Radical Surgery in Cervical Cancer Survivors: Shat is the Matter of Concern in Low-Resources Societies?

10.30699/jogcr.8.4.411 Background & Objective: Pelvic exenteration and other types of super-radical procedures are the standard of care in the management of patients with recurrent or persistent cervical cancer. But, since the extent of surgery and possible morbidities are considered as an important challenge in low-resource countries, there is need to investigate the outcomes of similar patient. Materials & Methods: The present study tries to report the successful outcome of radical surgery in detailed in 7 cases in a low-economic setting Results: Total Pelvic exenteration was performed in three but free margin could be achieved by less radical approach in others. All were alive up to 5yaers of follow-up. Conclusion: What we had noticed was the excellent survival prognosis even in curative intent. It is highly recommended, considering the psychological effect of such an extensive surgery and quality of life in these patients with advanced disease and loss of hope.


Introduction
Pelvic exenteration (PE) as a super-radical surgery had been described for the first time in 1948 with the aim of last line choice in cases with central-pelvic recurrence of gynecological or colorectal cancers (1).Since then, eliminating the extension of operation alongside with obtaining the free tumoral margin, came into focus (2, 3).Moreover, selecting properly the best candidate for such an extended surgery, with palliation or cure intent, remains as a matter of concern.Regarding this, in an experienced hand, the most important points are the absence of distant metastasis and having acceptable health performance (4-6).Although, there is more than half a century experience on this surgical hope, the restricted knowledge of the feasibility and prognosis of this super-radical surgery in gynecologic cancers, especially in low resources countries had provoked us to try it at our tertiary center in skilled hand and with precise multidisciplinary consultation in each situation.

Methods
This prospective study was conducted at an academic hospital in Mashhad, one of the largest cities in Iran, from 2014 to 2019.The preliminary inclusion criteria for such a radical surgery were patients with documented tissue-biopsy of persistent or recurrent cervical cancer, who had no sign of distant metastasis in pre-operative workup consisting of physical examination, magnetic resonance imaging (MRI), and PET/CT scan.The other important point in included cases was their physically and mentally eligibility for such a super-radical surgery.The candidates were consulted by a multidisciplinary team including the oncological surgeon, urologist, oncologist, psychologist, pathologist, and radiologist.The informed consent was obtained from all the patients before entering the program.Patients underwent surgery with a midline incision, which was followed by para-aortic lymph-node (PA-LN) and pelvic-wall sampling to exclude the tumoral involvement by frozen section study.After confirming the feasibility of surgery, resection of the involved pelvic organs was started, with sought to achieve a microscopic free margin.All patients were hospitalized until fully mobilized and bowel movement done, with an order of prophylactic anti-thromboembolic-agent. Regular follow-up visits were done up to present time.

Results
There were totally 8 eligible patients, in whom tumoral recurrence was diagnosed by image-guided tissue sampling in 7 and tumoral-persistence in the other one.The median age of patients was 53.4 years.Total PE was performed in three due to tumoral involvement of the rectosigmoid and bladder.But free margin could be achieved by anterior PE with neocystostomy and bilateral ureter reimplantation (Boari flap) in one.The other 3 patients underwent type-3 radical hysterectomy or partial vaginectomy and parametrectomy.It is notable to describe the last case outcome, whose diagnosis of tumoral recurrence was found only after two years of radical surgery and adjuvant radiotherapy.In the mentioned case, unfortunately the surgery was abrupted because of histologically positive PA-LN and she died in less than two months with a diagnosis of major depression, anorexia and loss of hope.The patients' characteristics are detailed in the Table 1.11).Above that, one of the most highlighted points in upgrading the surgical prognosis and the strongest pint in present study was timely decision for taking action in recurrences (12, 13).The last point that needs to be more evaluated in future is the value of psychological consultation appointment not only before, but also after surgery.This must be taken into consideration, especially in cases who developed post-operative complications or who had not successful surgery.It is unfortunate that we missed the last case not due to the underlying disease, but because of mood deterioration and loss of hope.Moreover, our restricted resources in providing the ability of intra-operative-radiotherapy should be given more attention in other low economic societies to rise the chance of saving life in cases with no opportunity in surgery (7, 14, 15).

Conclusion
Regarding the desirable rate of survival in the present study, the most important limitation is lack of life quality assessment in these survived patients that could be affected mostly by surgical complications and highly recommended to be noticed in future trials.

Figure 1 .
Figure 1.P MRI; extension of the tumor to adjacent organ in the pelvis (A & B: with & without contrast: sagittal view); C) Surgical specimen of total PE; D) Pathologic study (H&E 100×): Proliferation of atypical squamous cell with mitosis and nuclear pleomorphism with invasion to stroma Discussion The preliminary purpose of PE was palliative intent in recurrent or persistent cervical cancer (4, 5), but the present study established its curative potential in the precisely selected patients and multidisciplinary consultation.Smith B et al. also believed on the vital role of tumor size and surgical margins status on prognosis (7).As mentioned before, there are limited trials in low resources settings.Uzan et al. had reported 3 out of 5 recurrences after laparoscopic exenteration, and Maharaj et al. described the experience of single PE(8, 9).So, according to one of the largest studies by Schmidt et al., the cons and pros of these supra-radical surgeries should be mentioned in patient consultation, in other word describe the risk of long-term complications like what had happened in some cases in the present study in compare with 60% chance of adding survival benefits (10).These statistics differ based on patient characteristics and absolutely the surgeons' experience, which is in about 57% and 73% respectively inYoung et al. study (11).Above that, one of the most highlighted points in upgrading the surgical prognosis and the strongest pint in present study was timely decision for taking action in recurrences (12, 13).The last point that needs to be more evaluated in future is the value of psychological consultation appointment not only before, but also after surgery.This must be taken into consideration, especially in