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The British Journal of Radiology 2016Our objective is to describe an approach for retrorectal/presacral mass evaluation on imaging with attention to imaging features, allowing for refinement of the... (Review)
Review
Our objective is to describe an approach for retrorectal/presacral mass evaluation on imaging with attention to imaging features, allowing for refinement of the differential diagnosis of these masses. Elaborate on clinically relevant features that may affect biopsy or surgical approach, of which the radiologist should be aware. A review of current literature regarding the diagnosis and treatment of retrorectal/presacral masses was performed with attention to specific findings, which may lend refinement to the differential diagnosis of these masses. Cases were obtained by searching through a radiology database at a single institution after Institutional Review Board approval. Recent advances in imaging and treatment methods have led to the increased role of radiology in both imaging and tissue diagnosis of retrorectal masses. Surgical philosophies surrounding the treatment of these masses have not significantly changed in recent years, but there are a few key factors of which the radiologist must be aware. The radiologist can offer refinement of the differential diagnosis of retrorectal masses and can elaborate on salient findings which could alter the need for neoadjuvant chemoradiation therapy, pre-surgical tissue diagnosis and surgical approach. This article presents an imaging approach to retrorectal/presacral masses with emphasis on findings which can dictate the ultimate need for neoadjuvant therapy and pre-surgical tissue diagnosis and alter the preferred surgical approach. This article consolidates key findings, so radiologists can become more clinically relevant in the evaluation of these masses.
Topics: Diagnosis, Differential; Humans; Magnetic Resonance Imaging; Pelvic Neoplasms; Sacrococcygeal Region; Tomography, X-Ray Computed
PubMed: 26828969
DOI: 10.1259/bjr.20150698 -
The American Journal of Surgical... Aug 2015Extrapulmonary lymphangioleiomyomatosis (LAM) is a rare neoplasm of spindle cells exhibiting melanocytic and myoid differentiation that arises as a mass in the...
Incidental Pelvic and Para-aortic Lymph Node Lymphangioleiomyomatosis Detected During Surgical Staging of Pelvic Cancer in Women Without Symptomatic Pulmonary Lymphangioleiomyomatosis or Tuberous Sclerosis Complex.
Extrapulmonary lymphangioleiomyomatosis (LAM) is a rare neoplasm of spindle cells exhibiting melanocytic and myoid differentiation that arises as a mass in the mediastinum, retroperitoneum, uterine wall, and/or intraperitoneal lymph nodes. Many patients also have pulmonary LAM, tuberous sclerosis complex (TSC), and/or other neoplasms of the perivascular epithelioid cell tumor family. This study reports 26 patients with clinically occult LAM involving pelvic/para-aortic lymph nodes removed from women undergoing surgical staging of a uterine (17), ovarian (5), cervical (3), or urinary bladder (1) neoplasm. None of the patients exhibited symptoms of pulmonary LAM, and the median patient age (56 y) was older than what would be expected for patients presenting with pulmonary LAM. Only 2/26 patients had TSC. Four patients also had uterine LAM. One of these 4 had uterine perivascular epithelioid cell tumor, and 1 had vaginal angiomyolipoma. In all 26 patients the lymph node LAM was grossly occult, measured 3.5 mm on average (1 to 19 mm), and involved either a single lymph node (12/26) or multiple lymph nodes (14/26). HMB45 was positive in 24/25 cases, mostly in a focal or patchy distribution. Other melanocytic markers included MiTF (12/14) and MelanA (2/12). Myoid markers included smooth muscle actin (23/23) and desmin (15/16), mostly in a diffuse distribution. Estrogen receptor was positive in all cases tested, as was D240 expression in the lymphatic endothelium lining the spindle cell bundles. Concurrent findings in the involved lymph nodes included metastatic carcinoma (3/26), endosalpingiosis (3/26), and reactive lymphoid hyperplasia (13/26). This study demonstrates that clinically occult lymph node LAM can be detected during surgical staging of pelvic cancer and is not commonly associated with pulmonary LAM or TSC, although these patients should still be formally evaluated for both of these diseases.
