Invasive group A streptococcal infection can be fatal to pregnant women in restricted medical resources remote areas-Emergent alert after COVID-19 pandemic.

Invasive group A streptococcal (iGAS) infection is a leading cause of maternal death. The increase in the number of patients with iGAS in Japan is markedly greater than before the coronavirus pandemic. We encountered a case of iGAS infection, on a remote island with restricted medical resources, in a third-trimester pregnant woman, resulting in both maternal and fetal death. A 34-year-old woman was admitted via a local general hospital with a high fever. Intrauterine fetal death disseminated intravascular coagulation, and septic shock were confirmed. Broad-spectrum antibiotics were started, and the patient was returned to the local general hospital. Eight hours after arrival, the patient died of circulatory and respiratory dysfunction complications. iGAS infections in remote areas may directly lead to life-threatening conditions and should be treated as an emergency, comparable to the serious conditions of placental abruption or placenta previa.

Oscillating Gradient Diffusion-Weighted MRI for Risk Stratification of Uterine Endometrial Cancer.

BACKGROUND: Oscillating gradient diffusion-weighted imaging (DWI) enables elucidation of microstructural characteristics in cancers; however, there are limited data to evaluate its utility in patients with endometrial cancer. PURPOSE: To investigate the utility of oscillating gradient DWI for risk stratification in patients with uterine endometrial cancer compared with conventional pulsed gradient DWI. STUDY TYPE: Retrospective. SUBJECTS: Sixty-three women (mean age: 58 [range: 32-85] years) with endometrial cancer. FIELD STRENGTH/SEQUENCE: 3 T MRI including DWI using oscillating gradient spin-echo (OGSE) and pulsed gradient spin-echo (PGSE) research sequences. ASSESSMENT: Mean value of the apparent diffusion coefficient (ADC) values for OGSE (ADCOGSE ) and PGSE (ADCPGSE ) as well as the ADC ratio (ADCOGSE /ADCPGSE ) within endometrial cancer were measured using regions of interest. Prognostic factors (histological grade, deep myometrial invasion, lymphovascular invasion, International Federation of Gynecology and Obstetrics [FIGO] stage, and prognostic risk classification) were tabulated. STATISTICAL TESTS: Interobserver agreement was analyzed by calculating the intraclass correlation coefficient. The associations of ADCOGSE , ADCPGSE , and ADCOGSE /ADCPGSE with prognostic factors were examined using the Kendall rank correlation coefficient, Mann-Whitney U test, and receiver operating characteristic (ROC) curve. A P value of <0.05 was statistically significant. RESULTS: Compared with ADCOGSE and ADCPGSE , ADCOGSE /ADCPGSE was significantly and strongly correlated with histological grade (observer 1, τ = 0.563; observer 2, τ = 0.456), FIGO stage (observer 1, τ = 0.354; observer 2, τ = 0.324), and prognostic risk classification (observer 1, τ = 0.456; observer 2, τ = 0.385). The area under the ROC curves of ADCOGSE /ADCPGSE for histological grade (observer 1, 0.92, 95% confidence intervals [CIs]: 0.83-0.98; observer 2, 0.84, 95% CI: 0.73-0.92) and prognostic risk (observer 1, 0.80, 95% CI: 0.68-0.89; observer 2, 0.76, 95% CI: 0.63-0.86) were significantly higher than that of ADCOGSE and ADCPGSE . DATA CONCLUSION: The ADC ratio obtained via oscillating gradient and pulsed gradient DWIs might be useful imaging biomarkers for risk stratification in patients with endometrial cancer. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

Evaluation of the one-step nucleic acid amplification assay for detecting lymph node metastasis in patients with cervical and endometrial cancer: A multicenter prospective study.

