Aggressive carcinosarcoma of the uterine cervix associated with high levels of granulocyte colony stimulating factor: Case report and laboratory correlates

Cervical Carcinosarcoma: Current Understanding on Pathogenesis, Diagnosis, Management and Future Perspectives

Cervical carcinosarcoma (CCS) is a rare aggressive tumor which was referred to as a sarcoma initially with its morbidity less than 1% of all cervical cancers. Four theories have been proposed for the pathogenesis of CCS. The “metaplastic theory,” also called “monoclonal theory,” has been widely accepted so far. The most common clinical symptom of CCS is abnormal vaginal bleeding. CCS is much less common than the counterparts in uterine corpus and usually confused with uterine carcinosarcoma (UCS) or common cervical cancer. The management for CCS has been mainly extrapolated from studies of UCS or cervical cancers. However, CCS has its special anatomical position and biological behaviors and is usually diagnosed at an early stage than UCS. Currently, there is no consensus on the survival, management and prognosis factors of CCS. We reviewed and summarized the literatures regarding to the epidemiology, clinical presentations, pathogenesis, diagnosis and treatment of CCS for providing clinicians with comprehensive information to diagnose and treat this malignancy.

Granulocyte-colony stimulating factor-producing uterine cervical cancer treated with chemoradiotherapy: A case report with mutation analysis and literature review

Granulocyte-colony stimulating factor-producing uterine cervical cancer is a rare aggressive disease, which may be genetically distinct from other uterine cervical cancers.

Combined PLT and NE to predict the prognosis of patients with locally advanced cervical cancer

Cervical cancer is one of the most common tumors in women. Neutrophils (NEs) and platelets (PLTs) are components of cells in circulating blood. NEs are one of the components of white blood cells (WBCs), accounting for the vast majority of WBCs, recognized as one of the indicators of inflammation. PLTs are associated with thrombosis and inflammation. Both of them play an important role in tumor growth and metastasis. According to pre-radiotherapy PLT and NE media levels, we divided the patients into three groups: PLT and NE both high levels group, single high level group and both low group. By using COX regression models and nomogram, a prognostic model for patients was established. Both high levels of pre-radiotherapy PLT and NE group or high levels of post-radiotherapy PLT and NE group were correlated with worst overall survival (OS) compared with the other two groups. PLT and NE were correlated with outcomes of the patients with locally advanced cervical cancer.

Prognostic values of lymphocyte and eosinophil counts in resectable cervical squamous cell carcinoma

Aim: Cervical cancer is one of the leading causes of cancer mortality in women. Peripheral white blood cell parameters such as neutrophil (NE), eosinophil (EO), basophil (BA), as well as lymphocyte (LY) and monocyte (MO), are correlated with tumor outcomes. Methods: In total, 110 cervical squamous cell carcinoma patients were recruited in this study. The potential prognostic factors were evaluated by univariate and multivariate survival analysis. Results: Cox regression analysis model indicated that higher pretreatment EO level and increased post-/preradiotherapy EO ratio were independently associated with worse progression-free survival. Lower pretreatment LY or higher EO levels and increased post-/preradiotherapy EO ratio were independently associated with worse overall survival. Conclusion: LY and EO are correlated with outcomes of cervical squamous cell cancer.

Neutrophilia in locally advanced cervical cancer: A novel biomarker for image-guided adaptive brachytherapy?

Objective

To study the prognostic value of leucocyte disorders in a prospective cohort of cervical cancer patients receiving definitive chemoradiation plus image—guided adaptive brachytherapy (IGABT).

Results

113 patients were identified. All patients received a pelvic irradiation concomitant with chemotherapy, extended to the para-aortic area in 13 patients with IVB disease. Neutrophilia and leukocytosis were significant univariate prognostic factors for poorer local failure-free survival (p = 0.000 and p = 0.002, respectively), associated with tumor size, high-risk clinical target volume (HR-CTV) and anemia. No effect was shown for distant metastases but leukocytosis and neutrophila were both poor prognostic factors for in-field relapses (p = 0.003 and p < 0.001). In multivariate analysis, HR-CTV volume (p = 0.026) and neutrophils count > 7,500/μl (p = 0.018) were independent factors for poorer survival without local failure, with hazard ratio (HR) of 3.1.

Materials and methods

We examined patients treated in our Institution between April 2009 and July 2015 by concurrent chemoradiation (45 Gy in 25 fractions +/− lymph node boosts) followed by a magnetic resonance imaging (MRI)-guided adaptive pulse-dose rate brachytherapy (15 Gy to the intermediate-risk clinical target volume). The prognostic value of pretreatment leucocyte disorders was examined. Leukocytosis and neutrophilia were defined as a leukocyte count or a neutrophils count exceeding 10,000 and 7,500/μl, respectively.

