Staging of carcinoma of the uterine cervix and endometrium

Carcinoma of the uterine cervix and endometrium are common gynecologic malignancies. Both carcinomas are staged and managed by means of the International Federation of Gynecology and Obstetrics (FIGO) staging system. In uterine cervical cancer, the FIGO staging system is determined preoperatively by limited conventional procedures. Although this system is effective for early stage disease, it has inherent inaccuracies in advanced stage diseases and does not address nodal involvement. CT and MR imaging are widely used as comprehensive imaging modalities to evaluate tumor size and extent, and nodal involvement. MR imaging is an excellent modality for depicting invasive cervical carcinoma and can provide objective measurement of tumor volume, and provides high negative predictive value for parametrial invasion and stage IVA disease. In contrast, endometrial cancer is surgically staged. Beside recognition of the important prognostic factors, including histologic subtype and grade, accurate assessment of the tumor extent on preoperative MR imaging is expected to greatly optimize surgical procedure and therapeutic strategy. Contrast-enhanced MR imaging can offer “one stop” examination for evaluating the depth of myometrial invasion cervical invasion and nodal metastases. Evaluation of myometrial invasion on MR imaging may be an alternative to gross inspection of the uterus during the surgery.     

Irradiation of para-aortic lymph node metastases from carcinoma of the cervix or endometrium. Preliminary results

Twenty-two patients with biopsy-proved para-aortic lymph node metastases from carcinoma of the cervix (15 patients) or endometrium (7 patients) received a median dose of 5,000 rad/25 fractions. Para-aortic nodal metastases were controlled in 77% of cases. Control was significantly lower following radical retroperitoneal lymph node dissection than less extensive sampling procedures. Obstruction of the small bowel developed in 3 patients with tumor recurrence in the para-aortic region. Eight of the 10 patients who were disease-free at 2 years received greater than 5,000 rad. Three patients were still alive without disease at 129, 63, and 60 months, respectively. The 5-year disease-free survival rate was 40% for cervical cancer and 60% for endometrial cancer: in the former group, it was significantly different depending on whether the para-aortic nodes were irradiated (40%) or not (0%). The authors suggest that 5,000-5,500 rad in 5-5.5 weeks is well tolerated and can control aortic nodal metastases in cervical and possibly endometrial cancer.     

Imaging of cancer of the uterine cervix

Recently, magnetic resonance imaging (MRI) and transrectal or transvaginal ultrasound (TRUS, TVUS) had an important place in imaging techniques of cervical carcinomas and raise the question of modifying the imaging strategies. For the diagnosis of primitive tumor, those techniques cannot take the place of clinical examination and gross examination. In the assessment of parametrial involvement, TRUS which has better accuracy than clinical examination, and MRI which is considered as the most accurate technique, have an important role to play. In the follow-up and the detection of recurrences, MRI is actually considered as the best imaging technique. The authors, according to recent data in literature and their own experience, present basic concepts of imaging strategies for staging and follow-up of cervical carcinomas.     

A prospective randomized study on the fractionation of afterloading therapy of cancer of the cervix and endometrium

A prospective randomized clinical study is made on patients with uterine cervix and endometrium carcinomas treated only by radiotherapy. The fractionation schemes of 4 times 10 Gy, and 5 times 8 Gy, and 8 times 5 Gy at the reference points A and My, respectively, of a short-term afterloading therapy combined with percutaneous telecobalt therapy with 45 Gy at the pelvic wall are investigated. A tendency is shown towards better tumor control and less radiogenic effects with an increased number of fractions. The results are discussed on the basis of the NSD and LQ models. The problems caused by the equipment type and dosage specificity hampering the applicability of the results on other afterloading therapy units are pointed out.     

Psoas lymph node metastasis in patients with carcinoma of the uterine cervix

Enlargement of lymph nodes between the psoas muscle and lumbar spine was demonstrated on CT in three of 14 cases having Stage IIb and III uterine cervical carcinoma with iliac or paraaortic lymphadenopathy. In two of these, the adjacent lumbar vertebral body was destroyed. We define psoas lymph nodes to include all lymph nodes located between the psoas muscle and the spine. Psoas lymph nodes may be divided into upper and lower groups: the upper group distributed along the lumbar arteries above in level of L4-L5 and the lower group distributed along the lumbar branches of the iliolumbar arteries below L5. There appears to be paravertebral communication between these two groups. The region of the psoas lymph nodes should be scrutinized in interpretating CT in patients with malignant pelvic tumors which have already spread to iliac or paraaortic lymph nodes. Obliteration of fat plane between psoas muscle and lumbar vertebra is a clue to the presence of enlargement of the psoas lymph nodes on CT. Massive enlargement of psoas lymph nodes may be difficult to distinguish from metastasis to psoas muscle. In such cases, MR imaging would be of help to differentiate these two conditions.     