Topics: Adult; Aged; Biomarkers, Tumor; Biopsy; Female; Humans; Immunohistochemistry; Incidental Findings; Lymph Node Excision; Lymph Nodes; Lymphangioleiomyomatosis; Middle Aged; Neoplasm Staging; Pelvic Neoplasms; Predictive Value of Tests; Tuberous Sclerosis
PubMed: 25786086
DOI: 10.1097/PAS.0000000000000416 -
Khirurgiia 2022To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical...
OBJECTIVE
To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical practice.
MATERIAL AND METHODS
The study included 111 patients with pelvic tumors who underwent extended pelvic surgery. The control group included 59 patients whose perioperative management implied traditional approaches (2018-2019), the main group - 52 patients with FTS protocol (2020-2021). Age, BMI and ECOG status were similar. In the main group, females (90.4% vs. 74.6%; =0.046), patients with recurrent (46.2% vs. 22.0%; =0.009) and complicated tumors (26.9% vs. 11.9%; =0.054) prevailed. Obstructive resection without anastomosis was less common in the main group (28.8% vs. 47.5%; =0.068).
RESULTS
Surgery time was higher (319±125 min vs. 236±79 min, <0.001) in the main group, but blood loss (238±154 ml vs. 282±150 ml, =0.029) and incidence of blood transfusions (23.1% vs. 42.4%, =0.043) were lower. Moreover, complications (36.6% vs. 54.3%; =0.086), mild complications (Clavien-Dindo class I-II) (11.6% vs. 28.8%; =0.034) and local infectious complications (19.2% vs. 42.4%; =0.009) were less common in the main group. Two patients died in the control group due to sepsis following colonic anastomosis and bladder suture failure, respectively. Postoperative hospital-stay was similar (14±9.1 days vs. 14.4±9 days; =0.89).
CONCLUSION
FTS protocol is possible and safe in patients with locally advanced and recurrent malignant pelvic tumors. This approach reduces blood loss, the number of blood transfusions and risk of postoperative infections.
Topics: Female; Humans; Pelvic Neoplasms; Neoplasm Recurrence, Local; Postoperative Complications; Perioperative Care; Incidence; Length of Stay; Treatment Outcome
PubMed: 36562674
DOI: 10.17116/hirurgia202212259 -
Asian Journal of Surgery Sep 2017In locally advanced pelvic malignancies, there is often involvement of urological organs, necessitating resection and reconstruction, which can be associated with...
BACKGROUND
In locally advanced pelvic malignancies, there is often involvement of urological organs, necessitating resection and reconstruction, which can be associated with significant complications.
METHODS
We retrospectively reviewed 20 patients undergoing urological reconstructions during pelvic oncological surgeries from January 2004 to December 2013. All patients had imaging-proven involvement of at least one urological organ preoperatively. Primary outcome was urological complication rate. Secondary outcomes were nonurological complication, recurrence rate, and overall survival.
RESULTS
Median age of presentation was 51 years. Six and 14 patients underwent resections for primary and secondary tumors, respectively. Colorectal tumors were the most common, followed by gynecological cancers. The ureter was the most common urological organ involved, followed by the bladder, prostate, and seminal vesicles. Reconstructive procedures included ileal and sigmoid conduits, ureteroneocystostomies, Boari flap, transureteroureterostomies (TUUs) and direct ureteroureterostomies. Six patients developed major urological complications, requiring endoscopic and surgical reinterventions. The follow-up time was 34 months. Thirteen patients developed recurrence, associated with higher tumor grade and lymphovascular invasion, and occurred at a median time of 10 months. These patients had an overall survival of 20 months, compared to 45 months in patients without recurrence.
CONCLUSION
Careful patient selection in pelvic oncological surgeries can significantly prolong survival. Recurrent tumors and greater intraoperative blood loss are associated with higher urological complications. A limited pelvic exenteration and lower radiation doses can reduce complication rates. If higher doses are necessary, conformal techniques and hyperfractionated radiotherapy should be explored. Urological reconstruction should be individualized, according to the extensiveness of urological involvement and exposure of radiation.
