A novel combined operative and radiotherapeutic treatment approach for recurrent gynecologic malignant lesions infiltrating the pelvic wall

Abstract

Patients who have recurrent gynecologic malignant conditions infiltrating the pelvic wall still have a poor prognosis, although based on the biologic factor of the tumor, 50 per cent might be salvaged if local control is achieved. For patients with unilateral disease, we have designed a combined operative and radiotherapeutic treatment (CORT) that involves subtotal resection of the tumor, intraoperative placement of guiding tubes for postoperative high dose rate brachytherapy of the residual tumor and tumor bed at the pelvic wall and pelvic wall plasty with autologous tissue flaps. We use either flaps of the greater omentum and inferiorly based rectus abdominis muscle flaps from the abdominal route or (de-epithelialized) gluteal thigh flaps from the vaginal and perineal route to cover the tumor bed and overlying tubes. Thus, a protective distance between the radiation source and radiointolerant pelvic organs is created and the risk of local infection and hypoxia is reduced. With this combination of surgical and radiation treatment, the therapeutic ratio between tumor control and tissue damage in the pelvic area is thought to be improved. Higher local doses can be applied compared with conventional methods in instances in which surgical treatment has been performed and reirradiation with tumoricidal doses may be possible after primary or adjuvant radiation therapy. The encouraging first experience with the CORT concept in nine patients with a short follow-up period is reported.