Radiosensitivity test for cancer of the uterine cervix

In selecting the method of treating uterine cervical cancer, radiosensitivity is one of the most important factors. To know this factor before treatment, we are trying to estimate radiosensitivity with changes of primary tumors before and after the irradiation. Tumors must be irradiated uniformly with small doses, and based on these considerations, we are attempting external test irradiation for estimation of radiosensitivity. Radiosensitivity was determined histopathologically by comparing the results of histological specimens taken before and seven days after test irradiation. Radiosensitivity is closely related to prognosis: of 183 cases with good sensitivity, 146 cases (79.8%) were surviving at five years after radiotherapy. On the other hand, the five-year survival rate of cases with poor sensitivity was only 37.2%. Comparing radiation with operation in operable cases of stage I and II, the five-year survival rate in cases with good sensitivity was about the same (90%). On the contrary, in cases with poor sensitivity, there was a substantial difference: that is, 66.0% of operated cases had a five-year survival compared with 39.7% of radiated cases.     

Postoperative radiation therapy for carcinoma of the uterine cervix

Postoperative radiation therapy (PORT) for cervical cancer has been empirically performed for patients with pathologic risk factors for recurrence after surgery. The efficacy of PORT is mainly supported by retrospective studies. Despite convincing evidence demonstrating a reduction in pelvic recurrence rates when PORT is employed, there is no evidence that it eventually improves patient survival. Local recurrence, such as vaginal stump recurrence, is not always fatal if diagnosed earlier. Some patients, unfortunately, may develop distant metastases even after PORT. The positive effects of PORT also may be counterbalanced by increased toxicities that result from combining local therapies. These factors obscure the efficacy of PORT for cervical cancer patients. There has been no consensus on the predictive value of risk factors for recurrence, which renders indication of PORT for early-stage cervical cancer quite variable among institutions. Today, efforts have been made to divide patients into three risk groups based on the combination of risk factors present after radical hysterectomy. In Europe/USA and Japan, however, a fundamental difference exists in the indications for radical surgery, highlighting differences in the concept of PORT; “adjuvant pelvic irradiation after stage IB-IIA patients after complete resection” in Europe/USA and “pelvic irradiation after surgery irrespective of initial clinical stage and surgical margin status” in Japan. Thus, it is questionable whether scientific evidence established in Europe/USA is applicable to Japanese clinical practice. The purpose of this article is to review the role of PORT by interpreting the results of clinical studies. The contents of the current article were presented as an educational lecture on the 64^th JRS meeting (April 2005) in Yokohama.     

Radiation therapy for brain metastases from breast cancer by histological classification

One hundred thirteen patients with metastatic brain tumor from breast cancer who were treated with external irradiation between 1989 and 1997 at Cancer Institute Hospital were studied. The patients were all histopathologically proven to have invasive ductal carcinoma (scirrhous type 54 cases, papillotubular type 18, solid-tubular type 41). The patients were evaluated for efficacy and histopathological subtypes. The time interval between the diagnosis of breast cancer and brain metastases was 53.6 months for the scirrhous type, 75.0 months for the papillotubular type, and 35.5 months for the solid-tubular type. The time interval between the diagnosis of initial distant metastases and brain metastases was 14.3 months for the scirrhous type, 22.5 months for the papillotubular type, and 12.5 months for the solid-tubular type. Efficacy rates (CR + PR) for external irradiation of the brain metastases were 40.0% for the scirrhous type, 66.7% for the papillotubular type, and 36.6% for the solid-tubular type. The papillotubular type had a favorable efficacy rate compared with the other two types. Median survival time (MST) from the start of treatment for brain metastases and one-year survival rate were 5 months and 11.1% for the scirrhous type, 7 months and 41.5% for the papillotubular type, and 4 months and 28.3% for the solid-tubular type, respectively. No statistically significant difference between survival rates was observed among the histopathological types. Univariate analysis showed performance status, number of metastatic tumors, and existence of extracranial metastases without bony metastasis to be significantly related to prognosis. Multivariate analysis showed only extracranial metastases without bony metastases to be related to prognosis.     

