Ovarian Function Preservation in Patients With Cervical Cancer Undergoing Hysterectomy and Ovarian Transposition Before Pelvic Radiotherapy.

To examine the factors associated with ovarian failure (OF) and assess the effectiveness of ovarian transposition (OT) before pelvic irradiation for preserving ovarian function in patients with cervical cancer (CC) undergoing hysterectomy. During 2003 to 2017, patients who underwent hysterectomy with preservation of one or both ovaries were retrospectively enrolled. Patients were divided into 4 groups, depending on whether radiotherapy (RT) and OT were performed: group 1, RT(+) and OT(+); group 2, RT(+) and OT(-); group 3, RT(-) and OT(+); group 4, RT(-) and OT(-). OF was defined as serum follicle-stimulating hormone levels of ≥30 mIU/mL. Sixty-six patients (59 [89.4%] invasive CC and 7 [10.6%] cervical intraepithelial neoplasia) were included. The 2-year OF-free survival rate was 61.4% (95% confidence interval [CI] 37.8-86.0), 0%, 91.7% (95% CI 76.0-100), and 75.8% (95% CI 58.2-93.4) for groups 1, 2, 3, and 4, respectively. In groups 1 and 2 receiving RT, OT, and combination of external beam radiotherapy and vaginal brachytherapy were associated with OF on multivariate analysis (MVA) (P-value = .002 and .046, respectively). In groups 3 and 4 without RT, older age (40 years old) and OT did not affect OF; however, the number of remaining ovaries was independently associated with OF in MVA (P = .035). OT could effectively preserve ovarian function in patients treated with adjuvant RT, while OT procedure itself did not affect ovarian failure. OT should be considered in the management of premenopausal cervical cancer patients.

Endocervical gastric-type adenocarcinoma, an unrelated HPV tumour: difficulties in screening and diagnosis.

Gastric-type adenocarcinoma of the cervix (GAS) is an uncommon and aggressive tumour unrelated to human papillomavirus (HPV) infection with distinctive histological and immunohistochemical characteristics. GAS may be associated with lobular endocervical glandular hyperplasia (LEGH), another unusual lesion. We report a case of a 59-year-old woman with screening cytology 'AGC-Neo' and cervical conisation exhibiting cervical intraepithelial neoplasia grade 1, extensive LEGH and canal sampling with abundant mucinous cells. Based on the possible association between LEGH and GAS, a total hysterectomy was performed. The histological diagnosis revealed a morphological gradient of lesions: LEGH, minimal deviation adenocarcinoma and GAS with lymphatic invasion. Immunohistochemistry revealed strong MUC6 expression and no p16 staining. After pelvic radiotherapy, the patient continues follow-up evaluation. The diagnostic difficulties of GAS and its relationship with LEGH are discussed. This rare tumour is important because it is poorly symptomatic and potentially aggressive. In addition, the methods for cancer control related to HPV do not affect this tumour.

[New challenges to the treatment of cervical intraepithelial neoplasia].

Due to the progress of intracavitary afterloading technology and dosage of brachytherapy, a similar dose distribution as that of cervical conization can be achieved and can be applied to the treatment of cervical intraepithelial neoplasia (CIN), it is called "afterloading conization" . Being adjusted the radioactive source movement and weight, low exposure doses to the ovary, endometrium and vagina can be assured. So a high quality of life after treatment could be maintained and overcomes the shortcomings of cervical conization and hysterectomy, such as anesthesia, bleeding, over or insufficient treatment, early ovarian ageing and operative complications.

Factors contributing to high ThinPrep® Pap test unsatisfactory rates in an academic medical center laboratory.

Specimen adequacy is a key component in the cytologic evaluation of cervical Pap tests. At our institution, yearly unsatisfactory rates continue to be high, placing our laboratory in the 95th percentile for CAP benchmark data for unsatisfactory Pap test rates. Using the 2001 Bethesda System criteria, unsatisfactory Pap test rates were calculated over a ten year period (January 2002 to December 2011) and contributing factors were analyzed. Of the 124,457 ThinPrep Pap tests performed, 4,163 (3.3%) were unsatisfactory for evaluation, the majority (90%) due to too few squamous epithelial cells. Peri/postmenopausal women and those who had received radiation/chemotherapy had the highest unsatisfactory rates; 55% and 25%, respectively. Higher unsatisfactory Pap test rates are related to the patient population served. Defined, reproducible adequacy criteria need to be defined for Pap tests from patients in certain clinical conditions.

