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Malignant non-Hodgkin's-type lymphoma of the cervix uteri occurring during pregnancy
GYNECOLOGIC
ONCOLOGY
Malignant
7,
385-393 (1979)
Non-Hodgkin’s-Type Lymphoma of the Cervix Uteri Occurring during Pregnancy
JOSH C. TUNCA, M.D. ,l,* P. R. REDDI, M.D. ,t SHEILA H. SHAH, M.D.,S AND STEPHEN T. SLACK, PH.D.§ *Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, University of Wisconsin Center for Health Sciences, Madison, Wisconsin 53706; 1‘Radiation Oncology, St. Louis University Hospital, 1325 South Grand Boulevard, St. Louis, Missouri 63104; *Department of Pathology and ODivision of Medical Physics and Radiation Therapy, West Virginia University Medical Center, Morgantown, West Virginia 26505
Received June 29, 1978 Histiocytic lymphoma, arising from the cervix uteri, especially during pregnancy, has rarely been found. The present case appears to be the second case reported in the English literature. The literature review and also the present case suggest that, if the histiocytic lymphoma arises primarily from the cervix uteri and is confined to the pelvis, it may be treated by irradiation and cure may be obtained.
The incidence of malignant non-Hodgkin’s lymphoma is about 6 per 100,000 of the population and is the cause of about 5% of all cancer deaths. Disease may present as pain-free lymphadenopathy either as a nodal type or as an extranodal type with massive organ infiltration. The most common primary sites of extranodal malignant lymphomas are skin, nasopharyngeal tract, gastrointestinal tract, and bone. When the disease progresses, the female genital tract may be involved in a part of the generalized process [Il. Primary female genital tract lymphoma originating in the cervix uteri is quite uncommon; during pregnancy it is extremely rare [2]. To our knowledge the present case is the second reported in the literature. A clinically similar case was reported by Vieaux and McGuire in 1964 [3]. CASE REPORT
Our patient was a 22-year-old white female, gravida 1, para 1, abortus 0, referred to the West Virginia University Hospital on December 28, 1975. Her private physician had diagnosed an extensive cervicovaginal tumor. The patient’s medical history revealed that she had become pregnant in January 1975. On March 25, 1975, multiple 2 x 2-cm enlargements were found involving ’ Previous address: Department of OB/GYN, West Virginia University Medical Center, Morgantown, W. Va. 26505. 385 0090-8258/79/030385-09$01.00/O Copyright @ 1979 by Academic Press, Inc. All rights of reproduction in any form reserved.
386
TUNCA
ET AL.
the cervix and the lower uterine segment. Cytology of the cervix was negative. Two consultants felt that the nodularities represented cervical multiple leiomyomas and that delivery should be carried out by cesarean section. The pregnancy progressed without complications and a cesarean section was performed on September 8, 1975. A 7-pound, 4-0~ normal male infant was delivered uneventfully. One month after delivery the patient began to bleed vaginally. On December 15, 1975, she was admitted to the emergency room in the regional hospital with profuse vaginal bleeding and a hematocrit of 18%. A pack was placed in the patient’s vagina prior to transferring her to the West Virginia University Hospital. Physical examination revealed no lymphadenopathy and no hepatosplenomegaly. Pelvic examination showed the upper two-thirds of the vagina and cervix occupied by 2- to 3-cm necrotic and actively bleeding masses. Rectovaginal exam revealed no free space between the central tumor and the right pelvic wall. The left parametrium was occupied at least 80% by tumor. The patient was staged as cervical malignancy, FIG0 IIIB. Initial biopsy of the tumor was reported as poorly differentiated stromal sarcoma. Another gynecologic pathologist consultant’s opinion was that the tumor represented a poorly differentiated cancer of the cervix. General metastatic workup was normal except that an intravenous pyelogram revealed no visualization of the right kidney due to a right ureteral obstruction (as shown in Fig. 1). The left kidney was normal. It was decided that the patient would be treated as a cervical sarcoma by irradiation and chemotherapy. On December 30, 1975, a Burnette applicator was placed in the vaginal vault delivering a 3500-rad, 0.5 cm-depth dose, in 63.6 hr. This was followed by external beam therapy using a cobalt-60 unit. A tumor dose of 3600 rad in 18 fractions was given to the whole pelvis through 15 x 15-cm anterior and posterior ports with a 4500-Ci source, at a source-skin distance of 80 cm. The vaginal mucosa received a total of 7200 rad. During irradiation the patient received adjuvant chemotherapy using 1.25 mg vincristine intravenously on a weekly schedule. This was administered for 13 weeks. The patient developed parasthesias and constipation. Therefore, the vincristine was stopped on March 22, 1976. A response was observed with partial mobilization of the right parametrium and morphological restoration of the vagina and cervix. On April 20, 1976, an intravenous pyelogram showed significant improvement of the excretory capacity of the right kidney (as shown in Fig. 2). On April 26, 1976, the patient underwent postirradiation laparotomy to determine the status of pelvic and paraaortic lymph nodes. Biopsy of various pelvic and paraaortic lymph nodes was negative. The liver and spleen were not enlarged. Biopsies from the cul-de-sac and pararectal-paravesical spaces were negative. Due to persistent induration of the right parametrium, 26 seeds containing iodine-125 were permanently implanted in the right parametrium and the cervix. A dose of over 20,000 rad was delivered to a volume of 3 x 3 x 2 cm and 10,000 rad to 4 x 4 x 3 cm. Approximately 2000 rad was delivered to points 2 cm or more from the margins of the implants.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
387
FIG. 1. Initial intravenous pyelogram reveals no visualization of the right kidney due to right ureteral obstruction.
