Vaginal Extension Research Articles

PO41: Comparison of Volume Doses from Rotterdam Applicator vs. Intrauterine & Tandem Applicator in Cervical Cancer with Vaginal Extension

PO41: Comparison of Volume Doses from Rotterdam Applicator vs. Intrauterine & Tandem Applicator in Cervical Cancer with Vaginal Extension

Bladder Rupture Following Both Successful and Failed Trial of Labor After Cesarean [02L

INTRODUCTION: The incidence of bladder injury during cesarean section is estimated to be 0.08 to 0.94%. In patients with previous cesarean delivery, rate of bladder injury after successful VBAC is 0.2% while unsuccessful TOLAC confers 1.1% risk. The average length of bladder injury is 4.2 cm. METHODS: Case presentation. RESULTS: The first patient is a 26 year-old gravida 3 para 2 presenting at 39w3d in spontaneous labor with history of 31 week emergent cesarean for breech presentation at complete dilation. Labor augmented with oxytocin and patient progressed to complete. Successful vacuum-assisted delivery performed for fetal bradycardia. Approximately 90 minutes after delivery, patient was noted to have copious amounts of fluid from the vagina upon retrograde bladder fill. Exploratory laparotomy demonstrated posterior bladder rupture from dome to neck and anterior cervicovaginal rupture causing cervical avulsion. The second patient is a 34 year-old gravida 2 para 1 presenting at 38w6d in spontaneous labor with history of cesarean for failed vacuum delivery. Patient progressed to complete by own mechanism but opted for cesarean after 1 hour of pushing. After an atraumatic delivery of infant, entirety of Foley catheter was noted within surgical field. Large cystotomy present from posterior aspect of dome distally through trigone and bladder neck concurrent with uterine rupture demonstrating vaginal extension. CONCLUSION: Successful VBAC does not preclude urologic injury. TOLAC counseling should be individualized based upon prior operative reports, with high indices of suspicion when hysterotomy may have been performed lower than anticipated. With early recognition of injury, favorable prognosis can be achieved.

The Effect of Different Surgical Methods on Female and Male Sexual Activity and Marital Quality in Patients With Early-Stage Cervical Cancer.

IntroductionSexual activity is important for marital quality, especially in cervical cancer survivors. Vagina extension following laparoscopic radical hysterectomy with bilateral ovarian preservation (VEOP), vagina extension following laparoscopic radical hysterectomy with bilateral oophorectomy (VEBO), radical hysterectomy with bilateral ovarian preservation (RHOP), and radical hysterectomy with bilateral oophorectomy (RHBO) are the common surgeries for young cervical cancer patients.AimTo investigate the effect of the 4 surgical methods on female/male sexual activity and marital quality in early-stage cervical cancer survivors.MethodsMultiple linear regression analysis was conducted in 205 patients with stage Ia1–IIa2 cervical cancer to evaluate the factors that affected male/female sexual function and marital quality.Main Outcome MeasureFemale Sexual Function Index (FSFI), modified Kupperman Index (KI), modified Sexual Life Quality Questionnaire (mSLQQ-QoL), and ENRICH marital inventory were used to reflect changes in female/male sexual function and marital quality in the 4 groups.ResultsFemale/male sexual function and marital quality were both highest in the VEOP group and lowest in the RHBO group. The regression results showed that ovarian preservation and vaginal extension were associated with female/male sexual function and marital quality. Furthermore, when vaginal extension and ovarian preservation were replaced by vaginal length, sexual psychological change, and hormone level index (KI), respectively; male sexual function was associated with vaginal length and sexual psychological change, whereas female sexual function and marital quality were only associated with hormone level and sexual psychological change. Clinical statistics found that four-fifths of the recurrent patients had vaginal extension (P = .042), and 3-quarters of these patients had large tumors.ConclusionOvarian preservation and vaginal extension are both important for male/female sexual activity and marital quality. Vaginal extension may play a positive role in female sexual life via psychology and in male sexual life via vaginal length. Vaginal extension may not be suitable for patients with large masses.Zhang Y, Sun S, Ding J, et al. The Effect of Different Surgical Methods on Female and Male Sexual Activity and Marital Quality in Patients With Early-Stage Cervical Cancer. Sex Med 2020;8:307–314.

