Akihiko Wakayama

Radiotherapy- or radical surgery-induced female sexual morbidity in stages IB and II cervical cancer.

Objective The objective of this study was to evaluate the sexual function in cervical cancer survivors after radiotherapy (RT) or radical surgery (RS). Methods This was an observational and cross-sectional study. The Female Sexual Function Index (FSFI) self-reported questionnaires were distributed to 175 patients after RT (RT group) or RS (RS group) and 521 healthy women (control) between 2011 and 2012. Sexual functions were compared among these 3 groups. Results Eligible 92 patients (46 in RT group, 46 in RS group) and 148 control subjects were included for analysis. There was a significant difference in median (range) FSFI total score of 5.5 (3.6–34.7) in the RT group, 18.9 (3.4–31.2) in the RS group, and 22.1 (2–34.2) in the control group (P < 0.001). The median FSFI total score in the RT group was significantly lower than that in the control group (P < 0.001). Six sexual domains (desire, arousal, lubrication, orgasm, satisfaction, pain) were all significantly affected in the RT group, and no significant differences, except pain, were observed in the RS group as compared with the control group. Conclusions Interventions involving counseling and rehabilitation for female sexual function should be provided in cervical cancer survivors, especially after RT.

Recurrent female adnexal tumor of probable Wolffian origin treated with debulking surgery, imatinib and paclitaxel/carboplatin combination chemotherapy: A case report

In view of the small number of recurrent and metastatic cases of female adnexal tumors of probable Wolffian origin (FATWO), there is a distinct lack of evidence to support recommendations regarding treatment. In the present study, a 37-year-old female was diagnosed with a left adnexal tumor and underwent a left salpingo-oophorectomy (SO). The tumor was found to arise from the left tubal fimbria and extend to the posterior leaf of the broad ligament. Pathological examination identified a number of solid, tubular and cystic architectures, with areas of hyalinization, hemorrhage and necrosis. Immunohistochemistry detected that the tumor cells were positive for cytokeratin (CK)7, vimentin, inhibin and calretinin, and negative for CK20, epithelial membrane antigen, and the estrogen and progesterone receptors. Thus, the patient was diagnosed with FATWO. Following 15 months, the patient developed recurrent tumors and subsequently underwent a total abdominal hysterectomy, a right SO and extirpation of the disseminated tumors, but with incomplete debulking. The tumor cells were immunoreactive for KIT. As there are a limited number of treatment options and few reported cases, limiting the therapy recommendations, imatinib mesylate was administered for 6 months and the tumors were temporarily stabilized for 4 months until the disease progressed. The patient underwent a further debulking surgery that did not achieve complete debulking and was subsequently administered a combination chemotherapy of paclitaxel and carboplatin. This regimen resulted in an almost complete response after 10 cycles. The tumors continued to decrease in size, and the tumors in the left side of the Douglas pouch and the right para-colic gutter were no longer detectable. To the best of our knowledge, the current study is the first to report carboplatin and paclitaxel combination therapy demonstrating a response of this degree to recurrent FATWO following the failure of imatinib treatment. However, surgical debulking remains the most effective treatment for FATWO when is it is possible. The precise role of chemotherapy, radiotherapy and molecular-targeting therapy in the treatment of recurrent or metastatic FATWO remains to be elucidated, and therefore, novel strategies to overcome this disease must be prioritized.

Diffuse Venous Malformation of the Uterus in a Pregnant Woman with Klippel-Trénaunay Syndrome Diagnosed by DCE-MRI.

Background. We experienced a rare case of a pregnant woman with Klippel-Trénaunay syndrome complicated with diffuse venous malformation of the uterus. This is the first report on the usefulness of dynamic contrast-enhanced-MRI for the diagnosis of diffuse venous malformation of the uterus. Case Presentation. A 23-year-old woman presented with convulsions and talipes equinus position of both lower limbs at 11 weeks of gestation. At 27 weeks, ultrasonography demonstrated tubular echolucent spaces throughout the myometrium. Dynamic MRI at 37 weeks revealed that the myometrial lesion was enhanced slowly and showed homogeneous enhancement even on a 10 min delayed image. Taken together with unilateral foot hypertrophy, varices, and port-wine stain, the patient was diagnosed as having Klippel-Trénaunay syndrome complicated with diffuse venous malformation of the pregnant uterus. The patient underwent elective cesarean section because of severe dystonia. The lower uterine segment was thickened and heavy venous blood flow was observed at the incision. Histological diagnosis of the myometrial biopsy specimen was venous malformation. Conclusions. Both diffuse venous malformation and Klippel-Trénaunay syndrome during pregnancy can involve considerable complications, in particular, massive bleeding during labor. Women who suffer from this syndrome should be advised about the risk of complications of pregnancy.

Endometrial carcinoma with peritoneal keratin granulomas mimicking peritoneal carcinomatosis: a case report and imaging diagnosis

We report the case of a 71-year-old woman diagnosed as having endometrioid adenocarcinoma with squamous differentiation (adenoacanthoma, grade 1) and peritoneal keratin granuloma. Preoperative diagnostic imaging showed a uterine cavity filled with a large mass, many peritoneal nodules, and free fluid in the Douglas pouch, indicating a peritoneal carcinomatosis. Endometrial biopsy revealed grade 1 endometrioid adenocarcinoma. Eventually, postoperative histopathological examination led to the diagnosis. Although peritoneal keratin granulomas mimicking peritoneal carcinomatosis are due to endometrial carcinomas containing squamous elements, gynecological oncologists should keep in mind such situations. The combination of contrast-enhanced T1-weighted and diffusion-weighted magnetic resonance imaging is helpful for preoperative differential diagnosis.