Conclusions

Neutrophilia is a significant prognostic factor for local relapse in locally advanced cervical cancer treated with MRI-based IGABT. This biomarker could help identifying patients with higher risk of local relapse and requiring dose escalation.

Therapy Modalities, Prognostic Factors, and Outcome of the Primary Cervical Carcinosarcoma: Meta-analysis of Extremely Rare Tumor of Cervix

Objective

The aim of this study was to evaluate the prognostic factors, treatment options, and survival outcomes of primary carcinosarcomas of the uterine cervix.

Methods

An electronic search of the literature was conducted from 1951 to February 2017 to identify articles on primary cervical carcinosarcoma. After comprehensive evaluation of case series and case reports, 81 cases were included in the study.

Results

The most common clinical FIGO (International Federation of Gynecology and Obstetrics) stage was IB at 53% of cases. Median follow-up time was 15 months (range, 1.75–156 months). Two-year disease-free survival (DFS) and overall survival (OS) of the entire cohort were 49% and 60%, respectively. Both 2-year DFS and OS were significantly higher in patients with stage I than in those with stage II disease or greater (73% vs 22%, P = 0.000 and 82% vs 33%, P = 0.000, respectively). Two-year OS was 17% for patients who received primary radiotherapy, whereas it was 68% for those who underwent only surgery (P = 0.003). Surgery followed by adjuvant radiotherapy with or without chemotherapy was significantly associated with improved DFS and OS compared with primary radiotherapy. Two-year DFS was 63% in patients who underwent primary surgery, whereas it was 100% in patients treated with primary surgery followed by adjuvant radiotherapy with chemotherapy (P = 0.030). Stage alone was an independent prognostic factor for risk of both recurrence and death (hazard ratios, 9.8 [P = 0.004] and 14 [P = 0.018], respectively).

Conclusions

In due course of presentation, the tumor stage has a great importance because it is the only independent factor for prognosis. Surgery followed by adjuvant radiotherapy with or without chemotherapy seems to be related with better OS and DFS.

Leukocytosis due to markedly elevated granulocyte-colony stimulating factor levels in a patient with endometrial cancer: Case report and literature review

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Granulocyte-colony stimulating factor (GCSF) secretion by gynecologic tumors is rare.

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Elevations in serum GCSF can be seen in the absence of tumor GSCF secretion.

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Extreme leukocytosis is associated with autocrine tumor growth and poor prognosis.

[Carcinosarcomas in female genital tracts: general review]

Carcinosarcoma, also known as mixed mesodermal tumor or malignant mixed Mullerian tumor (MMMT) is a pathological entity combining a sarcomatous and a carcinomatous component. Found in thoracic, digestive, genitourinary, liver or skin locations, the most common location is the female genital tract. In gynecological tumors, carcinosarcoma accounts for about 2-5% of endometrial cancers, and 1% of ovarian cancers. To date, there is no consensus on the therapeutic strategy. It relies mostly on maximum cytoreductive surgery. Adjuvant therapy remains controversial, and few prospective studies investigating its interest. Retrospective studies show the benefits of adjuvant chemotherapy based on platinum in most cases. Radiation therapy has a place in the adjuvant situations of endometrial and cervical carcinosarcoma. A more detailed pathological knowledge, and the use of targeted therapies may be promising in this histological subtype whose prognosis remains very poor. The objective of this study is to present the main principles of carcinosarcoma management in female genital tracts, describing pathological and prognostic features at the same time.

The prognostic significance of preoperative leukocytosis in epithelial ovarian carcinoma: a retrospective cohort study

OBJECTIVE

Preoperative leukocytosis is known to be a negative prognostic factor for several gynecologic malignancies, but its relationship with epithelial ovarian carcinoma (EOC) is unknown. We sought to evaluate the prognostic implications of preoperative leukocytosis for women with EOC.

METHODS

We retrospectively reviewed the medical records of patients who underwent primary debulking surgery and adjuvant platinum-based chemotherapy for EOC between January 1993 and October 2011. Associations between leukocytosis and recurrence-free survival (RFS) and overall survival (OS) were determined by univariate analyses. Multivariate Cox proportional hazards regression was used to identify independent prognostic factors for RFS and OS.