High-dose-rate intracavitary radiotherapy in the management of cervical intraepithelial neoplasia 3 and carcinoma in situ presenting with poor histologic factors after undergoing excisional procedures.

PURPOSE: To assess the effectiveness of high-dose-rate intracavitary radiotherapy (HDR-ICR) in patients with cervical intraepithelial neoplasia 3 (CIN 3) and carcinoma in situ (CIS) presenting with poor histologic factors for predicting residual disease after undergoing diagnostic excisional procedures. METHODS AND MATERIALS: This study was a retrospective analysis of 166 patients with CIN 3 (n=15) and CIS (n=151) between October 1986 and December 2005. They were diagnosed by conization (n=158) and punch biopsy (n=8). Pathologic analysis showed 135 cases of endocervical gland involvement (81.4%), 74 cases of positive resection margins (44.5%), and 52 cases of malignant cells on endocervical curettage (31.3%). All patients were treated with HDR-ICR using Co6° or Ir¹9² at a cancer center. The dose was prescribed at point A located 2 cm superior to the external os and 2 cm lateral to the axis of the tandem for intact uterus. RESULTS: Median age was 61 years (range, 29-77). The median total dose of HDR-ICR was 30 Gy/6 fractions (range, 30-52). At follow-up (median, 152 months), 2 patients developed recurrent diseases: 1 CIN 2 and 1 invasive carcinoma. One hundred and forty patients survived and 26 patients died, owing to nonmalignant intercurrent disease. Rectal bleeding occurred in one patient; however, this symptom subsided with conservative management. CONCLUSIONS: Our data showed HDR-ICR is an effective modality for CIN 3 and CIS patients presenting with poor histologic factors after excisional procedures. HDR-ICR should be considered as a definitive treatment in CIN 3 and CIS patients with possible residual disease after undergoing excisional procedures.

Low-dose-rate definitive brachytherapy for high-grade vaginal intraepithelial neoplasia.

BACKGROUND: Treatment of high-grade vaginal intraepithelial neoplasia (VAIN) is controversial and could include surgical excision, topical medication, brachytherapy, or other treatments. We report the results of low-dose-rate (LDR) vaginal brachytherapy for grade 3 VAIN (VAIN-3) over a 25-year period at Gustave Roussy Institute. PATIENTS AND METHODS: We retrospectively reviewed the files of all patients treated at Gustave Roussy Institute for VAIN-3 since 1985. The treatment consisted of LDR brachytherapy using a personalized vaginal mold and delivered 60 Gy to 5 mm below the vaginal mucosa. All patients had at least an annual gynecological examination, including a vaginal smear. RESULTS: Twenty-eight patients were eligible. The median follow-up was 41 months. Seven patients had a follow-up <2 years, and the median follow-up for the remaining 21 patients was 79 months. The median age at brachytherapy was 63 years (range, 38-80 years). Twenty-six patients had a history of VAIN recurring after cervical intraepithelial neoplasia and 24 had a previous hysterectomy. The median brachytherapy duration was 4.5 days. Median doses to the International Commission of Radiation Units and Measurements rectum and bladder points were 68 Gy and 45 Gy, respectively. The median prescription volume (60 Gy) was 74 cm(3). Only one "in field" recurrence occurred, corresponding to a 5- and 10-year local control rate of 93% (95% confidence interval, 70%-99%). The treatment was well tolerated, with no grade 3 or 4 late toxicity and only one grade 2 digestive toxicity. No second cancers were reported. CONCLUSION: LDR brachytherapy is an effective and safe treatment for vaginal intraepithelial neoplasia.

