Cerrahinin Uç Noktası: Nüks Uterin Karsinosarkomda Multidisipliner Total Pelvik Ekzenterasyon Deneyimi
Özet
Giriş: Total pelvik ekzenterasyon (TPE), özellikle pelvik organlara sınırlı, invaziv veya nüks etmiş jinekolojik malignitelerde, küratif amaçla uygulanan radikal bir cerrahi yaklaşımdır. Bu çalışmada, pelviste kemoterapi sonrası gelişen nüks nedeniyle TPE uygulanan bir uterin karsinosarkom olgusu sunulmaktadır.
Vaka takdimi: Kemoterapi almış ve takip sürecinde pelviste nüks gelişmiş olan 69 yaşındaki kadın hastaya, tümör kurulu kararıyla TPE uygulandı. Cerrahi sınırlar negatif (R0) olarak raporlandı. Postoperatif 46. günde gelişen dispne, subfebril ateş, pürülan vajinal akıntı ve karın ağrısı ile başvuran hastada pnömoni ve vajinal cuff dehissensi saptandı. Uygun cerrahi ve medikal tedavi sonrası hasta taburcu edildi.
Tartışma: TPE, yüksek morbidite riski taşımasına rağmen uygun hasta seçiminde yaşam süresini uzatabilir. Cerrahinin başarı oranı, multidisipliner yaklaşım, komplikasyon yönetimi ve rekonstrüktif cerrahi ile doğrudan ilişkilidir.
Sonuç: Uterin karsinosarkom gibi agresif tümörlerde, lokal nüks varlığında TPE, seçilmiş hastalarda etkili bir tedavi seçeneği olabilir. Cerrahi karar sürecinde hasta bilgilendirmesi ve kapsamlı klinik değerlendirme esastır.
Referanslar
Silverberg SG, Major FJ, Blessing JA, et al. Carcinosarcoma (Malignant Mixed Mesodermal Tumor) of the Uterus: A Gynecologic Oncology Group Pathologic Study of 203 Cases. Int J Gynecol Pathol, 1990;9(1):1–19.
Euscher ED, Deavers MT, Lopez-Terrada D, et al. Uterine Tumors With Neuroectodermal Differentiation: A Series of 17 Cases and Review of the Literature. Am J Surg Pathol, 2008;32(2):219–228.
Vellone VG, Spina B, Grillo F, et al. Mixed malignant mullerian tumor with neuroendocrine features in an irradiated uterus for cervical carcinoma. A unique association? A morphological, immunohistochemistry and ultrastructural study. Pathol Res Pract, 2012;208(1):47–51.
Nama N, Cason FD, Misra S, et al. Carcinosarcoma of the Uterus: A Study From the SEER Database. J Surg Res, 2020;251:175–182.
Powell MA, Filiaci VL, Rose PG, et al. Phase II Evaluation of Paclitaxel and Carboplatin in the Treatment of Carcinosarcoma of the Uterus: A Gynecologic Oncology Group Study. Gynecol Oncol, 2010;119(2):274–279.
Singh R. Review literature on uterine carcinosarcoma. J Cancer Res Ther, 2014;10(3):461–468. doi:10.4103/0973-1482.138197
Meseci E, Naki MM. Prognostic factors, survival outcomes, and surgical practices when dealing with uterine sarcomas: 8 years’ clinical experience. Turk J Obstet Gynecol, 2020;17(2):93–98.
Sherman ME, Devesa SS. Analysis of racial differences in incidence, survival, and mortality for malignant tumors of the uterine corpus. Cancer, 2003;98(1):176–186.
Gadducci A, Cosio S, Romanini A, et al. The management of patients with uterine sarcoma: a debated clinical challenge. Crit Rev Oncol Hematol, 2008;65(2):129–142.
Iwasa Y, Haga H, Konishi I, et al. Prognostic factors in uterine carcinosarcoma: A clinicopathologic study of 25 patients. Cancer, 1998;82(3):512–519.
Denschlag D, Ulrich UA. Uterine carcinosarcomas – Diagnosis and management. Oncol Res Treat, 2018;41(11):675–679.