OBJECTIVE: This multicenter study aimed to evaluate the accuracy of the one-step nucleic acid amplification (OSNA) assay in diagnosing lymph node metastasis (LNM) in patients with cervical and endometrial cancers. METHODS: Surgically removed LNs from patients with cervical and endometrial cancer were sectioned at 2-mm intervals along the short axis direction and alternately examined using the OSNA assay and conventional histopathological examination. Ultrastaging (200-µm LN sections) was performed for metastatic LNs using hematoxylin and eosin staining and immunostaining with an anti-CK19 antibody in cases where the OSNA assay and histopathological examination (performed using 2-mm LN sections) results showed discordance. RESULTS: A total of 437 LNs from 133 patients were included; 61 patients (14%) showed metastasis by histopathological examination, with a concordance rate of 0.979 (95% confidence interval [CI]: 0.961-0.991) with the OSNA assay. The sensitivity and specificity of the OSNA assay were 0.918 (95% CI: 0.819-0.973) and 0.989 (95% CI: 0.973-0.997), respectively. Discordance between the two methods was observed in nine LNs (2.1%), and allocation bias of metastatic foci was identified as the major cause of discordance. CONCLUSIONS: The OSNA assay showed equally accurate detection of LN metastasis as the histopathological examination. We suggest that the OSNA assay may be a useful tool for the rapid intraoperative diagnosis of LN metastasis in patients with cervical and endometrial cancers.

The first report of surgery for gynecological diseases using the hinotori™ surgical robot system.

OBJECTIVE: This study aimed to report the first surgery for gynecological diseases using a new robotic platform, the hinotori™, and validate its feasibility in clinical settings. METHODS: The world's first robot-assisted total hysterectomy for a gynecological ailment was carried out at Kagoshima University Hospital in December 2022 utilizing the hinotori™ surgical robot system. Eleven other patients then underwent comparable procedures. The surgical team was certified to execute the procedure and had undergone official hinotori™ training. RESULTS: Preoperative diagnoses indicated five cases of endometrial cancer, four cases of uterine myoma and one case each of atypical endometrial hyperplasia, uterine adenosarcoma and high-grade cervical intraepithelial neoplasia. Median age and body mass index were 51 (range: 38-70) years and 26.9 (range: 17.3-33.3) kg/m2, respectively. Median roll-in, cockpit and operation times were 15 (range: 10-18), 161 (range: 110-225) and 214 (range: 154-287) min, respectively. The median blood loss was 22 (range: 7-83) mL and conversion to laparotomy was not allowed. Only one patient had postoperative pelvic region infection. The median length of hospital stay was 6 (range: 4-10) days. CONCLUSION: Based on our experience with presented 12 cases, robotic surgery with the hinotori™ is a feasible technique of minimally invasive surgery for gynecological diseases.

Cytopathological features associated with POLE mutation in endometrial cancer.

OBJECTIVE: For patients with endometrial cancer, the POLE (polymerase epsilon) mutation (POLEmut)-subtype, one of four molecular-analysis-based categories in the Cancer Genome Atlas (TCGA), has the best prognosis. The following histological characteristics are typically observed in endometroid carcinoma cases with the POLEmut-subtype: (1) the presence of tumour giant cells, (2) numerous tumour-infiltrating lymphocytes (TILs) and/or peri-tumoral lymphocytes, and (3) a high grade. However, in the context of cytology, the morphological characteristics of this subtype remain unknown. METHODS: DNA extracted from formalin-fixed paraffin-embedded (FFPE) tissues was subjected to next-generation sequencing analysis and categorised according to the TCGA classifications. Genomic mutation, tumour mutation burden (TMB), and microsatellite instability were also assessed. Cytological specimens of resected uteri obtained using the Papanicolaou method were histologically separated into three types. RESULTS: Seven out of 112 patients (6%) with endometrial cancer were diagnosed with the POLEmut-subtype between January 2019 and August 2021. Tumour giant cells were observed in three cases (43%) on histology and cytology. TIL and/or peritumoral lymphocytes with inflammatory cells were detected in five cases (71%) on histology and three cases (43%) on cytology. Cases in which these three characteristics were observed on both cytology and histology may have belonged to the POLEmut-subtype. There were no cases in which these characteristics were absent on histology but present on cytology. TMB tended to be higher in cases when the three characteristics were observed in both cytological and histological findings. CONCLUSIONS: Preoperative endometrial cytology highlighted the characteristics of the POLEmut-subtype in the histological analysis of resected uterine specimens and has the potential to play an important role in treatment decisions.

A preliminary study on the detection of lymph node metastasis in cervical cancer using a quantitative RT-PCR assay.