Intensity modulated radiation therapy boost in locally-advanced cervical cancer in the absence of brachytherapy

ObjectiveStandard treatment in locally-advanced cervical cancer is external beam radiotherapy concomitant with platinum-based chemotherapy, followed by brachytherapy. The goal of our study was to determine whether an intensity modulated radiation...

Clinicopathological and Molecular Differences Between Gastric-type Mucinous Carcinoma and Usual-type Endocervical Adenocarcinoma of the Uterine Cervix.

We investigated differences in the clinicopathological and molecular characteristics between gastric-type mucinous carcinoma (GMC) and usual-type endocervical adenocarcinoma (UEA). We collected the clinicopathological information and performed targeted genomic sequencing analysis. GMCs exhibited significantly deeper invasion depth, larger horizontal spread, more advanced stage, more frequent distant metastasis, and more frequent parametrial and vaginal extension. Disease-free survival time of GMC patients was significantly shorter than that of UEA patients. GMCs displayed mutant p53 immunostaining pattern, whereas UEAs exhibited p16 block positivity. GMCs harbored mutations in KRAS, TP53, NF1, CDKN2A, STK11, and ARID1A. One GMC exhibited MDM2 amplification. In contrast, UEAs harbored mutations in HRAS, PIK3CA, and BRCA2. Two UEAs were found to have novel TP53 mutations. GMC is associated with more aggressive behavior than UEA. Distinctive p53 and p16 immunostaining patterns enable differential diagnosis. GMC and UEA exhibit genetic heterogeneity with potentially actionable molecular alterations.

Use of Vaginal Reconstructive Surgery in Cervical Cancer Patients to Prevent Vaginal Stump Contracture

Purpose The life quality of cervical cancer patients is severely compromised due to the vaginal stump contracture after surgery combined with radiotherapy. Therefore, our study focuses on ameliorating or preventing postoperative vaginal contracture. The objectives of this study were (1) to evaluate the method of ileal graft with vascular pedicle to extend the length of vagina and (2) to investigate the effect of the operation to prevent vaginal stump contracture after cervical cancer surgery combined with radiotherapy. Methods Twenty-five patients with vaginal stump contracture after cervical cancer radical resection with sequential radiotherapy were recruited for the study between 2011 and 2014. The therapy includes releasing the adhesion between vaginal stump and rectum as well as bladder, resecting the vaginal stump but reserving the exterior orifice of vagina, and extending the vaginal length using vascularized ileal graft. Results No postoperative complications such as infection and bleeding were observed in all 25 patients. The patients were satisfied with the length and width of vagina after extension; the discharge of reconstructed vagina was acceptable. All patients had sexual intercourse on the follow-up examination, and five patients complained of vaginal bleeding during or after sexual intercourse, although no abnormality was found on colposcopy. Conclusions The patients demonstrated a high level of safety, efficacy, and satisfaction with the ileal–vaginal extension for treating vaginal stump contracture after cervical cancer surgery combined with radiotherapy, suggesting that this method is valid for broad clinical application to improve the life quality of cervical cancer patients after surgery.

Dosimetric Analysis Using the Venezia Applicator, and Comparison with the Split Ring Applicator, in Combined Intracavitary/Interstitial High Dose Rate Brachytherapy for Cervix Cancer

High dose rate (HDR) brachytherapy is an effective local treatment for gynecologic malignancies. Hybrid intracavitary/interstitial gynecologic applicators deliver a more conformal dose to target volumes in locally advanced disease, though may increase doses to surrounding organs at risk (OARs). We adopted use of a new and novel hybrid applicator with two lunar-shaped ovoids that form a ring with ovoid holes with the ability to pass interstitial needles at both straight and oblique angles, a perineal template for wider parametrial and vaginal source distribution as well as multi-channel vaginal extension caps for enhanced proximal dose coverage (“Venezia” Elekta AB, Sweden). We performed a retrospective dosimetric analysis of the new applicator and comparison with the our standard split ring (Mick Radionuclear, New York).

Which Patients With Cervical Squamous Cell Carcinoma Might Benefit From Neoadjuvant Chemotherapy?

