Читать книгу Surgical Management of Advanced Pelvic Cancer - Группа авторов - Страница 14

While elsewhere PE was being developed principally for patients with LARC, in New York, Alexander Brunschwig was performing PE as a palliative procedure for locally advanced gynecologic malignancies. Before the introduction of PE, the prognosis for locally advanced cervical cancer was particularly poor. External beam radiation therapy was the mainstay of management. Local extension commonly occurred and cure rates were as low as 20% for primary disease [9]. Forty percent of deaths were the result of advanced disease confined to the pelvis [10]. Patients with end‐stage malignancy suffered refractory pain, as well as intestinal and ureteric obstruction as major complications [11, 12].

Brunschwig, who had been among the first to report a one‐stage radical pancreatico‐duodenectomy in 1937 [1, 13], observed that PE was a “procedure of desperation since all other attempts to control the disease had failed.” Initially his only selection criterion was that disease must be “confined to the pelvis.” Interestingly, “not a single patient refused the operation even after detailed explanation of the procedure and the complications associated with surgery” [1]. The operative approach was similair (Figure 1.1).

Although Many surgeons were critical, considering it “a thoughtless form of mutilation, with limited chance of success for palliation, much less cure” [14]. In the earliest series, the survival outcomes were poor, with one in every three operations resulting in perioperative mortality [1, 15]. In Brunschwig’s 1948 article, he reported operating on 22 patients with 5 deaths. [4].

By 1950, Bricker was also investigating the role of PE in the management of cervical cancer. His first patient, despite widespread local invasion, had a disease‐free survival of 42 years [6]. The suitability of PE for the management of cervical and other gynecological cancers was later confirmed by Brunschwig in several series [16, 17]. In the ensuing decades, several units (mostly in North America) increasingly performed PE for advanced cancer of the vulva [18], ovary [19], and prostate [20], and for pelvic sarcoma [21]. The first documented non‐malignant application for PE was for management of severe radiation necrosis of several pelvic organs in 1951. This remained a relatively common indication for PE until more contemporary radiation therapies became available [22].