Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report

Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report In Sun Hwang, Soo Young Hur This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5800557/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Jul, 2025 Read the published version in BMC Women's Health → Version 1 posted 6 You are reading this latest preprint version Abstract Background Total pelvic exenteration (PE) is a surgical resection of all pelvic organs used as a palliative treatment for locally advanced or recurrent pelvic malignancies. This case report describes an entero-vascular fistula as a severe complication following radiotherapy in a patient with recurrent cervical cancer who underwent PE. Case presentation We present the case of a 47-year-old woman who was diagnosed with cervical cancer at the age of 43 years, classified as FIGO stage IIB. She underwent a radical hysterectomy followed by concurrent chemoradiotherapy (CCRT). In 2023, she developed a recto-urethral fistula and subsequently underwent PE. In March 2024, she was admitted for right buttock and leg pain. An evaluation revealed bone metastasis in the lumbar vertebrae, left iliac bone, and sacrum, for which local radiotherapy was administered. Later, she complained of bloody discharge from a sacral fistula and upper abdominal pain. Her blood pressure was 105/65 mmHg, heart rate 75 beats per minute (BPM), and hemoglobin level was 7.8g/dL, prompting an emergency blood transfusion. Abdomino-pelvic computed tomography (APCT) scan and esophagogastroduodenoscopy (EGD) revealed a large amount of bloody fluid in the stomach and suggested communication with the bowel loop. CT angiography showed contrast extravasation from the left external iliac artery and a large hematoma. A stent graft was inserted at the site of the entero-vascular fistula to achieve embolization. Conclusion This case highlights an entero-vascular fistula as one of the severe complications following PE and radiotherapy for recurrent cervical cancer. Patients who have undergone multimodal treatment, including PE, may have a pelvic condition that is more vulnerable to radiation. Therefore, the complications that may arise from radiation therapy, such as fistula formation, could be higher compared to patients who have not undergone PE. Pelvic Exenteration Uterine Cervical Neoplasms Chemoradiotherapy Palliative Care Vascular Fistula Figures Figure 1 Figure 2 Background Total pelvic exenteration (PE) is a surgical resection of all pelvic organs, including the rectum, bladder, and the reproductive organs, for locally advanced primary or recurrent pelvic malignancies [ 1 ]. This radical surgery is often the last curative option for patients who have undergone multimodal treatment. Traditionally, this aggressive surgical extirpation has been associated with a high rate of complications and few long-term survivors [ 2 ]. However, since Brunschwig first described it in 1948 for the treatment of recurrent gynecologic malignancies [ 3 ], advances in surgical techniques and perioperative care have significantly decreased surgical morbidity and mortality rates [ 1 , 4 ]. Five-year survival rates after PE have been reported to range between 28.2%-59% with mortality rates approximately 0.5%-2% [ 1 , 5 , 6 ]. The 30-day morbidity rate was reported to be 67.2%, often associated with three or more major complications [ 7 ]. Commonly reported major peri- or post-operative complications include rectovaginal fistula, anastomotic site leak, sepsis, and pulmonary embolism. PE is considered a palliative surgical treatment for advanced or recurrent cervical cancer and is worthwhile when the expected survival is approximately 1 year [ 8 , 9 ]. While PE remains the final curative option in select patients, recent advances in systemic therapies — such as immune checkpoint inhibitors [ 10 ], targeted therapies [ 11 ], and image-guided brachytherapy [ 12 ] — have expanded the therapeutic landscape for recurrent or metastatic cervical cancer, nevertherless, in patients with central pelvic recurrence confined to the pelvis, surgical resection may still offer the only chance of cure. This case report describes a patient with recurrent cervical cancer who developed bone metastasis following PE and subsequently experienced an entero-vascular fistula as a severe complication during radiotherapy. Case Presentation We present the case of a 47-year-old woman who was diagnosed at 43 years of age in 2020 with cervical cancer, specifically mucinous carcinoma of the gastric type, well-differentiated, involving the parametrium, and classified as FIGO stage IIB. She underwent a radical hysterectomy followed by concurrent chemoradiotherapy (CCRT). In 2023, due to the development of a recto-urethral fistula, she subsequently underwent PE, including abdominoperineal resection (APR), right hemicolectomy, total vaginectomy, radical cystectomy with ileal conduit, ureterostomy, and multiple tumor excisions around the left external iliac artery and the right common iliac artery. The patient presented to the emergency room in March 2023 with a chief complaint of right buttock and leg pain. She was admitted for evaluation and pain control. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans revealed bone metastasis in the third and fifth lumbar vertebrae (L3-L5), left iliac bone, and sacrum. Local radiotherapy was administered. On the 36th day of hospitalization, the patient complained of bloody stool from a fistula that developed in the sacrum. A 5mm-sized fistula near the sacrum was identified, from which bloody stool was noted, even though the patient had a colostomy that produced normal stool. Her blood pressure was 105/65 mmHg with a heart rate of 75 beats per minute, and her hemoglobin level was 7.8g/dL, prompting an emergency blood transfusion. Simultaneously, the patient complained of cramping pain in the upper abdomen, leading to an emergency abdominopelvic computed tomography (APCT) scan and esophagogastroduodenoscopy (EGD). The APCT showed air bubbles in a complicated fluid collection in the presacral area, suggesting communication with a bowel loop. Immediate EGD demonstrated blood pooling in the stomach, but no active bleeding lesions were found. The yellow stool was observed at the ileostomy site. Examination through the fistula revealed a large amount of bloody fluid collection in the pelvic cavity; however, communication with the bowel loop was difficult to observe (Figure. 1). To identify the active bleeding focus, a CT angiography was performed, which revealed contrast extravasation from the left external iliac artery and a large amount of hematoma. Additionally, contrast extravasation was observed in the adjacent pelvic ileal loop, indicating active bleeding from the left external iliac artery with a pelvic ileal fistula (Figure. 2). Abdominal aortography and left iliac angiography were performed, and a 6 mm-4 cm stent graft was inserted at the site of the arterial rupture to achieve embolization. Despite emergency procedures, including blood transfusions and the use of vasopressors, the patient succumbed to hypovolemic shock. Her hospital course is summarized as a timeline in Table 1 . Table 1 Timeline for the patient’s hospitalization Patient Information Age/Sex 47-year-old female Diagnosis Cervical cancer (FIGO stage IIB, diagnosed in 2020) Treatment History Radical hysterectomy and adjuvant concurrent chemoradiotherapy (2020) Systemic chemotherapy and salvage radiotherapy (2022) Pelvic exenteration (2023) Hospital Day Clinical Course HD#1 Visited the emergency room for right buttock and leg pain. Admitted for evaluation and pain control. HD#10 PET-CT performed. HD#15 Pelvic MRI performed. HD#36 A fistula-like opening was observed in the sacrococcygeal skin, with bloody discharge draining from the site. The patient subsequently complained of sudden-onset cramping upper abdominal pain. APCT and EGD were performed. HD#37 CT angiography and embolization performed. - The patient expired Discussion Pelvic exenteration (PE) is a radical procedure primarily used in advanced or recurrent cervical cancer to achieve complete tumor resection. While PE remains one of the few therapeutic options after multimodal treatment failure, it is associated with significant peri-and post-operative morbidity [ 13 ]. Reported complication rates range between 32%-86% [ 14 ], with common post-operative issues including wound infection, wound dehiscence, and abdominal or pelvic collections. While less frequent compared to these complications, fistulae occur in approximately 1–2% of cases [ 15 ]. The most common type of fistula following PE is enterocutaneous, especially in the perineal region. Other types such as vesicovaginal, rectovaginal, and urinary fistulae have also been reported, but entero-vascular fistulae are extremely rare [ 16 ]. Based on a systematic review of fistulae formation in colorectal and bladder cancer cases, entero-vascular fistula is particularly uncommon in these malignancies. Colovesical fistulae, which are more frequently reported, occur in up to 6.5% of cancer cases, whereas entero-vascular fistula remains rarer [ 17 ]. Regarding patients with cervical cancer, adverse events related to PE have been reported to range between 25%-83.3%, with notably higher incidences in patients who have previously received radiation therapy [ 18 ]. Many studies have explored surgical techniques and prognostic factors aimed at improving surgical outcomes. Additionally, research has investigated long-term survival outcomes for patients undergoing PE for gynecological malignancies. A retrospective study conducted in China on patients who underwent PE found that 17 (41.5%) out of 41 patients experienced uncontrolled and recurrent cases [ 19 ]. Another retrospective study in Greece analyzed 138 cases of gynecologic cancers treated with PE, reporting a recurrence rate of 54.3%. Notably, patients with recurrent cervical cancer had a higher recurrence rate compared to those with other types of gynecologic cancers, including endometrial and ovarian cancers, although this difference was not statistically significant (p = 0.266) [ 20 ]. In 2012, the National Cancer Center in Korea reviewed patient characteristics, surgical outcomes, survival, recurrence, and complications in curative PE treatment [ 21 ]. The study found that eight patients experienced pelvic and distant recurrences. Subsequent treatments included chemotherapy for one patient, surgery and chemotherapy for one patient, radiation therapy and chemotherapy for seven patients, and hospice management for 12 patients. Eighteen patients died from the disease. Survival outcome were more strongly associated with R0 than R1 resection. Additionally, surgical outcomes can be influenced by prognostic factors such as lymph node involvement, the presence of perineural invasion, and the number of organs involved [ 22 ]. Colorectal cancer, a type of pelvic malignancy eligible for PE, shows improved local control with higher doses of radiotherapy. To achieve this while minimizing harm to healthy tissue, intraoperative radiotherapy (IORT) is used [ 23 ]. This approach delivers a high dose of radiation directly to the tumor bed after surgical resection. A large systematic review of 3,003 patients