Prediction of long-term survival in recurrent gynaecological malignancies treated with pelvic exenteration

Background: The desire to ensure prolonged survival for patients with advanced gynaecological cancer is a key concern for every doctor. This study presents an analysis of outcomes from an Estonian regional cancer center, evaluating prognostic factors associated with locally advanced gynecological cancer and the potential for long-term survival following pelvic exenteration. Methods: The study included patients with resistant or recurrent gynecological cancer. The analysis present data on all 34 cases in which pelvic exenteration was performed at the Tartu University Hospital. The majority of patients (88.2%) had tumour recurrence. Thirteen patients (38%) had previously undergone surgery for gynaecological cancer. Results: Of the 34 patients, 21 (62%) underwent total pelvic exenteration and 13 (38%) exenterations with vulvectomy. The median age of the study cohort was 59 years (range, 34–80). The median duration of surgery was 4.4 hours (range, 121–530 minutes). The median blood loss was 707 mL (range 100–2500 mL). The median tumor diameter was 7 cm (range 2–25 cm). The mean follow-up was 52 months. The overall postoperative complication rate was 41%. One patient died postoperatively (2.9%). Median survival for ovarian cancer was 48.3 months, cervical cancer 31.6 months, vaginal or urethral cancer 29.2 months and for endometrial cancer 7.7 months. Overall survival rates were 62% at 1 year, 44% at 3 years, 28% at 5 years, and 15% at 15 years. Multivariable analysis showed that distant metastasis (p = 0.0002), endometrial cancer (p = 0.0096), resection line (p = 0.017) were the most important factors affecting long-term survival. Conclusions: In the present study, we found that patients with relapsed or persistent locally advanced cervical, vaginal, or ovarian cancer who underwent pelvic exenteration demonstrated substantially better survival outcomes than patients with endometrial cancer, particularly those with aggressive histologic subtypes and multiple unfavorable prognostic markers.

Gynecological cancer; Recurrence; Pelvic exenteration; Prognostic factors; Long-term survival

[1] Egger EK, Liesenfeld H, Stope MB, Recker F, Döser A, Könsgen D, et al. Pelvic exenteration in advanced gynecologic malignancies—who will benefit? Anticancer Research. 2021; 41: 3037–3043.

[2] Sevin BU, Koechli OR. Pelvic exenteration. Surgical Clinics of North America. 2001; 81: 771–779.

[3] Xu C, Garda A, Kumar A. R0 Resection in recurrent gynecologic malignancy: pelvic exenteration and beyond. Current Treatment Options in Oncology. 2023; 24: 262–273.

[4] Chokshi RJ, Fowler J, Cohn D, Bahnson R, Lumbley J, Martin EW Jr. A single-institution approach to total pelvic exenteration. The American Journal of Surgery. 2011; 77: 1629–1639.

[5] Grimes WR, Dunton CJ, Stratton M. Pelvic exenteration. StatPearls Publishing: Treasure Island. 2024.

[6] Fix N, Classen-von Spee S, Baransi S, Luengas-Würzinger V, Rawert F, Lippert R, et al. Pelvic exenteration for recurrent endometrial cancer: a 15-year monocentric retrospective study. Cancers. 2023; 15: 4725.

[7] Rios-Doria E, Filippova OT, Straubhar AM, Chi A, Awowole I, Sandhu J, et al. A modern-day experience with Brunschwig’s operation: outcomes associated with pelvic exenteration. Gynecologic Oncology. 2022; 167: 277–282.

[8] Goldberg JM, Piver MS, Hempling RE, Aiduk C, Blumenson L, Recio FO. Improvements in pelvic exenteration: factors responsible for reducing morbidity and mortality. Annals of Surgical Oncology. 1998; 5: 399–406.

[9] Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Annals of Surgery. 2005; 242: 540–544; discussion 544–547.

[10] PelvEx Collaborative. Palliative pelvic exenteration: a systematic review of patient-centered outcomes. European Journal of Surgical Oncology. 2019; 45: 1787–1795.

[11] Gheorghe M, Cozlea AL, Kiss SL, Stanca M, Căpîlna ME, Bacalbașa N, et al. Primary pelvic exenteration: our experience with 23 patients from a single institution. Experimental and Therapeutic Medicine. 2021; 22: 1060.

[12] Straubhar AM, Chi AJ, Zhou QC, Iasonos A, Filippova OT, Leitao MM Jr, et al. Pelvic exenteration for recurrent or persistent gynecologic malignancies: clinical and histopathologic factors predicting recurrence and survival in a modern cohort. Gynecologic Oncology. 2021; 163: 294–298.

[13] Denschlag D, Ackermann S, Battista MJ, Cremer W, Egerer G, Fehr M, et al. Sarcoma of the uterus. Guideline of the DGGG, OEGGG and SGGG (S2k-level, AWMF registry No. 015/074, April 2021). Geburtshilfe und Frauenheilkunde. 2022; 82: 1337–1367.

[14] Ter Glane L, Hegele A, Wagner U, Boekhoff J. Pelvic exenteration for recurrent or advanced gynecologic malignancies—analysis of outcome and complications. Gynecologic Oncology Reports. 2021; 36: 100757.

