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A vascular graft for endometrial cancer groin recurrence
Gynecologic Oncology 104 (2007) 753 – 756 www.elsevier.com/locate/ygyno
Case Report
A vascular graft for endometrial cancer groin recurrence Tammy L. Shim a,⁎, Jason D. Wright b , Brian G. Rubin c , David G. Mutch a a
b
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, Box 8064, St. Louis, MO 63110, USA Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA c Division of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA Received 23 September 2006 Available online 13 December 2006
Abstract Background. Recurrent groin metastases from endometrial cancer that invades the femoral vasculature is debilitating and provides a management dilemma. Case. We present the first case of endometrial cancer with metastatic disease to the groin vasculature palliated with percutaneous endovascular embolization and stent grafting. Conclusion. Endovascular surgery provides an alternative option in those with metastatic endometrial cancer of the groin to improve the patient's quality of life by avoiding a major surgery with difficult postoperative recovery and prolonging the timecourse until the next major bleed. © 2006 Elsevier Inc. All rights reserved. Keywords: Endometrial cancer; Groin recurrence; Femoral vessels; Endovascular surgery
Introduction Endometrial cancer is the most common gynecologic malignancy; it is estimated that 40 880 women were diagnosed with the disease in 2005 while 7310 women died of the disease [1]. This malignancy is often characterized by early stage at diagnosis and a relatively good prognosis. Recent data indicate that 12.7% of stage I patients and 23–41% of Stage II–III patients will recur within 5 years [2]. Follow-up data has shown that if recurrence occurred in less than 24 months, the 5- and 10year survival was 46%. In those who recurred at greater than 24 months, the 5-year was 17% while the 10-year survival was 11% [3]. The most common sites of recurrence are the vagina, pelvis and then other distant locations such as the lungs. Vulvar cancer literature more commonly describes groin recurrences. Case reports have described an improved quality of life in patients who have undergone vascular reconstructive measures utilizing bypass techniques. In a similar manner, these
⁎ Corresponding author. Fax: +1 314 362 2893. E-mail address: [email protected] (T.L. Shim). 0090-8258/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2006.10.023
techniques may be applied to endometrial groin cancer recurrence since the most prominent obstacle is the femoral vasculature. However, in the context of a non-resectable and recurrent endometrial cancer, a less invasive procedure to enhance quality of life is clearly warranted. In this report, we describe the first report of percutaneous vascular embolization and stent grafting for groin recurrence of endometrial cancer invading the femoral vessels. Case A 69-year-old with recurrent endometrial cancer developed a large necrotic groin lesion that invaded the femoral vessels. This patient was originally diagnosed 7 years prior. Initial treatment consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. Pathology revealed a stage IC endometrioid adenocarcinoma. She received adjuvant whole pelvic radiation and vaginal brachytherapy. Three years later, the patient had notable right groin lymph node swelling. An excisional biopsy was performed and confirmed metastatic adenocarcinoma. FDGPET imaging revealed FDG uptake in both groins. She was
754
T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
Fig. 1. Necrotic wound bed of groin recurrence.
treated with cisplatin, doxorubicin, and cyclophosphamide followed by radiotherapy to the affected groin sites. Eight months following chemotherapy and radiation, a repeat PET showed no evidence of residual disease. Three years later, she developed drainage from her right groin. Excisional biopsy confirmed recurrence. MRI revealed a 3.8 × 7.9 cm soft tissue mass in the right groin. The right groin spontaneously opened. The full thickness wound bed measured 6.5 × 4 × 3 cm and was filled with necrotic tissue (Fig. 1). Due to the proximity to the femoral vasculature, the wound was gently debrided and irrigated with saline. The wound was cleansed with mild soap, packed and treated with topical metronidazole for odor control. One month after the patient initiated her wound care regimen, she awoke with oozing of blood from the groin site. Upon admission her hematocrit was 27.4%. CT angiogram of her iliofemoral arteries revealed encasement of the common femoral artery, profunda femoral artery, and superficial femoral artery with narrowing and possible invasion of the profunda greater than the superficial vessels (Fig. 2). No active extravasation of contrast or aneurysm was visualized. The patient was taken to the OR by the vascular surgery service. She underwent embolization of the profunda femoral artery by
Fig. 3. Angiography of night sided groin vasculature.