treated with IORT for locally advanced or recurrent rectal cancer demonstrated a significant improvement in local recurrence, disease-free survival and overall survival (HR 0.33; 95% CI 0.2– 0.54 p = 0.001) [ 24 ]. The overall complication rate ranged between 15%-59%, with short-term complications reported in 3%-46% of cases, predominantly wound-related. Gastrointestinal fistulas have been identified as post-treatment complications, with incidence ranging between 1%-8%. This case highlights the rare but severe complications of entero-vascular fistulas following PE and radiotherapy for recurrent cervical cancer. Entero-vascular fistulas are uncommon but life-threatening complications that require prompt diagnosis and management. Our patient's presentation with bloody stool from a sacral fistula, despite having a colostomy, underscores the complexity of post-surgical monitoring in these patients. The findings suggest that closer monitoring and proactive management strategies are necessary to address potential complications early. Future research should focus on developing predictive models to identify patients at higher risk for such complications and explore innovative techniques to prevent fistula formation. In conclusion, this case serves as a reminder of the complexities involved in managing advanced pelvic malignancies and the critical role of timely intervention in mitigating severe complications. Clinicians should maintain a high index of suspicion for vascular complications in patients presenting with unusual symptoms post-PE, and a coordinated, multidisciplinary approach is essential for optimal care. Conclusions This case highlights an entero-vascular fistula as one of the severe complications following PE and radiotherapy for recurrent cervical cancer. In comparison to existing literature, this case emphasizes that PE and radiotherapy present a risk of morbidity, such as fistula formation. Therefore, understanding these risks suggests that careful management strategies must be selected for the treatment of recurrences after PE. Abbreviations APCT Abdomino-pelvic computed tomography APR Abdominoperineal resection CCRT Concurrent chemoradiotherapy CI Confidence interval CT Computed Tomography EGD Esophagogastroduodenoscopy HR Hazard ratio IORT Intraoperative radiotherapy MRI Magnetic resonance imaging OS Overall survival PE Pelvic exenteration PET Positron emission tomography PFS Progression-free survival Declarations Acknowledgements We would like to thank Editage (www.editage.co.kr) for English language editing. Author’s contributions SYH conceived and designed the report; SYH and ISH collected and analyzed the case; ISH wrote the paper. All authors read and approved the final manuscript. Funding This study was not supported by any funding sources. Data availability No datasets were generated or analysed during the current study. Ethics approval The study was approved by the Institutional Review Board of our institution on November 8, 2024 (KC24ZASI0726).. Consent for Publication Written informed consent was obtained from the patient and/or her legal guardinas for their participation in this study. Additionally, written consent was secured from the individual and/or their legal guardians for the publication of any potentially identifiable images or data included in this article. Conflict of interest The authors declare that they have no conflicts of interest. References Pawlik TM, Skibber JM, Rodriguez-Bigas MA. Pelvic exenteration for advanced pelvic malignancies. Ann Surg Oncol. 2006;13(5):612–23. Anthopoulos AP, Manetta A, Larson JE, Podczaski ES, Bartholomew MJ, Mortel R. Pelvic exenteration: a morbidity and mortality analysis of a seven-year experience. Gynecol Oncol. 1989;35(2):219–23. Brunschwig A. Complete Excision of Pelvic Viscera in the Male for Advanced Carcinoma of the Sigmoid Invading the Urinary Bladder. Ann Surg. 1949;129(4):499–504. PELVEX Collaborative. Pelvic Exenteration for Advanced Nonrectal Pelvic Malignancy. Ann Surg. 2019;270(5):899–905. Harris CA, Solomon MJ, Heriot AG, Sagar PM, Tekkis PP, Dixon L, et al. The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg. 2016;264(2):323–9. Peacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, et al. Complications After Extended Radical Resections for Locally Advanced and Recurrent Pelvic Malignancies: A 25-Year Experience. Ann Surg Oncol. 2020;27(2):409–14. Tortorella L, Casarin J, Mara KC, Weaver AL, Multinu F, Glaser GE, et al. Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies. Gynecol Oncol. 2019;152(1):151–6. Young JM, Badgery-Parker T, Masya LM, King M, Koh C, Lynch AC, et al. Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy. Br J Surg. 2014;101(3):277–87. Rezk YA, Hurley KE, Carter J, Dao F, Bochner BH, Aubey JJ, et al. A prospective study of quality of life in patients undergoing pelvic exenteration: interim results. Gynecol Oncol. 2013;128(2):191–7. Colombo N, Dubot C, Lorusso D, et al. Pembrolizumab for Persistent, Recurrent, or Metastatic Cervical Cancer. N Engl J Med. 2024;385(20):1856–67. Tewari KS, Sill MW, Long HJ 3rd, et al. Improved Survival with Bevacizumab in Advanced Cervical Cancer. N Engl J Med. 2014;370(8):734–43. Lorusso D, Xiang Y, Hasegawa K, et al. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18):overall survival results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2024;404(10460):1321–32. Ubinha ACF, Pedrão PG, Tadini AC, Schmidt RL, Santos MHD, Andrade CEMDC, et al. The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature. Cancers (Basel). 2024;16(4):817. Platt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol. 2018;22(11):835–45. Venchiarutti RL, Solomon MJ, Koh CE, Young JM, Steffens D. Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity. Br J Surg. 2019;106(10):1393–403. Persson P, Chong P, Steele CW, Quinn M. Prevention and management of complications in pelvic exenteration. Eur J Surg Oncol. 2022;48(11):2277–83. Granieri S, Sessa F, Bonomi A, Paleino S, Bruno F, Chierici A, et al. Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence. BMC Surg. 2021;21(1):265. Moolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhuijzen LRCW, et al. Clinical outcomes of pelvic exenteration for gynecologic malignancies. Gynecol Oncol. 2023;171:114–20. Yu JH, Tong CJ, Huang QD, Ye YL, Chen G, Li H, et al. Long-term outcomes of pelvic exenterations for gynecological malignancies: a single-center retrospective cohort study. BMC Cancer. 2024;24(1):88. Haidopoulos D, Pergialiotis V, Aggelou K, Thomakos N, Alexakis N, Stamatakis E, et al. Pelvic exenteration for gynecologic malignancies: The experience of a tertiary center from Greece. Surg Oncol. 2022;40:101702. Yoo HJ, Lim MC, Seo SS, Kang S, Yoo CW, Kim JY, et al. Pelvic exenteration for recurrent cervical cancer: ten-year experience at National Cancer Center in Korea. J Gynecol Oncol. 2012;23(4):242–50. Schmidt A-M, Imesch P, Fink D, Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecol Oncol. 2012;125(3):604–9. Shine RJ, Glyn T, Frizelle F. Pelvic exenteration: a review of current issues/controversies. ANZ J Surg. 2022;92(11):2822–8. Mirnezami R, Chang GJ, Das P, Chandrakumaran K, Tekkis P, Darzi A, et al. Intraoperative radiotherapy in colorectal cancer: systematic review and meta-analysis of techniques, long-term outcomes, and complications. Surg Oncol. 2013;22(1):22–35. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Jul, 2025 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 15 May, 2025 Reviews received at journal 05 May, 2025 Reviewers agreed at journal 04 May, 2025 Reviewers invited by journal 28 Apr, 2025 Submission checks completed at journal 27 Apr, 2025 First submitted to journal 25 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5800557","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":449336275,"identity":"7261db6c-736c-4af7-befe-03e5e92be94a","order_by":0,"name":"In Sun Hwang","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"In","middleName":"Sun","lastName":"Hwang","suffix":""},{"id":449336276,"identity":"af304dfa-5352-4202-b03d-54e909135b73","order_by":1,"name":"Soo Young Hur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACAzBZAcQSDIwHEsA8NmK0nGFg4JFgYCBBC2MbVAsDMVrMJXIff+adZydvL9184MCDGgZ5/ga2tA/4tFjOSDeT5t2WbNgjcyzhQMIxBsMZB9gOz8DrsBtpbMy82w4w9kjkGBxIbGBg3MDA3ozfLzfSmD/zzjlgD9NiT4wWBmnehgOJMC2JGxjYDuPXcuYZm+ScY8nJPTfSQH6RSJ5xmC0Zv5bjacwf3tTY2bbPSD748EeNjW1/e5sxXi0gwMSDYANjh5mgBmBM/iBC0SgYBaNgFIxgAADrwkbGPOOsDQAAAABJRU5ErkJggg==","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":true,"prefix":"","firstName":"Soo","middleName":"Young","lastName":"Hur","suffix":""}],"badges":[],"createdAt":"2025-01-10 04:53:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5800557/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5800557/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-025-03840-x","type":"published","date":"2025-07-09T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82045063,"identity":"8977232a-9b30-4e86-85e2-4ebb3cce7a68","added_by":"auto","created_at":"2025-05-06 09:32:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46056,"visible":true,"origin":"","legend":"\u003cp\u003eThe findings of EGD and sigmoidoscopy. (a) Blood pooling contents were seen in the stomach through immediate EGD. (b) Large amount of bloody fluid collection was seen in the pelvic cavity through the fistula on the sacrum.\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5800557/v1/cf2771ff79040454e692c526.jpg"},{"id":82045067,"identity":"d0f0e33e-2af5-4a0f-9d5d-84df70ce7627","added_by":"auto","created_at":"2025-05-06 09:32:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30817,"visible":true,"origin":"","legend":"\u003cp\u003eThe finding of CT angiography. The arrow indicates the site of contrast extravasation.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5800557/v1/ec954ba4b11e022585e91bf6.jpg"},{"id":86699436,"identity":"f4de52a3-8b66-4b56-a5fb-6070341623da","added_by":"auto","created_at":"2025-07-14 16:09:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":461928,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5800557/v1/307240f5-8466-4211-acdf-bca190e1b77b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eTotal pelvic exenteration (PE) is a surgical resection of all pelvic organs, including the rectum, bladder, and the reproductive organs, for locally advanced primary or recurrent pelvic malignancies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This radical surgery is often the last curative option for patients who have undergone multimodal treatment. Traditionally, this aggressive surgical extirpation has been associated with a high rate of complications and few long-term survivors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, since Brunschwig first described it in 1948 for the treatment of recurrent gynecologic malignancies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], advances in surgical techniques and perioperative care have significantly decreased surgical morbidity and mortality rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFive-year survival rates after PE have been reported to range between 28.2%-59% with mortality rates approximately 0.5%-2% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The 30-day morbidity rate was reported to be 67.2%, often associated with three or more major complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Commonly reported major peri- or post-operative complications include rectovaginal fistula, anastomotic site leak, sepsis, and pulmonary embolism.