RESULTS

Of 155 women, 23 (14.8%) had leukocytosis and 132 (85.2%) did not have leukocytosis. RFS and OS were significantly shorter for women with leukocytosis than for women without leukocytosis (P=0.009 and P<0.0001, respectively). The mortality rate was also higher among women with leukocytosis (P<0.0001). Multivariate analysis revealed that preoperative leukocytosis (hazard ratio [HR]: 2.15; 95% confidence interval [CI]: 1.55-4.41; P=0.009), advanced stage (HR: 3.12; 95% CI: 1.44-6.75; P=0.004), and optimal cytoreduction (HR: 0.38; 95% CI: 0.14-0.70; P=0.031) were independent prognostic factors for RFS. Additionally, preoperative leukocytosis was independently associated with decreased OS (HR: 7.66; 95% CI: 2.78-21.16; P<0.0001).

CONCLUSIONS

Among women with EOC, preoperative leukocytosis might be an independent prognostic factor for RFS and OS. A larger-scaled, prospective study is needed to verify these results.

Elevated white blood cell count at the time of recurrence diagnosis is an indicator of short survival in patients with recurrent cervical cancer

OBJECTIVES

The aim of this study was to investigate the prognostic significance of elevated white blood cell (WBC) count at the time of the diagnosis of cervical cancer recurrence.

METHODS

The baseline characteristics and outcome data of 219 patients who had a diagnosis of recurrent cervical cancer between April 1996 and September 2010 were collected and reviewed. Survival after recurrence was compared between the leukocytosis group (WBC ≥9000/μL) and the nonleukocytosis group (WBC <9000/μL). A Cox proportional hazards regression model was used to investigate the prognostic significance of elevated WBC count in patients with recurrent cervical cancer.

RESULTS

The patients in the leukocytosis group showed significantly shorter disease-free interval (P = 0.0005) and more frequently had multiple recurrences (P = 0.0101) than those in the nonleukocytosis group. The median survival after recurrence of the patients with elevated WBC count was 9 months, which was significantly shorter than the 21 months observed in the patients without normal WBC count (log rank; P < 0.0001). Multivariate analyses revealed that clinical stage, tumor diameter, histology, an elevated WBC count (≥9000/μL), and an elevated neutrophil count (≥6500/μL) were significant prognostic factors in survival after recurrence.

CONCLUSION

The elevated WBC count at the time of the diagnosis of recurrence is an independent prognostic factor in patients with recurrent cervical cancer.

Granulocyte-colony stimulating factor-producing cervical cancers treated with carbon-ion irradiation

Granulocyte-colony stimulating factor (G-CSF)-producing tumor is a rare condition. It has an aggressive nature and shows resistance to conventional treatments. We report two cases of G-CSF-producing uterine cervical cancer who were successfully treated with carbon-ion radiotherapy (C-ion RT). The first case was a 76-year-old woman with stage IIIB uterine cervical cancer, and the second was a 75-year-old woman with bulky stage IIB disease. Prior to treatment, both patients presented severe granulocytosis and elevated serum G-CSF concentrations. After C-ion RT, their cervical tumors completely disappeared, and their granulocytosis and elevated serum G-CSF levels improved as well. C-ion RT has been reported to be effective for various aggressive tumors, and it may be a good treatment option for this rare aggressive tumor.

The first 2 cases of granulocyte colony-stimulating factor producing adenocarcinoma of the uterine cervix

Granulocyte colony-stimulating factor (G-CSF)-producing nonhematopoietic malignancies have been reported in various organs, and most of them have been associated with poor clinical outcome. However, because of the rarity of the reported cases, information regarding the G-CSF-producing gynecological malignancies is limited. We report the first 2 cases of G-CSF-producing cervical adenocarcinomas, which exhibited an aggressive clinical course. At initial diagnosis, both patients exhibited marked leukocytosis without an obvious sign of infections. Of these, one was initially treated with definitive radiotherapy and the other was treated with radical surgery. However, both of these patients experienced recurrences in a short period and died from disease progression in less than 6 months. According to the facts that the tumor cells were positive for G-CSF, the elevated serum level of G-CSF, and their clinical course correlated well with the white blood cell count, we concluded that these tumors were G-CSF-producing cancers. These cases strongly indicate the aggressive nature of the G-CSF-producing cervical adenocarcinomas.