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 55-year-old postmenopausal woman, gravida 5 para 5, with past medical history significant for hypertension, presented to the emergency department with profuse vaginal bleeding and a hemoglobin level of 9 g/dL. The biopsy from an irregular 6-cm cervical mass was consistent with moderately differentiated cervical squamous cell carcinoma. The physical examination did not reveal vaginal or parametrial extension of the tumor. Pelvic magnetic resonance imaging disclosed the known carcinoma, as well as a 9.2 × 7.7 × 6.7 cm anterior uterine fibroid (Fig 1). A staging positron emission tomography scan was negative for metastatic disease. After blood transfusion and vaginal packing, the patient was referred to discuss the immediate management of her newly diagnosed bleeding bulky cervical cancer. In the absence of parametrial or vaginal extension and in the absence of lymph node metastasis (both on clinical examination and imaging), she was classified as having International Federation of Gynecology and Obstetrics stage IB2 disease.

The efficacy of sentinel lymph node mapping with indocyanine green in cervical cancer

BackgroundLymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients. Given the importance of lymph node metastasis, it is imperative that patients harboring metastasis are identified and can undergo appropriate treatment. Sentinel lymph node (SLN) mapping has drawn attention as a lymph node mapping technique. We evaluated the feasibility and efficacy of (SLN) mapping using indocyanine green (ICG) in cervical cancer.MethodsWe performed a single-center, retrospective study of 103 surgically treated cervical cancer patients who underwent SLN mapping. After using ICG to detect SLN during surgery, we removed the SLNs followed by laparoscopic or robotic-assisted radical surgery and bilateral pelvic lymphadenectomy.ResultsStage IB1 was the most common (61.17%). At least one SLN was detected in all cases. Eighty-eight patients (85.44%) had bilateral pelvic SLNs. The mean number of SLN per patient was 2.34. The side-specific sensitivity was 71.43%, the specificity was 100%, the negative predictive value (NPV) was 93.98%, and the false negative rate (FNR) was 28.57%. In cases of tumors smaller than 2 cm with negative lymph node metastasis on imaging, the study revealed a side-specific sensitivity of 100%, a specificity of 100%, a NPV of 100%, and a FNR of 0%. Large tumor size (≥ 4 cm), a previous history of a loop electrosurgical excision procedure (LEEP), depth of invasion (≥ 50%), the microscopic parametrial (PM) invasion, and vaginal extension were significantly associated with the false-negative detection of SLN. Moreover, the microscopic PM invasion was the only risk factor of the false-negative detection of SLN in multivariate analysis.ConclusionSLN mapping with ICG in cervical cancer is feasible and has high detection rate. The sensitivity of 100% was high enough to perform SLN biopsy alone in an early stage in which the tumor is less than 2 cm, with no lymphadenopathy on image examination. However, for large or invasive tumors, we would have to be cautious about performing SLN biopsy alone.Trial registrationRetrospectively registered 2017-0600.

Vaginal extension improves sexual function in patients receiving laparoscopic radical hysterectomy

ObjectiveTo investigate as to whether vaginal extension (VX) following laparoscopic radical hysterectomy (LRH) improves sexual function in patients with early-stage cervical cancer patients. MethodsA total of 216 patients with stage Ia1–IIa2 cervical cancer were recruited, 115 of them received LRH concurrently with VX (group VX) and the other 101, LRH only (group C). Demographic, clinicopathological, and peri-operative data were collected. The Female Sexual Function Index (FSFI) questionnaire was administrated before and one year after surgery. Serum estrogen and follicle-stimulating hormone levels were also measured one year after surgery. The total and domain-wise FSFI scores before and after surgery were compared. ResultsIrrespective VX or not, all 6 domains of the FSFI scores in women with early-stage cervical cancer were significantly reduced one year after LRH. VX, however, significantly attenuated this reduction and improved all 6 FSFI domain scores, at the only cost of <20min longer operating time. In addition, more ovarian reserve and better pre-operational sexual function also contributed to the attenuation. The ovarian reserve was improved if ovarian preservation procedure was performed during LRH. ConclusionsWhile the sexual function in patients receiving VX procedure does not fully achieve the pre-operational level, the improvement is nonetheless global and significant. Ovarian preservation procedure during LRH may also help improve the sexual function. Therefore, VX and ovarian preservation may be desirable for patients with early-stage cervical cancer who undergo RH.