388
TUNCA ET AL.
FIG. 2. After treatment, intravenous pyelogram shows significant improvement of the excretory capacity of right kidney.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
389
Frequent examination of the patient has revealed no evidence of disease. She is currently employed as a social worker. Due to the patient’s extraordinary response to therapy, and to confirm the original diagnosis, the case history and pathology slides were presented to the Papanicolaou seminars of the Southern Medical Association on November 9, 1976. A panel of pathologists, from different medical schools, unanimously agreed that the patient had hystiocytic lymphoma of the cervix uteri during pregnancy (Figs. 3 and 4). DISCUSSION
Accurate staging of malignant lymphomas with histological subclassification is possibly the most important factor for prognosis and treatment. Lymphomas histologically produce two distinct patterns, diffuse or nodular. The cells comprising the lymphomas infiltrate around the intrinsic structures of the organs involved without destroying them. This aspect is most obvious in the uterine corpus and the cervix, and differs from that of primary or metastatic carcinoma which tends to obliterate the architecture of the organs [2]. Although malignant lymphomas may present as a unicentric organ disease in two-thirds of the patients, multicentric involvement is more common by the time the malignant lymphomas are diagnosed. The female genital tract is rarely the primary initial site of malignant nonHodgkin’s lymphomas. Chorlton et al. did an extensive review of the Armed Forces Institute of Pathology (AFIP) files and found only 13 cases among 9500 women (1 in 730) with nodal and extranodal malignant lymphomas [2]. Freeman et al. studied 1467 patients with extranodal lymphomas which represented 24% of all lymphoma cases. He found that 47% of the patients were women and that 14 of them (1 in 50) had extranodal lymphomas localized in the female genital tract [4]. According to Chorlton et al., if it is assumed that a similar percentage of the lymphomas in the AFIP files are extranodal and occur in women, then about 1 in 175 extranodal lymphomas is likely to originate in the female genital tract (excluding ovaries) [2]. Except for the large series of ovarian lymphomas, the literature contains a few scattered case histories and reviews of malignant lymphomas that originated in the female genital tract. Prior to 1974, 19 cases of cervical lymphomas were reported. Chorlton et al. described 6 additional cases [2]. Carr et al. [6] and Delgado et al. 171reported 2 and 4 more cases, respectively, in 1976. With the present case, there are 32 extranodal cervical lymphoma cases in the literature. Only 2 cases occurred during pregnancy. A pelvic mass was present in all cases when the malignant lymphoma primarily involved the cervix or vagina. Abnormal vaginal bleeding occurred in 60% of the cases, perineal discomfort in 40%, and vaginal discharge in 20% [2]. Since these symptoms occurred in the early stages of the disease process early diagnosis and treatment resulted in a better survival rate. To our best knowledge, there is only one cervical lymphoma case that occurred during pregnancy and that was reported in 1964 by Vieaux and McGuire 131.
390
TUNCA
FIG. 3.
Microscopic
view of cervical
ET AL.
biopsy specimen of histiocytic
lymphoma.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
FIG. 4. Higher magnification of histiocytic lymphoma.
