Carcinoma of the cervical stump: retrospective analysis of 77 cases

Advanced cervical stump cancer after laparoscopic subtotal hysterectomy: a case report of imaging, laparoscopic staging and treatment approach

BACKGROUND

Advanced cancer of the cervical stump, occurring years after a laparoscopic supracervical hysterectomy (LASH), is a rare but serious clinical condition. Many patients who undergo a LASH are unaware of this possible complication. Upon diagnosis of advanced cervical stump cancer, a holistic approach including imaging, laparoscopic surgery and multimodal oncological therapy is required.

CASE PRESENTATION

A 58-year-old patient presented to our department with the suspicion of advanced cervical stump cancer eight years after LASH. She reported pelvic pain, irregular vaginal bleedings and irregular discharge. Gynaecological examination revealed a locally advanced tumor of the uterine cervix with suspicion of infiltration of the left parametria and bladder. After thorough diagnostic imaging and laparoscopic staging, the tumor stage was determined as FIGO IIIB and the patient was treated with combined radiochemotherapy. The patient presented with tumor recurrence 5 months after the completion of therapy and she is currently being treated with multichemotherapy and immunotherapy regimens as palliative treatment.

CONCLUSION

Patients should be made aware about the risk of cervical stump carcinoma after LASH and the necessity for regular screening. Cervical cancer after LASH is often diagnosed at advanced stages and the treatment requires an interdisciplinary approach.

Characteristics, complications, and outcomes of early-stage cervical stump carcinoma: laparoscopy versus laparotomy

Objective

To compare the characteristics, surgical complications, and overall survival between patients undergoing laparoscopy versus laparotomy for treatment of early-stage cervical stump carcinoma.

Methods

Patients with International Federation of Gynecology and Obstetrics (FIGO, 2009) stage IA2 to IIA2 cervical stump carcinoma who underwent laparoscopy or laparotomy in the Obstetrics and Gynecology Hospital of Fudan University from January 2000 to June 2018 were retrospectively reviewed. All patients’ clinical characteristics, pathological features, complications, and follow-up data were retrieved.

Results

Seventy-two patients were included in the analysis; 58 underwent laparoscopy and 14 underwent laparotomy. With respect to surgical complications, laparoscopy was associated with a significantly lower complication rate, less blood loss, a shorter operative time, and a higher hospitalization fee than laparotomy. Survival was not significantly different between the laparoscopy and laparotomy groups.

Conclusions

Although survival was not significantly different between the two surgical approaches, the rate of surgical complications was much lower in the laparoscopy than laparotomy group.

Cervical Stump Cancer Treated With Radiotherapy Using Computed Tomography-Guided Brachytherapy

Cervical stump cancer, which arises in the remaining uterine cervix of a woman with a history of supravaginal hysterectomy, accounts for 1.6-4.4% of all cervical cancers. The close proximity of the rectosigmoid colon to the primary tumor, which is due to the absence of the uterine corpus, should be considered carefully in the treatment planning of brachytherapy. Although three-dimensional image-guided brachytherapy (3D-IGBT) is used widely to treat cervical cancer in those with an intact uterine corpus, the safety and efficacy of 3D-IGBT for cervical stump cancer remains unclear. Here, we report a case of cervical stump cancer (T3bN1M0) treated successfully with definitive radiotherapy, which combined external beam radiotherapy and computed tomography (CT)-based IGBT. By applying the dose prescription concept used for definitive brachytherapy of cervical cancer with an intact uterine corpus, IGBT achieved satisfactory dose conformity to the tumor while sparing the adjacent rectosigmoid colon. This led to local tumor control for three years and eight months, with no late adverse effects. This case suggests that radiotherapy using CT-based IGBT is a safe and effective treatment for cervical stump cancer.

Large pelvic mass arising from the cervical stump: A case report

BACKGROUND

A large cervical cyst with a cervical high-grade squamous intraepithelial lesion arising from the cervical stump is rare. After supracervical hysterectomy, there is a risk of various lesions occurring in the cervical stump. We review the types and characteristics of cervical stump lesions and compare total hysterectomy with subtotal hysterectomy. Gynecologists should choose the most suitable surgical method based on both the patient’s condition and wishes. If the cervix is retained, patients require a close follow-up.