Clinical applications of custom-made vaginal cylinders constructed using three-dimensional printing technology.

PurposeThree-dimensional (3D) printing technology allows physicians to rapidly create customized devices for patients. We report our initial clinical experience using this technology to create custom applicators for vaginal brachytherapy.Material and methodsThree brachytherapy patients with unique clinical needs were identified as likely to benefit from a customized vaginal applicator. Patient 1 underwent intracavitary vaginal cuff brachytherapy after hysterectomy and chemotherapy for stage IA papillary serous endometrial cancer using a custom printed 2.75 cm diameter segmented vaginal cylinder with a central channel. Patient 2 underwent interstitial brachytherapy for a vaginal cuff recurrence of endometrial cancer after prior hysterectomy, whole pelvis radiotherapy, and brachytherapy boost. We printed a 2 cm diameter vaginal cylinder with one central and six peripheral catheter channels to fit a narrow vaginal canal. Patient 3 underwent interstitial brachytherapy boost for stage IIIA vulvar cancer with vaginal extension. For more secure applicator fit within a wide vaginal canal, we printed a 3.5 cm diameter solid cylinder with one central tandem channel and ten peripheral catheter channels. The applicators were printed in a biocompatible, sterilizable thermoplastic.ResultsPatient 1 received 31.5 Gy to the surface in three fractions over two weeks. Patient 2 received 36 Gy to the CTV in six fractions over two implants one week apart, with interstitial hyperthermia once per implant. Patient 3 received 18 Gy in three fractions over one implant after 45 Gy external beam radiotherapy. Brachytherapy was tolerated well with no grade 3 or higher toxicity and no local recurrences.ConclusionsWe established a workflow to rapidly manufacture and implement customized vaginal applicators that can be sterilized and are made of biocompatible material, resulting in high-quality brachytherapy for patients whose anatomy is not ideally suited for standard, commercially available applicators.

Quality of marriage and sexual function of cervical cancer patients following radical hysterectomy and vaginal extension

Objective To investigate the quality of marriage and sexual function of cervical cancer patients following radical hysterectomy and vaginal extension. Methods Case-control and questionnaire-based methods were used in this study. Forty patients of early-stage (Ⅰb 1~Ⅰb2) cervical cancer who had undergone vaginal extension following classic radical hysterectomy were included in the observation group, while 40 patients with matching factors and radical hysterectomy only during the same period were included in the control group. The quality of marriage and sexual function were compared with OLSON marriage prolapse and incontinence sexual function questionnaire Shon Fonn (PISQ-12). Results The operation time and postoperative vaginal length in the observation group were higher than those in the control group (P<0.05 or P<0.01). The emotional, physical, and total scores during postoperation were lower than those during preoperation (P<0.01). The emotional, physical, and total scores in the control group were lower than those in the observation group (P<0.01). The marital satisfaction, husband and wife communication, conflict resolution methods, extracurricular activities and sex scores in the observation group were higher than those in the control group (P<0.05 or P<0.01). Conclusions Patients with peritoneovaginoplasty following radical hysterectomy had much longer vagina and less self-perceived short vagina. Vaginal extension following radical hysterectomy does not worsen the pelvic floor symptoms. Key words: Hysterectomy; Vagina/SU; Uterine cervical neoplasms/SU; Marriage; Quality of life; Sexual behavior

Quality of life and sexual function of cervical cancer patients following radical hysterectomy and vaginal extension