391
392
TUNCA
ET AL.
Their case is similar to the present case. Their patient was a 23-year-old white female, gravida 1, para 0. A 5- to 6-cm posterior cervical mass was diagnosed during the second month of pregnancy. They believed that this mass represented a cervical fibroid, and that the delivery should be carried out by cesarean section. Cervical cytology was also negative. The patient was delivered by cesarean section at term, and 1 month later the cervical mass was removed by marsupialization. The pathologic specimen revealed mixed histiocytic lymphocytic lymphoma. Extensive review of the literature by Villa Santa et al. revealed only 11 cases of malignant non-Hodgkin’s lymphomas that were associated with pregnancy, and only one case was located on the cervix [8]. TREATMENT
Successful treatment of malignant lymphoma depends on accurate staging of the disease. In order to make the diagnosis of primary lymphoma of the cervix, the lesions must be confined to the cervical region. No evidence of lymphoma should develop elsewhere [5]. Chorlton et al. have reported six cervical lymphoma cases. Two of the six cervical lymphoma cases in this series were treated with hysterectomy and were alive after 56 and 120 months, respectively [2]. Two other patients had hysterectomy followed by irradiation. Both patients were alive 15 and 12 months after treatment. The latter patient, however, was reported to have a recurrence. These four cases were IB or IIA by the FIG0 classification. One patient with FIG0 IIB staging was treated with irradiation and was dead in 30 months. Another patient with stage IV FIG0 classification had only chemotherapy and was dead in 1.5 months. Recently Carr et al. reported two cervical histiocytic lymphoma cases [6]. Both were treated with irradiation and both were alive without any evidence of recurrence after 3 years and 6 months, respectively. These two cases were the only cervical lymphoma cases among the total 25,000 primary cervical tumors. Delgado et al. reported four cervical histiocytic-type lymphoma cases [7]. One was staged as FIG0 IB. The other three were staged as FIG0 IIA. The FIG0 IB patient was treated with radical hysterectomy and pelvic lymphadenectomy and expired in 9 months due to dissemination of disease. The other three patients were treated according to the protocol for squamous cancer of the cervix. Each received a minimum of 4000 rad whole-pelvic irradiation plus intracavitary radium application. The diagnosis of histiocytic lymphoma of the cervix uteri was made after delivery in our case and in the case reported earlier by Vieaux and McGuire. When diagnosed during pregnancy, malignant cervical lymphomas may be treated with irradiation similar to invasive squamous cancer of the cervix uteri. When extranodal malignant non-Hodgkin’s lymphomas, especially of the histiocytic type, presented in organs other than lymph nodes there was usually disease elsewhere or it appeared shortly. However, our review of the literature reveals exceptions when the disease presents in the cervix uteri. Cures can be obtained with irradiation.
MALIGNANT
NON-HODGKIN’%TYPE
LYMPHOMA
393
REFERENCES 1. Carbone, P., and DeVita, V. In Cancer medicinr (F. F. Holland and E. Frei, Ed%), Lea & Febiger, Philadelphia, pp. 1302-1321 (1974). 2. Chorlton, I., Karnei, R. F., Jr., King, F. M., and Norris, H. J. Primary malignant reticuloendothelial disease involving the vagina, cervix and corpus uteri, Obsrrr. Gynecol. 44, 735-748 (1974). 3. Vieaux, J. W., and McGuire, D. E. Reticulum cell sarcoma of the cervix, Amer. J. Obstet. Gyned. 89, 134-135 (1964). 4. Freeman, C., Berg, J. W., and Cutters, J. Occurrence and prognosis of extranodal lymphomas, Cancer 29, 252-260 (1972). 5. Fox, H., and More, J. R. S. Primary malignant lymphoma of the uterus,J. C/in. Path/. 18,723-728 (1965). 6. Carr, J., Hill, A. S., Hancock, B., and Neal, F. E. Malignant lymphoma of the cervix uteri: Histology and ultrastructure, J. Clin. Pat/d. 29, 680-686 (1976). 7. Delgado, G., Smith, J., Luis, D., and Gallagher, S. Reticulum cell sarcoma of the cervix, Amer. J. Obstet. Gynecol. 125, 691-695 (1976). 8. Villa-Santa, U. H., Attar, S., and Jiji, R. Malignant histiocytic lymphoma in pregnancy, Gynecol. Oncol. 6, 383-390 (1978).
