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European Journal of Surgical Oncology :... Aug 2015Pelvic exenteration requires complete resection of the tumor with negative margins to be considered a curative surgery. The purpose of this review is to assess the... (Review)
Review
OBJECTIVE
Pelvic exenteration requires complete resection of the tumor with negative margins to be considered a curative surgery. The purpose of this review is to assess the optimal preoperative evaluation and surgical approach in patients with recurrent cervical cancer to increase the chances of achieving a curative surgery with decreased morbidity and mortality in the era of concurrent chemoradiotherapy.
METHODS
Review of English publications pertaining to cervical cancer within the last 25 years were included using PubMed and Cochrane Library searches.
RESULTS
Modern imaging (MRI and PET-CT) does not accurately identify local extension of microscopic disease and is inadequate for preoperative planning of extent of resection. Today, only half of pelvic exenteration procedures obtain uninvolved surgical margins.
CONCLUSION
Clear margins are required for curative pelvic exenterations, but are poorly predictable by pre-operative assessment. More extensive surgery, i.e. the infra-elevator exenteration with vulvectomy, is a logical surgical choice to increase the rate of clear margins and to improve patient survival following surgery for recurrent cervical carcinoma.
Topics: Chemoradiotherapy; Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Uterine Cervical Neoplasms
PubMed: 25922209
DOI: 10.1016/j.ejso.2015.03.235 -
Zhonghua Fu Chan Ke Za Zhi Jun 2014To evaluate the current status and outcomes of pelvic exenteration (PE) for recurrent cervical cancer. (Review)
Review
OBJECTIVE
To evaluate the current status and outcomes of pelvic exenteration (PE) for recurrent cervical cancer.
METHODS
The following electronic databases has been searched on recurrent cervical cancer management and treatment:Chinese Biological Medicine Disk (CBM), PubMed and Cochrane library. All retrieved studies had to fulfill the following inclusion criteria: cohort studies of recurrent cervical cancer, containing information of detailed patient and operation characteristics as well as the survival rate. Only publications in the English literature were included. All eligible literatures between Jan. 1990 and Aug. 2013 were assessed for quality. Relevant basic characteristics, complications, survival rate and prognostic factors were reviewed.
RESULTS
There were eight trials involving 607 patients with cervical cancer received PE, including 515 cases with recurrent disease and 92 cases with primary disease. Four hundred and ninety patients had received total pelvic exenteration (TPE) operation, 103 underwent anterior pelvic exenteration (APE) and 14 received posterior pelvic exenteration (PPE). The 5-year overall survival rate for recurrent cervical cancer fluctuate from 26.7% to 56.0%. Complication rates were from 34.3% to 83.3% and the mortality rate was 1.2% (7/607). Among the relevant factors affecting survival time, resection margin status seemed to be the most important.
CONCLUSION
Based on this systematic review, PE does help improve the survival of recurrent cervical cancer patients on the basis of strict selection of candidates.
Topics: Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Survival Analysis; Survival Rate; Uterine Cervical Neoplasms
PubMed: 25169641
DOI: No ID Found -
The Cochrane Database of Systematic... Feb 2014Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common... (Review)
Review
BACKGROUND
Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common cancers in women. Unfortunately, given the nature of the disease, cancer can recur or progress in some patients. Although the management of early-stage cancers is relatively straightforward, with lower associated morbidity and mortality, the surgical management of advanced and recurrent cancers (including persistent or progressive cancers) is significantly more complicated, often requiring very extensive procedures. Pelvic exenterative surgery involves removal of some or all of the pelvic organs. Exenterative surgery for persistent or recurrent cancer after initial treatment is difficult and is usually associated with significant perioperative morbidity and mortality. However, it provides women with a chance of cure that otherwise may not be possible. In carefully selected patients, it may also have a place in palliation of symptoms. The biology of recurrent ovarian cancer differs from that of other gynaecological cancers; it is often responsive to chemotherapy and is not included in this review.
OBJECTIVES
To evaluate the effectiveness and safety of exenterative surgery versus other treatment modalities for women with recurrent gynaecological cancer, excluding recurrent ovarian cancer (this is covered in a separate review).
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of clinical guidelines and review articles and contacted experts in the field.
SELECTION CRITERIA
Randomised controlled trials (RCTs) or non-randomised studies with concurrent comparison groups that included multivariate analyses of exenterative surgery versus medical management in women with recurrent gynaecological malignancies.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No studies were found; therefore no data were analysed.
MAIN RESULTS
The search strategy identified 1311 unique references, of which seven were retrieved in full, as they appeared to be potentially relevant on the basis of title and abstract. However, all were excluded, as they did not meet the inclusion criteria of the review.
AUTHORS' CONCLUSIONS
We found no evidence to inform decisions about exenterative surgery for women with recurrent cervical, endometrial, vaginal or vulvar malignancies. Ideally, a large RCT or, at the very least, well-designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances are needed to compare exenterative surgery versus medical management, including palliative care.
Topics: Adult; Female; Genital Neoplasms, Female; Humans; Neoplasm Recurrence, Local; Pelvic Exenteration
PubMed: 24497188
DOI: 10.1002/14651858.CD010449.pub2 -
Health Technology Assessment... Mar 2013Cancer of the uterine cervix is a common cause of mortality in women. After initial treatment women may be symptom free, but the cancer may recur within a few years. It... (Review)
Review
Positron emission tomography/computerised tomography imaging in detecting and managing recurrent cervical cancer: systematic review of evidence, elicitation of subjective probabilities and economic modelling.