To investigate the quality of life and sexual function of cervical cancer patients following radical hysterectomy (RH) and vaginal extension. Case-control and questionnaire- based method was employed in this study. Thirty-one patients of early-stage (I b1-I b2) cervical cancer who had undergone vaginal extension following classic RH in Peking Union Medical College Hospital from December 2008 to September 2012 were included in study group, while 28 patients with matching factors and RH only during the same period were allocated to control group. There was no significant difference between two groups in terms of clinical and demographic variables including age at diagnosis, tumor stage and follow-up time (P > 0.05). Patients were assessed retrospectively by validated self-reported questionnaires the European Organization for Research and Treatment of Cancer Cervix Cancer Module Questionnaire (EORTC QLQ-CX24) mainly for quality of life and sexual function for cervical cancer patients; the Sexual Function and Vaginal Changes Questionnaire (SVQ) further investigates sexual function and vaginal changes of patients with gynecologic malignancy at least 6 months after treatment. Vaginal length acquired by pelvic examination by gynecologic oncologists during follow-up visits was (10.0 ± 1.3) cm and (5.9 ± 1.0)cm in study group and control group respectively (P = 0.000). Sixty-eight percent (21/31) of cases in study group and 64% (18/28) of cases in control group had resumed sexual activity at the time of interview, and the time interval between treatment and regular sexual activity was mean 6 months (range 3-20 months) and mean 5 months (range 1-12 months) in study and control group respectively, in which there was not statistical significance (P > 0.05). No difference was observed regarding pelvic floor symptoms (P > 0.05) while difficulty emptying bladder, incomplete emptying and constipation were most commonly reported. Both group presented with hypoactive sexual desire disorder [88% (52/59)], orgasm dysfunction [72% (28/39)] and low enjoyment or relaxation after sex [51% (20/39)], which was not statistically significant (P > 0.05). Reduced vagina size and shorter vagina was more prominent in control group (12/18) than that in study group [19% (4/21)] with statistical significance (P < 0.05), while no difference in sexual desire, vaginal lubrication, dyspareunia and sexual enjoyment (P > 0.05). Patients with peritoneovaginoplasty following RH had much longer vagina and less self-perceived short vagina. Vaginal extension following RH does not worsen the pelvic floor symptoms.

Quality of Life and Sexual Function of Patients Following Radical Hysterectomy and Vaginal Extension

Radical hysterectomy (RH) has negative consequences on sexual function due to a shortened vagina, vaginal dryness, and dyspareunia. Peritoneovaginoplasty aims to extend vagina by vesical peritoneum and anterior rectal wall to improve postoperative sexual function. The aim of this study was to investigate whether vaginal extension can improve sexual function and quality of life and the problem of sexual dysfunction in early-stage cervical cancer survivors (CCSs) in China. Case-control and questionnaire-based methods were employed. Thirty-one patients who had undergone vaginal extension following RH and 28 patients with matching factors after RH alone were enrolled in the study. Both groups were assessed retrospectively by questionnaires at least 6 months after treatment. The European Organization for Research and Treatment of Cancer Quality-of-Life questionnaire cervical cancer module and the Sexual Function Vaginal Changes Questionnaire are validated measurements for disease- and treatment-specific issues. Vaginal length was 10.03 ± 1.26 cm and 5.92 ± 1.05 cm in study and control group, respectively (P < 0.05). In the study group, 67.7% patients and 64.3% of control group resumed sexual activity at the time of interview, averaging 6 months between treatment and sexual activity. While difficulty emptying bladder, incomplete emptying, and constipation were the most commonly reported symptoms, no significant difference was observed regarding pelvic floor symptoms. Reduced vagina size and shortened vagina was significantly more prominent in the control group, whereas both group presented with hypoactive sexual desire (88.1%), orgasm dysfunction (71.8%), and low enjoyment or relaxation after sex (51.3%). Shortened vagina was significantly less reported in study group, while no difference was observed in other sex-related dimensions. Vaginal extension does not worsen pelvic floor symptoms. Sexual rehabilitation interventions are of significance and should be paid more attention to the CCSs in China.

Is Stereotactic Body Radiation Therapy a Feasible Alternative to Brachytherapy for Definitive Treatment of Medically Inoperable Early Stage Endometrial Cancer?

and 82% &79%, respectively. Vaginal extension was the only negative predictor factor for the loco regional control (p5 0.045), while the grade was the only factor for the distant metastases free survival (p5 0.037). Grade 3 or 4 late rectal reaction was reported in 2 patients (3%), severe vaginal adhesion in one patient (1.5%), while no patients developed grade 3 or 4 urinary reaction Conclusions: Our study confirmed the efficacy of using concurrent chemoradiotherapy incorporating the HDR-BT in the treatment of cervix uteri cancer patients.

