Interdisziplinäre operative Tumortherapie: Pelvine Exenterationen bei rezidivierenden oder fortgeschrittenen gynäkologischen Tumoren

Pelvic exenteration (PE) is an ultima ratio procedure performed for advanced or recurrent carcinomas of the female reproductive organs. Far advanced or recurrent gynecologic malignancies are known to have a poor prognosis, especially when the tumor infiltrates adjacent organs or, in the case of recurrence, when patients have been previously treated with multiple therapies. Surgery includes resection of the female reproductive organs as well as the bladder (anterior PE) and/or the rectum (posterior PE). The procedure requires a pronounced expertise of the interdisciplinary team (consisting of physicians from gynecology, urology and visceral surgery) as well as a careful patient selection. Mainly for these reasons, it is rarely performed. Because of overall low case numbers, most single-center studies either evaluated data from relatively small patient cohorts or specified overall long data collection periods. The aim of this study was to evaluate the morbidity and mortality rates of the procedure at the University Hospital Giessen Marburg (UKGM, Marburg) and to identify possible influencing factors. For this study, data from 47 patients who had undergone PE at Marburg University Hospital between 2011 and 2016 were retrospectively analyzed. Demographic criteria (such as age, BMI), histopathologic features, pre-, intra-, and postoperative parameters, and postoperative complication rates were collected. Survival analysis was performed using data from the CCC Marburg (Comprehensive Cancer Center). The cumulative dissertation presented here includes two publications. In the first publication entitled "Pelvic exenteration for recurrent or advanced gynecologic malignancies - Analysis of outcome and complications " the results of the overall data collection were published and discussed. PE was conducted in 51.1% of cases due to cervical carcinoma. Other indications for PE were carcinoma of the vagina (17%), vulva (10.6%), endometrium (8.5%), ovary (4.3%), and uterus (2.1%). 1, 2, or 3 different prior treatment modalities had been received by 12.8%, 38.8%, and 21.2% of patients respectively. An ileum conduit was the predominant urinary diversion (75.5%). Serious complications (Clavien-Dindo ≥ III) were noted in 40.4% of cases, no complications were observed in 19.2% of cases. Early mortality rate was 4.3%. Median overall survival (mOS) was 14 months. The 2- and 3-year survival rates for the entire cohort were 38.8% and 21.2% respectively. Overall survival was 25.5% with a median follow-up time of 47 months. In patients without metastatic disease, the mOS was 20.6 months with 2- and 3-year survival rates of 46% and 35.2%, respectively. Overall survival in patients with R1 status was significantly worse (p=0.003). Having received neoadjuvant therapy (25.5%) correlated with R0 status (p=0.013), however it did not correlate with overall survival. The long-term data presented here, especially the acceptable complication rate as well as survival data, are remarkable considering the extent of the tumors operated and the fact that they usually have to be considered as out of therapy. The second publication, entitled "Palliative Surgical Therapy for Advanced Tumors in the Genital Area [Title in German originally]" focuses primarily on the surgical procedure itself and its’ palliative character. In these cases, the goal of the operation is local tumor control and thus the prevention of fistula or even cloacal formation through tumor destruction. It could be shown that PE is a possible and viable approach to symptom control in metastasized cases.