BACKGROUND
Cancer of the uterine cervix is a common cause of mortality in women. After initial treatment women may be symptom free, but the cancer may recur within a few years. It is uncertain whether it is more clinically effective to survey asymptomatic women for signs of recurrence or to await symptoms or signs before using imaging.
OBJECTIVES
This project compared the diagnostic accuracy of imaging using positron emission tomography/computerised tomography (PET-CT) with that of imaging using CT or magnetic resonance imaging (MRI) alone and evaluated the cost-effectiveness of adding PET-CT as an adjunct to standard practice.
DATA SOURCES
Standard systematic review methods were used to obtain and evaluate relevant test accuracy and effectiveness studies. Databases searched included MEDLINE, EMBASE, Science Citation Index and The Cochrane Library. All databases were searched from inception to May 2010.
REVIEW METHODS
Study quality was assessed using appropriately modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. Included were any studies of PET-CT, MRI or CT compared with the reference standard of histopathological findings or clinical follow-up in symptomatic women suspected of having recurrent or persistent cervical cancer and in asymptomatic women a minimum of 3 months after completion of primary treatment. Subjective elicitation of expert opinion was used to supplement diagnostic information needed for the economic evaluation. The effectiveness of treatment with chemotherapy, radiotherapy, chemoradiotherapy, radical hysterectomy and pelvic exenteration was systematically reviewed. Meta-analysis was carried out in RevMan 5.1 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark) and Stata version 11 (StataCorp LP, College Station, Texas, USA). A Markov model was developed to compare the relative cost-effectiveness using TreeAge Pro software version 2011 (TreeAge Software Inc., Evanston, IL, USA).
RESULTS
For the diagnostic review, a total of 7524 citations were identified, of which 12 test accuracy studies were included in the review: six studies evaluated PET-CT, two evaluated MRI, three evaluated CT and one evaluated both MRI and CT. All studies were small and the majority evaluated imaging in women in whom recurrence was suspected on the basis of symptoms. The PET-CT studies evaluated local and distant recurrence and most used methods similar to current practice, whereas five of the six CT and MRI studies evaluated local recurrence only and not all employed currently used methods. Meta-analysis of PET-CT studies gave a sensitivity of 92.2% [95% confidence interval (CI) 85.1% to 96.0%] and a specificity of 88.1% (95% CI 77.9% to 93.9%). MRI sensitivities and specificities varied between 82% and 100% and between 78% and 100%, respectively, and CT sensitivities and specificities varied between 78% and 93% and between 0% and 95%, respectively. One small study directly compared PET-CT with older imaging methods and showed more true-positives and fewer false-negatives with PET-CT. The subjective elicitation from 21 clinical experts gave test accuracy results for asymptomatic and symptomatic women and the results for symptomatic women were similar to those from the published literature. Their combined opinions also suggested that the mean elicited increase in accuracy from the addition of PET-CT to MRI and/or CT was less than the elicited minimum important difference in accuracy required to justify the routine addition of PET-CT for the investigation of women after completion of primary treatment. For the effectiveness review, a total of 24,943 citations were identified, of which 62 studies were included (chemotherapy, 19 randomised controlled trials; radiotherapy or chemoradiotherapy, 16 case series; radical hysterectomy and pelvic exenteration, 27 case series). None provided the effectiveness of cisplatin monotherapy, the most commonly used chemotherapeutic agent in the NHS, compared with supportive care in a background of other treatment such as radiotherapy in recurrent and persistent cervical cancer. The model results showed that adding PET-CT to the current treatment strategy of clinical examination, MRI and/or CT scan was significantly more costly with only a minimal increase in effectiveness, with incremental cost-effectiveness ratios for all models being > £1M per quality-adjusted life-year (QALY) and the additional cost per additional case of recurrence being in the region of £600,000.
LIMITATIONS
There was considerable uncertainty in many of the parameters used because of a lack of good-quality evidence in recurrent or persistent cervical cancer. The evidence on diagnostic and therapeutic impact incorporated in the economic model was poor and there was little information on surveillance of asymptomatic women.
CONCLUSIONS
Given the current evidence available, the addition of PET-CT to standard practice was not found to be cost-effective in the diagnosis of recurrent or persistent cervical cancer. However, although probabilistic sensitivity analysis showed that the main conclusion about cost-ineffectiveness of PET-CT was firm given the range of assumptions made, should more reliable information become available on accuracy, therapeutic impact and effectiveness, and the cost of PET-CT reduce, this conclusion may need revision. Current guidelines recommending imaging for diagnosis using expensive methods such as PET-CT need to be reconsidered in the light of the above.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Asymptomatic Diseases; Chemoradiotherapy; Cost-Benefit Analysis; Female; Humans; Hysterectomy; Magnetic Resonance Imaging; Models, Economic; Multimodal Imaging; Pelvic Exenteration; Positron-Emission Tomography; Quality-Adjusted Life Years; Recurrence; Sensitivity and Specificity; State Medicine; Survival Analysis; Tomography, X-Ray Computed; United Kingdom; Uterine Cervical Neoplasms
PubMed: 23537558
DOI: 10.3310/hta17120 -
Diseases of the Colon and Rectum Apr 2013Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer. (Review)
Review
BACKGROUND
Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer.
OBJECTIVE
This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration.
DATA SOURCES
A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified.
STUDY SELECTION
Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination.
MAIN OUTCOME MEASURES
Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates.
RESULTS
A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer.
LIMITATIONS
Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported.
CONCLUSIONS
Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.
Topics: Humans; Neoplasm Recurrence, Local; Pelvic Exenteration; Postoperative Complications; Rectal Neoplasms
PubMed: 23478621
DOI: 10.1097/DCR.0b013e31827a7868