placing two coils within the proximal portion. A covered stent graft was then placed from the external iliac artery to the superficial femoral artery (Figs. 3 and 4). The patient tolerated the procedure well and was discharged to home in 2 days. She had symptomatically improved and died 2 months following the procedure of her disease without evidence of a recurrent bleed (Fig. 5). Discussion Groin metastases, particularly with involvement of the femoral vasculature, from endometrial cancer are rare. Hopkins et al. described 34 patients with recurrent vulvar disease of which 10 had metastases to the groin. All 10 died of their disease [5]. There is currently no data to suggest an optimal
Fig. 2. Color angiography showing invasion of the right femoral vessel by groin tumor (white arrow).
T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
modality of treatment. Therapeutic options include radiation therapy, chemotherapy, and hormonal therapy with possible surgical intervention where an extensive bypass procedure may be anticipated. Given the proximity to the femoral vessels, many patients with groin metastases are considered inoperable. In the 1960s, Donahoe et al. described the use of the obturator iliofemoral bypass graft to allow radical inguinal excision of a groin carcinoma [6]. At the same time, endovascular surgery was beginning to form with the work of Gruntzig, Dotter, and Judkins. The endovascular approach to vascular repair offered a less morbid alternative to open surgery [7]. In 2000, the TransAtlantic Inter-Society Consensus (TASC) created guidelines for the treatment of chronic arterial disease of the aortoiliac vasculature. They determined that focal short lesions of the aorta, common iliac, and external iliac artery were best treated by the percutaneous endovascular route. Open surgical techniques were recommended for diffuse and complex lesions of the same vasculature [8]. The optimal treatment modality depends on the affected anatomy, functional status of the patient, co-morbid medical conditions and patient's desires. There have been a number of case reports and case series that have described alternative surgical therapies for groin recurrence. Major surgeries have incorporated leg amputation and hemipelvectomy in attempts to extirpate disease and prevent the threat of massive hemorrhage. Alternative limb sparing procedures, such as the obturator iliofemoral bypass have been used to circumvent the groin region. Sevin et al. described wide excision of an extensive vulvar necrotic groin recurrence after radiation therapy, with associated resection of the femoral artery and creation of an extra-anatomic axillopopliteal bypass with pain relief, cosmesis, and preservation of gait. Preoperative imaging confirmed com-
755
Fig. 5. Angiogram performed post embolization: covered stent placement showing preserved flow into the superticial femoral artery and no back-bleeding from embolized profunda femoris artery into the wound.
pression and encasement of the femoral vessels in this mass. Although the patient died 7 months post procedure due to rapidly progressive pulmonary disease, she regained function of her limb and preserved cosmesis [9]. Chao et al. described radical en block excision of a vulvar recurrence and involved right femoral vessels followed by a Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction. Graft vessel occlusion occurred 21 months post bypass, which was able to be debrided with removal of the graft and survival of the surrounding tissue secondary to collateral formation [10]. For patients who do not desire to undergo a major surgery or a prolonged recovery period, minimally invasive procedures provide an attractive alternative. A patient's quality of life becomes a major factor in determining the best intervention. In patients with endometrial cancer recurrence, the overall 5- and 10-year survival rates are 26% and 22%, respectively. Survival decreases to 8% at 5 years for patients with distant recurrences [3]. Several factors affected our patient's perspective on the quality of her life such as the desire to spend her remaining extended time with her grandchildren and family, to not suffer with a prolonged recovery course, and to minimize the threat of exsanguination. Endovascular stenting provides a minimally invasive alternative to improve quality of life in patients with metastatic groin lesions with invasion into the femoral vasculature. References
Fig. 4. Fluoroscopy showing the resulting coil embolization of the right profunda femories artery (thin arrow) and the endovascular stent grafting from the right external iliac artery to the right superficial femoral artery (thick arrows).