Topics: Adult; Aged; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies; Survival Rate; Urologic Neoplasms; Urologic Surgical Procedures
PubMed: 27317102
DOI: 10.1016/j.asjsur.2016.02.002 -
Sentinel Lymph Node Biopsy in Pelvic Tumors: Clinical Indications and Protocols Under Investigation.Clinical Nuclear Medicine Jun 2016Sentinel lymph node (SLN) sampling is an attractive alternative to complete lymphadenectomy. Based on the identification and sampling of the first LN draining a primary... (Review)
Review
Sentinel lymph node (SLN) sampling is an attractive alternative to complete lymphadenectomy. Based on the identification and sampling of the first LN draining a primary tumor, SLN biopsy is the most accurate and the only reliable method for microscopic nodal staging for solid tumors including breast cancer and melanoma. Lymph node status in pelvic tumors remains the most important prognostic factor for recurrence and survival and a major decision criterion for adjuvant therapy. We review the clinical indications, controversies, and perspective of SLN biopsy in male and female pelvic cancers.
Topics: Diagnostic Imaging; Humans; Pelvic Neoplasms; Preoperative Period; Sentinel Lymph Node Biopsy
PubMed: 26914577
DOI: 10.1097/RLU.0000000000001184 -
Journal of Surgical Oncology Jan 2018In this review, we first address the anatomic and technical considerations in the resection of pelvic soft tissue tumors, including the challenges unique to these... (Review)
Review
In this review, we first address the anatomic and technical considerations in the resection of pelvic soft tissue tumors, including the challenges unique to these tumors, such as the narrow anatomic confines of the bony pelvis, the often locally aggressive nature of these tumors, as well as the major functional deficits that may result from their resection. We then review the optimal, multidisciplinary, histology-driven treatment approach to pelvic tumors.
Topics: Humans; Pelvic Neoplasms; Soft Tissue Neoplasms
PubMed: 29266252
DOI: 10.1002/jso.24943 -
International Journal of Gynecological... Jan 2019To demonstrate a robotic-assisted psoas hitch with ureteral reimplantation.
OBJECTIVE
To demonstrate a robotic-assisted psoas hitch with ureteral reimplantation.
METHODS
We gleaned video footage from a robotic-assisted psoas hitch procedure performed for a patient with an isolated pelvic recurrence of ovarian cancer.
RESULTS
We demonstrate trocar placement and a robotic-arm docking strategy for pelvic recurrence of ovarian cancer. We also show surgical steps involved in a psoas hitch and reimplantation of a transected ureter into the bladder. Special emphasis is placed on guiding the surgeon using key robotic instruments and materials to optimize the robotic completion of this procedure. Key components of the procedure, including en bloc tumor excision and ureteral transection, are shown. The bladder is placed on traction using the fourth arm, and the avascular planes of dissection, including the space of Retzius and the paravesical spaces, are shown. The bladder is then backfilled to allow the surgeon to determine the ideal placement of the ureteral reimplantation to ensure the anastomosis is tension free. The surgeon then demonstrates where and how to place anchoring sutures from the bladder to the psoas muscle. The ureter is examined to determine where it can be implanted in the bladder with zero tension or angulation, which would compromise function and healing. The ureter is prepared for reimplantation, including trimming, tagging, and spatulation. An instrument tie technique is used to implant the ureter into the bladder and a ureteral stent is placed. Robotic-assisted psoas hitch with ureteral reimplantation has been described in the literature.1-4 CONCLUSIONS: Through the use of still photographs and video, we demonstrate the technique of robotic-assisted psoas hitch with ureteral reimplantation.
Topics: Female; Humans; Neoplasm Recurrence, Local; Ovarian Neoplasms; Pelvic Neoplasms; Prognosis; Psoas Muscles; Replantation; Robotic Surgical Procedures; Ureter; Video-Assisted Surgery
PubMed: 30640709
DOI: 10.1136/ijgc-2018-000009 -
Oncology 2017Surgical staging is associated with a significant rate of upstaging compared to clinical/radiological staging in patients with locally advanced cervical cancer. (Randomized Controlled Trial)
Randomized Controlled Trial
Incidence of Histologically Proven Pelvic and Para-Aortic Lymph Node Metastases and Rate of Upstaging in Patients with Locally Advanced Cervical Cancer: Results of a Prospective Randomized Trial.
BACKGROUND
Surgical staging is associated with a significant rate of upstaging compared to clinical/radiological staging in patients with locally advanced cervical cancer.
OBJECTIVE
To analyze the stage-specific percentage of pelvic and para-aortic lymph node metastases and the upstaging ratio in a prospective randomized trial (Uterus-11).
