Tsuyoshi Ota

Treatment of squamous cell carcinoma of the uterine cervix with radiation therapy alone: long-term survival, late complications, and incidence of second cancers.

The objective of this retrospective study was to determine the survival rate, incidence of late complications, and incidence of second cancers when radiation therapy alone is used for carcinoma of the uterine cervix. Between 1971 and 1995, 1495 patients with squamous cell carcinoma of the uterine cervix (stages I–IV) were treated with radiation therapy alone in our hospital. Radiation therapy consisted of a combination of high-dose-rate intracavitary brachytherapy and external beam radiotherapy. The cumulative 5-year survival rates for stages Ib, II, and III/IVa carcinoma were 93.5, 77.0, and 60.3%, respectively, and the 10-year survival rates were 90.9, 74.5, and 56.1%, respectively. Local control rates for stages Ib, II, and III/IVa carcinoma were 92.0, 79.4 and 64.2%, respectively. Eighty-two (5.5%) patients suffered grade III/IV or V (fatal) complications. A second cancer developed in 13 (0.87%) patients. Second cancers were observed most frequently in the rectum (five cases), colon (three cases), and uterine body (two cases). Long-term follow-up data revealed that our method of radiation therapy alone for locally advanced carcinoma of the uterine cervix is effective, with low incidences of late complications and second cancers.

Neoadjuvant chemotherapy followed by radical hysterectomy plus postoperative chemotherapy but no radiotherapy for Stage IB2-IIB cervical cancer—Irinotecan and platinum chemotherapy

OBJECTIVE To evaluate the effectiveness of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy plus postoperative chemotherapy but no radiotherapy for stage IB2-IIB cervical cancer. METHODS Forty-six consecutive patients with stage IB2-IIB cervical cancer were treated with NAC followed by radical hysterectomy plus postoperative chemotherapy. Median (range) body mass index (BMI) of the patients was 20.2 (16.2-26.4). Regimens for NAC and postoperative chemotherapy were irinotecan and cisplatin (CPT-11/CDDP) or CPT-11 and nedaplatin (CPT-11/NDP). A total of six cycles of NAC and postoperative chemotherapy were prescribed. No use of radiotherapy was scheduled, except in the case of a recurrence. RESULTS With a median follow-up period for survivors of 38.8 months (range 24-54 months), the 2- and 3-year progression-free survival rates were 91.2% and 86.1%, respectively. Overall response rate of NAC was 80.4%. Recurrence was observed in seven patients. In the absence of radiotherapy, pelvic recurrence was observed in only three patients; another two had para-aortic lymph nodes and the remaining two distant metastases. Toxicities due to chemotherapy were generally tolerable. Postoperative complications included urinary fistula (four patients, 8.7%) and bowel obstruction (two patients, 4.3%), all of which required surgical intervention. CONCLUSION The results indicate that NAC followed by surgery plus postoperative chemotherapy but no radiotherapy offers a viable option in the treatment of stage IB2-IIB cervical cancer. Although a relatively large incidence of postsurgical complications was observed among low-BMI patients, this treatment offers the advantage of minimizing radiation-induced morbidity, allowing radiotherapy to be reserved for the possible event of pelvic recurrence.

Adjuvant hysterectomy for treatment of residual disease in patients with cervical cancer treated with radiation therapy.

The objective of this retrospective study was to determine the efficacy of adjuvant hysterectomy for treatment of residual disease in cervical carcinoma treated with radiation therapy. Between 1971 and 1996, 1590 patients with carcinoma of the uterine cervix (stages I–IIIb) were treated with radiation therapy. Three months after completion of radiation therapy, the status of local control was investigated, and total abdominal hysterectomy was performed in cases in which central residual disease existed in the cervix. Of the 1590 patients, residual disease was identified in 162 patients. Among these patients, 35 showed an absence of distant metastasis or lateral parametrial invasion and underwent hysterectomy. The overall 5- and 10-year survival rates for these patients were 68.6 and 65.7%, respectively. There was no significant difference in survival between patients with squamous cell carcinoma and those with non-squamous cell carcinoma or between patients with stage I/II carcinoma and those with stage III carcinoma. With respect to treatment-related morbidity, five (14.3%) patients suffered grade III or IV complications after hysterectomy. Adjuvant hysterectomy is an effective addition to radiation therapy in the treatment of cervical cancer, even in patients with stage III disease and in those with non-squamous cell carcinoma.