ONCOLOGY
Malignant
7,
385-393 (1979)
Non-Hodgkin’s-Type Lymphoma of the Cervix Uteri Occurring during Pregnancy
JOSH C. TUNCA, M.D. ,l,* P. R. REDDI, M.D. ,t SHEILA H. SHAH, M.D.,S AND STEPHEN T. SLACK, PH.D.§ *Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, University of Wisconsin Center for Health Sciences, Madison, Wisconsin 53706; 1‘Radiation Oncology, St. Louis University Hospital, 1325 South Grand Boulevard, St. Louis, Missouri 63104; *Department of Pathology and ODivision of Medical Physics and Radiation Therapy, West Virginia University Medical Center, Morgantown, West Virginia 26505
Received June 29, 1978 Histiocytic lymphoma, arising from the cervix uteri, especially during pregnancy, has rarely been found. The present case appears to be the second case reported in the English literature. The literature review and also the present case suggest that, if the histiocytic lymphoma arises primarily from the cervix uteri and is confined to the pelvis, it may be treated by irradiation and cure may be obtained.
The incidence of malignant non-Hodgkin’s lymphoma is about 6 per 100,000 of the population and is the cause of about 5% of all cancer deaths. Disease may present as pain-free lymphadenopathy either as a nodal type or as an extranodal type with massive organ infiltration. The most common primary sites of extranodal malignant lymphomas are skin, nasopharyngeal tract, gastrointestinal tract, and bone. When the disease progresses, the female genital tract may be involved in a part of the generalized process [Il. Primary female genital tract lymphoma originating in the cervix uteri is quite uncommon; during pregnancy it is extremely rare [2]. To our knowledge the present case is the second reported in the literature. A clinically similar case was reported by Vieaux and McGuire in 1964 [3]. CASE REPORT
Our patient was a 22-year-old white female, gravida 1, para 1, abortus 0, referred to the West Virginia University Hospital on December 28, 1975. Her private physician had diagnosed an extensive cervicovaginal tumor. The patient’s medical history revealed that she had become pregnant in January 1975. On March 25, 1975, multiple 2 x 2-cm enlargements were found involving ’ Previous address: Department of OB/GYN, West Virginia University Medical Center, Morgantown, W. Va. 26505. 385 0090-8258/79/030385-09$01.00/O Copyright @ 1979 by Academic Press, Inc. All rights of reproduction in any form reserved.
386
TUNCA
ET AL.
the cervix and the lower uterine segment. Cytology of the cervix was negative. Two consultants felt that the nodularities represented cervical multiple leiomyomas and that delivery should be carried out by cesarean section. The pregnancy progressed without complications and a cesarean section was performed on September 8, 1975. A 7-pound, 4-0~ normal male infant was delivered uneventfully. One month after delivery the patient began to bleed vaginally. On December 15, 1975, she was admitted to the emergency room in the regional hospital with profuse vaginal bleeding and a hematocrit of 18%. A pack was placed in the patient’s vagina prior to transferring her to the West Virginia University Hospital. Physical examination revealed no lymphadenopathy and no hepatosplenomegaly. Pelvic examination showed the upper two-thirds of the vagina and cervix occupied by 2- to 3-cm necrotic and actively bleeding masses. Rectovaginal exam revealed no free space between the central tumor and the right pelvic wall. The left parametrium was occupied at least 80% by tumor. The patient was staged as cervical malignancy, FIG0 IIIB. Initial biopsy of the tumor was reported as poorly differentiated stromal sarcoma. Another gynecologic pathologist consultant’s opinion was that the tumor represented a poorly differentiated cancer of the cervix. General metastatic workup was normal except that an intravenous pyelogram revealed no visualization of the right kidney due to a right ureteral obstruction (as shown in Fig. 1). The left kidney was normal. It was decided that the patient would be treated as a cervical sarcoma by irradiation and chemotherapy. On December 30, 1975, a Burnette applicator was placed in the vaginal vault delivering a 3500-rad, 0.5 cm-depth dose, in 63.6 hr. This was followed by external beam therapy using a cobalt-60 unit. A tumor dose of 3600 rad in 18 fractions was given to the whole pelvis through 15 x 15-cm anterior and posterior ports with a 4500-Ci source, at a source-skin distance of 80 cm. The vaginal mucosa received a total of 7200 rad. During irradiation the patient received adjuvant chemotherapy using 1.25 mg vincristine intravenously on a weekly schedule. This was administered for 13 weeks. The patient developed parasthesias and constipation. Therefore, the vincristine was stopped on March 22, 1976. A response was observed with partial mobilization of the right parametrium and morphological restoration of the vagina and cervix. On April 20, 1976, an intravenous pyelogram showed significant improvement of the excretory capacity of the right kidney (as shown in Fig. 2). On April 26, 1976, the patient underwent postirradiation laparotomy to determine the status of pelvic and paraaortic lymph nodes. Biopsy of various pelvic and paraaortic lymph nodes was negative. The liver and spleen were not enlarged. Biopsies from the cul-de-sac and pararectal-paravesical spaces were negative. Due to persistent induration of the right parametrium, 26 seeds containing iodine-125 were permanently implanted in the right parametrium and the cervix. A dose of over 20,000 rad was delivered to a volume of 3 x 3 x 2 cm and 10,000 rad to 4 x 4 x 3 cm. Approximately 2000 rad was delivered to points 2 cm or more from the margins of the implants.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
387
FIG. 1. Initial intravenous pyelogram reveals no visualization of the right kidney due to right ureteral obstruction.
