Two cases of spindle cell variant diffuse large B-cell lymphoma of the uterine cervix.

Lymphoma with prominent spindle cell features is a morphological variant of diffuse large B-cell lymphoma (DLBCL) and is categorized as a rare variant by the WHO classification. Most cases arise from the skin, with only two cases reported in the uterine cervix to date. Here, we report two cases of spindle cell variant DLBCL of the uterine cervix. Although these cases might be rare, we believe that, as gynecologists and pathologists increase their knowledge of this variant type, more cases will be diagnosed properly.

Impact of the addition of concurrent chemotherapy to pelvic radiotherapy in surgically treated stage IB1-IIB cervical cancer patients with intermediate-risk or high-risk factors: a 13-year experience.

OBJECTIVES: To identify groups of patients who derive clinical benefit from postoperative adjuvant concurrent chemoradiotherapy (CCRT), we retrospectively investigated the survival outcomes of surgically treated early-stage cervical cancer patients. METHODS: We reviewed the medical records of 316 patients with FIGO stage IB1-IIB cervical cancer who had been treated with adjuvant radiotherapy (RT) (n = 124, RT group) or adjuvant CCRT (n = 192, CCRT group) after radical hysterectomy between January 1996 and December 2009. Of these, 187 patients displayed high-risk prognostic factors (high-risk group), and 129 displayed intermediate-risk prognostic factors (intermediate-risk group). Sixty patients with 1 intermediate-risk prognostic factor who received no adjuvant therapy were also identified and used as controls (NFT group). Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: In the high-risk group, adjuvant CCRT was significantly superior to RT alone with regard to recurrence rate, progression-free survival (PFS), and overall survival. In the intermediate-risk group, CCRT was superior to RT with regard to recurrence rate and PFS in patents with 2 or more risk factors. Among the patients with only 1 intermediate-risk factor, although no survival benefit of CCRT over RT was observed, addition of adjuvant treatment resulted in significantly improved PFS compared with the NFT group in patients with deep stromal invasion (log-rank, P = 0.012). CONCLUSIONS: Postoperative CCRT improved the prognosis of FIGO stage IB1-IIB cervical cancer patients in the high-risk group and patients who displayed 2 or more intermediate-risk factors. Patients who displayed deep stromal invasion alone also derived clinical benefit from adjuvant treatment.

Cervical non-squamous carcinoma: an effective combination chemotherapy of taxane, anthracycline and platinum for advanced or recurrent cases.

OBJECTIVE: An effective salvage chemotherapy for advanced and recurrent non-squamous carcinoma of the uterine cervix has not yet been established. The aim of the present study was to analyze the safety and efficacy of a combination chemotherapy for this disease using taxane, anthracycline, and platinum. STUDY DESIGN: This was a retrospective analysis of advanced and recurrent non-squamous cervical cancers treated at the Osaka University Hospital and the Osaka Medical Center for Cancer and Cardiovascular Diseases during a 10 year study period from 2000 to 2009. Single agent chemotherapies and combination chemotherapies for advanced and recurrent cervical cancer cases of non-squamous histology which were reported in the English literature were also reviewed. RESULTS: Salvage chemotherapy, using taxane, anthracycline and platinum, was performed for 5 advanced and 14 recurrent cases. Prior to the salvage chemotherapy, 15 (79%) of the 19 patients had already received either radiation or chemotherapy. A complete or partial tumor response was achieved in 8 (42%) of the 19 cases. The response rate for recurrent disease in a previously irradiated field was 40%. The median progression-free survival (PFS) and overall survival (OS) were 8 months (1-108) and 13 months (5-108), respectively. Grade 4 and febrile grade 3 neutropenia was observed in 6 cases (32%), but there was no case in which salvage chemotherapy had to be cancelled due to toxicity. According to previous reports, the cumulative response rate of combination chemotherapy (35%) was significantly higher than that of single agent chemotherapy (17%) (p<0.001). OS tended to be longer in the combination chemotherapy cases (8.7 months to 18 months) than that of single agent chemotherapy cases (7.3+ months to 9.1+ months). CONCLUSION: Combination chemotherapy of taxane, anthracycline, and platinum was found to have a survival benefit for advanced and recurrent cervical cancer patients of non-squamous carcinoma histology, with a tolerable toxicity.