[1] SEER Cancer Statistics Review, National Cancer Institute. Bethesda, MD: Available at: http://seer.cancer.gov/statfacts/html/corp.html?statfacts_page= corp.html & x=17 & y=16.
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T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
[2] Creasman W, Odicino F, Maisonneuve P, et al. Carcinoma of the corpus uteri. Annual report of the results of treatment in gynaecolgoical cancer, vol. 6. J. Epidemiol. Biostat.; 2001. p. 45–86. [3] Sartori E, Laface B, Gadducci A, Magginos T, Zola P, Landoni F, et al. Factors influencing survival in endometrial cancer relapsing patients: a cooperation task force (CTF) study. Int J Gynecol Cancer 2003; 13:458–65. [5] Hopkins MP, Reid GC, Morley GW. The surgical management of recurrent squamous cell carcinoma of the vulva. Obstet Gynecol 1990;75:1001–5. [6] Donahoe PK, Froio RA, Nabseth DC. Obturator bypass graft in radical excision of inguinal neoplasm. Ann Surg 1967;166:147–9.
[7] Hallett John W, et al. Comprehensive vascular and endovascular surgery. London: Mosby; 2004. [8] TASC Working Group. Management of Peripheral Arterial Disease (PAD). Transatlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31: S1–296. [9] Sevin BU, Abendstein B, Oldenburg WA, O'Connor M, Waldorf J, Klingler JP, et al. Limb sparing surgery for vulvar groin recurrence: a case report and review of the literature. Int J Gynecol Cancer 2001;11:32–8. [10] Chao A, Chyong-Huey L, Hung-Chi C, Hung-Chang H, Kee-Min Y. Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer. Gynecol Oncol 2001;82:559–62.
Case Report
A vascular graft for endometrial cancer groin recurrence Tammy L. Shim a,⁎, Jason D. Wright b , Brian G. Rubin c , David G. Mutch a a
b
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, Box 8064, St. Louis, MO 63110, USA Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA c Division of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA Received 23 September 2006 Available online 13 December 2006
Abstract Background. Recurrent groin metastases from endometrial cancer that invades the femoral vasculature is debilitating and provides a management dilemma. Case. We present the first case of endometrial cancer with metastatic disease to the groin vasculature palliated with percutaneous endovascular embolization and stent grafting. Conclusion. Endovascular surgery provides an alternative option in those with metastatic endometrial cancer of the groin to improve the patient's quality of life by avoiding a major surgery with difficult postoperative recovery and prolonging the timecourse until the next major bleed. © 2006 Elsevier Inc. All rights reserved. Keywords: Endometrial cancer; Groin recurrence; Femoral vessels; Endovascular surgery
Introduction Endometrial cancer is the most common gynecologic malignancy; it is estimated that 40 880 women were diagnosed with the disease in 2005 while 7310 women died of the disease [1]. This malignancy is often characterized by early stage at diagnosis and a relatively good prognosis. Recent data indicate that 12.7% of stage I patients and 23–41% of Stage II–III patients will recur within 5 years [2]. Follow-up data has shown that if recurrence occurred in less than 24 months, the 5- and 10year survival was 46%. In those who recurred at greater than 24 months, the 5-year was 17% while the 10-year survival was 11% [3]. The most common sites of recurrence are the vagina, pelvis and then other distant locations such as the lungs. Vulvar cancer literature more commonly describes groin recurrences. Case reports have described an improved quality of life in patients who have undergone vascular reconstructive measures utilizing bypass techniques. In a similar manner, these
⁎ Corresponding author. Fax: +1 314 362 2893. E-mail address: [email protected] (T.L. Shim). 0090-8258/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2006.10.023
techniques may be applied to endometrial groin cancer recurrence since the most prominent obstacle is the femoral vasculature. However, in the context of a non-resectable and recurrent endometrial cancer, a less invasive procedure to enhance quality of life is clearly warranted. In this report, we describe the first report of percutaneous vascular embolization and stent grafting for groin recurrence of endometrial cancer invading the femoral vessels. Case A 69-year-old with recurrent endometrial cancer developed a large necrotic groin lesion that invaded the femoral vessels. This patient was originally diagnosed 7 years prior. Initial treatment consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. Pathology revealed a stage IC endometrioid adenocarcinoma. She received adjuvant whole pelvic radiation and vaginal brachytherapy. Three years later, the patient had notable right groin lymph node swelling. An excisional biopsy was performed and confirmed metastatic adenocarcinoma. FDGPET imaging revealed FDG uptake in both groins. She was
754
T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
Fig. 1. Necrotic wound bed of groin recurrence.