\u003c/p\u003e \u003cp\u003ePE is considered a palliative surgical treatment for advanced or recurrent cervical cancer and is worthwhile when the expected survival is approximately 1 year [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While PE remains the final curative option in select patients, recent advances in systemic therapies \u0026mdash; such as immune checkpoint inhibitors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], targeted therapies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and image-guided brachytherapy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] \u0026mdash; have expanded the therapeutic landscape for recurrent or metastatic cervical cancer, nevertherless, in patients with central pelvic recurrence confined to the pelvis, surgical resection may still offer the only chance of cure.\u003c/p\u003e \u003cp\u003eThis case report describes a patient with recurrent cervical cancer who developed bone metastasis following PE and subsequently experienced an entero-vascular fistula as a severe complication during radiotherapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eWe present the case of a 47-year-old woman who was diagnosed at 43 years of age in 2020 with cervical cancer, specifically mucinous carcinoma of the gastric type, well-differentiated, involving the parametrium, and classified as FIGO stage IIB. She underwent a radical hysterectomy followed by concurrent chemoradiotherapy (CCRT). In 2023, due to the development of a recto-urethral fistula, she subsequently underwent PE, including abdominoperineal resection (APR), right hemicolectomy, total vaginectomy, radical cystectomy with ileal conduit, ureterostomy, and multiple tumor excisions around the left external iliac artery and the right common iliac artery.\u003c/p\u003e \u003cp\u003eThe patient presented to the emergency room in March 2023 with a chief complaint of right buttock and leg pain. She was admitted for evaluation and pain control. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans revealed bone metastasis in the third and fifth lumbar vertebrae (L3-L5), left iliac bone, and sacrum. Local radiotherapy was administered.\u003c/p\u003e \u003cp\u003eOn the 36th day of hospitalization, the patient complained of bloody stool from a fistula that developed in the sacrum. A 5mm-sized fistula near the sacrum was identified, from which bloody stool was noted, even though the patient had a colostomy that produced normal stool. Her blood pressure was 105/65 mmHg with a heart rate of 75 beats per minute, and her hemoglobin level was 7.8g/dL, prompting an emergency blood transfusion.\u003c/p\u003e \u003cp\u003eSimultaneously, the patient complained of cramping pain in the upper abdomen, leading to an emergency abdominopelvic computed tomography (APCT) scan and esophagogastroduodenoscopy (EGD). The APCT showed air bubbles in a complicated fluid collection in the presacral area, suggesting communication with a bowel loop. Immediate EGD demonstrated blood pooling in the stomach, but no active bleeding lesions were found. The yellow stool was observed at the ileostomy site. Examination through the fistula revealed a large amount of bloody fluid collection in the pelvic cavity; however, communication with the bowel loop was difficult to observe (Figure. 1).\u003c/p\u003e\u003cp\u003eTo identify the active bleeding focus, a CT angiography was performed, which revealed contrast extravasation from the left external iliac artery and a large amount of hematoma. Additionally, contrast extravasation was observed in the adjacent pelvic ileal loop, indicating active bleeding from the left external iliac artery with a pelvic ileal fistula (Figure. 2). Abdominal aortography and left iliac angiography were performed, and a 6 mm-4 cm stent graft was inserted at the site of the arterial rupture to achieve embolization. Despite emergency procedures, including blood transfusions and the use of vasopressors, the patient succumbed to hypovolemic shock. Her hospital course is summarized as a timeline in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTimeline for the patient\u0026rsquo;s hospitalization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePatient Information\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge/Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47-year-old female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCervical cancer (FIGO stage IIB, diagnosed in 2020)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment History\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadical hysterectomy and adjuvant concurrent chemoradiotherapy (2020)\u003c/p\u003e \u003cp\u003eSystemic chemotherapy and salvage radiotherapy (2022)\u003c/p\u003e \u003cp\u003ePelvic exenteration (2023)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital Day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Course\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD#1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisited the emergency room for right buttock and leg pain.\u003c/p\u003e \u003cp\u003eAdmitted for evaluation and pain control.