Preservation of ovarian function by ovarian transposition prior to concurrent chemotherapy and pelvic radiation for cervical cancer. A case report and review of the literature.

BACKGROUND: For over 45 years, ovarian transposition has been proposed for patients with cervical cancer to preserve ovarian function prior to pelvic radiation. We report a case of preservation of ovarian function and regular normal menstrual cycles after pelvic cisplatin-based chemoradiation and perform a literature review. CASE: A 29-year-old female with cervical cancer underwent laparoscopic ovarian transposition prior to cisplatin-based chemoradiation. At 3-year follow-up after completion of her chemoradiation treatment indicated that she was still free of any disease. She is experiencing normal menstrual cycles at regular monthly intervals. CONCLUSION: The present case shows that it is possible to retain ovarian function and menstrual cycles by ovarian transposition prior to pelvic chemoradiation. This provides an option for cervical cancer patients who desire preservation of ovarian function.

Small cell carcinoma of the endometrium: report of a case and review of the literature.

Small cell carcinomas of the endometrium are rare and carry an ominous prognosis. Most patients present with advanced disease. The histopathological diagnosis requires immunohistochemistry confirmation and the tumor should be positive for a neuroendocrine marker. This article reports a new case and reviews the pertinent literature on the subject.

Erythropoietin receptor expression in biopsy specimens from patients with uterine cervix squamous cell carcinoma.

Hypoxia, an important mechanism of radioresistance, is a strong stimulus for erythropoietin (EPO) production. The stimulatory effects of EPO are mediated through the activation of its receptors, EPO receptors (EPORs). The objective of this study is to determine whether EPORs are expressed in biopsy specimens of patients with squamous cell carcinoma of the cervix. Eighteen biopsy specimens were studied after obtaining Institutional Review Board-approved consent. Standard immunohistochemistry techniques were utilized. Expression of EPORs was present in 16 out of 18 (88.9%) specimens. The intensity (qualitative) and the frequency (semiquantitative) of EPORs expression showed a statistically significant correlation (P= 0.00379). Statistical analysis was performed to determine whether EPORs expression is related to other parameters such as age, FIGO stage, histologic grade, and hemoglobin levels. Only age showed a statistically significant correlation with EPORs frequency of expression (P= 0.00878). Currently, work is in progress in our laboratory to study the radiobiologic effects of EPO on the radiation response of cultured cancer cell lines in vitro.

High dose ratio (HDR) cervical ring applicator to control bleeding from cervical carcinoma.

The objective of this study was to evaluate the use of the high dose rate (HDR) cervical ring applicator to control acute cervical bleeding from carcinoma of the uterine cervix. This study consists of 15 patients presenting with invasive carcinoma of the uterine cervix with acute vaginal bleeding requiring transfusion. Initial irradiation, delivered emergently because of vaginal bleeding, consisted of two fractions (5 Gy each fraction to the surface of the cervix) utilizing the HDR intracavitary vaginal ring applicator. Two fractions were administered at one week intervals for a total of 10 Gy to the surface of the cervix. Irradiation doses from the HDR ring applications were not considered into the composite total dose to point A. Diagnostic imaging evaluation and initiation of external irradiation were commenced during this initial weekly interval between fractions. Vaginal bleeding requiring no additional transfusions was achieved in 93% (14/15) of patients. No acute or long-term Grades 3, 4, or 5 bowel or bladder sequelae were noted. In conclusion, HDR cervical ring brachytherapy is effective in controlling acute vaginal bleeding and can be delivered without undue acute or long-term toxicity.

Intensity-modulated radiation therapy (IMRT) reduces small bowel, rectum, and bladder doses in patients with cervical cancer receiving pelvic and para-aortic irradiation.

