, infection, ischemia, and necrosis as well as tumor recurrence on the initial and follow-up magnetic resonance imaging are illustrated and discussed.

Interfractional Variation of Treatment Delivery for High-Dose-Rate Interstitial Brachytherapy for Primary or Recurrent Gynecologic Malignancies: A Single-Institution Experience

For women who require high-dose-rate interstitial brachytherapy (HDR-ISBT) for primary or recurrent gynecologic malignancy, there can be significant interfractional variation from patient motion, post-implant swelling and organ filling. The purpose of this study was to evaluate the interfractional variation of dose distribution and displacement of catheters during HDR-ISBT in a single implant, consecutive day regimen. A total of 15 patients with primary or recurrent gynecologic malignancies who underwent HDR-ISBT were reviewed. Interstitial catheters and fiducials were placed under fluoroscopy and ultrasound guidance to confirm desired placement for clinical target volume (CTV) coverage and reproducibility. Patients underwent 4-5 treatments over 2-3 consecutive days. CT imaging was acquired on day of implant and days 2 and/or 3. Displacement of fiducials, their center of mass (CM) and self-consistency was calculated for each fraction. Additionally, the position of catheter tips and CTV’s relative to CM of fiducials were measured. The effects on dosimetric parameters such as dose covering 90% of high-risk CTV (D90), equivalent uniform BED (EUBED) and generalized biologically equivalent uniform dose (gBEUD) were compared for each fraction. 50 fiducials were tracked over 70 fractions. For a majority of patients (10 out of 15), the fiducial markers CM moved less than 0.2 cm. The positions of 278 catheters over the same fractions were measured relative to the fiducials CM and found to have an average interfractional movement of -0.06 +/- 0.31 cm. The CTV to needles interfractional shift was -0.09 +/- 0.36 cm. The average D90 for all fractions was 92.5 +/- 6.5% of the prescription dose (PD). The average gEUD across all patients was 1.57 +/- 0.19 and 18.44+/- 15.08 Gy/PD (a = -5 and 2, respectively). The average EUBED across all patients was 1.98+/- 0.16 and 2.43+/- 0.23 Gy/PD (α = 0.3 and 0.1, respectively). Volume integrated radiobiological metrics, gBEUD and EUBED showed very consistent effects for all implants. Center of mass for 3 or more markers seems a clinically acceptable reference for ensuring catheter tip and CTV positional interfractional reproducibility. Given the dose inhomogeneities accepted with HDR-ISBT, D90 is less sensitive than volume integrated metrics for describing the dose delivered. Combining the effects of a reproducibly accurate implant with unique identification of the importance of ‘hot’ sub-volumes is a promising method for improving patient outcomes with HDR-ISBT.

Safety and efficacy of a DKK1 inhibitor (DKN-01) as monotherapy or in combination with paclitaxel in patients with Wnt activated recurrent gynecologic malignancies

Safety and efficacy of a DKK1 inhibitor (DKN-01) as monotherapy or in combination with paclitaxel in patients with Wnt activated recurrent gynecologic malignancies

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

Utility of 18F-FDG-PET/CT imaging in patients with recurrent gynecological malignancies prior to pelvic exenteration.

In patients with recurrent gynecologic malignancies isolated to the pelvis, pelvic exenteration is a potential option. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT), is often used to confirm no evidence of metastatic disease. To assess the impact of PET/CT on clinical management of patients with recurrent gynecologic malignancies being considered for pelvic exenteration. Patients with recurrent gynecological malignancies who underwent PET/CT imaging between 2011 and 2014 were identified. All were considered for pelvic exenteration and underwent conventional imaging with CT +/- pelvic MRI. Patient anthropometric data, disease sites, histology, stage, treatment received, and treatment plan based on PET/CT findings were extracted. A total of 40 patients met inclusion criteria. In 15 (37.5%) of these patients, results of PET/CT changed the original plan of pelvic exenteration owing to metastatic disease/unresectability (11/15) or no evidence of disease on PET/CT imaging (4/15). Twenty-five (62.5%) patients had their planned surgery after PET/CT with 19 (76%) patients undergoing a completed exenteration procedure. Six (24%) patients with PET/CT indicating isolated pelvic recurrence ultimately had intra-operative findings of extra-pelvic metastasis or nodal disease and therefore the planned surgery was aborted. In nearly 40% of patients with recurrent gynecologic malignancies being considered for radical salvage surgery, PET/CT can significantly alter the originally intended treatment and hence may reduce the number of futile surgical procedures.