OBJECTIVE: This preliminary study aimed to assess the detection accuracy of sentinel lymph node metastasis in cervical cancer using quantitative reverse transcriptase-polymerase chain reaction. METHODS: We collected cervical cancer tissues and 70 pelvic lymph node samples from patients with cervical cancer. The quantitative reverse transcriptase-polymerase chain reaction assay was performed to investigate the expression of cytokeratin 19 mRNA in cervical cancer tissues and determine the cutoff value of cytokeratin 19 mRNA between the non-metastatic and metastatic lymph nodes. RESULTS: The expression of cytokeratin 19 mRNA in cancer tissues was detected in all (71/71) the tumours, with a median copy number of 7.56 × 105/µl of RNA by quantitative reverse transcriptase-polymerase chain reaction. Sixteen lymph nodes were diagnosed as positive by pathological examination. The median copy numbers of cytokeratin 19 mRNA for positive and negative lymph nodes were 43.3 × 104/µl and 121.1/µl, respectively. The expression of cytokeratin 19 mRNA in pathologically positive lymph nodes was higher than that in the negative lymph nodes (P < 0.0001) by quantitative reverse transcriptase-polymerase chain reaction analysis. Using a receiver operating characteristic plot, the maximum sensitivity (100%) and specificity (94.4%) were obtained when the cutoff value was set at 1169 copies/µl. CONCLUSIONS: After setting the cutoff value at 1169 copies/µl, a quantitative reverse transcriptase-polymerase chain reaction assay using cytokeratin 19 mRNA showed high accuracy in detecting lymph node metastasis in cervical cancer. We believe that the quantitative reverse transcriptase-polymerase chain reaction assay using cytokeratin 19 mRNA may be acceptable for lymph node metastasis detection in patients with cervical cancer.

Comparison of radio-isotope method with 99m technetium and near-infrared fluorescent imaging with indocyanine green for sentinel lymph node detection in endometrial cancer.

BACKGROUND: We aimed to compare the detection rate of pelvic sentinel lymph node between the radio-isotope with 99m technetium (99mTc)-labeled phytate and near-infrared fluorescent imaging with indocyanine green in patients with endometrial cancer. METHODS: This study included 122 patients who had undergone sentinel lymph node mapping using 99mTc and indocyanine green. In the radio-isotope method, sentinel lymph nodes were detected using uterine cervix 99mTc injections the day before surgery. Following injection, the number and locations of the sentinel lymph nodes were evaluated by lymphoscintigraphy. In addition, indocyanine green was injected into the cervix immediately before surgery. RESULTS: The overall pelvic sentinel lymph node detection rate (at least one pelvic sentinel lymph node detected) was not significantly different between 99mTc (95.9% [117/122]) and indocyanine green (94.3% [115/122]). Similarly, the bilateral sentinel lymph node detection rate was not significantly different between 99mTc (87.7% [107/122]) and indocyanine green (79.5% [97/122]). More than two sentinel lymph nodes per unilateral pelvic lymph node were found in 12.3% (15/122) and 27% (33/122) of cases with 99mTc and indocyanine green, respectively, in the right pelvic side, and 11.5% (14/122) and 32.8% (40/122) of cases with 99mTc and indocyanine green, respectively, in the left pelvic side. indocyanine green showed that there were significantly more than two sentinel lymph nodes in either the left or right pelvic sentinel lymph nodes (P < 0.0001). There was a significant difference in the mean number of total pelvic sentinel lymph nodes between 99mTc (2.2) and indocyanine green (2.5) (P = 0.028) methods. CONCLUSION: Although indocyanine green is useful for sentinel lymph node identification, we believe it is better to use it in combination with 99mTc until the surgeon is accustomed to it.

The use of bevacizumab is correlated with improved post-progression survival in advanced recurrent ovarian cancer.