PURPOSE: The emergent use of combined modality approach (chemotherapy and radiation therapy) for the treatment of patients with cervical cancer is associated with significant gastrointestinal and genitourinary toxicity. Intensity-modulated radiation therapy (IMRT) has the potential to deliver adequate dose to the target structures while sparing the normal organs and could also allow for dose escalation to grossly enlarged metastatic lymph node in pelvic or para-aortic area without increasing gastrointestinal/genitourinary complications. We conducted a dosimetric analysis to determine if IMRT can meet these objectives in the treatment of cervical cancer. METHODS AND MATERIALS: Computed tomography scan studies of 10 patients with cervical cancer were retrieved and used as anatomic references for planning. Upon the completion of target and critical structure delineation, the imaging and contour data were transferred to both an IMRT planning system (Corvus, Nomos) and a three-dimensional planning system (Focus, CMS) on which IMRT as well as conventional planning with two- and four-field techniques were derived. Treatment planning was done on these two systems with uniform prescription, 45 Gy in 25 fractions to the uterus, the cervix, and the pelvic and para-aortic lymph nodes. Normalization was done to all IMRT plans to obtain a full coverage of the cervix with the 95% isodose curve. Dose-volume histograms were obtained for all the plans. A Student's t test was performed to compute the statistical significance. RESULTS: The volume of small bowel receiving the prescribed dose (45 Gy) with IMRT technique was as follows: four fields, 11.01 +/- 5.67%; seven fields, 15.05 +/- 6.76%; and nine fields, 13.56 +/- 5.30%. These were all significantly better than with two-field (35.58 +/- 13.84%) and four-field (34.24 +/- 17.82%) conventional techniques (p < 0.05). The fraction of rectal volume receiving a dose greater than the prescribed dose was as follows: four fields, 8.55 +/- 4.64%; seven fields, 6.37 +/- 5.19%; nine fields, 3.34 +/- 3.0%; in contrast to 84.01 +/- 18.37% with two-field and 46.37 +/- 24.97% with four-field conventional technique (p < 0.001). The fractional volume of bladder receiving the prescribed dose and higher was as follows: four fields, 30.29 +/- 4.64%; seven fields, 31.66 +/- 8.26%; and nine fields, 26.91 +/- 5.57%. It was significantly worse with the two-field (92.89 +/- 35.26%) and with the four-field (60.48 +/- 31.80%) techniques (p < 0.05). CONCLUSION: In this dosimetric study, we demonstrated that with similar target coverage, normal tissue sparing is superior with IMRT in the treatment of cervical cancer.

The importance of hemoglobin levels during radiotherapy for carcinoma of the cervix.

BACKGROUND: It is unclear whether blood transfusion can overcome the negative impact of anemia before or during radiotherapy (RT) in patients with carcinoma of the cervix. The objective of this retrospective study was to examine the impact of anemia and blood transfusion on 605 patients with carcinoma of the cervix treated with radical RT at 7 centers across Canada in 1989, 1990, and 1992. METHODS: The data collected included hemoglobin (Hgb) levels from the time of diagnosis to the end of therapy; blood transfusions administered; and identifiable patient-, tumor-, and treatment-related factors. Survival, disease free survival, and pelvic control analyses were evaluated by univariate and multivariate analysis. RESULTS: The median follow-up was 41 months (range, 0-92 months). Presenting Hgb level, average weekly nadir Hgb (AWNH) during RT, and blood transfusion were correlated significantly with local control, disease free survival, and overall survival on univariate analysis. However, the AWNH remained significant on multivariate analysis, whereas Hgb at presentation and blood transfusion did not. The 5-year survival was 74% for patients with an AWNH >/= 120 g/L, 52% for patients with AWNH levels 110-119 g/L inclusive, and 45% for patients with AWNH levels < 110 g/L (P < 0.0001). At each Hgb level, patients who were transfused and maintained a specific Hgb level had a survival rate that was not significantly different from patients who were at that level spontaneously. There was a significant reduction in both pelvic and distant recurrence (P < 0.0001 and P < 0.0006, respectively) in patients whose AWNH level during RT was >/= 120 g/L compared with < 120 g/L. A reduction in the rate of distant recurrence was observed in patients with and without pelvic recurrence. CONCLUSIONS: AWNH is highly predictive of outcome for patients treated with RT for carcinoma of the cervix. Blood transfusion appears to overcome the negative prognostic effects of low presenting Hgb levels and AWNH levels.