Wataru Kudaka

External beam boost irradiation for clinically positive pelvic nodes in patients with uterine cervical cancer

The purpose of this study was to retrospectively analyze the treatment results of boost external beam radiotherapy (EBRT) to clinically positive pelvic nodes in patients with uterine cervical cancer. The study population comprised 174 patients with FIGO stages 1B1–4A cervical cancer who were treated with definitive radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT). Patients with positive para-aortic or common iliac nodes (≥10 mm in the shortest diameter, as evaluated by CT/MRI) were ineligible for the study. Fifty-seven patients (33%) had clinically positive pelvic nodes. The median maximum diameter of the nodes was 15 mm (range, 10–60 mm) and the median number of positive lymph nodes was two (range, one to four). Fifty-two of 57 patients (91%) with positive nodes were treated with boost EBRT (6–10 Gy in three to five fractions). The median prescribed dose of EBRT for nodes was 56 Gy. The median follow-up time for all patients was 66 months (range, 3–142 months). The 5-year overall survival rate, disease-free survival rate and pelvic control rate for patients with positive and negative nodes were 73% and 92% (P = 0.001), 58% and 84% (P < 0.001), and 83% and 92% (P = 0.082), respectively. Five of 57 node-positive patients (9%) developed pelvic node recurrences. All five patients with nodal failure had concomitant cervical failure and/or distant metastases. No significant difference was observed with respect to the incidence or severity of late complications by application of boost EBRT. The current retrospective study demonstrated that boost EBRT to positive pelvic nodes achieves favorable nodal control without increasing late complications.

Paclitaxel and carboplatin in patients with completely or optimally resected carcinosarcoma of the uterus: A phase II trial by the Japanese uterine sarcoma group and the tohoku gynecologic cancer unit

Objective This study aimed to evaluate the efficacy of paclitaxel and carboplatin in patients with completely or optimally resected uterine carcinosarcoma. Materials and Methods We conducted a single-arm multicenter prospective phase II trial at 20 Japanese medical facilities. Eligible patients had histologically confirmed uterine carcinosarcoma without prior chemotherapy or radiotherapy. Patients received 6 courses of 175 mg/m2 paclitaxel over 3 hours, followed by a 30-minute intravenous administration of carboplatin at an area under the serum concentration-time curve of 6. Results A total of 51 patients were enrolled in this study, 48 of whom underwent complete resection and 3 of whom underwent optimal resection. At 2 years, the progression-free survival and overall survival rates were 78.2% (95% confidence interval [CI], 64.1%–87.3%) and 87.9% (95% CI, 75.1%–94.4%), respectively. At 4 years, these rates were 67.9% (95% CI, 53.0%–79.0%) and 76.0% (95% CI, 60.5%–86.1%), respectively. Although 15 patients showed disease recurrence during the follow-up period (median, 47.8 months; range, 2.1–72.8 months), a total of 40 (78.4%) patients completed the 6 courses of treatment that had been planned. Conclusions The combination of paclitaxel and carboplatin was a feasible and effective postoperative adjuvant therapy for patients with completely or optimally resected uterine carcinosarcoma.

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.

Ovarian preservation in young women with endometrial cancer of endometrioid histology.

To clarify the frequency and risk factors of ovarian metastasis in women with endometrial cancer of endometrioid histology.

Computed tomography–based image-guided brachytherapy for cervical cancer: correlations between dose–volume parameters and clinical outcomes

Abstract This study evaluated the oncologic outcomes and complications of cervical cancer patients in terms of CT-based image-guided brachytherapy (IGBT) parameters. Of 68 cervical cancer patients treated with definitive radiotherapy/concurrent chemoradiotherapy, most received whole-pelvis external beam RT (EBRT) of 40 Gy in 20 fractions, pelvic EBRT with central shield of 10 Gy in 5 fractions, and CT-based IGBT of 18 Gy in 3 fractions prescribed to point A. Cumulative EBRT and IGBT doses were calculated as the total equivalent dose in 2 Gy fractions (EQD2). The median follow-up was 31 (3–52) months. The 2-year overall survival, local control, pelvic control, and disease-free survival rates of the 68 patients were 92%, 83%, 82% and 73%, respectively. The HR-CTV D90, length from the tandem axis to left/right margin of the HR-CTV (T-LR), and HR-CTV volume were significant IGBT parameters for predicting local/pelvic control. Patients who received an HR-CTV D90 of >60 Gy, compared with ≤60 Gy, had significantly better local/pelvic control. Furthermore, 70 Gy was a marginally significant HR-CTV D90 cut-off affecting local control. T-LR was an independent IGBT parameter predicting local/pelvic control on multivariate analysis. Three patients developed Grade 3 or higher treatment-related complications. The D2cm3 of organs at risk were not significant predictors of complications. Future challenges for further improving outcomes include additional interstitial needles for irregularly shaped HR-CTVs, and moderate dose escalation, especially for patients with poor tumor responses.

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.

Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions

Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.

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.

Prognostic factors and optimal therapy for stages I–II neuroendocrine carcinomas of the uterine cervix: A multi-center retrospective study

PURPOSE We aimed to determine appropriate treatment guidelines for patients with stages I-II high-grade neuroendocrine carcinomas (HGNEC) of the uterine cervix in a multicenter retrospective study. PATIENTS AND METHODS We reviewed the clinicopathological features and prognoses of 93 patients with HGNEC of International Federation of Gynecology and Obstetrics (FIGO) stages I and II. All patients were diagnosed with HGNEC by central pathological review. RESULTS The median overall survival (OS) and disease-free survival (DFS) were 111.3months and 47.4months, respectively. Eighty-eight patients underwent radical surgery, and five had definitive radiotherapy. The hazard ratio (HR) for death after definitive radiotherapy to death after radical surgery was 4.74 (95% confidence interval [CI], 1.01-15.90). Of the surgery group, 18 received neoadjuvant chemotherapy. Pathological prognostic factors and optimal adjuvant therapies were evaluated for the 70 patients. Forty-one patients received adjuvant chemotherapy with etoposide-platinum (EP) or irinotecan-platinum (CPT-P). Multivariate analyses identified the invasion of lymphovascular spaces as a significant prognostic factor for both OS and DFS. Pelvic lymph node metastasis was also a prognostic factor for DFS. Adjuvant chemotherapy with an EP or CPT-P regimen appeared to improve DFS (HR=0.27, 95% CI, 0.10-0.69). A trend toward improved OS was also observed, but was not statistically significant (HR=0.39, 95% CI, 0.15-1.01). CONCLUSION Radical surgery followed by adjuvant chemotherapy with an EP or CPT-P regimen was optimal treatment for stages I and II HGNEC of the uterine cervix.

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.