Lymphatic vessel involvement is predictive for lymph node metastasis and an important prognostic factor in endometrial cancer

BackgroundLymphovascular space involvement is reported to be an important risk factor in endometrial cancer. This study was conducted to evaluate the separate prognostic effects of lymphatic invasion and venous invasion on the outcomes of patients with endometrial cancer.MethodsFrom 2006 to 2013, 189 histologically confirmed endometrial cancer patients were examined. To study the venous invasion (v) of the endometrial cancer, Victoria blue–H&E staining—which positively stains the elastic fibers of vessels—was performed. Immunohistochemical staining with D2-40 was used to study the lymphatic invasion (ly) of the endometrial cancer.ResultsThe median age of the patients was 57 (range 25–84) years. ly(+) and/or v(+) patients were significantly more likely to present an advanced cancer stage, G3 tumor, and deep myometrial invasion than ly(−)/v(−) patients. The incidence of lymph node metastasis was high in ly(+) patients, and that of ovarian metastasis was high in v(+) patients. Lymphatic vessel invasion was significantly correlated with regional lymph node metastasis. We found a significantly higher incidence of distant metastasis in ly(+) patients. Most recurrences in ly(+)/v(−) patients occurred in lymph nodes, while those in ly(+)/v(+) patients occurred mainly at distant organs. Finally, the prognosis was significantly poorer for ly(+) patients, in whom lymphatic invasion was an independent prognostic factor along with distant metastasis.ConclusionsOur study suggests that by separately evaluating lymphatic invasion and blood vessel invasion in endometrial cancer cases, useful information for predicting lymph node metastasis and recurrence sites as well as prognostic information can be obtained.

Secondary uterine carcinosarcoma after concurrent chemoradiotherapy for cervical cancer: Case reports

Highlights • Secondary uterine sarcomas occur in < 1% of patients treated with CCRT.• Secondary uterine sarcomas can occur > 5 years from CCRT.• The median survival period from the secondary tumor occurrence was only 4 months.• All our patients had heterologous carcinosarcoma of the uterine corpus.

Concurrent weekly cisplatin versus triweekly cisplatin with radiotherapy for locally advanced squamous-cell carcinoma of the cervix: a retrospective analysis from a single institution

Objective: To compare patients with cervical cancer who were primarily treated with concurrent chemoradiotherapy (CCRT) using 20 mg m−2 CDDP for 5 days every 3 weeks with weekly regimens of 40 mg m−2. Methods: We retrospectively analyzed 185 patients with Stage IB–IVA squamous-cell carcinoma of the cervix who were treated with CCRT between 2005 and 2013 at our hospital. The CCRT regimen consisted of cisplatin (CDDP) at 20 mg m−2 for 5 days every 3 weeks or 40 mg m−2 weekly, administered concomitantly with RT. Results: The median age was 50 years (range: 22–70 years) in the triweekly group and was 50.5 years (range: 28–70 years) in the weekly group. The 5-year overall survival rate in the triweekly and weekly groups were 82.0% and 83.3%, respectively (p = 0.851); their disease-free survival rate was 79.6% and 78.1%, respectively (p = 0.672). In the triweekly group, 56 patients (50.9%) had grade 3/4 leukopenia, which was significantly higher than that of 11 patients (15%) in the weekly group (p < 0.0001). Conclusion: The weekly CDDP regimen for CCRT seems better in patients with International Federation of Gynecology and Obstetrics Stages IB–IVA squamous-cell carcinoma of the cervix. Advances in knowledge: The weekly CDDP regimen for CCRT seems better in patients with International Federation of Gynecology and Obstetrics Stages IB–IVA squamous-cell carcinoma of the cervix.

Metastatic placental site trophoblastic tumour successfully treated with hysterectomy and EMA/CO chemotherapy

(Enzinger and Smith 1976). Preoperative diagnosis may be difficult but MRI appearances have previously been described (Craven et al. 1992; Kehagias et al. 1999). The use of multiple immunohistochemical stains is generally needed to establish a diagnosis (Espat et al. 2002). At the time of diagnosis, haemangiopericytoma was a distinct histopathological entity but now is preferably recognised as a subtype of solitary fibrous tumour (Gengler and Guillou 2006). Complete excision with adequate margins remains the treatment of choice but is usually complicated by bleeding because of the close proximity of dilated vascular beds (Enzinger and Smith 1976). Vascular embolisation may reduce the risk of bleeding during surgery (Craven et al. 1992; Dozois et al. 2009). A favourable clinical benefit was observed with sunitinib, an oral VEGFR, and PDGFR kinase inhibitor (Mulamalla et al 2008). Radiotherapy has been used as adjuvant therapy for aggressive tumours, inadequate resection margins and recurrences (Craven et al. 1992; Staples et al. 1990; Chakrabarti et al. 2009). Chemotherapy using Adriamycin alone or in combination regimens against recurrent or unresectable disease can achieve palliation (Wong et al. 1978; Beadle et al. 1983). This disease in the pelvis is best managed by a multidisciplinary team, which should include an interventional radiologist, gynaecological oncologist, radiation oncologist, medical oncologist and a colorectal surgeon. Long-term prognosis is difficult to predict as most available information is based on case reports or case series that include different sites due to the rarity of this disease. However, prolonged survival is uncommon in the presence of a large tumour burden. Disease recurrences may occur after long periods of disease-free time even up to 17 years (Begum et al. 2002). Local recurrence preceded metastasis in more than two-thirds of the patients with evidence of metastasis. The 10-year survival rate has been reported at 70 per cent (Enzinger and Smith 1976). Therefore, patients who survive should be followed for long periods.