BACKGROUND: The recent improvements in anti-cancer therapy following first-line treatment can potentially impact post-progression survival. We evaluated the factors that influence post-progression survival in advanced recurrent ovarian cancer. METHODS: Eighty-nine patients who underwent first-line treatment between June 2005 and December 2017 were included. The post-progression survival was defined as the difference between overall survival and initial progression-free survival. The effects of age, histology, stage, optimal surgery, secondary debulking surgery, bevacizumab administration, platinum sensitivity, and olaparib maintenance in recurrence were compared and independent risk factors were determined. RESULTS: The median follow-up duration was 60.0 months (range: 2-181). Platinum-sensitive recurrence had longer post-progression survival than platinum-resistant (P < 0.001). Inclusion of bevacizumab in first-line treatment did not produce a significant difference in post-progression survival (P = 0.462). Secondary debulking surgery (P = 0.013), bevacizumab administration (P < 0.001), and olaparib maintenance (P = 0.001) during recurrence increased post-progression survival. In multivariate analysis, histologies other than serous or endometrioid (hazard ratio = 2.389; 95% confidence interval = 1.200-4.754; P = 0.013) and non-bevacizumab usage in recurrence (hazard ratio = 4.484; 95% confidence interval = 1.939-10.370; P < 0.001) were independently correlated with poorer prognosis. Bevacizumab administration beyond progressive disease elicited improved post-progression survival (P < 0.001). In patients receiving bevacizumab in first-line treatment, exclusion of bevacizumab in the recurrent therapy (hazard ratio = 5.507; 95% confidence interval = 2.301-12.124; P < 0.001) was independently correlated with poorer prognosis. CONCLUSIONS: The continuous use of bevacizumab beyond progressive disease improves post-progression survival suggesting its important role in first-line and recurrence treatment for ovarian cancer.

Zinc supplementation during chemotherapy for gynecological malignancy.

OBJECTIVE: To determine the significance of zinc supplementation for zinc deficiency during chemotherapy for gynecologic malignancies. METHODS: Twenty-eight patients suspected of zinc deficiency before chemotherapy were prospectively evaluated. Gustatory test, serum zinc, blood count, and biochemical examinations were made pre-chemotherapy at 3- and 6-week intervals. Patients with serum zinc levels <70 µg were prescribed oral zinc acetate hydrate (167.8 mg/day) for 3 weeks. The primary outcome was efficacy of zinc supplementation, the secondary outcomes were zinc deficiency rates and adverse effects of the zinc supplement. RESULTS: Fifteen (mean serum zinc level: 67.4 ± 6.2 µg/dL) out of 28 patients were administered zinc supplementation pre-chemotherapy, and subsequent serum zinc levels reached 83.2 ± 15.3 µg/dL in 3 weeks. Factors associated with chemotherapy (vs. chemoradiation, p = 0.041) and taxane + platinum (p = 0.048) were significant risk factors for decreasing zinc levels following chemotherapy. Although patients that required zinc supplementation showed decreased serum zinc levels after chemotherapy and tended to experience taste alteration (sour: p = 0.041), zinc supplementation for zinc deficiency during chemotherapy did not alter taste perception. CONCLUSION: Zinc supplementation promptly increased serum levels without major complications and may prevent an alteration in taste perception.

Comparison of lymphatic complications between sentinel node navigation surgery and pelvic lymphadenectomy in patients with cervical cancer.

BACKGROUND: Sentinel node navigation surgery (SNNS) has been frequently used in early cervical cancer. However, the incidence and potential reduction of lymphatic complications following the removal of the sentinel lymph node remain unknown. Thus, this study aimed to evaluate the occurrence of lymphatic complications post sentinel node navigation surgery in patients with early cervical cancer. METHODS: A total of 167 patients, including 70 and 97 patients who had undergone SNNS and pelvic lymphadenectomy (PLA), respectively, were enrolled in this study. We compared the lymphatic complications (lower extremity lymphedema and pelvic lymphocele) between the SNNS and PLA groups. RESULTS: The median number of sentinel lymph nodes removed was 2 (range: 1-14). Among the 70 patients in the SNNS group, there were 0 (0%) and 3 (4.3%) occurrences of lower extremity lymphedema and pelvic lymphocele, respectively. The occurrences of lower extremity lymphedema and pelvic lymphocele were significantly lower in the SNNS group than in the PLA group, despite circumflex iliac node removal. CONCLUSIONS: The occurrence of lymphatic complications (lower extremity lymphedema and pelvic lymphocele) was significantly lower in the SNNS group than in the PLA group. We found that SNNS, and not PLA, was the best treatment option for preventing the development of lower extremity lymphedema and pelvic lymphocele, despite circumflex iliac node preservation.

Comparison of survival outcomes between laparoscopic and open surgery in patients with low-risk endometrial cancer.