Unusual Trocar Site Metastasis in a Uterine Leiomyosarcoma after Laparoscopic Hysterectomy

With widespread use of laparoscopy in patients with gynecologic malignancy, occasionally port-site metastasis is an item of concern. Herein we report a case of leiomyosarcoma of the uterus that metastasized to an accessory port after laparoscopic-assisted vaginal hysterectomy. A 46-year-old woman with a preoperative diagnosis of leiomyoma underwent laparoscopic-assisted vaginal hysterectomy. Final histopathologic findings revealed leiomyosarcoma. A postoperative abdominopelvic computed tomography scan demonstrated no evidence of metastatic tumor. The patient received 6 courses of combined chemotherapy consisting of cisplatin and ifosfamide. Follow-up computed tomography was performed because of pelvic pain at 4 months after treatment and revealed a recurrent pelvic tumor and a metastatic mass at previous right trocar site. At debulking surgery, a pelvic mass measuring 10 cm was observed, and a subcutaneous nodule measuring 4 cm was noted at the site of the right accessory port, with intact underlying peritoneum. After complete removal of both tumors, concurrent chemoradiation consisting of external radiotherapy and cisplatin was administered. Six months after the second surgery, a pelvic mass measuring 15 cm was observed. A second debulking surgical procedure was performed. However, the patient died of the disease 6 months after the second recurrence.

Shimodaira-Taniguchi conization method: its utility and reliability.

Introduction: Introduced in 1992, the Shimodaira-Taniguchi conization procedure addresses the disadvantages of the loop electrosurgical excision procedure by relying on a high frequency current of 150 W and a triangular probe with a 0.25-mm linear excision electrode to extract a single informative specimen. We conducted a retrospective study to evaluate Shimodaira-Taniguchi conization as a conservative therapy for cervical intraepithelial neoplasia (CIN) and microinvasive cancer of the cervix. Methods: Subjects were 455 patients who underwent Shimodaira-Taniguchi conization for CIN, carcinoma in situ, adenocarcinoma in situ, or stage IA microinvasive cervical carcinoma at our hospital from January 2005 to December 2008. Patient follow-up ranged from 13 to 60 months. Clinical data were obtained and evaluated. Results: Mean operation time was 11 minutes, and average blood loss was 9.9 mL. Margins were positive in 178 (39.1%) cases. Postsurgical complications occurred in 61 patients, with secondary hemorrhage occurring in 46 patients. None required transfusion. None were lost to follow-up, and there was no disease-related death. Disease recurred in 6 (1.3%) patients: 4 with a positive excision margin and 2 with a negative margin. Cervical stenosis occurred in 15 (3.3%) patients, 3 of whom suffered cervical obstruction, including 1 with dysmenorrhea who underwent hysterectomy. In most cases (n = 357, 78%), a single adequate specimen was extracted. Conclusions: As a conservative treatment for CIN and microinvasive cervical cancer, Shimodaira-Taniguchi conization is useful. It is easy, provides adequate histologic specimens (often singular), and results in few postoperative complications.

Small cell carcinoma of the uterine cervix metastasizing to the bone marrow: A case report

We report a case of small cell carcinoma (SmCC) of the uterine cervix that metastasized to the bone marrow. A 60‐year‐old woman with stage IIB SmCC of the cervix was treated with three courses of neoadjuvant chemotherapy followed by radical hysterectomy. Because of the presence of a large residual tumor, the patient underwent postoperative adjuvant chemotherapy. Two months after the last course of chemotherapy, severe pancytopenia developed, and erythroblastic cells were found in the peripheral blood. The hematological disorder was shown to be secondary to bone marrow metastasis, and no other metastases were found. The patient died of the disease 8 months after the initial diagnosis. This case suggests that SmCC of the cervix can metastasize to bone marrow, that such metastasis can occur in isolation and lead to severe pancytopenia, influencing the clinical course of the disease.