Efectividad de la fulguración con argón plasma en el tratamiento de la proctitis actínica crónica / Effectiveness of argon plasma coagulation in the treatment of chronic actinic proctitis

Introducción: existen 2 tipos de proctitis actínica, una aguda autolimitada, que dura aproximadamente 3 meses y otra crónica que aparece a los meses o años de la radioterapia. La incidencia de proctitis actínica crónica es del 5-20% de los tumores prostáticos irradiados. Objetivo: evaluar la efectividad de la fulguración con argón plasma en el tratamiento de este tipo de proctitis. Material y método: estudio retrospectivo. Realizamos una búsqueda retrospectiva de aquellos pacientes diagnosticados de proctitis actínica entre 2004 y 2007. Analizamos el número de sesiones de fulguración con plasma de argón que fueron necesarias para la resolución de la sintomatología. Resultados: hemos hallado 22 pacientes con el diagnóstico de proctitis actínica. Diecinueve de los pacientes eran varones (86,4%) y tres mujeres (13,6%). De todos los pacientes 19 fueron diagnosticados de adenocarcinoma prostático (86,4%), una fue diagnosticada de carcinoma epidermoide de cérvix uterino (4,5%) y dos fueron diagnosticadas de adenocarcinoma de endometrio (9,1%). La media de sesiones de fulguración con plasma de argón necesarias para resolución de la clínica presentada fue de 2,58 (rango entre 1 y 7 sesiones) y con un mediana de 2 sesiones. Conclusión: en la literatura hay descritos múltiples tratamientos para la proctitis actínica. No obstante, ninguno de ellos ha presentado resultados demasiado prometedores. Nuestros resultados sugieren que la fulguración con plasma de argón es efectiva en el tratamiento de esta patología, consiguiendo una resolución rápida y mantenida de la sintomatología con pocas sesiones, además de presentar un buen perfil de seguridad(AU)

Introduction: there are two kinds of actinic proctitis - one is acute and self-limited, and lasts about 3 months; the other is chronic and develops months to years after radiation therapy. The incidence of chronic actinic proctitis is about 5-20% of radiated prostate tumors. Objective: to evaluate the effectiveness of argon plasma coagulation in the treatment of chronic actinic proctitis. Material and method: a retrospective search of patients with the diagnosis of actinic proctitis. The number of argon plasma coagulation therapies needed to achieve the symptom resolution was analyzed. Results: we found 22 patients with a diagnosis of actinic proctitis. Nineteen were males (86.7%) and three (13.6%) were females. Nineteen patients (86.4%) had a diagnosis of prostate adenocarcinoma, one had a diagnosis of squamous-cell cervix carcinoma (4.5%), and two had a diagnosis of endometrial carcinoma (9.1%). The mean number of coagulation sessions needed for symptom resolution was 2.58 (absolute range 1-7) with a median of 2 sessions. Conclusion: multiple treatments are described in the literature. None of them have shown promising results. Our results suggest that argon plasma coagulation is effective in the treatment of this condition, and achieves a rapid and sustained response with few sessions and a good safety profile(AU)

Villoglandular papillary adenocarcinoma of cervix associated with cervical intraepithelial neoplasia: a case report and review of literature.

Well differentiated villoglandular adenocarcinoma of uterine cervix is a rare tumour which usually occurs in young women. It is considered to be an indolent tumour with favorable prognosis and most of them were treated by conservative procedures. We report a 35 year old lady who came with complaints of 3 months amenorrhoea and an episode of spontaneous bleeding. Urine pregnancy test was negative. Physical examination revealed a cervical polyp. Histopathological findings were consistent with villoglandular papillary adenocarcinoma associated with high grade cervical intraepithelial neoplasia (CIN-3). Left parametrial and left ureteral involvement, proved by biopsy, causing left hydroureteronephrosis was detected. The patient was thus found to be in an advanced stage, stage- III b (FIGO). The patient is currently undergoing radiotherapy. A review of literature showed that only occasional cases showing disease spread have been reported, suggesting caution in the management and regular follow up of the patient.

Oxidative status in patients submitted to conization and radiation treatments for uterine cervix neoplasia.