OBJECTIVE: To evaluate the feasibility, safety and surgical outcomes of laparoscopic surgery for the treatment of low-risk endometrial cancer. METHODS: Of 155 patients with low-risk endometrial cancer, who were included in this retrospective study between May 2008 and March 2017, 82 and 73 underwent laparoscopic and open surgery, respectively. Clinicopathological and surgical data, recurrence-free survival and overall survival were analyzed. RESULTS: No statistically significant differences in median age, final pathological type, International Federation of Gynecology and Obstetrics stage and lymphovascular space involvement were observed between the laparoscopic and open surgery groups. No procedure in the laparoscopic surgery group was converted to open surgery. The median follow-up period was 60 months, with oncologic recurrence identified in three cases (one lung carcinoma and two pelvic cavity carcinomas) in the laparoscopic surgery group. There was no significant between-group difference in 5-year recurrence-free survival (laparoscopic surgery group: 96.3%, open surgery group: 92.6%) and overall survival (laparoscopic surgery group: 100%, open surgery group: 95.4%). CONCLUSIONS: Laparoscopic surgery is a feasible and safe treatment for endometrial cancer and should be considered as a standard treatment option for low-risk endometrial cancer.

Comparison of lymphoscintigraphy and single photon emission computed tomography with computed tomography (SPECT/CT) for sentinel lymph node detection in endometrial cancer.

BACKGROUND: Endometrial cancer is the most common gynecologic cancer, and lymph node metastasis is one of the most important prognostic factors. Increasing evidence shows that sentinel lymph node (SLN) mapping is an effective alternative to comprehensive lymphadenectomy. Single photon emission CT with computed tomography (SPECT/CT) is associated with a high SLN detection rate. OBJECTIVE: To compare the clinical efficacy of SPECT/CT with that of lymphoscintigraphy in detecting SLNs in patients with endometrial cancer. METHODS: Between May 2014 and October 2018, 151 patients with endometrial cancer were enrolled in this study at the Department of Obstetrics and Gynecology of the Kagoshima University Hospital. Inclusion criteria were patients with endometrial cancer, older than 18 years, and with pre-operative International Federation of Gynecology and Obstetrics (FIGO) staging of I and II. All patients underwent pre-operative CT, and patients with suspected peritoneal dissemination and lymph node metastasis were excluded from this study. Pelvic SLNs were detected by injection of tecnetium-99m-labeled phytate into the uterine cervix. The number and locations of SLNs detected using lymphoscintigraphy and SPECT/CT were evaluated. JMP software (version 14, SAS Institute Inc., Cary, North Carolina, USA) was used for statistical analysis. RESULTS: A total of 151 patients who underwent pre-operative lymphoscintigraphy and SPECT/CT were included in the study. The median age was 57 years (range 24-79), and the median body mass index was 24.3 kg/m2 (range 16-40). The final pathology was as follows: 135 (89%) endometrioid carcinoma, 11 (7%) serous carcinoma, one (1%) clear cell carcinoma, and four (3%) other histotypes. Based on SPECT/CT, 204 pelvic SLNs were detected. The bilateral pelvic SLN detection rate was better for SPECT/CT (43% (65/151)) than for lymphoscintigraphy (32% (48/151)) (p<0.0001). The overall pelvic SLN detection rate (at least one pelvic SLN detected) was also better with SPECT/CT (77% (16/151)) vs lymphoscintigraphy (68% (102/151)) (p<0.0001). The distribution of SLN locations detected using SPECT/CT was as follows: external iliac, 91 (45%); obturator, 61 (30%); common iliac, 28 (14%); internal iliac, 19 (9%); para-aortic, 2 (1%); parametrium, 2 (1%), and presacral, 1 (1%). The SLN detection rate using SPECT/CT was significantly worse in patients of advanced age (p<0.0001). DISCUSSION: Overall and bilateral SLN detection rate was better with SPECT/CT than with lymphoscintigraphy in patients with stage I/II endometrial cancer.

Quantitative RT-PCR Assay for Detecting Lymph Node Metastasis in Endometrial Cancer: A Preliminary Study.

