Case History
A 32-year-old woman (para 0) was referred to our hospital because of abnormal vaginal bleeding. She had a history of sexually transmitted infection at age 14 years and had been diagnosed with acute myeloid leukemia at age 26 years, for which she had received allo-SCT. Cervical cytology showed squamous cell carcinoma (Figure 1). We performed cervical conization and the pathological diagnosis was cervical intraepithelial neoplasia (Figure 2). The cervical margin was negative. After conization, the cervical cytology persistently showed squamous cell carcinoma or high-grade squamous intraepithelial lesion (HSIL). Ideally, re-conization or hysterectomy would have been performed. However, we could not perform these procedures as the patient had pancytopenia caused by late marrow failure following allo-SCT. Hence, transfusions were frequently performed for the pancytopenia. Because there was no evidence of cervical tumor on MRI, she underwent a second allo-SCT before gynecological treatment. She then developed acute GVHD, with high fever, skin eruptions, and diarrhea. Although chronic GVHD developed after acute GVHD, the dose of immunosuppressant was gradually decreased and she was discharged 4 months after the second allo-SCT. The patient still has chronic GVHD and requires regular adjustment of the immunosuppressant dose.
Although the cervical cytology showed squamous cell carcinoma prior to the second allo-SCT, it transformed to HSIL at 4 months (Figure 3), atypical squamous cells of undetermined significance at 11 months (Figure 4), and NILM at 16 months (Figure 5) after the second allo-SCT. The cervical cytology remained NILM for 1 year, but again changed to HSIL 33 months after the second allo-SCT. Since the abnormal cervical cytology persisted, we performed abdominal total hysterectomy and bilateral salpigo-oophorectomy 4 years after the second allo-SCT. The pathological diagnosis was cervical intraepithelial neoplasia, grade 3/HSIL (Figure 6). The surgical margin was negative. Though the vaginal stump cytology showed squamous cell carcinoma after the operation (Figure 7), it improved to HSIL 5 months postoperatively (Figure 8). Three years after the hysterectomy, the cytology had transformed from HSIL to NILM without treatment (Figure 9).