Endobronchial metastases from cervical cancer: A case report

An unusual pattern of early metastatic spread in a postpartum patient with cervical cancer is presented. This appears to be the first case of cervical cancer metastatic to a major bronchus reported in the literature. The possible relationship of this young woman's pregnancy to the natural course of her tumor is briefly discussed.     

Umbilical Richter's hernia after minimally invasive laparoscopy. A case report

A case of Richter's hernia in the umbilical trocar site following laparoscopic radiofrequency thermal ablation of uterine myomas is presented. A 10-mm trocar was inserted through the umbilical site and the radiofrequency needle was introduced percutaneously into the uterine fibroid. Trocar was extracted under direct visual control after carbonic gas deflation. The fascial layer of umbilical port was not sutured. The umbilical Richter's hernia presented 13 days later required bowel resection. This case stresses the importance of suturing the fascial defects of 5-mm larger ports also in diagnostic and in minimally invasive laparoscopic procedures.     

Splenic metastases from cervical carcinoma: a case report

Splenic metastasis from squamous cell carcinoma of the uterine cervix is an unusual event in the natural history of the disease. The authors report one such uncommon occurrence in a 41-year-old female who presented initially with cervical carcinoma (stage IIB) and was treated with radical radiotherapy with concurrent weekly chemotherapy. Following a disease-free interval of less than a year, she developed hepatosplenic metastases despite being locally controlled. The literature relevant to the report is also discussed. This report reaffirms the notion that splenic metastases from cervical carcinoma are rare events but can occur as part of widespread dissemination.     

Neoadjuvant chemotherapy followed by vaginal radical trachelectomy in bulky stage IB1 cervical cancer: case report

BACKGROUND: We present 3 young women with bulky stage IB1 cervical cancer treated with neoadjuvant chemotherapy followed by laparoscopic pelvic node dissection and vaginal radical trachelectomy. CASES: In the last year, we have treated 3 young women with large cervical lesions who wished to preserve fertility with induction chemotherapy followed by fertility-sparing surgery. They all had lesions measuring 3 to 4 cm and felt to be too big to safely undergo a radical trachelectomy. Three cycles of platinum-based combination chemotherapy were given and were well tolerated. The 3 patients had a significant clinical response to chemotherapy. A complete pathological response was confirmed by the absence of residual invasive cancer in the three trachelectomy specimens. There has been no recurrence so far and no pregnancy yet. CONCLUSION: Neoadjuvant chemotherapy followed by a fertility-sparing surgery may become a valuable option for young women with bulky stage IB1 cervical cancer who wish to preserve their fertility potential.     

Management strategies for stage IB2 cervical cancer: a cost-effectiveness analysis

OBJECTIVE: To assess the potential effectiveness and medical costs of three common strategies to manage Stage IB2 squamous cell carcinoma of the cervix (CXCA). METHODS: A decision analysis model compared three strategies to manage Stage IB2 CXCA: (1) radical hysterectomy with pelvic and para-aortic lymphadenectomy followed by tailored chemoradiation therapy for high-risk patients (RHYST); (2) primary chemoradiation therapy for all patients (CTRT); and (3) neoadjuvant chemotherapy followed by radical hysterectomy and tailored chemoradiation therapy for high-risk patients (NAC). RESULTS: RHYST was the least expensive strategy with a cost of 284 Million (M) per 10,000 women and a 5-year disease free survival (5-DFS) of 69%. Both NAC and CTRT had similar 5-DFS (69.3% and 70%, respectively); however, both NAC and CTRT were more expensive than RHYST at 299 M and 508 M, respectively. This translated into a higher cost-effectiveness ratio for NAC and CTRT ($43,197 and $72,613, respectively) when compared to RHYST ($41,212). NAC yielded 30 additional survivors compared to RHYST but at a cost of $499,783 per survivor. CTRT was more effective than RHYST with 100 additional survivors but at a substantial cost of $2,240,000 per survivor. CONCLUSIONS: RHYST is the most cost-effective strategy to manage Stage IB2 CXCA and would be favored in settings where resources are limited. Although NAC and CTRT are reasonable treatment strategies, policymakers must be willing to spend approximately $500,000 per additional survivor (NAC) or $2.2 M per additional survivor (CTRT).     

The significance of peritoneal cytology in stage IB cervical cancer.

OBJECTIVE: The purpose of this study was to determine the incidence of positive peritoneal cytology and to evaluate its usefulness in the management of patients with early-stage cervical cancer. METHODS: Peritoneal cytology was studied in 273 women undergoing primary surgical exploration for International Federation of Gynecology and Obstetrics stage IB cancer of the cervix. Charts were reviewed retrospectively for clinicopathologic data concerning tumor size, cell type, lymph node status, and outcome. RESULTS: Cytology was positive in four women, three of whom had enlarged pelvic or para-aortic lymph nodes or intraperitoneal disease. There was no association between tumor histology or tumor size and peritoneal cytology. CONCLUSION: The incidence of positive peritoneal cytology in early-stage cervical cancer is low, and the prognostic significance of positive cytology is overshadowed by other risk factors more obvious at surgery. The routine collection of cytologic specimens at laparotomy should be abandoned in this setting.     