The prognostic significance of multiple pelvic node metastases in cervical cancer patients treated with radical hysterectomy plus adjuvant chemoradiotherapy.

OBJECTIVE: We investigated the prognostic significance of multiple pelvic node metastases in cervical cancer patients who were treated with radical hysterectomy plus adjuvant chemoradiotherapy. METHODS: We retrospectively reviewed the medical records of 311 patients with International Federation of Gynecology and Obstetrics stage IB1-IIB cervical cancer who had been treated with radical hysterectomy plus adjuvant radiotherapy (RT) between January 1998 and December 2008. Of these, 119 received adjuvant RT and 192 received adjuvant concurrent chemoradiotherapy (CCRT) postoperatively. Multivariate analysis for progression-free survival (PFS) was performed using the Cox proportional hazards regression model to investigate the prognostic significance of pelvic node metastases in the 2 treatment groups. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: Multivariate analysis demonstrated pelvic node metastasis to be an independent prognostic factor for shorter PFS in both treatment groups. When the node-positive patients were analyzed according to the number of positive pelvic nodes, we found that the patients with multiple pelvic node metastases (≥3) displayed significantly shorter PFS than those with 1 or 2 pelvic node metastases in the RT group. In contrast, in the CCRT group, the PFS of the patients with multiple pelvic node metastases (≥3) was similar to that observed of the patients with 1 or 2 pelvic node metastases. CONCLUSIONS: The presence of multiple pelvic node metastases was not an independent predictor of shorter PFS in the CCRT group.

Investigating the relative efficacies of combination chemotherapy of paclitaxel/carboplatin, with or without anthracycline, for endometrial carcinoma.

PURPOSE: Recently a combination of paclitaxel and carboplatin (TC) (without an anthracycline) has begun to be used as an adjuvant or remission induction therapy, without any critical supportive evidence of its efficacy relative to a combination chemotherapy of taxane, platinum and anthracycline such as TEC (paclitaxel, epirubicin and carboplatin). The aim of our present study was to conduct the required clinical evaluations of the relative effectiveness of TC compared to TEC. METHODS: A retrospective comparison between the efficacy of TEC and TC regimens used for endometrial carcinoma at the Osaka University Hospital and the Osaka Medical Center for Cancer and Cardiovascular Diseases in Osaka, Japan, respectively, from 1999 to 2009 was performed. The clinical characteristics of the patients who received either TEC or TC were not significantly different, and TEC and TC therapies were initiated based on similar indications for chemotherapy. TEC regimen was paclitaxel (150 mg/m(2)), epirubicin (50 mg/m(2)) and carboplatin (AUC 4). TC regimen consisted of paclitaxel (175 mg/m(2)) and carboplatin (AUC 5). RESULTS: TEC was demonstrated to provide significantly better survival than TC as an adjuvant therapy for resected Stage III/IV diseases (p = 0.017 for progression-free survival and p = 0.014 for overall survival, by the log-rank test). However, in recurrent or more advanced cases, TC and TEC demonstrated similar effects on survival (p = 0.55 for progression-free survival and p = 0.63 for overall survival). CONCLUSIONS: TEC should be offered as an adjuvant therapy to Stage III/IV patients. TC may be considered for recurrent or unresectable cases as a remission induction therapy.

Dissection of unsuspicious para-aortic lymph nodes does not improve prognosis of advanced endometrial carcinoma with intra- or extra-abdominal metastasis.