CASE SUMMARY

A 57-year-old woman was admitted to the Gynecology Department for a large pelvic mass. Her chief complaint was abdominal distention for two months. She had undergone subtotal supracervical hysterectomy for leiomyoma 14 years prior. Abdominal ultrasonography detected a 9.1 cm × 8.5 cm × 8.4 cm anechoic mass with silvery fluid in the pelvic cavity and high-risk human papilloma virus 53 (HPV53) was positive. The admission diagnosis we first considered was a pelvic mass mimicking carcinoma of the cervical stump. We performed a laparotomy and a rapid frozen biopsy was suggestive of a fibrous cyst wall coated with a high squamous intraepithelial lesion. The pelvic mass was removed, and a bilateral adnexectomy was implemented. Final pathology confirmed that the pelvic mass was a large inflammatory cyst with a cervical high-grade squamous intraepithelial lesion. After successful intervention, the patient was discharged one week after surgery and there was no recurrence of the vaginal stump at 43 mo.

CONCLUSION

When addressing benign uterine diseases, gynecologists should pay adequate attention to retaining the cervix. If the cervix is retained, patients require a close follow-up.

No. 238-Supracervical Hysterectomy

OBJECTIVE

This guideline reviews the evidence relating to the potential benefits of the vaginal hysterectomy (VH) and supracervical hysterectomy (SCH) versus total abdominal hysterectomy (TAH) with respect to postoperative sexual function, urinary function, and peri- and postoperative complications. Laparoscopic options are not included in this guideline.

OPTIONS

Women considering hysterectomy for benign disease can be given the option of retaining the cervix or proceeding with a total hysterectomy.

OUTCOMES

The outcomes measured are postoperative sexual function and urinary function, and peri- and postoperative complications.

EVIDENCE

The Cochrane Library, Medline, and Embase were searched for articles published in English from January 1950 to March 2008 specifically comparing VH and SCH with TAH in the prevention of sexual dysfunction, urinary dysfunction, and peri- and postoperative complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Additional publications were identified from the bibliographies of these articles. Randomized controlled trials were considered evidence of the highest quality, followed by cohort studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table).

RECOMMENDATIONS

Retrospective analysis of surgery for cervical stump carcinoma at early stage

Cervical stump cancer is a rare type of disease as total hysterectomies are performed infrequently. The purpose of this retrospective study was to assess the diagnosis, treatment, follow-up methods and complications of 10 patients with cervical stump carcinoma treated with surgery in Anhui Provincial Hospital affiliated to Anhui Medical University (Hefei, China). From January 2006 to October 2016 a total of 10 patients underwent surgery for carcinoma of the cervical stump. The pathological reports revealed 80% of cases were squamous cell carcinoma and 20% of cases were adenocarcinoma. The FIGO stage distribution was as follows: Carcinoma in situ (10%); IB₁ (70%); IIA (20%). The patients received a transvaginal trachelectomy or a radical trachelectomy and pelvic lymphadenectomy (either laparoscopic or laparotomic abdominal); four of the patients were treated with adjuvant chemotherapy, and two with concurrent chemoradiotherapy. The parametrial and resection margin infiltration, lymph node metastasis and lymph vascular space invasion (LVSI) were negative in all patients, and the deep stromal invasion rate was 66.7% (6/9). No incidences of recurrence or mortality were recorded during the follow-up interval of 6-120 months. Compared with the four patients who received laparotomic abdominal surgery, significantly less blood loss was recorded for the five patients who underwent laparoscopic surgery (P<0.01). There was no significant difference observed in the surgery time (P>0.01) or in the hospital stay duration (P>0.01) for the patients treated with laparotomic abdominal surgery and laparoscopic surgery. One patient experienced bladder fistula due to bladder over-dilation, but recovered quickly after the catheter was reinserted. Surgery for cervical stump cancer at an early-stage is a viable and safer procedure, particularly the laparoscopic approach.

Operable Stages IB and II cervical carcinomas: a retrospective study comparing preoperative uterovaginal brachytherapy and postoperative radiotherapy

PURPOSE

To evaluate our data concerning prognostic factors and treatment toxicity in a series of operable cervical carcinomas.