Template-based high-dose-rate interstitial brachytherapy in gynecologic cancers: A single institutional experience

To report the outcome and toxicities of radical external beam radiotherapy (EBRT) and template-based high-dose-rate interstitial brachytherapy (ISBT) in patients diagnosed with cervical cancer undergoing inadvertent surgery, vault cancers, and vaginal cancers at our institution. Between January 2000 and December 2008, 113 patients (37patients of cervical cancer post-inadvertent surgery, 57 patients with vault cancers, and 19 patients with primary vaginal cancers) were treated with Martinez Universal Perineal Interstitial Template brachytherapy boost after EBRT. The median EBRT dose was 50Gy, median ISBT dose was 20Gy, whereas median total dose was 73Gy equivalent dose at 2Gy per fraction in all three groups. Median followup of surviving patients for the whole group was 43 months (interquartile range, 19-67 months). The 3-year actuarial disease-free survival and overall survival for three groups was 61%, 61%, 59% and 64%, 64%, and 56%, respectively. Grade III/IV rectal toxicity was seen in 11 (10%) patients, bladder toxicity in 5 (4.5%) patients, whereas 7 (6%) patients developed Grade III small bowel toxicity. Residual disease at brachytherapy had significant impact on DFS and OS. Other factors such as age, disease volume, parametrial extension, and vaginal extension did not impact the survivals. Martinez Universal Perineal Interstitial Template-based high-dose-rate ISBT boost in gynecologic cancer results in a reasonable outcome in terms of survivals with acceptable late toxicities. The use of template-based ISBT is associated with a definite learning curve.

Pre‐pubertal isolated plexiform neurofibroma of labium majus without clitoral involvement

Sir, Neurofibromas are tumors of neural crest origin with protean manifestations which can affect virtually every organ and system. Isolated involvement of the female genital organs by this disease is rare and clitoral hypertrophy is the most common presentation. Genital neurofibromas usually enlarge in size and become symptomatic during puberty and pregnancy; however, we report an isolated plexiform neurofibroma in one labium majus without clitoral involvement and with documented rapid growth in a pre-pubertal girl. A 9-year-old girl presented with a swelling in the vulval region present since birth and with progressive painless enlargement for the last two years. The mass remained completely asymptomatic till the age of six years when it started to increase in size, causing discomfort during walking. The girl was 112 cm tall, breasts were Tanner's stage I and pubic and axillary hair absent. Multiple (more than six) café-au-lait spots measuring >15 mm were present over the abdomen, back and buttocks (Figure 1). A 7.2 × 5.4-cm sized irregular growth was noted in the left labium majus leading to disfigurement. The clitoris was unremarkable. The growth was firm, not tender, irreducible, with ill-defined margins and without vaginal extension. Ultrasound showed a predominantly hypo-echoic lesion with septae without any pelvic organ abnormality. Fine needle aspiration cytology suggested a benign spindle cell tumor. The mass was excised and histopathology revealed plexiform neurofibromatosis (Figure 1). Multiple café-au-lait spots and histopathological slide showing a well circumscribed lesion composed of spindle cells in a loose fibrillary matrix in isolated vulvar plexiform neurofibroma in a pre-pubertal girl. Neurofibromatosis-1 (NF1) is an autosomal dominant neuro-cutaneous syndrome with a reported incidence of 1 in 3000 live births. It is a multisystem disorder which may affect virtually every structure of the body; however, involvement of the external genitalia is extremely unusual (1) and most commonly affects the clitoris. Non clitoral involvement, as in this case, is exceptionally rare. Labial neurofibromas grow in size during puberty and pregnancy (2), due to elevated sex steroids, growth hormone and/or other growth factors (3). To the best of our knowledge only five cases of isolated labial neurofibroma without clitoral involvement have been reported in the English literature, but all became symptomatic during or after pubertal transition. In our case no pubertal changes were present, suggesting causative factors other than steroids or growth hormone. The diagnosis of a labial neurofibroma should prompt a search for other stigmata of the disease. The mainstay of treatment for a symptomatic isolated neurofibroma is local resection with preservation of genital anatomy. Complete removal can be difficult because of size, encroachment into surrounding tissues and indistinct margins (4).

