late effects from surgerylate effects from surgery j. sehouli director of the department of...
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LATE EFFECTS
from Surgery
J. Sehouli
Director of the Department of GynecologyEuropean Competence Center for Ovarian
CancerCharité Comprehensive Cancer Center
Charité/ Campus Virchow-Klinikum
University of Berlin
©Sehouli 2017 Charité Berlin
V. renalis sinistra
V. cava sinistra
V. cava
dextra
A. renalis dextra
A. mestenterica inf.
V. renalis dextra
A. Iliaca dextra
A. Iliaca sin
V. ovarica sinistraUreter sin.
Plexus
hypogastricus
Aorta abdominalis
V. ovarica dextra
N. Ilio-inguinalis sin©Sehouli 2017 Charité Berlin
Modifications➢ Preperation of ureter
➢ Resection of
Lig. sacro-uterinum
➢ Resection of parametry
➢ Vaginal cuff
➢ Adnectomy
➢ Nerve sparing
techniques
➢ En bloc resections
(across compartment
surgery)
©Sehouli 2017 Charité Berlin
„Surgery will never cause late
toxities, it is only caused by
adjuvant therapy!“
©Sehouli 2017 Charité Berlin
intraoperative
Anesthesia
aspiration
Cardiac arrest
trachea injury
pneumothorax
positioning injury
surgical:
„Operability“
Rogan injuries
bleeding (tumorinduced/iatrogen)
nerve leasions(positioning)
postoperative
Internistisch:
Thromboembol.
cardiopulmonary morbidity
Infections
SIRS
Liver failure
TakotsuboCardiomypathy
surgical:
Fistula/ Perforations, (bowel, pancreas, bladder, stomach,
vessels)
secondary woundhealing
peritonitis
hemorraghy
Bowel obstruction
Ischemia/Infarct
lymphorroe
compartmentsyndr.
emboly
COMPLICATIONS
MORBIDITY - MORTALITY©Sehouli 2017 Charité Berlin
Surgery and late toxicities
➢Methodical limitations
➢Most of the reports retrospective and
monocentric
➢Underreporting of side effects
➢Unsystematic application of toxicity
scales (eg. Clavien-Dindo):
➢Questionaire: Who? When? How?
©Sehouli 2017 Charité Berlin
Surgery and late toxicities
➢Frequent use of adjuvant (multimodal
therapies)
➢Influence of comorbidities and
comedication are generally ingnored
➢Long term toxicities need long term
observation and awareness!
©Sehouli 2017 Charité Berlin
...“drains to prevent
lymphocyst formation
can safely be omitted
following radical
hysterectomy and
pelvic LND“
©Sehouli 2017 Charité Berlin
Epidemiology about lymph edema in gynecologicalcancer patients
• Only few prospective multicentric data• Most only short observation time
• High bias of adjuvant therapies and comorbidities
Quality of life
Forgynecologicalmalignanciesincidence of
40%
Adipositas and cardio-vasculary
diseases havesignificantimpact on incidence
Füller J et al.Lymph Edema of the Lower Extremities after Lymphadenectomy and Radiotherapy for Cervical Cancer 2008
Ohba Y et al. Risk factors for lower-limb lymphedema after surgery for cervical cancer Int J Clin Oncol. 2011
Neuhüttler S. et al. Beitrag zur Epidemiologie des Lymphödems. Phlebologie 2003
Ryan M. et al. Aetiology and prevalence of lower limb lymphoedema following treatment for gynaecological cancer. Aust N Z J Obstet
Gynaecol 2003
Greene AK et al. Obesity induced lymphedema: clinical and lymphoscintigraphic features. Plast Reconstr Surg 2015
Dale RF. Et al. The inheritance of primary lymphoedema. Journal of Medical Genetics 1985
Foldi M. et al. Das vernachlässigte Gefäßsystem. MMW-FortschritMed 2004 ©Sehouli 2017 Charité Berlin
Patients with arm
lymphedama:diagnosis of secondary arm lymphedema
in 86% of the patients within 12 months
(0.6 +/- 2.3 years)
Patients with leg
lymphedemaaverage time to diagnosis 0.5 +/- 1.8 years
(1.7 +/- 3.8 years)
Blome et al. Lymphedema – the long way to diagnosis
and therapy VASA 2013©Sehouli 2017 Charité Berlin
Psychological stress
34% increased psycholgical stress (35% needsprofessional support)
Quality of life andbody imaging conceptare inferior
Cancer patients with