BACKGROUND: The aim of this study was to analyze the significance of dissection of unsuspicious para-aortic lymph nodes (PAN) in patients with advanced endometrial carcinomas with intra- or extra-abdominal metastasis. PATIENTS AND METHODS: We conducted a retrospective comparison of the results of PAN dissection versus non-dissection for endometrial carcinomas with macroscopic metastatic lesions beyond the uterus (without significant swelling of the regional lymph nodes, including PAN), whose lesions were completely resected. RESULTS: Disease-free survival and overall survival did not exhibit a significant difference between the two groups. Multivariate Cox proportional hazards analysis demonstrated that PAN dissection was not an independent prognostic factor for survival. The frequency of PAN involvement at the first recurrence did not differ between the two groups. CONCLUSION: For advanced endometrial carcinomas with macroscopic metastatic lesions beyond the uterus, without significant swelling of regional lymph nodes, PAN dissection may be omitted without a significant adverse effect on prognosis and survival.

Radical hysterectomy with adjuvant radiotherapy versus definitive radiotherapy alone for FIGO stage IIB cervical cancer.

OBJECTIVES: The aim of this study was to compare the treatment outcomes and adverse effects of radical hysterectomy followed by adjuvant radiotherapy with definitive radiotherapy alone in patients with FIGO stage IIB cervical cancer. METHODS: We retrospectively reviewed the medical records of FIGO stage IIB cervical cancer patients who were treated between April 1996 and December 2009. During the study period, 95 patients were treated with radical hysterectomy, all of which received adjuvant radiotherapy (surgery-based group). In addition, 94 patients received definitive radiotherapy alone (RT-based group). The recurrence rate, progression-free survival (PFS), overall survival (OS), and treatment-related complications were compared between the two groups. RESULTS: Radical hysterectomy followed by adjuvant radiotherapy resulted in comparable recurrence (44.2% versus 41.5%, p=0.77), PFS (log-rank, p=0.57), and OS rates (log-rank, p=0.41) to definitive radiotherapy alone. The frequencies of acute grade 3-4 toxicities were similar between the two groups (24.2% versus 24.5%, p=1.0), whereas the frequencies of grade 3-4 late toxicities were significantly higher in the surgery-based group than in the RT-based group (24.1% versus 10.6%, p=0.048). Cox multivariate analyses demonstrated that treatment with surgery followed by adjuvant radiotherapy was associated with an increased risk of grade 3-4 late toxicities, although the statistical significance of the difference was marginal (odds ratio 2.41, 95%CI 0.97-5.99, p=0.059). CONCLUSIONS: Definitive radiotherapy was found to be a safer approach than radical hysterectomy followed by postoperative radiotherapy with less treatment-related complications and comparable survival outcomes in patients with FIGO stage IIB cervical cancer.

Postoperative whole pelvic radiotherapy plus concurrent chemotherapy versus extended-field irradiation for early-stage cervical cancer patients with multiple pelvic lymph node metastases.

OBJECTIVES: The aim of this study was to compare the efficacy of postoperative pelvic radiotherapy plus concurrent chemotherapy with that of extended-field irradiation (EFRT) in patients with FIGO Stage IA2-IIb cervical cancer with multiple pelvic lymph node metastases. METHODS: We retrospectively reviewed the medical records of patients with FIGO Stage IA2-IIb cervical cancer who had undergone radical surgery between April 1997 and March 2008. Of these, 55 patients who demonstrated multiple pelvic lymph node metastases were treated postoperatively with pelvic radiotherapy plus concurrent chemotherapy (n=29) or EFRT (n=26). Thirty-six patients with single pelvic node metastasis were also treated postoperatively with pelvic radiotherapy plus concurrent chemotherapy. The recurrence rate, progression free survival (PFS), and overall survival (OS) were compared between the treatment groups. RESULTS: Pelvic radiotherapy plus concurrent chemotherapy was significantly superior to EFRT with regard to recurrence rate (37.9% vs 69.2%, p=0.0306), PFS (log-rank, p=0.0236), and OS (log-rank, p=0.0279). When the patients were treated with pelvic radiotherapy plus concurrent chemotherapy, there was no significant difference in PFS or OS between the patients with multiple lymph node metastases and those with single node metastases. With regards to grade 3-4 acute or late toxicities, no statistically significant difference was observed between the two treatment groups. CONCLUSIONS: Postoperative pelvic radiotherapy plus concurrent chemotherapy is superior to EFRT for treating patients with FIGO Stage IA2-IIb cervical cancer displaying multiple pelvic lymph node metastases.

