5-YEAR EXPERIENCE WITH COMBINED OPERATIVE AND RADIOTHERAPEUTIC TREATMENT OF RECURRENT GYNECOLOGIC TUMORS INFILTRATING THE PELVIC WALL

BACKGROUND. Whereas 25 to 50% of selected patients with gynecologic tu mors who relapse centrally in an irradiated pelvis can be salvaged by exenteration, postirradiation recurrence infiltrating the pelvic side wall generally has been fatal. We have designed the combined operative and radiotherapeutic treatment (CORT) procedure for the treatment of postirradiation recurrence infiltrating the pelvic wall and developed several new techniques for its realization. The aim of the surgery is as follows: (1) total resection of the tumor with only a microscopic m argin (R1) at the pelvic wall, preserving the bony pelvis and the neur ovascular support of the leg; (2) modulation of the therapeutic index for a second high-dose irradiation of the pelvic wall by transferring autologous tissue from the abdomen or the thigh, and (3) reconstructio n of pelvic organ functions lost due to tumor resection. The tumor bed is irradiated postoperatively with brachytherapy through transcutaneo us guide tubes implanted at the pelvic wall. METHODS, Between April 19 89 and December 1994, we treated 48 patients with postirradiation recu rrent or persistent gynecologic malignancies infiltrating the pelvic w all with CORT and followed them prospectively with the following endpo ints: tumor control, survival, complications, and quality of life. RES ULTS. At a median follow-up of 33 months (range, 3-71 months), the 5-y ear survival probability calculated with the Kaplan-Meier method was 4 4%. The overall local control rate was 68%, and 85% in the last 25 pat ients in the series. The censored severe complication rate at 5 years was 33%. No patient died as a consequence of the treatment. Quality of life was self-assessed with a validated questionnaire by 15 patients without evidence of disease, and was rated with a total of 74% of the maximum score points. Age of the patient, state of resection at the pe lvic wall (R1 vs. R2), and recurrent tumor size independently influenc ed tumor progression after CORT in this series. CONCLUSIONS, CORT appe ars to be a feasible, innovative treatment with long term survival pot ential and acceptable quality of life for selected patients with posti rradiation gynecologic tumor recurrence infiltrating the pelvic wall. R1 resection of the tumor at the pelvic wall is mandatory; however, th e reconstruction options within the pelvis are limited.