Drug-induced aortitis in a patient with ovarian cancer treated with bevacizumab combination therapy

OBJECTIVE To review and evaluate drug-induced vasculitis, which is an extremely rare complication of chemotherapy. CASE REPORT A 47-year-old woman with ovarian cancer developed aortitis during bevacizumab combination chemotherapy. Contract-enhanced CT showed concentric thickening of the descending aorta. Antibiotics were administered, but a repeat CE-CT scan showed no resolution of the aortitis. To treat the aortitis, she was started on oral prednisolone. A subsequent CE-CT scan showed no signs of aortitis. She was thus re-started on a modified chemotherapy regimen. CONCLUSION Aortitis should be considered in patients receiving bevacizumab combination therapy who develop persistent fever and upper-abdominal pain. Contrast-enhanced CT is useful for detecting drug-induced aortitis.

Temporary Endovascular Balloon Occlusion of the Internal Iliac Arteries to Prevent Hemorrhage During Uterine Cervical Myomectomy

Cervical myomectomy carries a significant risk of hemorrhagic complications. Herein, we describe a prophylactic procedure—temporary endovascular balloon occlusion of the internal iliac arteries—that can be used to prevent excessive bleeding during surgical removal of a huge uterine cervical myoma. Endovascular occlusion catheters are placed in both internal iliac arteries. During myomectomy, the balloons are inflated to occlude these vessels. Upon completion of the surgery, and thus after the myometrium is sutured, the balloons are deflated, hemostasis is confirmed, and the catheters are removed. Thus far, we have used this method to reduce blood loss in 16 patients undergoing cervical myomectomy, and there has been no adverse effect. We have found the procedure, which we describe in detail, to be useful not only for the patients undergoing simple cervical myomectomy but also for the patients requiring cervical myomectomy concomitant with hysterectomy.

Anti-NMDA receptor encephalitis due to large-cell neuroendocrine carcinoma of the uterus

A 44-year-old woman presented with a large-cell neuroendocrine carcinoma and uterine endometrioid carcinoma with anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. Following the diagnosis of uterine cancer, the patient suddenly developed psychosis with abnormal behaviors, delusions, irritability, and forgetfulness. The cerebrospinal fluid tested positive for anti-NMDAR antibodies (encoding the NR1 subunit). The patient was diagnosed with paraneoplastic limbic encephalitis due to uterine cancer. Histology of multiple abdominal metastatic samples revealed a neuroendocrine tumor. Her consciousness improved temporarily after tumor resection and comprehensive immunomodulatory therapy. On day 104 after admission, the patient died of multiple organ failure. The autopsy revealed a perivascular infiltration of inflammatory cells in the amygdala and NMDAR-positive cells in the primary uterine cancer. Our findings demonstrated that neuroendocrine tumors can induce anti-NMDAR encephalitis, which is consistent with three previous reports. A comprehensive treatment with resection of the carcinoma, immunoglobulins, and plasma exchange can induce a partial improvement of the symptoms.

Long‐term efficacy and safety of aromatase inhibitor use for leiomyomatosis peritonealis disseminata

Leiomyomatosis peritonealis disseminata is a rare disease characterized by pelvic smooth‐muscle nodules of various sizes. It is sometimes misdiagnosed as ovarian or peritoneal carcinoma metastasis; therefore, surgical excision for pathological diagnosis is required. Treatment options include bilateral salpingo‐oophorectomy (BSO), gonadotrophin‐releasing hormone agonist therapy, and aromatase inhibitor therapy. All of these suppress estrogen levels, but a standard treatment has not been established. A 40‐year‐old woman had multiple pelvic tumors, suspicious for ovarian cancer. She underwent laparotomy, where frozen sections of the nodules revealed leiomyomatosis peritonealis disseminata. After she completed gonadotrophin‐releasing hormone agonist therapy, we performed a total abdominal hysterectomy and BSO with residual‐nodule resection, but the nodules recurred 6 months after surgery. We then started letrozole, and 3 years have now elapsed without nodule enlargement or development of new lesions. The long‐term use of aromatase inhibitor therapy is thought to be effective and safe for patients with recurrence after BSO.