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD#10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePET-CT performed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD#15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePelvic MRI performed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD#36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA fistula-like opening was observed in the sacrococcygeal skin, with bloody discharge draining from the site. The patient subsequently complained of sudden-onset cramping upper abdominal pain.\u003c/p\u003e \u003cp\u003eAPCT and EGD were performed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHD#37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCT angiography and embolization performed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe patient expired\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003ePelvic exenteration (PE) is a radical procedure primarily used in advanced or recurrent cervical cancer to achieve complete tumor resection. While PE remains one of the few therapeutic options after multimodal treatment failure, it is associated with significant peri-and post-operative morbidity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Reported complication rates range between 32%-86% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], with common post-operative issues including wound infection, wound dehiscence, and abdominal or pelvic collections. While less frequent compared to these complications, fistulae occur in approximately 1\u0026ndash;2% of cases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The most common type of fistula following PE is enterocutaneous, especially in the perineal region. Other types such as vesicovaginal, rectovaginal, and urinary fistulae have also been reported, but entero-vascular fistulae are extremely rare [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on a systematic review of fistulae formation in colorectal and bladder cancer cases, entero-vascular fistula is particularly uncommon in these malignancies. Colovesical fistulae, which are more frequently reported, occur in up to 6.5% of cancer cases, whereas entero-vascular fistula remains rarer [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding patients with cervical cancer, adverse events related to PE have been reported to range between 25%-83.3%, with notably higher incidences in patients who have previously received radiation therapy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Many studies have explored surgical techniques and prognostic factors aimed at improving surgical outcomes. Additionally, research has investigated long-term survival outcomes for patients undergoing PE for gynecological malignancies.\u003c/p\u003e \u003cp\u003eA retrospective study conducted in China on patients who underwent PE found that 17 (41.5%) out of 41 patients experienced uncontrolled and recurrent cases [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another retrospective study in Greece analyzed 138 cases of gynecologic cancers treated with PE, reporting a recurrence rate of 54.3%. Notably, patients with recurrent cervical cancer had a higher recurrence rate compared to those with other types of gynecologic cancers, including endometrial and ovarian cancers, although this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.266) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2012, the National Cancer Center in Korea reviewed patient characteristics, surgical outcomes, survival, recurrence, and complications in curative PE treatment [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The study found that eight patients experienced pelvic and distant recurrences. Subsequent treatments included chemotherapy for one patient, surgery and chemotherapy for one patient, radiation therapy and chemotherapy for seven patients, and hospice management for 12 patients. Eighteen patients died from the disease.\u003c/p\u003e \u003cp\u003eSurvival outcome were more strongly associated with R0 than R1 resection. Additionally, surgical outcomes can be influenced by prognostic factors such as lymph node involvement, the presence of perineural invasion, and the number of organs involved [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eColorectal cancer, a type of pelvic malignancy eligible for PE, shows improved local control with higher doses of radiotherapy. To achieve this while minimizing harm to healthy tissue, intraoperative radiotherapy (IORT) is used [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This approach delivers a high dose of radiation directly to the tumor bed after surgical resection. A large systematic review of 3,003 patients treated with IORT for locally advanced or recurrent rectal cancer demonstrated a significant improvement in local recurrence, disease-free survival and overall survival (HR 0.33; 95% CI 0.2\u0026ndash; 0.54 p\u0026thinsp;=\u0026thinsp;0.001) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The overall complication rate ranged between 15%-59%, with short-term complications reported in 3%-46% of cases, predominantly wound-related. Gastrointestinal fistulas have been identified as post-treatment complications, with incidence ranging between 1%-8%.\u003c/p\u003e \u003cp\u003eThis case highlights the rare but severe complications of entero-vascular fistulas following PE and radiotherapy for recurrent cervical cancer. Entero-vascular fistulas are uncommon but life-threatening complications that require prompt diagnosis and management. Our patient's presentation with bloody stool from a sacral fistula, despite having a colostomy, underscores the complexity of post-surgical monitoring in these patients.\u003c/p\u003e \u003cp\u003eThe findings suggest that closer monitoring and proactive management strategies are necessary to address potential complications early. Future research should focus on developing predictive models to identify patients at higher risk for such complications and explore innovative techniques to prevent fistula formation.