Squamous cell carcinoma of the uterine cervix producing granulocyte colony-stimulating factor: a report of 4 cases and a review of the literature

Granulocyte colony-stimulating factor (G-CSF)-producing malignant tumor has been reported to occur in various organs, and most of which has been associated with poor clinical outcome. However, because of the rarity of the reported cases, information regarding the G-CSF-producing gynecological malignancies is limited. We report 4 cases of G-CSF-producing cervical cancers. At initial diagnosis, all of the 4 patients exhibited marked leukocytosis without an obvious sign of infection. Of the 4 patients, 3 had their disease initially treated with definitive radiotherapy, and one was treated with radical surgery. Despite the aggressive treatments, all of these patients experienced recurrences within 6 months. In all cases, the white blood cell count returned to the normal range in response to the initial treatment and then increased again with recurrences. Based on the facts that the tumor cells were positive for G-CSF, the serum level of G-CSF was elevated, and their clinical course correlated well with the white blood cell count, we concluded that these tumors were G-CSF-producing cancers. All patients died from disease progression in less than 15 months. These cases strongly indicate the aggressive nature of the G-CSF-producing cervical cancer.

Carcinosarcoma of the uterine cervix: Case report and discussion

BACKGROUND

Cervical carcinosarcomas are rare neoplasms; optimal treatment is unclear. CASE 1: A 42-year-old woman underwent abdominal hysterectomy because of bleeding, anaemia and uterine fibromatosis. Histology showed a homologous carcinosarcoma of the cervix. Laparoscopic re-staging (pelvic lymphadenectomy, bilateral salpingo-oophorectomy) was negative for neoplasia. Adjuvant chemotherapy with ifosfamide and cisplatin was performed. At 48 months of follow-up, the patient is NED. CASE 2: A 74-year-old woman reporting vaginal bleeding, with carcinosarcoma on the cervical biopsy, underwent radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and paraortic lymphadenectomy. Histology confirmed a homologous carcinosarcoma of the cervix, stage IIb. Whole-pelvis irradiation and brachytherapy were carried out. Nine months later, the patient developed systemic recurrence and died of disease. Aggressive primary therapy can result in cure of early-stage cervical carcinosarcomas. Extracervical disease is associated with a poor prognosis.

The prognostic significance of leukocytosis in cervical cancer

Cervical cancer is a frequent tumor with established prognostic factors such as FIGO stage and hemoglobin levels among others. Despite the fact that paraneoplastic leukocytosis is relatively common in many solid tumors, only isolated cases of cervical cancer patients presenting this abnormality have been published; hence, the clinical significance of leukocytosis is unknown in this tumor type. Retrospective review on the medical records of 294 consecutive newly diagnosed and untreated locally advanced cervical cancer patients who received radiotherapy and concurrent cisplatin was conducted. Leukocytosis was defined as a persistent white blood cell count exceeding 10,800/microL, determined at least twice before commencing chemoradiation providing that patients were free of any active acute or chronic infection or any other condition known to elevate the leukocyte count. The frequency of leukocytosis and their correlation with clinicopathologic features were investigated, as well as their impact on tumor response and survival. Leukocytosis with a median value of 13,300/microL (11,100-28,800) was observed in 35 (11.9%) patients at diagnosis. Leukocytosis was statistically associated only with advanced stages. Clinical complete response was observed in 57% versus 86% of the patients with and without leukocytosis, respectively. In the univariate analysis, leukocytosis, stage, and hemoglobin levels were significant predictors of survival; however, only leukocytosis and the hemoglobin level remained significant predictors of survival in the multivariate analysis. Leukocytosis is common in cervical cancer patients and has a negative prognostic significance.

Adult human sarcomas. I. Basic science

When connective tissue undergoes malignant transformation, glioblastomas and sarcomas arise. However, the ancient biochemical mechanisms, which are now operational in sarcomas distorted by mutations and gene fusions in misaligned chromosomes, were originally acquired by those cells that emerged during the Cambrian explosion. Preserved throughout evolution up to the genus Homo, these mechanisms dictate the apoptosis- and senescence-resistant immortality of malignant cells. A 'retroviral paradox' distinguishes human sarcomas from those of the animal world. In contrast to the retrovirally induced sarcomatous transformation of animal (avian, murine, feline and simian) cells, human sarcomas have so far failed to yield a causative retroviral isolate. However, the proto-oncogenes/oncogenes transduced from their host cells by retroviruses of animals are the same that are active in human sarcomas. Since the encoded oncoproteins arise after birth, they are recognized frequently by the immune system of the host. Immune lymphocytes that kill autologous sarcoma cells in vitro commonly fail to do so in vivo. Sarcoma vaccines generate immune T- and natural killer cell reactions; even when vaccinated patients do not show a clinical response, their tumors become more sensitive to chemotherapy. The aim of this review is to lay a solid molecular biological foundation for the conclusion that targeting the sarcoma oncogenes will result in regression of the disease.