Postoperative radiotherapy in stage IB squamous cell cervical cancer

OBJECTIVE: The purpose of the study was to evaluate postoperative whole pelvic radiation for high-risk patients with FIGO Stage IB cervical cancer. METHODS: One hundred and forty-eight patients with Stage IB squamous cell carcinoma of the cervix underwent radical hysterectomy and pelvic lymphadenectomy. The low-risk group included patients without unfavorable prognostic factors who were treated only by surgery. The high-risk group included women with pelvic node metastases, with positive or close surgical margins, clinical tumor size > 4.0 cm, depth of stromal invasion > 1/3 the cervical wall, grade 3 tumor and presence of lymphovascular space involvement. High-risk patients received whole pelvic radiotherapy between two and four weeks after surgery. RESULTS: Seventy patients (47.3%) were low risk and 78 patients (52.7%) were high risk. Locoregional recurrences were diagnosed in nine cases (12.8%) in the surgery group and in 11 patients (14.1%) assigned to radiotherapy. The incidence of distant metastases was 2.8% in the surgery group and 6.4% in the surgery and radiotherapy group. Overall survival at five years was 88.6% in the low-risk group and 84.7% in the high-risk group. CONCLUSION: Five-year overall survival, locoregional and distant metastases were similar in the low-risk and high-risk groups of patients, thus emphasizing the value of whole pelvic radiation in patients with unfavorable prognostic factors in Stage IB cervical cancer.     

Incarcerated Richter's hernia after laparoscopy: a case report

An unusual case of Richter's hernia on the 5th day after laparoscopy is presented. The complaints simulated a postoperative hematoma, but they became so intense that the expansion was surgically explored: a conservative procedure on the loop of small bowel was possible. To prevent this complication after laparoscopy careful shaking of the abdominal wall at removal of the instruments is necessary.     

Femoral neuropathy after laparoscopy. A case report

Femoral neuropathy has been reported to occur after abdominal hysterectomies and has been related to nerve compression by abdominal wound retractors. We report a case of a 35-year-old woman with infertility who developed unilateral femoral nerve palsy after laparoscopy and hysteroscopy. This rare complication, secondary to extreme flexion, abduction and lateral rotation of the hip joint, can be prevented by careful preoperative patient positioning.     

Conservative surgical management of small-volume stage IB1 cervical cancer

Objective  To determine outcomes of women with small-volume stage IB1 disease managed by conservative surgical treatment.
Design  A retrospective review.
Setting  The Northern Gynaecological Oncology Center, Queen Elizabeth Hospital, Gateshead, UK.
Population  Women with stage IB1 cervical cancer who were managed by conservative surgery over a 6-year period between 1 January 2000 and 31 December 2005.
Main outcome measures  Pelvic lymph node metastases, recurrence rates and outcome survival.
Results  A total of 17 women with conservatively managed stage IB1 cervical cancer were identified. Their ages were 25–67 years, median 37 years, 4 women were nulliparous. All women presented with an abnormal screening smear showing at least severe dyskaryosis. Estimated tumour volumes ranged from 16 to 640 mm³, median 72 mm³. Four women showed multifocal invasion. All four nulliparous women and one parous woman underwent fertility-sparing treatment, i.e. loop cone ± laparoscopic pelvic node dissection. The other 12 women underwent laparoscopic assisted vaginal hysterectomy/total abdominal hysterectomy ± pelvic lymph node dissection. There were no cases of residual disease in any of the definitive treatment specimens. There were no cases of metastatic spread to pelvic lymph nodes. To date, no women have developed recurrent disease, and all women are alive and well (median follow up, 29 months).
Conclusions  The conservative surgical management of small-volume stage IB1 cases in this series showed an excellent outcome with no cases showing pelvic lymph node involvement and no cases developing recurrent disease. A more formal assessment of tumour volume with a more active approach to determining the third dimension will allow more women the option of conservative treatment, thereby minimising the adverse effects of radical surgery.     

Umbilical hemangioma: a case report

Introduction

Umbilical cord tumors are extremely rare with hemangiomas and teratomas accounting for the most common tumors.

Case report

A 26-year-old woman had an anomaly scan at 22 weeks. There was an echogenic area in the umbilical cord, the mass, which appeared enlarged and oedematous findings represented an umbilical cord hemangioma, but no fetal abnormalities (Fig. 1). The second ultrasound examination for follow-up showed that the fetus was dead. The macerating fetus (46XY) weighing 650 g was autopsied, and the report confirmed umbilical cord hemangioma and no significant congenital abnormalities (Figs. 2, 3).

