Ciclosporin/everolimus/methylprednisolone

Abstract

Stage IIB invasive squamous cell carcinoma of the cervix secondary to human papillomavirus infection: case report A 41-year-old woman developed stage IIB invasive squamous cell carcinoma of the cervix secondary to human papillomavirus (HPV) infection during immunosuppressive treatment with ciclosporin, everolimus and methylprednisolone [routes, dosages and durations of treatments to reactions onsets not stated]. The gravida 2 para 1 woman had a history of chronic pyelonephritis in childhood that had resulted in late-stage renal disease and kidney failure requiring a kidney transplant. She had received a donor kidney transplant from her mother, 9 years prior to the current presentation. Following transplant, she had been receiving immunosuppressive treatment with ciclosporin [cyclosporine], everolimus and methylprednisolone [Medrol]. Later, she was found to have vaginal bleeding for 2 months during her routine nephrologist appointment. Her HPV test was positive for type 31. Morphological analysis of the cervical biopsy demonstrated moderately differentiated squamous cell carcinoma. She was referred to another hospital for further evaluation and treatment (current presentation). Laboratory investigations revealed elevated urea, elevated creatinine and elevated potassium. Abdominal ultrasound revealed contraction of both kidneys without para-aortic lymphadenopathy. Pathology of her cervical biopsy revealed fragments of squamous cell carcinoma, grade 2. There were no clear signs of lymphovascular space invasion, the largest fragment was 5mm. An additional endometrial biopsy revealed late-secretory type endometrium. Pelvic examination showed normal external genitalia, and speculum examination revealed gross tumour of the cervix approximately 4cm in diameter with extension into the left fornix of the vagina. Colposcopy showed exophytic lesion and atypical vessels. The rectovaginal examination confirmed a barrelshaped cervix extending into the left fornix of the vagina. The right parametrium was clear, and the left parametrium had limited access due to the presence of a transplanted kidney. MRI scan in the anterior lip and left part of the cervix revealed a tumour of 3.9 × 2.7 × 1.5cm in size which had infiltrated the anterior and left fornixes of the vagina. Functional MRI with diffusion-weighted images showed that there was invasion of the left parametrium with limited diffusion. The tumour did not extend to the bladder and rectum. The ovaries contained only bilateral follicles. No pelvic lymphadenopathy was observed. According to the FIGO classification, she was diagnosed with stage IIB invasive squamous cell carcinoma of the cervix secondary to HPV infection, which was attributed to immunosuppressive therapy. Subsequently, she was referred to a radiation oncologist for consultation. The woman was treated with pelvic external beam radiation therapy (EBRT). A volumetric-modulated arc therapy technique of an intensity-modulated radiotherapy plan was applied prior to the treatment to spare the graft and the usual organs at risk. She was treated for 5 weeks. The EBRT was followed by MRI-guided high-dose rate brachytherapy. Implants were performed under unspecified general anaesthesia in an operating room using MR imaging. At first 3 month follow-up after completing radiotherapy, her pelvic MRI showed complete tumour clinical response. At 6 month follow-up, she was in complete remission without evidence of the disease. Her MRI showed asymptomatic post-radiation changes in the pelvic tissues, slightly dilated and tortuous ureter. Kidney function was relatively normal.