Objective. We describe the clinical presentation, evaluation, management, a
nd outcome of patients experiencing sigmoid perforation following radiation
therapy for cervical cancer.
Methods. A database consisting of over 5000 patients with stage IB-IIIB cer
vix cancer treated between 1963 and 1992 revealed 35 patients with sigmoid
perforation. Twenty-seven were diagnosed and managed at one institution, an
d they form the study group.
Results. The median age at the time of perforation was 50 years, and the me
dian follow-up care was 78 months (range 6-396). The median time from compl
etion of radiotherapy to perforation was 13 months (range 3-98). The mean i
nterval from the first documented complaint to the index admission was 90 d
ays. Nine (33%) of 27 patients were treated with high-dose radiation therap
y. The most common complaint was abdominal pain in 25 (93%) patients, nause
a occurred in 12 (44%) patients, weight loss in 12 (44%) patients, and vomi
ting in 10 (37%) patients. The pain was described as mild in 16 (73%) of 22
patients. Only 5 (18.5%) of 27 patients had physical signs of acute perito
nitis, 8 (30%) of 27 patients had some form of tenderness, and 11 (41%) of
27 had a benign exam. A total of 20 (74%) patients had an abdominal radiogr
aph, and 12 (44%) patients had a contrast enema for evaluation. Evidence of
perforation was present in 5 (25%) of 20 plain abdominal radiographs and 1
(8%) of 12 contrast enemas. Following admission, 17 (63%) patients were ob
served initially with subsequent surgery after symptoms either failed to re
solve or worsened. The median duration under observation was 4 days (range
1-23). Surgery was performed immediately in 8 patients (30%), and 2 (7%) we
re observed without operation. In these 2 patients, perforation was diagnos
ed postmortem. Seventeen (68%) of 25 patients had a localized abscess. Thre
e of the patients who underwent immediate exploration and 7 who had surgery
after a period of observation died postoperatively (10/25, 40%). Five (55%
) of 9 patients in the group who received high-dose radiation therapy died
because of sigmoid perforation. When the time frame of presentation was eva
luated, we noted that 10 (50%) of 20 patients died between 1960 and 1979 an
d 1 (14%) of 7 died between 1980 and 1992.
Conclusions. Sigmoid perforation following pelvic radiation for cervical ca
ncer does not usually present with the typical signs of a ruptured viscus.
A high degree of suspicion remains a priority in the care of radiated patie
nts who present with abdominal pain given the atypical presentation of perf
oration in this group. (C) 2001 Academic Press.