388
TUNCA ET AL.
FIG. 2. After treatment, intravenous pyelogram shows significant improvement of the excretory capacity of right kidney.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
389
Frequent examination of the patient has revealed no evidence of disease. She is currently employed as a social worker. Due to the patient’s extraordinary response to therapy, and to confirm the original diagnosis, the case history and pathology slides were presented to the Papanicolaou seminars of the Southern Medical Association on November 9, 1976. A panel of pathologists, from different medical schools, unanimously agreed that the patient had hystiocytic lymphoma of the cervix uteri during pregnancy (Figs. 3 and 4). DISCUSSION
Accurate staging of malignant lymphomas with histological subclassification is possibly the most important factor for prognosis and treatment. Lymphomas histologically produce two distinct patterns, diffuse or nodular. The cells comprising the lymphomas infiltrate around the intrinsic structures of the organs involved without destroying them. This aspect is most obvious in the uterine corpus and the cervix, and differs from that of primary or metastatic carcinoma which tends to obliterate the architecture of the organs [2]. Although malignant lymphomas may present as a unicentric organ disease in two-thirds of the patients, multicentric involvement is more common by the time the malignant lymphomas are diagnosed. The female genital tract is rarely the primary initial site of malignant nonHodgkin’s lymphomas. Chorlton et al. did an extensive review of the Armed Forces Institute of Pathology (AFIP) files and found only 13 cases among 9500 women (1 in 730) with nodal and extranodal malignant lymphomas [2]. Freeman et al. studied 1467 patients with extranodal lymphomas which represented 24% of all lymphoma cases. He found that 47% of the patients were women and that 14 of them (1 in 50) had extranodal lymphomas localized in the female genital tract [4]. According to Chorlton et al., if it is assumed that a similar percentage of the lymphomas in the AFIP files are extranodal and occur in women, then about 1 in 175 extranodal lymphomas is likely to originate in the female genital tract (excluding ovaries) [2]. Except for the large series of ovarian lymphomas, the literature contains a few scattered case histories and reviews of malignant lymphomas that originated in the female genital tract. Prior to 1974, 19 cases of cervical lymphomas were reported. Chorlton et al. described 6 additional cases [2]. Carr et al. [6] and Delgado et al. 171reported 2 and 4 more cases, respectively, in 1976. With the present case, there are 32 extranodal cervical lymphoma cases in the literature. Only 2 cases occurred during pregnancy. A pelvic mass was present in all cases when the malignant lymphoma primarily involved the cervix or vagina. Abnormal vaginal bleeding occurred in 60% of the cases, perineal discomfort in 40%, and vaginal discharge in 20% [2]. Since these symptoms occurred in the early stages of the disease process early diagnosis and treatment resulted in a better survival rate. To our best knowledge, there is only one cervical lymphoma case that occurred during pregnancy and that was reported in 1964 by Vieaux and McGuire 131.
390
TUNCA
FIG. 3.
Microscopic
view of cervical
ET AL.
biopsy specimen of histiocytic
lymphoma.
MALIGNANT
NON-HODGKIN’S-TYPE
LYMPHOMA
FIG. 4. Higher magnification of histiocytic lymphoma.