用 131I治疗不能切除的分化型甲状腺癌转移性淋巴结

目的　探讨1 31 I治疗不能手术切除的分化型甲状腺癌转移性淋巴结 (LMDTC)的治疗剂量和疗效。方法　对 2 4例分化型甲状腺癌术后不能手术切除的 84个LMDTC ,在 7 4～ 16 6 5GBq范围内选择不同剂量1 31 I治疗。分别于治疗后 1、3、6和 12个月随访观察LMDTC的状况。对≥ 2cm的LMDTC ,1 31 I治疗后视其变化确定再手术切除时间。结果　 84个不能手术切除的分化型LMDTC ,1 31 I治疗后有 78个分别消除、缩小和再次手术切除 ,有效率为 92 9% (78 84个 )。对 37个≥ 2cm的LMDTC1 31 I治疗后结合再手术治疗 ,切除病灶 16个 ,再切除率占 4 3 2 % (16 37个 )。与单纯用1 31 I治疗 <2cm的LMDTC的结果比较 ,差异有极显著性 (P <0 0 1)。1 31 I剂量为 3 7～ 12 95GBq时 ,各剂量组对LMDTC的疗效差异无显著性 (P均 >0 0 5 )。结论　大剂量1 31 I治疗分化型LMDTC有较好的疗效。     

Accurate and economical intracavitary endocurietherapy in the treatment of uterine cervix cancer

A modified afterloading cervical applicator and intracavitary endocurietherapy application technique eliminates several problems associated with the Henschke cervical applicator, and conventional preloading technique. The Kumar cervical applicator minimizes patient discomfort, and improves patient mobility while reducing the tendency of the applicator to rotate during the 40 to 50 hours of uterine intracavitary endocurietherapy. The use of hygroscopic laminaria tent for gradual cervical dilatation in place of manual cervical dilatation, and the use of inflatable Foley balloon threaded onto the tandem instead of vaginal packing, to separate the 137Cesium sources away from the rectum and bladder, eliminate the need of general anesthesia for the majority of patients undergoing intracavitary endocurietherapy.     

Lymphography in the diagnosis of metastases from carcinoma of the uterine cervix stages i and ii.

The lymphographic accuracy in the diagnosis of metastasis was analysed in 300 patients with carcinoma of the uterine cervix stages Ib and II. Pelvic lymphadenectomy was performed in all patients. Lymphographic and microscopic correlation was assured by means of radiography of the lymphadenectomy specimen. The criteria of metastatic infiltration were critically evaluated.     

正常子宫内膜和子宫内膜癌的扩散加权成像特点

目的探讨子宫内膜癌、子宫内膜不同周期及病理状态下的扩散加权成像的特点,研究表观扩散系数(ADC)及相对表观扩散系数(rADC)在子宫内膜癌的鉴别诊断应用价值。方法对29例子宫内膜癌,9例子宫内膜良性病变者和26例正常对照者行1.5T MRI检查并进行ADC值的测定(b值为800s/mm2)。闭孔内肌作参比部位,测量正常子宫内膜及内膜癌的rADC值,将不同组别ADC、rADC值相比较,进行统计学分析。结果子宫内膜癌ADC、rADC值分别为〔(0.96±0.22)×10-3 mm2/s、0.72±0.22〕,显著低于正常子宫内膜的ADC、rADC值〔(1.39±0.27)×10-3 mm2/s、1.02±0.22〕和子宫内膜良性病变ADC、rADC值〔(1.33±0.18)×10-3 mm2/s、1.02±0.28〕。萎缩期子宫内膜ADC、rADC值〔(1.62±0.37)×10-3 mm2/s、1.16±0.27〕显著高于增生期〔(1.29±0.14)×10-3 mm2/s、0.98±0.19〕和分泌期内膜〔(1.27±0.12)×10-3 mm2/s、0.94±0.12〕。结论 ADC有潜力鉴别子宫良性病变与子宫内膜癌,以闭孔内肌作为参比部位,所获得的rADC值可以很好的反映子宫内膜癌及正常子宫的扩散特征。