METHODS AND MATERIALS

Between May 1972 and January 1994, 414 patients with cervical carcinoma, staged according to the 1995 FIGO staging system (286 Stage IB1, 38 Stage IB2, 56 Stage IIA, and 34 Stage IIB with 1/3 proximal parametrial involvement), underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection (N+: n = 68). Group I included 168 patients who received postoperative radiation therapy (RT): 64 patients had low-dose-rate vaginal brachytherapy with a median total dose (MTD) of 50 Gy; 93 patients had external beam pelvic RT (EBPRT) with an MTD of 45 Gy over 5 weeks, followed by low-dose-rate vaginal brachytherapy (MTD: 20 Gy); and 11 patients had EBPRT alone (MTD: 50 Gy over 6 weeks). Group II included 246 patients treated with preoperative low-dose-rate uterovaginal brachytherapy (MTD: 65 Gy); 32 of these 246 patients also received postoperative EBPRT (MTD: 45 Gy over 5 weeks) delivered to the parametria and pelvic nodes. Mean follow-up from the beginning of treatment was 106 months.

RESULTS

First events included isolated locoregional recurrences (35 patients), isolated distant metastases (27 patients), and locoregional recurrences with synchronous metastases (13 patients). The 10-year disease-free survival (DFS) rate was 88% for Stage IB1, 44% for Stage IB2, 65% for Stage IIA, and 48% for Stage IIB. Multivariate analysis showed that independent factors influencing the probability of DFS were as follows: cervical site (exocervical or endocervical vs. both endo- and exocervical, relative risk [RR]: 1.77, p = 0.047), vascular space invasion (no vs. yes, RR: 1.95, p = 0.041), age (>51 years vs. <or=51 years, RR: 1.90, p = 0.013), 1995 FIGO staging system (IB1 vs. IIA, RR: 2.95, p = 0.004; IB1 vs. IB2, RR: 3.49, p = 0.0009; and IB1 vs. IIB, RR: 4.54, p = 0.00002), and histologic pelvic lymph node involvement (N- vs. N+, RR: 2.94, p = 0.00009). The sequence of adjuvant RT did not influence the probability of DFS (Group I vs. Group II, p = 0.10). In Group II, after univariate analysis, DFS was significantly influenced by histologic residual cervical tumor in the hysterectomy specimen (yes vs. no: 71% vs. 93%, respectively, p < 10(-6)) and by the size of the residual tumor (<or=1 cm vs. >1 cm: 83% vs. 41%, respectively, p = 0.001). The overall postoperative complication rate was 10% in Group I and 9% in Group II (p = 0.7). The rate of postoperative ureteral complications requiring surgical intervention was lower in Group I than in Group II (0.6% vs. 2.3%, respectively, p = 0.03). The overall 10-year rate for Grade 3 and 4 late radiation complications was 10.4%. Postoperative EBPRT significantly increased the 10-year rate for Grade 3 and 4 late radiation complications (yes vs. no: 22% vs. 7%, respectively, p = 0.0002).

CONCLUSION

The prognosis for patients with cervical carcinoma was not influenced by the sequence of adjuvant RT (preoperative uterovaginal brachytherapy vs. postoperative RT) for Stages IB, IIA, and IIB with 1/3 proximal parametrial involvement. However, postoperative EBPRT increased the risk of late radiation complications.

[Operable stage IB and II cancer of the uterine neck: retrospective comparison between preoperative utero-vaginal curietherapy and initial surgery followed by radiotherapy]

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable stages IB and II cervical carcinomas.

PATIENTS AND METHODS

Between May 1972 and January 1994, 414 patients (pts) with cervical carcinoma staged according to the 1995 FIGO staging system underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection. Lateral ovarian transposition to preserve ovarian function was performed on 12 pts. The methods of radiation therapy (RT) were not randomised and depended on the usual practices of the surgical teams. Group I: 168 pts received postoperative RT (64 pts received vaginal brachytherapy alone [mean total dose (MD): 50 Gy], 93 pts had external beam pelvis RT (EBPRT) [MD: 45 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 20 Gy], and 11 pts had EBPRT alone [MD: 50 Gy over 6 weeks]. Group II: 246 pts received preoperative utero-vaginal brachytherapy [MD: 65 Gy], and 32 of theses 246 pts also received postoperative EBPRT [MD: 45 Gy over 5 weeks] delivered to the parametric and the pelvic lymph nodes with a midline pelvic shield. The mean follow-up was 106 months.

