A case of primary non-Hodgkin's lymphoma of the uterine cervix treated by combination chemotherapy (THP-COP)

Management of Primary Uterine Cervix B-Cell Lymphoma Stage IE and Fertility Sparing Outcome: A Systematic Review of the Literature

The female genital tract can be involved as a secondary manifestation of disseminated lymphomas or leukaemia but can rarely be the primary site of so-called extranodal lymphomas. Primary lymphomas of the female genital tract can affect the uterine corpus, uterine cervix, vulva, vagina, or adnexa. Only about 0.008% of all cervical tumours are primary malignant lymphomas. The most common clinical presentation of primary cervical lymphomas is a history of prolonged minor abnormal uterine bleeding, while unstoppable bleeding at presentation is rarely reported in the literature. "B" symptoms related to nodal lymphomas are usually absent. Since vaginal bleeding is a nonspecific symptom, the first diagnostic hypothesis is usually of one of the more common female genital conditions such as cervical or endometrial carcinoma or sarcoma, fibroids, adenomyosis, or endometriosis. Cervical cytology is usually negative. Preoperative diagnosis requires deep cervical biopsy. No guidelines regarding optimal treatment exists; radiotherapy, chemotherapy, and surgery are used in different combinations. Conservative treatment with the combination of surgery and chemotherapy or surgery and radiotherapy has been reported in a few cases with apparent success. With this review, we aim to understand what the best therapeutic approaches for this rare pathology in young and elderly women are. Moreover, we find favorable pregnancy outcome in patients treated with a fertility sparing approach.

Primary lymphomas of the cervix and uterus: the University of Pennsylvania's experience and a review of the literature

Primary lymphomas of the cervix and uterus are rare with approximately 150 cases reported in the world literature to date. Appropriate diagnosis is often delayed until the post-operative setting as clinical and radiographic presentations are non-specific. Several sub-types of lymphoma arising primarily in the cervix or uterus have been reported with diffuse large B-Cell lymphoma (DLBCL) being the most frequent. Due to the low incidence of this disease, no randomized clinical trials exist to help guide treatment. This study reports the experience of four patients with primary lymphomas of the uterus and cervix that reflect the heterogeneity of cases reported in the literature to date. The patients had a mean age at diagnosis of 46 (range 35 - 56) and presented with abnormal uterine bleeding. One patient was diagnosed by total abdominal hysterectomy (TAH), two patients were diagnosed by cervical biopsy and one patient was diagnosed by endometrial biopsy. Three patients had DLBCL and one patient had marginal zone lymphoma (MZL). All patients had stage IIE disease. Of the patients with DLBCL, one received chemotherapy followed by TAH and two received TAH followed by chemotherapy. Two of these three patients remain disease-free post-initial therapy with the third now disease-free post-salvage therapy and autologous stem cell transplant. The patient with MZL was treated with TAH alone and remains disease-free. Based on the case series and a review of available literature, primary lymphomas of the uterus or cervix are rare and require an individualized approach to treatment. In general, patients with limited stage disease should be treated with localized and systemic therapy to optimize chances of cure.

Conservative management in primary genital lymphomas: the role of chemotherapy

BACKGROUND

The female genital lymphomas are an extremely rare disease accounting for less than 0.5% of gynecological cancers and for 1.5% of all NHL. Because of their low incidence there is no widely accepted consensus on its treatment. Literature data support a radiotherapy-based treatment in case of primary genital lymphomas stages I-II. The role of chemotherapy as neoadjuvant or exclusive treatment is still to be defined.

METHODS

From 1984 to 2003, the treatments in our institution of 19 patients with genital lymphoma were reviewed. Nine women presented with cervical, 3 with vaginal, 1 with cervical-vaginal, 2 with vulvar and 4 with ovarian lymphoma. Seven were staged IE, nine IIE, one IIIE and two IVE. As a whole, chemotherapy was used in 18/19 cases: chemotherapy was proposed as first line treatment in 12 cases, while surgery in 7 (followed by chemotherapy in 6 cases).

RESULTS

Primary chemotherapy alone obtained a complete response (CR) in 9/12 patients; pathological complete response (pCR) was confirmed in 3 operated patients out of 9. Partial response (PR) was observed in 3, requiring radiotherapy. Chemotherapy obtained CR after incomplete surgical debulking in 3 out of 4 cases. Two patients relapsed in the group treated with chemotherapy alone. Both have been salvaged by further chemotherapy. Only one patient deceased due to her tumor after surgery and chemotherapy.

CONCLUSION

The use of exclusive chemotherapy obtained promising results not only as regards survival rates but also for reducing the need of radiotherapy. A conservative management based on exclusive chemotherapy in primary genital lymphoma stages I-II may be attempted in selected patients desiring pregnancy.

Lymphoma of the female genital tract: current status

SUMMARY

: Primary lymphomas affecting the female reproductive system are uncommon but often pose a diagnostic challenge if their existence is not suspected. This article reviews the pathological and clinical features of lymphomas occurring in various sites in the female genital tract including the vulva, vagina, cervix, endometrium, fallopian tubes, and ovaries. Using the recent World Health Organization classification, the various types of lymphomas are identified as separate diseases and not as morphological variations of the same disease. The immunophenotypic and cytogenetics features of the major lymphomas are summarized. The incidence, presenting symptoms, gross and microscopic features, major differential diagnostic considerations, response to therapy, and expected outcome are discussed. Using published data on patient outcome, the International Federation of Obstetricians and Gynecologists and Ann Arbor staging systems are compared for their predictive value, and the difficulty in assigning primary and secondary status in extranodal lymphomas is emphasized. The observed differences in the behavior of some lymphomas in gynecological sites compared with their usual nodal location are presented. Finally, the possible etiology of these conditions is discussed in light of the emerging paradigm of mucosa-associated lymphoid tissue lymphomas.