El Husseiny G, Al Bareedy N, Mourad W, et al. Prognostic Factors and Treatment Modalities in Uterine Sarcoma. Am J Clin Oncol, 2002;25(3):256–260.
Toboni MD, Crane EK, Brown J, et al. Uterine carcinosarcomas: From pathology to practice. Gynecol Oncol, 2021;161(1):182–190. doi:10.1016/j.ygyno.2021.05.003
Concin N, Planchamp F, Abu-Rustum NR, et al. European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma. Int J Gynecol Cancer, 2021;31:1508–1529.
Matsuzaki S, Klar M, Matsuzaki S, et al. Uterine carcinosarcoma: Contemporary clinical summary, molecular updates, and future research opportunity. Gynecol Oncol, 2021;160:586–601.
Concin N, Matias-Guiu X, Vergote I, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer, 2021;31(1):12–39. doi:10.1136/ijgc-2020-002230
Abu-Rustum N, Yashar C, Arend R, et al. Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 2023;21:181–209.
Schiavone MB, Zivanovic O, Zhou Q, et al. Survival of Patients with Uterine Carcinosarcoma Undergoing Sentinel Lymph Node Mapping. Ann Surg Oncol, 2016;23:196–202.
Zammarrelli WA, Greenman M, Rios-Doria E, et al. Sentinel lymph node biopsy alone compared to systematic lymphadenectomy in patients with uterine carcinosarcoma. Gynecol Oncol, 2022;165:287–292.
Cory L, Brensinger C, Burger RA, et al. Patterns of adjuvant treatment and survival outcomes in stage I uterine carcinosarcoma. Gynecol Oncol Rep, 2022;39:100930.
Makker V, Abu-Rustum NR, Alektiar KM, et al. A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I–IV uterine carcinosarcoma. Gynecol Oncol, 2008;111(2):249–254.
Abaid LN, Rettenmaier MA, Brown JV 3rd, et al. Sequential chemotherapy and radiotherapy as sandwich therapy for the treatment of high-risk endometrial cancer. J Gynecol Oncol, 2012;23(1):22–27.
Felix AS, Stone RA, Bowser R, et al. Comparison of survival outcomes between patients with malignant mixed mullerian tumors and high-grade endometrioid, clear cell, and papillary serous endometrial cancers. Int J Gynecol Cancer, 2011;21(5):877–884.
Bansal N, Herzog TJ, Seshan VE, et al. Uterine carcinosarcomas and grade 3 endometrioid cancers: Evidence for distinct tumor behavior. Obstet Gynecol, 2008;112(1):64–70.
Vorgias G, Fotiou S. The role of lymphadenectomy in uterine carcinosarcomas (malignant mixed mullerian tumours): A critical literature review. Arch Gynecol Obstet, 2010;282(6):659–664.
Hatch K.D., Berek J.S. Pelvic exenteration. In: Berek J.S., Hacker N.F., eds. Practical Gynecologic Oncology. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2005:801–816.
Barton D., Heath O., Shahnawaz R., et al. Pelvic Exenteration for Central Pelvic Cancer. Pelvic Cancer Surgery; 2025. doi:10.1007/978-3-031-66772-5_38
Grimes W.R., Dunton C.J., Stratton M. Pelvic Exenteration. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 33085416.