391
392
TUNCA
ET AL.
Their case is similar to the present case. Their patient was a 23-year-old white female, gravida 1, para 0. A 5- to 6-cm posterior cervical mass was diagnosed during the second month of pregnancy. They believed that this mass represented a cervical fibroid, and that the delivery should be carried out by cesarean section. Cervical cytology was also negative. The patient was delivered by cesarean section at term, and 1 month later the cervical mass was removed by marsupialization. The pathologic specimen revealed mixed histiocytic lymphocytic lymphoma. Extensive review of the literature by Villa Santa et al. revealed only 11 cases of malignant non-Hodgkin’s lymphomas that were associated with pregnancy, and only one case was located on the cervix [8]. TREATMENT
Successful treatment of malignant lymphoma depends on accurate staging of the disease. In order to make the diagnosis of primary lymphoma of the cervix, the lesions must be confined to the cervical region. No evidence of lymphoma should develop elsewhere [5]. Chorlton et al. have reported six cervical lymphoma cases. Two of the six cervical lymphoma cases in this series were treated with hysterectomy and were alive after 56 and 120 months, respectively [2]. Two other patients had hysterectomy followed by irradiation. Both patients were alive 15 and 12 months after treatment. The latter patient, however, was reported to have a recurrence. These four cases were IB or IIA by the FIG0 classification. One patient with FIG0 IIB staging was treated with irradiation and was dead in 30 months. Another patient with stage IV FIG0 classification had only chemotherapy and was dead in 1.5 months. Recently Carr et al. reported two cervical histiocytic lymphoma cases [6]. Both were treated with irradiation and both were alive without any evidence of recurrence after 3 years and 6 months, respectively. These two cases were the only cervical lymphoma cases among the total 25,000 primary cervical tumors. Delgado et al. reported four cervical histiocytic-type lymphoma cases [7]. One was staged as FIG0 IB. The other three were staged as FIG0 IIA. The FIG0 IB patient was treated with radical hysterectomy and pelvic lymphadenectomy and expired in 9 months due to dissemination of disease. The other three patients were treated according to the protocol for squamous cancer of the cervix. Each received a minimum of 4000 rad whole-pelvic irradiation plus intracavitary radium application. The diagnosis of histiocytic lymphoma of the cervix uteri was made after delivery in our case and in the case reported earlier by Vieaux and McGuire. When diagnosed during pregnancy, malignant cervical lymphomas may be treated with irradiation similar to invasive squamous cancer of the cervix uteri. When extranodal malignant non-Hodgkin’s lymphomas, especially of the histiocytic type, presented in organs other than lymph nodes there was usually disease elsewhere or it appeared shortly. However, our review of the literature reveals exceptions when the disease presents in the cervix uteri. Cures can be obtained with irradiation.
MALIGNANT
NON-HODGKIN’%TYPE
LYMPHOMA
393
REFERENCES 1. Carbone, P., and DeVita, V. In Cancer medicinr (F. F. Holland and E. Frei, Ed%), Lea & Febiger, Philadelphia, pp. 1302-1321 (1974). 2. Chorlton, I., Karnei, R. F., Jr., King, F. M., and Norris, H. J. Primary malignant reticuloendothelial disease involving the vagina, cervix and corpus uteri, Obsrrr. Gynecol. 44, 735-748 (1974). 3. Vieaux, J. W., and McGuire, D. E. Reticulum cell sarcoma of the cervix, Amer. J. Obstet. Gyned. 89, 134-135 (1964). 4. Freeman, C., Berg, J. W., and Cutters, J. Occurrence and prognosis of extranodal lymphomas, Cancer 29, 252-260 (1972). 5. Fox, H., and More, J. R. S. Primary malignant lymphoma of the uterus,J. C/in. Path/. 18,723-728 (1965). 6. Carr, J., Hill, A. S., Hancock, B., and Neal, F. E. Malignant lymphoma of the cervix uteri: Histology and ultrastructure, J. Clin. Pat/d. 29, 680-686 (1976). 7. Delgado, G., Smith, J., Luis, D., and Gallagher, S. Reticulum cell sarcoma of the cervix, Amer. J. Obstet. Gynecol. 125, 691-695 (1976). 8. Villa-Santa, U. H., Attar, S., and Jiji, R. Malignant histiocytic lymphoma in pregnancy, Gynecol. Oncol. 6, 383-390 (1978).