MR imaging evaluation of postmenopausal adnexal masses: correlation with final pathologic diagnosis.

OBJECTIVE: Adoption of transvaginal ultrasound in usual clinical settings allowed us to find asymptomatic adnexal masses more frequently in postmenopausal women. These masses were traditionally considered as the indication of surgical excision to determine histological diagnosis. Recently, if the appearance of that is simple cyst, conservative management may be acceptable because ultrasound benign diagnosis is proved to be reasonably reliable. We investigate here the reliability of benign diagnosis by MR imaging with gadolinium enhancement for both of simple and complex postmenopausal adnexal cystic masses. METHOD: We retrospectively examined the data of 121 postmenopausal patients who underwent surgery during a 3-years-period (from January, 2000 to December 2002) for adnexal mass under diagnosis of benign adnexal cysts based on MR imaging. RESULTS: Pathological examination identified two cases of malignancy among 121 cases diagnosed as benign by MR imaging. Among the cysts that revealed a simple pattern by MR imaging, 64/66 cases (97.0%) were benign histology and among the cysts that showed a complex pattern by MR imaging, 55/55 cases (100%) were benign histology. Among the cysts with diameter less than or equal to 10cm, 48/49 simple cysts and 32/32 complex cysts were benign histology. CONCLUSIONS: The diagnosis of benign adnexal mass in postmenopausal women by MR imaging was reliable. Conservative observation for postmenopausal patients of asymptomatic and small cysts under benign diagnosis based on MR imaging with gadolinium enhancement will be feasible even if the cysts appearances are complex, with careful follow-up program.

Clinical over- and under-estimation in patients who underwent hysterectomy for atypical endometrial hyperplasia diagnosed by endometrial biopsy: the predictive value of clinical parameters and diagnostic imaging.

OBJECTIVE: The aim of this study was to analyze the clinical and imaging characteristics in patients diagnosed with atypical endometrial hyperplasia based on endometrial biopsy in comparison with the final diagnosis from resected uteri; i.e. to determine the rates of underestimation (endometrial cancer), equivalent diagnosis (atypical hyperplasia), and overestimation (hyperplasia without atypia or non-hyperplastic lesion). MATERIALS AND METHODS: We reviewed 33 patients who were diagnosed with atypical endometrial hyperplasia by endometrial biopsy using a small curette and then underwent total abdominal hysterectomy between September 1992 and May 2002. Clinical parameters obtained from patients' charts, and imaging analyses using transvaginal ultrasonography (TUS) and magnetic resonance (MR) imaging were retrospectively re-examined. RESULTS: Among 33 patients who underwent hysterectomy due to a diagnosis of atypical hyperplasia, nine cases (27.2%) were underestimated (cancer), nine cases (27.2%) were equivalent and 15 cases (45.6%) were overestimated as indicated by examination of the endometrium of the resected uterus. There was no difference among these groups in either clinical parameters or diagnostic images obtained by TUS or MR. CONCLUSION: Diagnosis of atypical endometrial hyperplasia by endometrial biopsy often resulted in under- or over-estimation, as shown by examination after hysterectomy. As there is neither a reliable clinical parameter nor imaging feature to distinguish between these groups, hysterectomy is still the best treatment for these patients if they are willing to give up their fertility.