BACKGROUND: Cervical cancer is a major cause of morbidity among women. We investigated the treatment effect on oxidative status from patients submitted to radiotherapy or conization surgery to high-grade SIL (squamous intraepithelial lesion) treatment, and oxidative profile from patients newly diagnosed for uterine cervix cancer, without treatment. METHODS: We determined the catalase activity in blood, reduced glutathione (GSH) in plasma, TBARS and protein carbonyl content from serum samples of the patients. RESULTS: The catalase activity, GSH levels, TBARS and protein carbonyl content had no statistical differences related to the controls, neither when the 2 treatments were compared, possibly because the antioxidant defense may be acting in the first period of the neoplasic transformation, and maybe indicating a possible arrest of the tumor cells caused by the efficiency of the treatments. In the non-treated patients, TBARS and protein carbonyl contents, GSH levels and catalase activity were shown to be increased comparing with the treated patients and compared with the controls indicating an tumor effect on oxidative profile, and the antioxidant activity been increased in the beginning of the tumor development. CONCLUSIONS: We suggest that the treatments were efficient in arrest of the tumor.

Combined chemotherapy and radiation therapy for cervical cancer.

More than 50% of patients with newly diagnosed cervical cancer will undergo radiation therapy as a primary treatment modality. Results from five phase III trials conducted by National Cancer Institute (NCI)-sponsored cooperative groups showed significant survival advantages from the addition of cisplatin-based chemotherapy to primary radiation therapy, changing the standard of care for patients with bulky or locally advanced cervical carcinoma. The majority of patients for whom treatment fails, however, have persistent pelvic disease. Other agents (alone or in combination with cisplatin) with potential synergy with radiation therapy should be studied. Future trials should investigate potential interrelationships between anemia, tumor hypoxia, angiogenesis, and the effectiveness of radiation therapy. Therapies specific to tumor hypoxia (tirapazamine) or strategies to maintain higher nadir hemoglobin levels during treatment (aggressive transfusion policies; erythropoietin) should also be studied.

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies.

OBJECTIVE: To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies. METHODS: Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated. RESULTS: A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%. CONCLUSIONS: ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.

Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment.

OBJECTIVE: To investigate patients with invasive cervical carcinoma associated with pregnancy, with special reference to the maternal and neonatal outcomes after planned treatment delay to improve fetal maturity. METHODS: The medical records of 28 patients with invasive cervical carcinoma diagnosed during pregnancy or within 1 month after pregnancy were retrospectively reviewed. RESULTS: Twenty-two patients (79%) had Stage I disease and 6 (21%) had Stage II or III disease. Tumor histology revealed squamous cell carcinoma in 27 cases and adenocarcinoma in 1. Twenty cases were diagnosed before 22 weeks gestation, 4 between 22 and 36 weeks, 1 after 36 weeks gestation, and 3 were diagnosed postpartum. In the immediate treatment group (n = 16), the diseases were Stage IA in 3 cases, IB in 7, and II or III in 6. In 11 patients, hysterectomy was performed after therapeutic abortion or with fetus in situ. In 2 patients, cesarean section was followed by hysterectomy or radiotherapy. Three patients diagnosed postpartum were treated with either hysterectomy or radiotherapy. Fifteen patients were free of disease during the follow-up of 27 to 114 months. In the delayed treatment group (n = 12), the diseases were Stage IA1 in 8 cases, IA2 in 1, IB1 in 2, and IB2 in 1 case. In 8 patients with Stage IA1 tumor, the treatment was deferred until term with a delay of 6 to 25 weeks, and hysterectomy or therapeutic conization was performed after delivery. In 4 patients with Stage IA2, IB1 or IB2 tumor, the treatment was postponed until after 30 weeks gestation with a delay of 6 to 15 weeks. No disease progression was documented. Cesarean delivery was followed by hysterectomy in these patients. All patients were free from disease during the follow-up of 70 to 156 months and their babies were well with no sequelae. CONCLUSION: Delay in treatment to allow for fetal maturity is safe in patients with early Stage I cervical carcinoma associated with pregnancy.

Treating intraepithelial lesions of the uterine cervix by laser CO2. Evaluation of the past, appraisal for the future.

