Maintenance of ovarian function in end-of-life cervical cancer patient following primary surgico-radiotherapy and ovarian transposition
A 35-year-old gravida 4 para 0 Taiwanese woman diagnosed with stage IB2 cervical adenocarcinoma underwent total laparoscopic radical hysterectomy, bilateral salpingectomy, pelvic lymph node dissection and ovarian transposition in June 2009. It is the practice of the Gynecologic Oncology Service of Chang Gung Memorial Hospital to perform radical hysterectomy for patients with bulky cervical adenocarcinoma. She had no concomitant illnesses or family history of breast or ovarian cancer. Previous menstrual cycles were normal except for intermenstrual bleeding that occurred four months prior to the diagnosis. Baseline pelvic examination revealed an exophytic cervical mass measuring over 4 cm, with smooth parametria. Preoperative tumor markers squamous cell carcinoma (0.8 ng/mL), carcinoembryonic antigen (CEA, 1.9 ng/mL) and CA-125 (24.3 U/mL) were within normal limits.\nShe underwent ovarian transposition during radical hysterectomy. Five trocars were inserted for four handed surgery with the primary trocar placed at Lee-Huang point (midway between the umbilicus and the xiphoid process). Grossly normal ovaries were fixed retroperitoneally at the antero-lateral abdominal wall, 3 cm above the umbilicus, below the upper trocars on each side. Metal clips were placed on the pedicles of both ovaries for radiologic detection.\nThe uterus measured 9.5×6.5×3.3 cm with an exophytic cervical mass measuring 7.5×4.3×1.8 cm. Vaginal length was 1.7 cm with right and left parametria measuring 3×1.5×1.5 cm and 3.5×2.8×2 cm, respectively. On microscopic examination, there was full cervical stromal invasion and involvement of the endometrium. There was focal lymphovascular space invasion. All surgical margins were negative. One of out seven left pelvic lymph nodes was positive for metastasis. Tumor was focally positive for CEA but negative for estrogen receptor, progesterone receptor, and vimentin. Final histopathology was moderately differentiated cervical adenocarcinoma. She received five cycles of weekly cisplatin at 40 mg/m2 concurrent with external beam radiotherapy to the whole pelvis and true pelvis at a dose of 4,050 cGy and 5,040 cGy, respectively, and underwent three sessions of brachytherapy, 200 cGy/fraction.\nImaging, papanicolau smear and tumor markers post-treatment were normal. One year and 3 months after ovarian transposition, estradiol was <7 pg/mL, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were elevated at 95.9 mIU/mL and 139.1 mIU/mL, respectively. She had no complaints of hot flashes. Five months later, the patient experienced low back pain radiating to the right thigh. Pelvic computed tomography revealed tumor recurrence at the left vaginal stump, bilateral pelvic sidewalls and right common iliac bifurcation with severe right hydronephrosis. Computed tomography (CT)-guided biopsy of the pelvic mass showed metastastic adenocarcinoma. She received cisplatin 50 mg/m2 (day 3) and topotecan 0.75 mg/m2 (day 1-3) for 6 cycles as palliative chemotherapy. She underwent external beam radiotherapy to the pelvis for pain control with a dose of 2,500 cGy/10 fractions at the same period. Two years and three months after the initial surgery, estradiol was 30.41 pg/mL, LH 0.2 mIU/mL, and FSH 5.6 mIU/mL. Repeat CT scan at this time showed transposed ovaries with metallic clips remained fixed to the anterior abdominal wall and uninvolved in tumor recurrence. Ultrasonography revealed both ovaries to be normal in size (). After two months, estradiol decreased to 13.5 pg/mL, and LH and FSH remained low, at <0.1 mIU/mL and 1.6 mIU/mL, respectively.\nBilateral percutaneous nephrostomy was performed for azotemia secondary to tumor progression. At present, the patient is receiving supportive palliative care. On her last follow-up, 2 years and 9 months after ovarian transposition, estradiol was 23.5 pg/mL, LH 1.97 U/L, and FSH 1.4 U/L.