treated with cisplatin, doxorubicin, and cyclophosphamide followed by radiotherapy to the affected groin sites. Eight months following chemotherapy and radiation, a repeat PET showed no evidence of residual disease. Three years later, she developed drainage from her right groin. Excisional biopsy confirmed recurrence. MRI revealed a 3.8 × 7.9 cm soft tissue mass in the right groin. The right groin spontaneously opened. The full thickness wound bed measured 6.5 × 4 × 3 cm and was filled with necrotic tissue (Fig. 1). Due to the proximity to the femoral vasculature, the wound was gently debrided and irrigated with saline. The wound was cleansed with mild soap, packed and treated with topical metronidazole for odor control. One month after the patient initiated her wound care regimen, she awoke with oozing of blood from the groin site. Upon admission her hematocrit was 27.4%. CT angiogram of her iliofemoral arteries revealed encasement of the common femoral artery, profunda femoral artery, and superficial femoral artery with narrowing and possible invasion of the profunda greater than the superficial vessels (Fig. 2). No active extravasation of contrast or aneurysm was visualized. The patient was taken to the OR by the vascular surgery service. She underwent embolization of the profunda femoral artery by
Fig. 3. Angiography of night sided groin vasculature.
placing two coils within the proximal portion. A covered stent graft was then placed from the external iliac artery to the superficial femoral artery (Figs. 3 and 4). The patient tolerated the procedure well and was discharged to home in 2 days. She had symptomatically improved and died 2 months following the procedure of her disease without evidence of a recurrent bleed (Fig. 5). Discussion Groin metastases, particularly with involvement of the femoral vasculature, from endometrial cancer are rare. Hopkins et al. described 34 patients with recurrent vulvar disease of which 10 had metastases to the groin. All 10 died of their disease [5]. There is currently no data to suggest an optimal
Fig. 2. Color angiography showing invasion of the right femoral vessel by groin tumor (white arrow).
T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
modality of treatment. Therapeutic options include radiation therapy, chemotherapy, and hormonal therapy with possible surgical intervention where an extensive bypass procedure may be anticipated. Given the proximity to the femoral vessels, many patients with groin metastases are considered inoperable. In the 1960s, Donahoe et al. described the use of the obturator iliofemoral bypass graft to allow radical inguinal excision of a groin carcinoma [6]. At the same time, endovascular surgery was beginning to form with the work of Gruntzig, Dotter, and Judkins. The endovascular approach to vascular repair offered a less morbid alternative to open surgery [7]. In 2000, the TransAtlantic Inter-Society Consensus (TASC) created guidelines for the treatment of chronic arterial disease of the aortoiliac vasculature. They determined that focal short lesions of the aorta, common iliac, and external iliac artery were best treated by the percutaneous endovascular route. Open surgical techniques were recommended for diffuse and complex lesions of the same vasculature [8]. The optimal treatment modality depends on the affected anatomy, functional status of the patient, co-morbid medical conditions and patient's desires. There have been a number of case reports and case series that have described alternative surgical therapies for groin recurrence. Major surgeries have incorporated leg amputation and hemipelvectomy in attempts to extirpate disease and prevent the threat of massive hemorrhage. Alternative limb sparing procedures, such as the obturator iliofemoral bypass have been used to circumvent the groin region. Sevin et al. described wide excision of an extensive vulvar necrotic groin recurrence after radiation therapy, with associated resection of the femoral artery and creation of an extra-anatomic axillopopliteal bypass with pain relief, cosmesis, and preservation of gait. Preoperative imaging confirmed com-
755
Fig. 5. Angiogram performed post embolization: covered stent placement showing preserved flow into the superticial femoral artery and no back-bleeding from embolized profunda femoris artery into the wound.