Discussion

A high perinatal mortality and morbidity rate has been reported with hemangiomas of umbilical cord. Impaired umbilical circulation is considered as the predisposing factor for fetal demise. It is associated with premature delivery, cardiac failure, severe fetal hemorrhage, IUGR and intrauterine death. The differential diagnosis of umbilical cord hemangioma should include hematomas, varices, aneurysms, thrombosis and tumors. Close antenatal follow-up is mandatory, with serial USS examinations, which should involve AFI, tumor size and Doppler studies. The examination should be at 4 weeks intervals up to 32–34 weeks and every 1–2 weeks thereafter depending on the findings.

Conclusion

The prenatal diagnosis of umbilical cord hemangioma should be suspected when an echogenic mass is visualized within the umbilical cord.

     

Isolated metastases of cervical cancer to the abdominal wall--a case report

We described an unusual case of skin metastases of the uterine cervix in 63 year old woman. Previously, she was found having a Stage IIa squamous carcinoma of the cervix. She underwent bilateral salpingo-oophorectomy, total abdominal hysterectomy and pelvic node dissection. Then the patient was treated by external and intracavitary radiation. Within the next six months she was readmitted to the hospital because of abdominal pain and urinary stress incontinence after irradiation. The examination revealed three firm, freely-movable, solid subcutaneous nodules on the abdominal wall, umbilical site and urinary fistula. No other significant physical phenomena were noted. Radical excision of all the lesions was conducted and followed by four courses of adjuvant chemotherapy. Histopathological examination of the excised nodules revealed nests of squamous cell carcinoma, which were histologically identical to the previous carcinoma of the cervix. After successful treatment, the patient was continued for three months now, without any clinical evidence of recrudescence, and with good results from the urinary fistula treatment. Moreover, in these case-report we presented a review of current literature about new techniques and treatment methods of the cervical carcinomas.     

Umbilical endometriosis in pregnancy: a case report.

To our knowledge, this is the first case reported in the literature of umbilical endometriosis in a pregnant woman. We report a case of umbilical endometriosis in a pregnant woman at 16 weeks of gestation. The patient revealed a reddish-brown polypoid nodule within the umbilical depression, with the typical history of monthly bleeding from the umbilicus. A nodule biopsy, testing of serum levels of CA-125 and a transabdominal ultrasound examination were performed. The diagnosis of endometriosis was confirmed by pathological examination. Serum levels of CA-125 were slightly increased and the pelvic ultrasound examination did not identify ovarian cysts of a possible endometriotic nature. The patient was also examined at 24 weeks' gestation, after delivery and in the late postpartum period. No therapy was given and the lesion resolved spontaneously 2 months after the biopsy was taken.     

Prognostic significance of single versus multiple lymph node metastases in cervical carcinoma stage IB

From January 1, 1970, to December 31, 1985, 51 patients with stage IB (FIGO) carcinoma of the cervix with lymph node metastases were treated at the University Hospital, Groningen, The Netherlands. The survival rate was 54% and the average duration of follow-up was 78 months (range 47-132). Important clinical variables for survival were investigated retrospectively: the survival rate in patients with a single lymph node metastasis (with tumor confined to the node itself) (n = 23) appeared to be much better than that of patients with multiple node involvement and/or single nodes with extranodular tumor infiltration (n = 28); survival was 85 and 24%, respectively (P less than 0.001). The same applied to patients with only occult lymph node involvement: the survival rate in patients with occult involvement of the hypogastric, external iliac, or obturator nodes was 87% in 19 patients with a single metastasis and 53% in 15 patients with multiple node involvement (P less than 0.02). The survival rate in 8 patients with adenomatous histological components was 42%. In 42 patients with squamous cell carcinoma, the survival rate was 56%. This difference was not statistically significant. Treatment complications and the effect of treatment on the site of recurrence were investigated.     