Pelvic exenteration for primary and recurrent rectal or gynecological malignancies: a meta-analysis

Pelvic exenteration for primary and recurrent rectal or gynecological malignancies: a meta-analysis

The impact of inter-fraction changes for perineal template-based interstitial gynecologic brachytherapy implants.

PurposePerineal template-based interstitial gynecologic brachytherapy (ISBT) treatments are evaluated to determine whether adaptive inter-fraction re-planning is beneficial and necessary to meet the treatment aims of the American Brachytherapy Society (ABS) consensus guidelines for interstitial brachytherapy. Adherence to the EMBRACE II protocol is also assessed.Material and methodsTen patients receiving radical intent treatment for locally advanced or recurrent gynecologic malignancies underwent a three-fraction ISBT treatment with an ABS-recommended prescription regimen of 21 to 24 Gy. Clinical treatment plans were created according to a computed tomography (CT) acquired immediately post-implant. The first fraction was delivered on the same day as the implant (Day 1). The remaining two fractions were delivered on the next day (Day 2), at least six hours apart. Prior to treating on Day 2, a verification CT was acquired, permitting assessment of over-night changes. The Day 2 CT was used to evaluate deviations in 2-Gy-per-fraction equivalent dose (EQD2) from the clinically intended dosimetry for clinical target volume (CTV), bladder, rectum, and sigmoid.ResultsFor all patients, the median (range) difference between the intended and the delivered dosimetry for the CTV D90% was 1.4 Gy10 (0.3-4.4 Gy10). For all normal tissues, the median (range) difference from the intended normal tissue dose was 2.6 Gy3 (0.1-15.5 Gy3). In all cases, the deviation from clinically intended dosimetry did not lead to a violation of recommended normal tissue dose guidelines. For two of 10 patients with large normal tissue differences (> 10 Gy3 from the intended dose), inter-fraction adaptive planning did improve the plan quality, but was not strictly required to meet the normal tissue dose planning aims.ConclusionsThe implementation of perineal template-based ISBT treatment without inter-fraction adaptive planning can be delivered to comply with the ABS normal tissue dose guidelines and EMBRACE II limits for prescribed dose.

Efficacy and safety of laparoscopic surgery in the management of recurrent gynecologic malignancies

Efficacy and safety of laparoscopic surgery in the management of recurrent gynecologic malignancies

Disparities in access to palliative care for patients treated for gynecologic oncology.

136 Background: Palliative care intends to improve quality of life for patients with life-threatening illness, but ethnic and linguistic minority patients have worse outcomes with palliative care. Methods: This is a single institution retrospective chart review of patients with an advanced stage or recurrent gynecologic malignancy who were seen in the clinic from 2010 to 2015. Women were defined as being from a minority group if they met one of the inclusion criteria including English not the primary language, race other than white, ethnically Hispanic/Latina, or their country of origin was not the United States. We then compared rates of referral to palliative care between those women who were deemed to be minority women as compared to those who were non-minority. We also compared the time to referral between these two groups. Results: Our study included 277 women of which 20% were categorized as minority. Demographic data between the two groups were well matched with the exception that minority women were diagnosed at a younger age and were more likely to have cervical cancer. Although not statistically significant, more minority women were referred to palliative care than non-minority (79% vs. 89%, p=0.08). In contrast, fewer minority patients were referred to palliative care at least 3 months prior to death when compared to non-minority patients (50% vs. 38%, p =0.10). There was no difference between referral location [inpatients (35% vs. 36%) and outpatients (65% vs. 64%, p=.92)] in minority versus non-minority patients. There was also no significant difference in those patients entering hospice while admitted to the hospital. Minority patients had significantly more cancer-related hospitalizations per year (0.6 vs 1.0, p value 0.02). Conclusions: Our study shows that there is a tendency towards later referral to palliative care for minority patients as compared to non-minority patients. Although more minority patients are referred to palliative care, they are hospitalized for cancer related symptoms at a significantly higher rate suggesting that perhaps their utilization of palliative care services is suboptimal.