lymphedema have a signifikant
higher risk for depression and
psychological dysbalances
VitalityPsychostatus
Performance Status
Williams AF. et al. A phenomenological study of the lived
experiences
of people with lymphoedema. Int J Palliat Nurs 2004
McWayne J. et al. Psychologic and social sequelae of secondary
lymphedema: a review. Cancer 2005
QoL
©Sehouli 2017 Charité Berlin
LEL + LEL -
LND Pelvic
and
paraortal
LND
pelvic
40 62.5%
24 37.5%
37 57.8%
27 42.2%
Lymphedema in gynecological cavcer patients…the Charité experience and the experience of
others… (results of a prospective study*)
N
45
54 LEL + group has
with 46.3% > 30 N
LEL – group has with
20% > 30 N
Odds Ratio: 3,4
p-Wert = 0,006
©Sehouli 2017 Charité Berlin *not yet published:Auletta,Sehouli,Vercellino
*Effect of radiochemotherapy on lymphedema
LEL +LEL + group has received in
38.9% adjuvant
radiochemotherapy
LEL –LEL + group
received in 15% adjuvant
radiochemotherapy
33
21
9
51
none
Radiochemo
therapy
no
Radiochemo
therapy
Odds Ratio 3,6
p-Wert = 0,004 ©Sehouli 2017 Charité Berlin*not yet published:Auletta,Sehouli,Vercellino
N=251 Cervical cancer
(2005-2013)
…the Charité experience and the experience
of others… (results of a prospective study*)
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
Bladder Score
…the Charité experience and the experience
of others… (results of a prospective study*)
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
Feeling of missing stool evacuation*
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
Bowel dysfunction after surgery*
+/-
+/- +/- +/-+/-
- - --
+ -
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
Sexual function score*
+/- +/- +/-+/-
- - --
+/- + -
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
Pelvic floor dysfunction*
©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler
➢Use of information resources about sexuality after gynecological cancer
therapies
No information 40%
physician(s) 25%
brochures 15%
relatives 5%
friends 5%
other patients 5%
partner 5%
internet 5%
Pilger A, Richter R, Fotopoulou C, Beteta C, Klapp C, Sehouli J.
Anticancer 2012©Sehouli 2017 Charité Berlin
Quality of life and sexuality of patients after treatment for
gynaecological malignancies: results of a prospective study in
55 patients.
Pilger A, Richter R, Fotopoulou C, Beteta C, Klapp C, Sehouli J.
Anticancer Res. 2012 Nov;32(11):5045-9.
78% of the patients suffered from sexual
dysfunction
Reasons:
➢ feeling of losting her atractivity 45%
➢ Dryness of the vagina 25%
➢ Dyspareunia 20%
Similar results: Hopkins et al. Climacteric 2014©Sehouli 2017 Charité Berlin
Quality of life after surgery and
chemotherapy in ovarian cancer
Richter R, Oskay-Oezcelik G, Chekerov R, Pilger A, Hindenburg HJ, Sommer H, Camara O, Keil E,
Einenkel J, Sehouli J, Anticancer 2012.
Longterm side effects in gynecological
cancer patients
➢ n=1029 pts
(median 4.9 years)
Westin et al. J Cancer Surviv
2016
Cancer as a chronic disease
➢ Worldwide, every year more than 14 millions will be
primary diagnosed wit cancer
➢ More than 65% of the cancer patients will survive
more than 5 years
➢ Tendency of significant increasements for both facts
WHO 2016
©Sehouli 2017 Charité Berlin
➢ Critical indication for any surgical procedures for
every individual patient
➢ Best surgical techniques with preserving healt
thissues and compartments (incl. Nervesparing
aproach)
➢ Be critical for adjuvant therapies (what therapy
for what goal)
➢ Systematic evaluation of acute and late toxicities
➢ Create a systematic interprifessional and
interdisciplinary network for best supportive care
➢ Conduction of prospective trials focussing on
lymphedema, bladder and stoll function,
sexuality and QoL
©Sehouli 2017 Charité Berlin
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