Pelvic fractures and changes in bone mineral density after radiotherapy for cervical, endometrial, and vaginal cancer: A prospective study of 239 women.

BACKGROUND: Advances in radiotherapy (RT) have led to improved oncologic outcomes for women with gynecologic cancers; however, the long-term effects and survivorship implications need further evaluation. The purpose of this study was to determine the incidence of pelvic fractures and changes in bone mineral density (BMD) after pelvic RT. METHODS: Two hundred thirty-nine women who had pelvic RT for cervical, endometrial, or vaginal cancer between 2008 and 2015 were prospectively studied. BMD scans and biomarkers of bone turnover were obtained at the baseline and 3 months, 1 year, and 2 years after RT. Imaging studies were assessed for pelvic fractures for up to 5 years. Patients with osteopenia, osteoporosis, or pelvic fractures at any point were referred to the endocrinology service for evaluation and treatment. RESULTS: The median age at diagnosis was 51 years; 132 patients (56%) were menopausal. The primary diagnoses were cervical (63.6%), endometrial (30.5%), and vaginal cancer (5.9%). Sixteen patients (7.8%; 95% confidence interval, 4.5%-12.4%) had pelvic fractures with actuarial rates of 3.6%, 12.7%, and 15.7% at 1, 2, and 3 years, respectively. Fractures were associated with baseline osteoporosis (P < .001), higher baseline bone-specific alkaline phosphatase (P < .001), and older age (P = .007). The proportion of patients with osteopenia/osteoporosis increased from 50% at the baseline to 58%, 59%, and 70% at 3 months, 1 year, and 2 years, respectively. CONCLUSIONS: A high proportion of women had significant decreases in BMD after pelvic RT, with 7.8% diagnosed with a pelvic fracture. BMD screening and pharmacologic intervention should be strongly considered for these high-risk women.

High-Grade Cervical Dysplasia following Radiation Therapy for Invasive Cervical Cancer: A Report of Four Cases.

INTRODUCTION: The standard treatment for locally advanced cervical cancer is chemoradiation, with the majority of patients having a complete response to the therapy. The current surveillance recommendations from the Society of Gynecologic Oncology include annual cytology, with a small proportion of patients subsequently diagnosed with high-grade cervical dysplasia (CIN 2/3). To date, there is limited information regarding the optimal treatment and outcome for patients diagnosed with CIN 2/3. The current report describes the diagnosis, management and outcome of 4 patients diagnosed with CIN 2/3 following chemoradiation. CASE DESCRIPTION: We describe 4 patients who developed CIN 2/3 seven months to 8 years following radiation therapy for locally advanced cervical cancer. All 4 patients were asymptomatic and the abnormalities were first detected by a Pap test. Three of the patients were managed conservatively with observation, and the CIN 2/3 resolved without intervention. One patient underwent 2 cervical conizations followed by a hysterectomy with no residual dysplasia noted on the hysterectomy specimen. CONCLUSION: The majority of patients with recurrent cervical cancer after chemoradiation are symptomatic, and most cases are detected by a physical examination. The role of cytology, colposcopy and biopsies may be of limited value. Furthermore, the significance of the diagnosis of CIN 2/3 in patients previously treated with radiation therapy was not associated with recurrent disease in the 4 patients described. Our results suggest that cytology may be of limited value in detecting recurrence in patients following radiation therapy, even when CIN 2/3 is detected.

Radiotherapy for recurrent small cell carcinoma of the ovary: A case report and review of the literature.

•Small cell carcinoma of the ovary is a rare and aggressive malignant tumor.•No effective treatment for recurrent disease has yet been described.•Patients with recurrent disease may respond to salvage surgery, chemotherapy, radiotherapy or a combination of these modalities.

Primary malignant melanoma of the vagina.

OBJECTIVE: To describe the clinical and pathologic features of vaginal melanoma and to determine predictors of outcome in patients with this disease. METHODS: Thirty-seven women with clinical and radiographic stage I vaginal melanoma treated at one institution between 1980 and 2009 were included in this retrospective study. Treatment modalities were assigned to one of three categories: pelvic exenteration, wide excision, and nonsurgical (primary radiation therapy, chemotherapy, or both). Overall survival and progression-free survival were calculated from the date of the surgical diagnosis. RESULTS: The median age was 60.6 years. Eighty-four percent of patients were white. Vaginal bleeding was the most common presenting symptom. Lesions were located in the distal third of the vagina in the majority (65%) of patients. Initial management included a wide local or radical excision (76% of patients); pelvic exenteration (14%); and radiotherapy, chemotherapy, or radiotherapy and chemotherapy (10%). At a median follow-up of 17.4 months, 33 women experienced disease recurrence. Recurrence was local only in seven patients (22%), distant only in 20 (63%), and both in five (15%). The most common sites of distant recurrence were lungs and liver. Median progression-free survival was 11.4 months, and median overall survival was 19 months. The 5-year progression-free and overall survival rates were 9.5% and 20.0%, respectively. Patients treated surgically had significantly longer survival than those treated nonsurgically (P=.01). Radiotherapy after wide excision reduced local recurrence risk and increased survival from 16.1 months to 29.4 months, although the increase was not significant (P=.46). CONCLUSION: Malignant vaginal melanoma, even when localized at presentation, has a very poor prognosis. Patients treated surgically have longer survival than those treated nonsurgically. Radiotherapy after wide excision reduces local but not distant recurrences.