RESULTS

The 10-year disease-free survival (DFS) rate was 80%. From 75 recurrences, 35 were isolated locoregional. Multivariate analysis showed that independent factors decreasing the probability of DFS were: both exo and endocervical tumour site (p = 0.047), lymph-vascular space invasion (p = 0.041), age < or = 51 yr (p = 0.013), 1995 FIGO staging system (stage IB1 vs stage IIA, p = 0.004, stage IB1 vs stage IB2, p = 0.0009, and stage IB1 vs stage IIB with 1/3 proximal parametrical infiltration, p = 0.00002), and histological pelvic involved lymph nodes (p = 0.00009). Methods of adjuvant RT did not influence the probability of DFS (group I vs group II, p = 0.10). The postoperative complication rate was 10.2% in group I and 8.9% in group II (p = 0.7) but the postoperative urethral complication rate necessitating surgical intervention with reimplantation was lower in group I than in group II (0.6% vs 2.3%, respectively, p = 0.03). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 10.4%. EPRT significantly increased the 10-year rate for grade 3 and 4 late radiation complications (yes vs no: 22% vs 7%, respectively, p = 0.0002).

CONCLUSION

In our series, the methods of adjuvant RT (primary surgery vs preoperative uterovaginal brachytherapy) do not seem to influence the prognosis of the stage IB, IIA, and IIB (with 1/3 proximal parametrical involvement only) cervical carcinomas. The postoperative EPRT applied according to histopathological risk factors after surgical treatment increases the risk of late radiation complications.

Radical vaginal trachelectomy after supracervical hysterectomy

BACKGROUND

Radical vaginal trachelectomy (RVT) is an acceptable approach when applied toward a select group of patients with early stage cervical carcinoma. It is less invasive, can maintain fertility, and can be ideal in patients with significant comorbid factors compared to abdominal approaches. A small subset of patients with a previous supracervical hysterectomy can pose a surgical dilemma.

CASE

An 81-year-old woman with a history of severe cardiac disease on routine gynecological examination was found to have adenocarcinoma in situ with a focus suspicious for invasion of the cervical stump diagnosed by cone biopsy. She previously had a supracervical hysterectomy for benign disease of the uterus. A RVT was performed as definitive treatment and the patient recovered without complications.

CONCLUSION

In the rare case that presents with a history of supracervical hysterectomy, RVT with some technical modifications can still be considered as a therapeutic option for early stage cervical carcinoma.

Late radiation effects to the rectum and bladder in gynecologic cancer patients: the comparison of LENT/SOMA and RTOG/EORTC late-effects scoring systems

PURPOSE

To test the correlation of LENT/SOMA and RTOG/EORTC late-effect scales for rectum and bladder, 116 cases with gynecologic malignancies that were treated with radiotherapy were assessed with both scales.

METHODS AND MATERIALS

All cases had been treated at least 6 months before the date of assessment with external beam radiotherapy (50--54 Gy to midline) and 1--2 fractions of HDR brachytherapy (2 x 8.5 Gy to point-A for 32 inoperable cases; 1 x 9.25 Gy to 5--9 mm from the ovoid surface for 84 postoperative cases). The patients were questioned with both scales, and the correlation between the two scales was analyzed by Spearman's rho (rank correlation) test.

RESULTS

There were 64 cases with uterine cervix carcinoma and 52 cases with endometrium carcinoma, The overall (external + brachy) doses to ICRU points were 57.8 +/- 3.8 Gy for rectum and 59.3 +/- 4.9 Gy for bladder. The statistical analysis of LENT/SOMA and RTOG/EORTC scales revealed a very good correlation for rectum (r = 0.81; p < 0.01) and a good correlation for bladder (r = 0.72; p < 0.01).

CONCLUSION

The LENT/SOMA system is a further step on the reporting of late radiation effects. Some modifications will improve its precision, and multicentric randomized studies are needed to test its validity.