Primary cervical lymphoma: report of two cases and review of the literature

BACKGROUND

Primary lymphoma arising from the female genital tract has been rarely encountered. Primary cervical lymphoma is even rarer in gynecologic oncology practice and accounts for approximately only 1% of extranodal lymphomas. In this article, two cases of cervical lymphoma are presented with a review of the available literature.

CASE HISTORIES

A 51-year-old woman presented with abnormal vaginal discharge. On pelvic examination, cervix was apparently normal; however, a solid and mobile pelvic mass was palpated. Pap smear was reported as HSIL at another institution. Radiological evaluation revealed a cervical mass with a 3 cm diameter. Histopathological evaluation of LEEP material was reported as diffuse large B cell lymphoma. We performed abdominal hysterectomy plus bilateral salphingo-oopherectomy and the patient was treated with adjuvant 6 cycles of CHOP chemotherapy. A second case was a 49-year-old postmenopausal woman who had undergone a routine gynecologic follow-up examination without any complaint at another institution. Routine cytological smear revealed HSIL. Punch biopsy under colposcopic examination presented no remarkable pathology except for a benign inflammation. Due to discordance between cytology and histology, LEEP was performed under colposcopic examination, which revealed follicular lymphoma grade III. This patient was treated with 6 cycles CHOP chemotherapy without any surgery.

CONCLUSION

Primary cervical lymphoma is a rare disorder. Although most reported cases in the literature have a normal Pap smear, some may represent with co-existent cytological abnormalities. Therefore, cervical lymphomas should be kept in mind in patients with cytological abnormalities.

Clinicopathologic features of six cases of primary cervical lymphoma

OBJECTIVE

Primary lymphoma of the uterine cervix is rare, with less than 60 cases reported. We present a series of 6 patients with cervical lymphoma and review the literature.

STUDY DESIGN

Between 1988 and 2003, we identified 6 women with primary lymphoma of the uterine cervix treated at our institutions. Data for analysis were obtained from hospital charts, office records, and tumor registry files. We also reviewed 20 published reports on cervical lymphoma, providing information on 58 additional patients.

RESULTS

The median age at diagnosis was 52 years (range 40-76). Three patients had an abnormal Papanicolaou test within 6 months of the diagnosis. Mean tumor size was 8.3 cm (range 3-14 cm). On the basis of the Ann Arbor system of staging where "E" denotes extranodal tumor origin, 2 patients had stage IE, 1 had stage IIIE, and 3 had stage IVE disease. The median follow-up for these 6 women was 33 months (range 12-120). Adding the 6 patients in our series to the 58 patients obtained from published reports, 43 had stage IE, 14 had stage IIE, 2 had stage IIIE, and 5 had stage IVE disease. There was no consistent pattern of treatment identified from our literature review.

CONCLUSION

Primary lymphoma of the uterine cervix is a rare malignancy. Most patients present with stage IE disease. Women with localized disease typically respond to various combinations of surgery, chemotherapy, and radiotherapy. Combination chemotherapy with tailored radiotherapy appears to be the preferred treatment option in women with advanced disease.

Primary stage I–IIE non-Hodgkin's lymphoma of uterine cervix and upper vagina: evidence for a conservative approach in a study on three patients

BACKGROUND

Non-Hodgkin's Lymphomas (NHL) frequently affect the uterine corpus, cervix, and vagina in cases of advanced disease. However, these organs are rarely the site of origin of this type of neoplasia. Because of the rarity of primary genital tract lymphomas, a standard treatment has not been defined.

CASE

Three patients with large B-cell primary Non-Hodgkin's lymphoma of the lower genital tract (vaginal, cervical and cervico-vaginal) presented with bulky lesions and underwent diagnostic evaluation, staging, and chemotherapy with adriamycin-containing regimens. All three patients, including two with stage IIE and one with stage IE disease demonstrated complete remission and are alive and well without evidence of disease at 10, 7, and 6 years of follow-up, respectively.

CONCLUSIONS

Our observations suggest that young patients with large B-cell lymphomas of lower genital tract stages I-IIE, even with bulky lesions, may benefit from chemotherapy alone as initial treatment.

Lymphoma of the cervix. Imaging and transcatheter arterial embolization

A case of uterine cervix lymphoma with selective embolization after angiography is described. Chemotherapy and radiotherapy were carried out and surgery was avoided.

[Non-Hodgkin's lymphoma of the uterus: apropos of 4 cases and review of the literature]

The primary non hodgkin's lymphoma of the uterus is rare. This rarity explains of one part certain difficulties of the histological diagnosis and on the other hand the absence of a therapeutic strategy clearly established. We report 4 cases of primary non-hodgkin lymphoma of the uterus. Two patients had a cervical location, the two other had corpus location. The average age of our patients is of 59 years (extremes: 54-68). Histological diagnosis was confirmed by biopsy for the cervical location. For the corpus location, it is study of the uterus after hysterectomy which retained the diagnosis of lymphoma. The type of the lymphoma was low grade in two cases and high grade in the two other cases. The disease was limited to the pelvis for all our patients (stage IE according to Ann-Arbor's classification). The treatment consisted of an association of chemotherapy and radiotherapy in both cases of lymphoma of the cervix and in a radical hysterectomy followed by chemotherapy for the two cases of lymphoma of the corpus. Our patients are regularly followed, with an average follow-up of 56 months. Two patients are in disease free, the third patient presented a dissemination of the disease and the fourth patient presented a squamous cell carcinoma of the lung.