Radical hysterectomy and pelvic lymphadenectomy for stage IB2 cervical cancer

OBJECTIVE: We wished to evaluate survival and adverse outcomes of patients with stage IB2 cervical cancer treated primarily with radical hysterectomy and lymphadenectomy. METHODS: A review was performed of all patients undergoing primary radical hysterectomy for stage IB2 cervical cancer at two institutions from 1987 to 2002. Patients were stratified into low, intermediate (Gynecologic Oncology Group protocol 92 criteria), and high-risk (positive nodes, margins, or parametria) groups. Survival and progression-free interval were analyzed using the Kaplan-Meier method and multivariate analysis. RESULTS: Seventy-two patients underwent primary type III radical hysterectomy and lymphadenectomy (72 pelvic, 58 pelvic and paraaortic). Patients were classified as low (n = 6), intermediate (n = 49), or high (n = 17) risk for recurrence. Adjuvant therapy was administered to 94%, 12%, and 0% of the high-, intermediate-, and low-risk groups, respectively. Five-year survival was 72%, while 5-year progression-free survival was 63%. Five-year overall and progression-free survival by risk group were 47% and 40% (high-risk), 80% and 66% (intermediate-risk), 100% and 100% (low-risk). Predictors of survival in multivariate analysis were Caucasian race (P = 0.001), older age (P = 0.017), inner 2/3 cervical wall invasion (P = 0.045), and absence of lymph-vascular invasion (P < 0.001). Major complications were experienced by 10/72 (13.9%) patients. Among 34 patients who received radiation therapy, two (5.9%) experienced complications attributable to radiation. CONCLUSIONS: Radical hysterectomy and lymphadenectomy followed by tailored adjuvant therapy is a reasonable alternative to primary radiotherapy for stage IB2 cervical cancer. Patients with low- and intermediate-risk factors have satisfactory results after primary surgical management. A prospective randomized trial will clarify the optimal mode of initial therapy for patients with stage IB2 disease.     

Neoadjuvant chemotherapy and conservative surgery for stage IB1 cervical cancer

ObjectivesTo assess the effectiveness of chemo-surgical conservative therapy for stage IB1 cervical tumors in patients desiring to preserve fertility.MethodsFrom 1995 to April 2007 51 nulliparous patients with tumor ≤ 3 cm, aged ≤ 40 years with no uterine and lymphnode neoplastic involvement were evaluated. Three courses with cisplatin 75 mg/m², paclitaxel 175 mg/m² and ifosfamide 5 g/m² (epirubicin 80 mg/m² in adenocarcinoma) were followed by cold-knife conization and pelvic lymphadenectomy. When intraoperative frozen section revealed massive neoplastic cervical persistence a radical total hysterectomy was performed.ResultsThirty women (59%) did not accept the conservative approach. In the remaining 21 patients median age was 30 years and median tumor size was 15 mm (range 10–30 mm). Adenocarcinoma was present in 12 cases (57%) and indifferentiated neoplasia in 10 (48%). Following neoadjuvant treatment, pathological complete response was observed in 5 cases, in situ or microinvasive residue in 12 and stromal invasion > 3 mm in 4. Four women deemed ineligible for conservative surgery after chemotherapy and one refusing to preserve her genital apparatus underwent radical hysterectomy. After a median follow-up of 69 months no relapses were observed. Nine women attempted to conceive: ten pregnancies occurred in 6 patients and 9 live babies have been born, while one woman experienced a first-trimester miscarriage.ConclusionsThe high rate of pathological response confirms the effectiveness of the preoperative treatment for reducing the tumor volume allowing the removal only of a cervical cone instead of the entire cervix with cardinal ligaments as needed by radical trachelectomy. Successful pregnancies are possible after such integration.     

Peritoneal cytology in patients with stage IB cervical cancer undergoing radical hysterectomy: limited value.

Peritoneal cytology, obtained at the start of planned radical hysterectomy in 200 consecutive patients with Stage IB cervical cancer, none of whom had intra-abdominal extension of disease, was positive in only one patient; this patient received no adjuvant treatment and remains disease-free at 48 months. Routine peritoneal cytology during radical hysterectomy adds little information for patient management and may be safely omitted.     

Surgical treatment of lymph node metastases in stage IB cervical cancer. The laterally extended parametrectomy (LEP) procedure: experience with a 5 year follow-up

Introduction

In 2003, we published our preliminary experience with the use of an operative technique (laterally extended parametrectomy, the LEP procedure) without adjuvant therapy, in the treatment of 29 stage IB, cervical cancer patients with pelvic lymph node metastases. In our present paper, by an extended recruiting period, with a completed 5 year follow up, we studied the outcome of LEP operations, used with the same indications.

Methods

In 70 out of 106 LEP-Wertheim operated patients, no adjuvant treatment was used. In 36 patients, where histology suggested tumor spread beyond the threshold of our surgery, adjuvant chemo-radiotherapy was advised. 5 year follow up was completed (without any patient lost for follow up) for the whole cohort of patients.

Results

In 70 patients treated by LEP procedure alone, the overall 5-year survival was 91.4%. For those 36 patients, who were excluded due to disease spread above study criteria, 5 year survival was 44%. Complications in 10% of the cases necessitated a second operation. Apart from transient hyper continence and one case of permanent incontinence, no severe quality of life consequence of the operation was observed.

Conclusions

Our results suggest that in two-thirds of pelvic lymph node positive, stage IB cervical cancer cases surgery alone could provide equal or better survival (without the toxicity of chemo-radiotherapy), than any kind of multimodality treatment alternatives. LEP procedure should be considered a treatment option for stage IB cervical cancer patients with pelvic lymph node metastases.