Brunschwig A. Complete excision of pelvic viscera for advanced carcinoma: a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer. 1948;1(2):177–183. doi:10.1002/1097-0142(194807)1:2<177::AID-CNCR2820010203>3.0.CO;2-A
de Gregorio N., de Gregorio A., Ebner F., et al. Pelvic exenteration as ultimate ratio for gynecologic cancers: single-center analyses of 37 cases. Arch Gynecol Obstet. 2019;300(1):161–168. doi:10.1007/s00404-019-05154-4
Kelly M.E., Ryan E.J., Aalbers A.G.J., et al. Pelvic exenteration for advanced nonrectal pelvic malignancy: PelvEx Collaborative. Ann Surg. 2019;270(5):899–905. doi:10.1097/SLA.0000000000003533
Causa Andrieu P.I., Woo S., Rios-Doria E., et al. The role of imaging in pelvic exenteration for gynecological cancers. Br J Radiol. 2021;94(1125):20201460. doi:10.1259/bjr.20201460
Zeybek B., Borahay M.A., Kilic C.H., et al. Evaluation of survival and mortality in pelvic exenteration for gynecological malignancies: A systematic review, meta-analyses, and meta-regression study. Int J Gynecol Cancer. 2025;35(3):367–374. doi:10.1016/j.ijgc.2025.101829
Maggioni A., Roviglione G., Landoni F., et al. Pelvic exenteration: Ten-year experience at the European Institute of Oncology in Milan. Gynecol Oncol. 2009;114(1):64–68. doi:10.1016/j.ygyno.2009.03.010
Zhao H., Fan S., Sun J. Delayed wound healing in the elderly and a new therapeutic target: CD271. Curr Stem Cell Res Ther. 2024;19(3):316–323. doi:10.2174/1574888X18666230403083603
Höckel M., Dornhöfer N., Horn L.C., et al. Pelvic exenteration for gynecological tumours: achievements and unanswered questions. Lancet Oncol. 2006;7(10):837–847.
Diver E.J., Rauh-Hain A., del Carmen M.G. Total pelvic exenteration for gynecologic malignancies. Obstet Gynecol Int. 2012. doi:10.1155/2012/693535
Chiantera V., Rossi M., De Iaco P., et al. Survival after curative pelvic exenteration for primary or recurrent cervical cancer: A retrospective multicentric study of 167 patients. Int J Gynecol Cancer. 2014;24(6):1150–1156. doi:10.1097/IGC.0000000000000179
Westin S.N., Rallapalli V., Fellman B., et al. Overall survival after pelvic exenteration for gynecologic malignancy. Gynecol Oncol. 2014;134(3):546–551. doi:10.1016/j.ygyno.2014.06.013
Berek J.S., Howe C., Lagasse L.D., et al. Pelvic exenteration for recurrent gynecologic malignancy: Survival and morbidity analysis of the 45-year experience at UCLA. Gynecol Oncol. 2005;99(1):153–159. doi:10.1016/j.ygyno.2005.05.039
Omura Y., Ikeda K., Nabatame M., Kondo I. A quasi-experimental study of optimized retractor management on the incidence of femoral nerve injury following gynecological surgery. Cureus. 2024;16(12):e75610. doi:10.7759/cureus.75610
Standring S., ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Elsevier; 2016.
Kim D.H., Murovic J.A., Tiel R.L., et al. Intrapelvic and thigh level femoral nerve lesions: management and outcomes in 119 surgically treated cases. J Neurosurg. 2004;100(5):989–996.
Moore A.E., Stringer M.D. Iatrogenic femoral nerve injury: a systematic review. Surg Radiol Anat. 2011;33(7):649–658.
Cardosi R.J., Cox C.S., Hoffman M.S. Postoperative neuropathies after major pelvic surgery. Obstet Gynecol. 2002;100(2):240–244.
Fedeli P., Guida M., Giugliano P., et al. Femoral nerve injury in gynecologic surgery: medico-legal issues for best surgical practices. Gynecol Surg. 2021;18:6. doi:10.1186/s10397-021-01086-7
Kuo L.J., Penn I.W., Feng S.F., et al. Femoral neuropathy after pelvic surgery. J Chin Med Assoc. 2004;67(12):644–646.
Maneschi F., Nale R., Tozzi R., et al. Femoral nerve injury complicating surgery for gynecologic cancer. Int J Gynecol Cancer. 2014;24(6):1112–1117.
Adibatti M., Sangeetha V. Study on variant anatomy of sciatic nerve. J Clin Diagn Res. 2014;8(8):AC07–AC09. doi:10.7860/JCDR/2014/9116.4725
Kuponiyi O., Alleemudder D.I., Latunde-Dada A., et al. Nerve injuries associated with gynaecological surgery. Obstet Gynaecol. 2014;16(1):29–36. doi:10.1111/tog.12064
Tortorella L., Cintoni M., Loverro M., et al. Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: A large single-institution experience. Gynecol Oncol. 2023;173(2):392–398. doi:10.1016/j.ygyno.2023.08.008