OBJECTIVE: The detection accuracy of sentinel lymph node (SLN) metastasis by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) for endometrial cancer (EC) remains unclear and was assessed in this preliminary study. METHODS: We studied primary cancer tissues and pelvic lymph nodes (PLN) from 105 patients with EC. qRT-PCR assay was performed to determine the copy numbers of CK19 mRNA in EC tissues, and negative and positive LN samples. Further, qRT-PCR results were compared with pathological findings. RESULTS: CK19 mRNA expression was detected in 98% (104/106) of the tumors, with a median copy number of 3.0 × 105/µL. Twelve LN were diagnosed as positive by pathological examination. The median copy number of CK19 mRNA for positive and negative LN was 8.1 × 104/µL and 90.4/µL, respectively. CK19 mRNA expression was higher in pathologically positive LN than in pathologically negative LN (p < 0.01); the pathological and qRT-PCR findings showed no discrepancy. When the cutoff value was set at 4,500 copies/µL, qRT-PCR assay using CK19 mRNA exhibited high sensitivity and specificity. CONCLUSIONS: Our results demonstrated that qRT-PCR assay, using CK19 mRNA, exhibits a high accuracy for detecting LN metastasis in EC and represents a useful alternative to conventional pathological diagnosis of EC.

Learning curve and surgical outcomes for laparoscopic surgery, including pelvic lymphadenectomy, for early stage endometrial cancer.

BACKGROUND: The purpose of this study was to determine the learning curve of laparoscopic surgery for the treatment of early endometrial cancer and report the surgical outcomes. METHODS: Patients: Data were retrospectively extracted from the medical charts of patients who underwent laparoscopic surgery. INTERVENTION: Laparoscopic surgery, including pelvic lymphadenectomy, was performed using the same technique and instruments for all patients. OUTCOMES: The learning curve for the surgical technique, characterized by the operative time, number of lymph nodes removed, and volume of intra-operative blood loss, was analyzed. RESULTS: Over the period of observation, 82 patients were enrolled. For analysis, cases were classified into four groups, based on their surgery date. Between-group comparisons identified a significant decrease in operative time and volume of blood loss between Groups 1 and 4 (P < 0.05). However, the number of lymph nodes removed, and the length of hospital stay were not influenced by learning. CONCLUSION: The operative time and the amount of blood loss significantly decreased with an increase in the surgeon's experience but with no effect of learning on the number of lymph nodes removed and length of hospital stay.

Impact of taxane plus bevacizumab for ovarian sex cord tumor with annular tubules.

Sex cord tumor with annular tubules (SCTAT) is rare, and 20% of SCTAT cases, excluding those associated with Peutz-Jeghers syndrome, are clinically malignant. Limited data is available regarding the role of chemotherapy in the management of SCTAT. We encountered a 44-year-old woman with recurrent SCTAT complicated by peritoneal dissemination following a right adnexectomy. The surgical resection could not be performed completely due to the wide extension of the tumor. Considering the potential of becoming malignant, we chose a combination of bleomycin, etoposide and cisplatin (BEP) as postoperative chemotherapy treatment. However, the patient showed partial response following a complete BEP regimen. The patient received three courses of chemotherapy with docetaxel and carboplatin plus bevacizumab. After the combination chemotherapy, positron emission tomography-computed tomography scan confirmed a complete response, and is currently continuing bevacizumab treatment without relapsing and having no major adverse effects from complications. This case proved the potential of a combination of taxane and bevacizumab in patients with recurrent SCTAT.

Risk factors for lymphatic complications following lymphadenectomy in patients with cervical cancer.

BACKGROUND: The purpose of this study was to evaluate the occurrence of lymphatic complications following pelvic lymphadenectomy (PLA) in patients with cervical cancer. METHODS: A retrospective study of 169 cervical cancer patients was conducted. Lower extremity lymphedema (LEL) was diagnosed using the International Society of Lymphology guidelines, and pelvic lymphocele (PL) was evaluated using trans-vaginal ultrasonography and computed tomography. RESULTS: The median patient age was 46 years (range: 22-74) and median body mass index was 21.7 kg/m2 (range: 15.7-37.1). The median number of lymph nodes (LNs) removed was 27 (range: 22-74); 94 (55.6%) patients underwent circumflex iliac node (CIN) dissection; 39 (23.1%) patients received adjuvant chemotherapy; and 81 (47.9%) patients received adjuvant postoperative radiotherapy. There were 28 (16.6%) and 32 (18.9%) occurrences of LEL and PL, respectively. In multivariate logistic regression analysis, the number of LNs removed (odds ratio [OR]: 3.37; 95% CI: 1.43-8.54; P = 0.0053) and CIN removal (OR: 3.92; 95% CI: 1.55-11.4; P = 0.0033) were independent risk factors for LEL; however, no risk factors were significantly associated with PL. CONCLUSIONS: Our results demonstrated that CIN removal and the number of LNs removed were significant risk factors for LEL in patients with cervical cancer. However, we did not identify any significant risk factors for PL in this study. We instead speculate that LN dissection itself causes PL. We suggest that establishment of comprehensive PLA without CIN dissection, or use of the sentinel lymph node concept, will prevent the occurrence of lymphatic complications in cervical cancer patients.