The effect of art therapy on the quality of life in patients with a gynecologic cancer receiving chemotherapy

ObjectivesMost art therapy research has involved patients with malignancies other than gynecologic cancer. The current study aimed to assess the impact of an art therapy intervention on the quality of life (QOL) in patients with gynecologic cancer who were receiving chemotherapy. MethodsThis was a prospective, non-randomized, pilot study. Eligible patients had a primary or recurrent gynecologic malignancy scheduled to be treated with at least 6 cycles of chemotherapy over 18 weeks. The intervention consisted of five sessions of art therapy during the chemotherapy. Patients completed a Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire prior to starting chemotherapy, and again at completion of the fifth session. Differences between the FACT-G scores were examined by paired t-tests. An increase in the mean FACT-G score indicated an improvement in QOL. At each session, the patients completed a separate, supplemental questionnaire to subjectively rate the benefit of the session and to express their experience with the art intervention. ResultsTwenty-four patients enrolled. Eight did not complete the study, leaving 16 evaluable patients. The mean FACT-G score pre-chemotherapy was 82.3 (95% CI: 75.5, 89.2), and post-art therapy was 78.6 (95% CI: 71.7, 85.5). The mean change in QOL was −3.7 points (95% CI: −10.7, 3.2, p = 0.270). A supplemental questionnaire indicated that 15 of 16 patients felt that art therapy was beneficial at each session. ConclusionsFACT-G scores did not significantly change over the course of chemotherapy in patients with gynecologic cancers receiving art therapy. Several published studies have indicated that chemotherapy is associated with a decline in QOL. Our results suggest art therapy may help to prevent or mitigate this decline.

Inversely and adaptively planned interstitial brachytherapy: A single implant approach

ObjectiveTo evaluate the efficacy, feasibility and safety of image-based, inversely and adaptively planned high-dose rate interstitial brachytherapy (HDR-ISBT) to treat advanced primary or recurrent gynecologic malignancy in a single implant, three-consecutive-day regimen. MethodsClinical demographics and outcome data were abstracted from all patients with primary and recurrent gynecologic malignancies who received HDR-ISBT boost from 2014 to 2017. Treatment consisted of a single implant (~7 Gy × 4 fractions) of interstitial needles using the Syed-Neblett template over a three-day hospital admission. CT-based (3D) simulation with inverse and adaptive planning was utilized for each fraction. MR prior to and MR immediately after external beam therapy were fused for HDR-ISBT target delineation. ResultsForty women with an overall median follow-up of 18 months (range: 6–54 months) received an HDR-ISBT boost. Of the 30 primary cases (83% cervix, 10% vaginal, 7% uterine), 44% had organ invasion (bladder, rectal or both) on MRI. Median coverage and dose are reported (V100: 98%, HR-CTV EQD2: 85.1 Gy, D90: 92 Gy). A significant association existed between rectal doses exceeding GEC-ESTRO recommendations (D2cc < 75 Gy) and the development of grade 3 gastrointestinal toxicity with a relative risk of 1.4 [1.1–1.8] (p = .046). Actuarial two-year overall survival (OS), local control (LC) and progression-free survival (PFS) were 81%, 81% and 64%, respectively. ConclusionsA four fraction, inversely and adaptively planned, single-implant approach of image-based HDR-ISBT provides excellent coverage, minimal toxicity and effective local control in patients with advanced and recurrent disease.