BACKGROUND AND OBJECTIVE: Carbon dioxide laser (CO2) has been widely used in the past for the treatment of squamous intraepithelial lesions (SIL) of the uterine cervix. We present our 10-year experience of using this modality while evaluating its current and future use. MATERIALS AND METHODS: From 1988 to 1998, 3,078 women were treated for an intraepithelial lesion of the uterine cervix (SIL) by laser CO2 either by vaporization or conization. The procedure was performed on an outpatient basis and was well tolerated by the great majority of patients. The mean age of the women treated by vaporization was 27.5 years whereas of those managed by conization, 34.8 years. RESULTS: From the 3,078 women, 750 (24.4%) underwent laser vaporization and the remaining 2,328 (75.6%), conization of the cervix. Complications were minimal and consisted of intraoperative and postoperative bleeding (0.56%), pelvic infections (0.04%) and cervical stenosis (1.1%). Mean follow-up time was 83 months (range 24-142). Relapsing disease (either persistent or recurrent) was detected in 5.6% of the vaporization and 3.9% of the conization group. CONCLUSIONS: The management of SIL of the uterine cervix by laser CO2 offers excellent success rates with minor complications. The preservation of the anatomical integrity of the cervical tissue offers a better follow-up of these patients and the potential for repeat treatment. Although other treatment modalities are available, we believe that laser CO2 represents an excellent surgical tool for the management of intraepithelial lesions of the uterine cervix.

Bilateral radical radiotherapy in a patient with uterus didelphys.

We report a case of congenital abnormality of uterus didelyphys in a patient who developed invasive carcinoma of the cervix. She received radical radiotherapy by a combination of external beam pelvic radiotherapy and high dose rate brachytherapy by insertion of afterloading catheters into both uterine canals. A newly defined prescription point was used midway between the two catheters and 2 cm above the mean cervical os position. The classical point A was regarded as inappropriate in this patient with a rare condition. Acute toxicity was minor and the patient is tumour free with no significant normal tissue late effects after follow-up of nearly 3 years.

[Condylomata acuminata. The correlation between affecting sexual partners and the risk of developing preneoplasia of the cervix uteri. The therapeutic potentials of the Nd-Yag laser]. / Condylomata acuminata. Korelatsiia mezhdu zasiagiane na seksualnite partn'ori i riska ot razvitie na preneoplazii na matochnata shiika. Terapevtichni vuzmozhnosti na Nd YAG laser.

The present study summarized results from 206 patients (120 females and 80 males) with diagnosis condylomata acuminata. The diagnostic and surveillance methods used in the present work were: clinical, colposcopic, histologies and microbiological examination. 114 from all patients--46.5% females, and 62.2% males were sexual partners. In 25 women (43.8%) from that group HPV-lesions were found. In 8 patients with cervical lesions CIN I-III was diagnosed. Our results confirmed the previously announced literary data about an enhanced risk for CIN development in women with HPV infection, whose sexual partners had clinical data of Condylomata acuminata. Our therapeutic protocol with Nd-YAG laser treatment in a determined scheme and number of applications according to the stage of the disease and pathological diagnosis was very successful, as compared to data from the literature.

[Treatment of intraepithelial cervical neoplasia with REP Radiosurgical Excision Procedure)]. / Intervento di REP (Radiosurgical Excision Procedure) nel trattamento della neoplasia cervicale intraepiteliale.

Radiosurgical cervical excision has been performed in 59 patients affected by CIN of various stages. This non-traumatic method uses 3.8 MHz radio waves to cut and/or coagulate without postoperative pain and tissue destruction. The radiosurgical excision has been performed in local anesthesia by a loop electrode or microneedle according to the seat of the lesion. The therapy was "effective" in 98% of cases (58/59) whereas the "incomplete excision" of CIN was observed in 6.7% (4/59). Complications (postoperative and late bleeding) occurred in 3.2% of the patients (2/59). Therefore, the Radiosurgical Excision Procedure (REP) can be considered an easy technique in ambulatory surgery; this method is effective in the treatment of CIN with either therapeutic and economic advantages and guarantee the functional and anatomic integrity of the cervix.