METHODS
FIGO stage IIB-IVA cervical cancer patients were randomized to surgical staging (arm A) or to clinical staging and primary chemoradiation (arm B). Arm B patients underwent CT-guided biopsy of suspicious para-aortic lymph nodes. Confirmed para-aortic metastasis patients received extended-field radiation therapy.
RESULTS
A total of 234 patients were enrolled, including 120 (arm A) and 114 (arm B) treated per protocol. The groups were well balanced. Pelvic and para-aortic lymph node metastases were identified after surgical staging in 51 and 24% of patients, respectively (p < 0.001). Pelvic and para-aortic lymph node metastases were confirmed in 45 and 20% of IIB patients and in 71 and 37% of IIIB patients, respectively. Upstaging occurred in 39/120 (33%) in arm A and in 9/114 (8%) in arm B (p < 0.001).
CONCLUSION
The histological results in both groups led to a considerable rate of upstaging. Oncological data from the Uterus-11 study may reveal whether modified therapy translates into a survival benefit.
Topics: Adult; Aged; Aorta; Female; Humans; Lymphatic Metastasis; Middle Aged; Pelvic Neoplasms; Prospective Studies; Tomography, X-Ray Computed; Uterine Cervical Neoplasms; Young Adult
PubMed: 28142146
DOI: 10.1159/000453666 -
The British Journal of Surgery Sep 2019Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the...
BACKGROUND
Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery.
METHODS
Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay.
RESULTS
There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved.
CONCLUSION
Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.
Topics: Analysis of Variance; Blood Loss, Surgical; Critical Care; Female; Humans; Kaplan-Meier Estimate; Length of Stay; Male; Middle Aged; Neoplasm Recurrence, Local; Operative Time; Patient Readmission; Pelvic Exenteration; Pelvic Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 31282571
DOI: 10.1002/bjs.11203 -
Role of pelvic and para-aortic lymphadenectomy in abandoned radical hysterectomy in cervical cancer.World Journal of Surgical Oncology Jan 2017Cervical cancer (CC) occupies fourth place in cancer incidence and mortality worldwide in women, with 560,505 new cases and 284,923 deaths per year. Approximately, nine...
BACKGROUND
Cervical cancer (CC) occupies fourth place in cancer incidence and mortality worldwide in women, with 560,505 new cases and 284,923 deaths per year. Approximately, nine of every ten (87%) take place in developing countries. When a macroscopic nodal involvement is discovered during a radical hysterectomy (RH), there is controversy in the literature between resect macroscopic lymph node compromise or abandonment of the surgery and sending the patient for standard chemo-radiotherapy treatment. The objective of this study is to compare the prognosis of patients with CC whom RH was abandoned and bilateral pelvic lymphadenectomy and para-aortic lymphadenectomy was performed with that of patients who were only biopsied or with removal of a suspicious lymph node, treated with concomitant radiotherapy/chemotherapy in the standard manner.
METHODS
A descriptive and retrospective study was conducted in two institutions from Mexico and Colombia. Clinical records of patients with early-stage CC programmed for RH with an intraoperative finding of pelvic lymph, para-aortic nodes, or any extracervical involvement that contraindicates the continuation of surgery were obtained. Between January 2007 and December 2012, 42 clinical patients complied with study inclusion criteria and were selected for analysis.
RESULTS
In patients with CC whom RH was abandoned due to lymph node affectation, there is no difference in overall survival or in disease-free period between systematic lymphadenectomy and tumor removal or lymph node biopsy, in pelvic lymph nodes as well as in para-aortic lymph nodes, when these patients receive adjuvant treatment with concomitant radiotherapy/chemotherapy.
CONCLUSIONS
This is a hypothesis-generator study; thus, the recommendation is made to conduct randomized prospective studies to procure better knowledge on the impact of bilateral pelvic and para-aortic lymphadenectomy on this group of patients.
Topics: Adenocarcinoma; Adult; Aorta; Carcinoma, Squamous Cell; Female; Follow-Up Studies; Humans; Hysterectomy; Immunoenzyme Techniques; Lymph Node Excision; Middle Aged; Neoplasm Grading; Neoplasm Staging; Pelvic Neoplasms; Prognosis; Retrospective Studies; Survival Rate; Uterine Cervical Neoplasms
PubMed: 28088221
DOI: 10.1186/s12957-016-1067-2