Pagetoid Adenocarcinoma In Situ of the Cervix With Pagetoid Spread Into the Vagina

Pagetoid spread of adenocarcinoma in situ of the cervix into vaginal epithelium is a rare phenomenon, mimicking Paget's disease of the vulva. We report a case of in situ squamous cell and in situ adenocarcinoma of the cervix in a 44-year-old woman who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and upper vaginectomy. Pathologic evaluation showed pagetoid endocervical adenocarcinoma in situ spreading into the vagina with positive margins. Malignant cells were positive for mucin, P16, CK-7, and carcinoembryonic antigen. The asymptomatic occult finding of pagetoid changes in the vagina should raise the suspicion of vaginal extension of pagetoid genital or urothelial carcinoma in situ; however, it can be mistaken as vaginal dysplasia or primary Paget's disease. Immunohistochemical profiling may help in the differential diagnosis.

The importance of precise pT diagnosis for prognostic prediction of uterine cervical cancer—a single institutional report at a Japanese comprehensive cancer hospital

We previously reported that the majority of Japanese pathologists misunderstand the International Union against Cancer-pT2 criteria for uterine cervical cancer (UCC). We compared the prognosis of originally diagnosed pT2 (ori-pT) UCC cases at our hospital with reclassified pT2 (re-pT) cases to assess the importance of making a correct pT diagnosis. There were 43 International Federation of Gynecology and Obstetrics (FIGO) II (i.e., cT2) and/or ori-pT2 UCC cases who received surgery without neoadjuvant chemotherapy at Shikoku Cancer Center from 1991 to 2003. The cases (seven ori-pT1 and 36 ori-pT2; 43 cN0 with six pN1) were reclassified as 22 re-pT1 and 21 re-pT2. Fifteen of the 23 ori-pT2a cases (65%) were re-pT1 because their vaginal extension had only been intraepithelial. The difference in the 5-year survival rate (5Y-SR) was not significant between the ori-pT1 and ori-pT2 cases using Fisher's exact test (F test): P = 0.236 > 0.05, whereas 5Y-SR of re-pT1 cases was significantly higher than re-pT2, including pN1 cases and excluding them (F test: P = 0.00164 < 0.01 and P = 0.0108 < 0.05, respectively). The 5Y-SR of ori-pT2-re-pT1 (overdiagnosed pT2) was significantly higher that of ori-pT2-re-pT2 (true pT2) including pN1 cases and excluding them (F test: P = 0.00694 < 0.01 and P = 0.0305 < 0.05, respectively). These results indicated that pT2 of UCC could be frequently misdiagnosed at an institutional level, and that misdiagnosed pT2 might impair the evidence-based medicine of UCC. Multi-institutional assessment of the accuracy of pTNM is recommended, because it is not likely that this is an endemic problem to our hospital.

Tumor Volume and Uterine Body Invasion Assessed by MRI for Prediction of Outcome in Cervical Carcinoma Treated with Concurrent Chemotherapy and Radiotherapy

The aim of this study was to evaluate the prognostic significance of primary tumor volume and uterine body invasion assessed by pre-treatment MRI for uterine cervical cancer patient treated with concurrent chemotherapy and radiotherapy. A retrospective analysis of 106 patients with IB-IIIB cervical carcinoma was performed. Potential prognostic factors were stage, clinical tumor diameter, histology, age, pelvic lymph node, vaginal extension, parametrial invasion, tumor volume and uterine body invasion status. Multivariate analyses were performed to identify the prognostic factor for overall survival (OS) and disease-free survival (DFS). The 5-year OS, DFS rate were 59.7 and 56.6%. Using multivariate analyses, a large tumor volume (>/=30 ml; P = 0.012) and uterine body invasion (P = 0.020) and positive pelvic lymph node (LN) enlargement (P = 0.040) showed a significantly unfavorable influence on OS. Using these three factors, patients were divided into four subgroups: the OS rates of patients with risk 0 (volume <30 ml, no uterine body invasion, and negative LN), risk 1 (one of these three factors), risk 2 (two of these three factors) and risk 3 (volume >/=30 ml, uterine body invasion, and positive LN) were 96.3, 77.5, 53.0 and 14.8%, respectively (P < 0.0001). Tumor volume and uterine body invasion determined by MRI were significant prognostic factors for patients with cervical carcinoma. Pelvic lymph node enlargement diagnosed by CT also proved to be a significant prognostic factor in OS. Using these three parameters, we devised a practical and effective model to predict OS.