[15] Zimmermann ML, Innos K, Härmaorg P, Leif E, Mändla T, Mägi M. Cancer in Estonia: incidence 2021, survival 2017–2021 and cancer cases diagnosed in screening. Tervise Arengu Instituut: Tallinn. 2024.

[16] Tammik O, Lang A, Pisarev H, Lang K, Tammik K. Is long-term survival possible when conventional cervical cancer treatment options are exhausted? European Journal of Gynaecological Oncology. 2024; 45: 52–59.

[17] ERAS® Society. ERAS® guidelines for colorectal surgery. 2022. Available at: https://erassociety.org/guidelines/ (Accessed: 13 November 2018).

[18] Martínez-Gómez C, Angeles MA, Martinez A, Malavaud B, Ferron G. Urinary diversion after pelvic exenteration for gynecologic malignancies. International Journal of Gynecological Cancer. 2021; 31: 1–10.

[19] Lewandowska A, Szubert S, Koper K, Koper A, Cwynar G, Wicherek L. Analysis of long-term outcomes in 44 patients following pelvic exenteration due to cervical cancer. World Journal of Surgical Oncology. 2020; 18: 234.

[20] Stanca M, Căpîlna DM, Căpîlna ME. Long-term survival, prognostic factors, and quality of life of patients undergoing pelvic exenteration for cervical cancer. Cancers. 2022; 14: 2346.

[21] Pleth Nielsen CK, Sørensen MM, Christensen HK, Funder JA. Complications and survival after total pelvic exenteration. European Journal of Surgical Oncology. 2022; 48: 1362–1367.

[22] Di Donato V, Kontopantelis E, De Angelis E, Arseni RM, Santangelo G, Cibula D, et al.; Pelvic Exenteration Study Group. Evaluation of survival and mortality in pelvic exenteration for gynecologic malignancies: a systematic review, meta-analyses, and meta-regression study. International Journal of Gynecological Cancer. 2025; 35: 101829.

[23] Classen-von Spee S, Baransi S, Fix N, Rawert F, Luengas-Würzinger V, Lippert R, et al. Pelvic exenteration for recurrent vulvar cancer: a retrospective study. Cancers. 2024; 16: 276.

[24] Vigneswaran HT, Schwarzman LS, Madueke IC, David SM, Nordenstam J, Moreira D, et al. Morbidity and mortality of total pelvic exenteration for malignancy in the US. Annals of Surgical Oncology. 2021; 28: 2790–2800.

[25] Levin G, Slomovitz B, Wright JD, Pareja R, Hamilton KM, Schneyer R, et al. Risk factors for major complications following pelvic exenteration: a NSQIP study. European Journal of Surgical Oncology. 2024; 50: 108761.

[26] Bouraoui I, Bouaziz H, Tounsi N, Ben Romdhane R, Hechiche M, Slimane M, et al. Survival after pelvic exenteration for cervical cancer. The Journal of Obstetrics and Gynecology of India. 2022; 72: 66–71.

[27] Petruzziello A, Kondo W, Hatschback SB, Guerreiro JA, Filho FP, Vendrame C, et al. Surgical results of pelvic exenteration in the treatment of gynecologic cancer. World Journal of Surgical Oncology. 2014; 12: 279.

[28] Palaiologos K, Karkia R, Nikoloudaki Z, Mohamed A, Lavelle R, Booth S, et al. Pelvic exenteration: a retrospective study in a tertiary referral cancer center in the UK. Minerva Obstetrics and Gynecology. 2024; 76: 509–515.

[29] de Gregorio N, de Gregorio A, Ebner F, Friedl TWP, Huober J, Hefty R, et al. Pelvic exenteration as ultimate ratio for gynecologic cancers: single-center analyses of 37 cases. Archives of Gynecology and Obstetrics. 2019; 300: 161–168.

[30] Bizzarri N, Chiantera V, Loverro M, Ercoli A, Vizzielli G, Scambia G. Minimally invasive pelvic exenteration for gynaecological malignancies: the challenge of patients’ selection. Facts, Views and Vision in ObGyn. 2023; 15: 193–196.

[31] Baiocchi G, Guimaraes GC, Rosa Oliveira RA, Kumagai LY, Faloppa CC, Aguiar S, et al. Prognostic factors in pelvic exenteration for gynecological malignancies. European Journal of Surgical Oncology. 2012; 38: 948–954.

[32] Chao X, Song X, Wu H, You Y, Wu M, Li L. Selection of treatment regimens for recurrent cervical cancer. Frontiers in Oncology. 2021; 11: 618485.

[33] Peiretti M, Zapardiel I, Zanagnolo V, Landoni F, Morrow CP, Maggioni A. Management of recurrent cervical cancer: a review of the literature. Surgical Oncology. 2012; 21: e59–e66.

[34] Glane LT, Hegele A, Wagner U, Boekhoff J. Gynecologic oncology: pelvic exenteration for advanced or recurring cervical cancer—a single center analysis. Cancer Diagnosis & Prognosis. 2022; 2: 308–315.