pression and encasement of the femoral vessels in this mass. Although the patient died 7 months post procedure due to rapidly progressive pulmonary disease, she regained function of her limb and preserved cosmesis [9]. Chao et al. described radical en block excision of a vulvar recurrence and involved right femoral vessels followed by a Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction. Graft vessel occlusion occurred 21 months post bypass, which was able to be debrided with removal of the graft and survival of the surrounding tissue secondary to collateral formation [10]. For patients who do not desire to undergo a major surgery or a prolonged recovery period, minimally invasive procedures provide an attractive alternative. A patient's quality of life becomes a major factor in determining the best intervention. In patients with endometrial cancer recurrence, the overall 5- and 10-year survival rates are 26% and 22%, respectively. Survival decreases to 8% at 5 years for patients with distant recurrences [3]. Several factors affected our patient's perspective on the quality of her life such as the desire to spend her remaining extended time with her grandchildren and family, to not suffer with a prolonged recovery course, and to minimize the threat of exsanguination. Endovascular stenting provides a minimally invasive alternative to improve quality of life in patients with metastatic groin lesions with invasion into the femoral vasculature. References
Fig. 4. Fluoroscopy showing the resulting coil embolization of the right profunda femories artery (thin arrow) and the endovascular stent grafting from the right external iliac artery to the right superficial femoral artery (thick arrows).
[1] SEER Cancer Statistics Review, National Cancer Institute. Bethesda, MD: Available at: http://seer.cancer.gov/statfacts/html/corp.html?statfacts_page= corp.html & x=17 & y=16.
756
T.L. Shim et al. / Gynecologic Oncology 104 (2007) 753–756
[2] Creasman W, Odicino F, Maisonneuve P, et al. Carcinoma of the corpus uteri. Annual report of the results of treatment in gynaecolgoical cancer, vol. 6. J. Epidemiol. Biostat.; 2001. p. 45–86. [3] Sartori E, Laface B, Gadducci A, Magginos T, Zola P, Landoni F, et al. Factors influencing survival in endometrial cancer relapsing patients: a cooperation task force (CTF) study. Int J Gynecol Cancer 2003; 13:458–65. [5] Hopkins MP, Reid GC, Morley GW. The surgical management of recurrent squamous cell carcinoma of the vulva. Obstet Gynecol 1990;75:1001–5. [6] Donahoe PK, Froio RA, Nabseth DC. Obturator bypass graft in radical excision of inguinal neoplasm. Ann Surg 1967;166:147–9.
[7] Hallett John W, et al. Comprehensive vascular and endovascular surgery. London: Mosby; 2004. [8] TASC Working Group. Management of Peripheral Arterial Disease (PAD). Transatlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31: S1–296. [9] Sevin BU, Abendstein B, Oldenburg WA, O'Connor M, Waldorf J, Klingler JP, et al. Limb sparing surgery for vulvar groin recurrence: a case report and review of the literature. Int J Gynecol Cancer 2001;11:32–8. [10] Chao A, Chyong-Huey L, Hung-Chi C, Hung-Chang H, Kee-Min Y. Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer. Gynecol Oncol 2001;82:559–62.