Tumor bleeding requiring intervention and the correlation with anemia in uterine cervical cancer for definitive radiotherapy.

BACKGROUND: The prognostic impact of tumor bleeding requiring intervention and the correlation with anemia on the survival outcome of cervical cancer radiotherapy is unclear. METHODS: One hundred and ninety-six patients requiring hemostatic intervention between January 2006 and March 2014 were retrospectively investigated. The correlation between anemia and bleeding during radiotherapy, the prognostic impact of genital bleeding during radiotherapy and the influence of blood transfusion were estimated. RESULTS: None of the patients had incomplete or prolonged treatment exceeding 1 week due to bleeding. All tumor bleeding could be controlled by gauze packing, and no patients suffered from fatal genital bleeding. Bleeding significantly correlated with progression-free survival (P = 0.015) and overall survival (P = 0.048). Regarding the risk factors of anemia: age (P = 0.043), FIGO stage (P < 0.001), tumor diameter (P < 0.001), and bleeding (P = 0.002) were significant. Multivariate analysis revealed FIGO stage (Odds Ratio: 2.360; 95% CI = 1.202-4.633; P = 0.013), tumor diameter (Odds Ratio: 2.089; 95% CI = 1.048-4.162; P = 0.036) and Bleeding (Odds Ratio: 2.226; 95% CI = 1.052-4.709; P = 0.036) were independent to anemia. Anemia (Hazard Ratio = 1.894; 95% CI = 1.082-3.318; P = 0.025) was only independently correlated with progression free survival, while bleeding (Hazard Ratio = 1.156; 95% CI = 0.556-2.406; P = 0.698) had no independent correlation. Blood transfusion did not improve progression-free survival in patients with anemia or genital bleeding (P = 0.742). CONCLUSION: We have proved that genital bleeding requiring intervention during cervical cancer radiotherapy is a negligible prognostic factor and is the independent factor for causing anemia. Easily bleeding tumors are potential prognostic markers, which are not effectively treated using existing radiotherapy.

Genital bleeding hemostasis in gynecologic neoplasm with balloon tamponade: New treatment option.

Genital bleeding is the most common and serious complication in gynecologic malignancy. Different techniques are available for the control of severe bleeding, but standard treatment strategies have not been determined. Herein we report on the successful use of the balloon technique in two cases of genital bleeding in uterine neoplasm. The first case was of advanced cervical cancer with massive genital bleeding during radiotherapy. A metreurynter (mini-metro) was inserted into the vagina and hemostasis was indirectly achieved in the vaginal hematoma. The other case was of postoperative recurrent bleeding after cervical conization. A Foley balloon catheter was inserted into the endocervical canal and balloon tamponade directly stopped the bleeding. This technique is safe for massive genital bleeding in some cases of gynecological cancer, and can be conventionally performed regardless of the facility or department. The need for invasive treatment for fatal bleeding in gynecological cancer in which gauze packing is ineffective may be avoided by balloon tamponade without serious complications.

Potential proton beam therapy for recurrent endometrial cancer in the vagina.

Proton beam radiotherapy mainly has been used in the gynecological field in patients with cervical cancer. The efficacy of proton beam therapy in patients with recurrent endometrial cancer has not yet been determined. A 77-year-old endometrial cancer patient presented with recurrence in the vagina without distant metastasis following hysterectomy. A hard mass measuring 6 cm originated from the apex of the vagina, surrounded the vaginal cavity, and infiltrated the proximal and distal vagina. The patient received proton beam radiotherapy using a less invasive particle treatment system while minimizing the dose to the surrounding normal tissues. The dose to the planning target volume was 74 Gy (relative biological effectiveness) with 37 fractions. The patient was treated with 150-210-MeV proton beams for 53 days. Proton beam therapy led to the disappearance of tumors without any complications except for grade 1 cystitis although evidence of further complications is not available past our 6-month follow-up period. Proton beam therapy may become a useful treatment modality for recurrent endometrial cancer as well as cervical uterine cancer.