\u003c/p\u003e \u003cp\u003eIn conclusion, this case serves as a reminder of the complexities involved in managing advanced pelvic malignancies and the critical role of timely intervention in mitigating severe complications. Clinicians should maintain a high index of suspicion for vascular complications in patients presenting with unusual symptoms post-PE, and a coordinated, multidisciplinary approach is essential for optimal care.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case highlights an entero-vascular fistula as one of the severe complications following PE and radiotherapy for recurrent cervical cancer. In comparison to existing literature, this case emphasizes that PE and radiotherapy present a risk of morbidity, such as fistula formation. Therefore, understanding these risks suggests that careful management strategies must be selected for the treatment of recurrences after PE.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAPCT Abdomino-pelvic computed tomography\u003c/p\u003e\n\u003cp\u003eAPR\u0026nbsp; \u0026nbsp;\u0026nbsp;Abdominoperineal resection\u003c/p\u003e\n\u003cp\u003eCCRT\u0026nbsp;\u0026nbsp;Concurrent chemoradiotherapy\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence interval\u003c/p\u003e\n\u003cp\u003eCT Computed Tomography\u003c/p\u003e\n\u003cp\u003eEGD Esophagogastroduodenoscopy\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hazard ratio\u003c/p\u003e\n\u003cp\u003eIORT Intraoperative radiotherapy\u003c/p\u003e\n\u003cp\u003eMRI Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eOS Overall survival\u003c/p\u003e\n\u003cp\u003ePE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pelvic exenteration\u003c/p\u003e\n\u003cp\u003ePET Positron emission tomography\u003c/p\u003e\n\u003cp\u003ePFS Progression-free survival\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.co.kr) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSYH conceived and designed the report; SYH and ISH collected and analyzed the case; ISH wrote the paper. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any funding sources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of our institution on November 8, 2024 (KC24ZASI0726)..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient and/or her legal guardinas for their participation in this study. Additionally, written consent was secured from the individual and/or their legal guardians for the publication of any potentially identifiable images or data included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePawlik TM, Skibber JM, Rodriguez-Bigas MA. Pelvic exenteration for advanced pelvic malignancies. Ann Surg Oncol. 2006;13(5):612\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnthopoulos AP, Manetta A, Larson JE, Podczaski ES, Bartholomew MJ, Mortel R. Pelvic exenteration: a morbidity and mortality analysis of a seven-year experience. Gynecol Oncol. 1989;35(2):219\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunschwig A. Complete Excision of Pelvic Viscera in the Male for Advanced Carcinoma of the Sigmoid Invading the Urinary Bladder. Ann Surg. 1949;129(4):499\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePELVEX Collaborative. Pelvic Exenteration for Advanced Nonrectal Pelvic Malignancy. Ann Surg. 2019;270(5):899\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris CA, Solomon MJ, Heriot AG, Sagar PM, Tekkis PP, Dixon L, et al. The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg. 2016;264(2):323\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, et al. Complications After Extended Radical Resections for Locally Advanced and Recurrent Pelvic Malignancies: A 25-Year Experience. Ann Surg Oncol. 2020;27(2):409\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTortorella L, Casarin J, Mara KC, Weaver AL, Multinu F, Glaser GE, et al. Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies. Gynecol Oncol. 2019;152(1):151\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung JM, Badgery-Parker T, Masya LM, King M, Koh C, Lynch AC, et al. Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy. Br J Surg. 2014;101(3):277\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRezk YA, Hurley KE, Carter J, Dao F, Bochner BH, Aubey JJ, et al. A prospective study of quality of life in patients undergoing pelvic exenteration: interim results. Gynecol Oncol. 2013;128(2):191\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColombo N, Dubot C, Lorusso D, et al. Pembrolizumab for Persistent, Recurrent, or Metastatic Cervical Cancer. N Engl J Med. 2024;385(20):1856\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTewari KS, Sill MW, Long HJ 3rd, et al. Improved Survival with Bevacizumab in Advanced Cervical Cancer. N Engl J Med. 2014;370(8):734\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorusso D, Xiang Y, Hasegawa K, et al. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18):overall survival results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2024;404(10460):1321\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUbinha ACF, Pedr\u0026atilde;o PG, Tadini AC, Schmidt RL, Santos MHD, Andrade CEMDC, et al. The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature. Cancers (Basel). 2024;16(4):817.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlatt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol. 2018;22(11):835\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenchiarutti RL, Solomon MJ, Koh CE, Young JM, Steffens D. Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity. Br J Surg. 2019;106(10):1393\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersson P, Chong P, Steele CW, Quinn M. Prevention and management of complications in pelvic exenteration. Eur J Surg Oncol. 2022;48(11):2277\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGranieri S, Sessa F, Bonomi A, Paleino S, Bruno F, Chierici A, et al. Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence. BMC Surg. 2021;21(1):265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoolenaar LR, van Rangelrooij LE, van Poelgeest MIE, van Beurden M, van Driel WJ, van Lonkhuijzen LRCW, et al. Clinical outcomes of pelvic exenteration for gynecologic malignancies. Gynecol Oncol. 2023;171:114\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu JH, Tong CJ, Huang QD, Ye YL, Chen G, Li H, et al. Long-term outcomes of pelvic exenterations for gynecological malignancies: a single-center retrospective cohort study. BMC Cancer. 2024;24(1):88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaidopoulos D, Pergialiotis V, Aggelou K, Thomakos N, Alexakis N, Stamatakis E, et al. Pelvic exenteration for gynecologic malignancies: The experience of a tertiary center from Greece. Surg Oncol. 2022;40:101702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo HJ, Lim MC, Seo SS, Kang S, Yoo CW, Kim JY, et al. Pelvic exenteration for recurrent cervical cancer: ten-year experience at National Cancer Center in Korea. J Gynecol Oncol. 2012;23(4):242\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt A-M, Imesch P, Fink D, Egger H. Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer. Gynecol Oncol. 2012;125(3):604\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShine RJ, Glyn T, Frizelle F. Pelvic exenteration: a review of current issues/controversies. ANZ J Surg. 2022;92(11):2822\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirnezami R, Chang GJ, Das P, Chandrakumaran K, Tekkis P, Darzi A, et al. Intraoperative radiotherapy in colorectal cancer: systematic review and meta-analysis of techniques, long-term outcomes, and complications. Surg Oncol. 2013;22(1):22\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pelvic Exenteration, Uterine Cervical Neoplasms, Chemoradiotherapy, Palliative Care, Vascular Fistula","lastPublishedDoi":"10.21203/rs.3.rs-5800557/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5800557/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTotal pelvic exenteration (PE) is a surgical resection of all pelvic organs used as a palliative treatment for locally advanced or recurrent pelvic malignancies. This case report describes an entero-vascular fistula as a severe complication following radiotherapy in a patient with recurrent cervical cancer who underwent PE.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eWe present the case of a 47-year-old woman who was diagnosed with cervical cancer at the age of 43 years, classified as FIGO stage IIB. She underwent a radical hysterectomy followed by concurrent chemoradiotherapy (CCRT). In 2023, she developed a recto-urethral fistula and subsequently underwent PE. In March 2024, she was admitted for right buttock and leg pain. An evaluation revealed bone metastasis in the lumbar vertebrae, left iliac bone, and sacrum, for which local radiotherapy was administered. Later, she complained of bloody discharge from a sacral fistula and upper abdominal pain. Her blood pressure was 105/65 mmHg, heart rate 75 beats per minute (BPM), and hemoglobin level was 7.8g/dL, prompting an emergency blood transfusion. Abdomino-pelvic computed tomography (APCT) scan and esophagogastroduodenoscopy (EGD) revealed a large amount of bloody fluid in the stomach and suggested communication with the bowel loop. CT angiography showed contrast extravasation from the left external iliac artery and a large hematoma. A stent graft was inserted at the site of the entero-vascular fistula to achieve embolization.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights an entero-vascular fistula as one of the severe complications following PE and radiotherapy for recurrent cervical cancer. Patients who have undergone multimodal treatment, including PE, may have a pelvic condition that is more vulnerable to radiation. Therefore, the complications that may arise from radiation therapy, such as fistula formation, could be higher compared to patients who have not undergone PE.\u003c/p\u003e","manuscriptTitle":"Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 09:32:51","doi":"10.21203/rs.3.rs-5800557/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-15T08:22:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-05T21:34:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98181858188577920621216076866730179384","date":"2025-05-04T10:05:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-28T21:52:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-28T00:05:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-04-25T04:34:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed8afcb6-df2a-46a8-ba3d-4fa01a28bcac","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T16:03:13+00:00","versionOfRecord":{"articleIdentity":"rs-5800557","link":"https://doi.org/10.1186/s12905-025-03840-x","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2025-07-09 15:57:49","publishedOnDateReadable":"July 9th, 2025"},"versionCreatedAt":"2025-05-06 09:32:51","video":"","vorDoi":"10.1186/s12905-025-03840-x","vorDoiUrl":"https://doi.org/10.1186/s12905-025-03840-x","workflowStages":[]},"version":"v1","identity":"rs-5800557","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5800557","identity":"rs-5800557","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}