論文

更年期障害を疑われ受診したが、甲状腺疾患を認めた2症例につき報告する。症例1:52歳、0妊0産。子宮頸部腺癌IB1期に対し広汎子宮全摘出術および両側付属器摘出術後である。冷え、関節痛を主訴に受診し、採血でTSH高値を認め精査にて潜在性甲状腺機能低下症の診断となった。症例2:65歳。1妊1産。ほてり、動悸を主訴に受診した。変動するTSHを認め、精査の結果、橋本病に合併した無痛性甲状腺炎の診断となった。甲状腺機能異常は亢進症/低下症ともに症状が更年期障害と類似していることから鑑別疾患の一つとして念頭に置くことが重要である。(著者抄録)

再発子宮体癌の化学療法無奏効例では治療法の選択に苦慮することが多い。われわれは、酢酸メドロキシプロゲステロン(MPA)を用いたホルモン療法とデノスマブを併用することで、長期の病勢コントロールが可能だった症例を経験した。症例は46歳で、子宮体癌IIIA期の類内膜癌G1に対して、広汎子宮全摘出術、両側付属器摘出術、傍大動脈リンパ節郭清、大網部分切除術を施行後、術後療法にてパクリタキセル、カルボプラチン療法(TC療法)を施行した。その後、骨盤腹膜および腟断端への再発が出現し、ドセタキセル、シスプラチン療法(DP療法)を施行するも奏効せず、その後症状を伴って出現した骨転移に対して緩和的放射線照射を施行した。しかし、照射野内再発により疼痛が増悪したことから、MPAとデノスマブを併用した治療を開始したところ、20ヵ月間にわたり病変縮小、疼痛軽快が維持された。骨転移を伴う婦人科癌では、デノスマブによる良好な病勢コントロールが得られる可能性が示唆された。(著者抄録)

© 2020 International Federation of Gynecology and Obstetrics Objective: To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery. Methods: In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection. Results: Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%). Conclusion: Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

子宮体癌IA期に対し腹腔鏡下子宮体癌手術を行った150例を対象に、骨盤リンパ節郭清を施行した75例(A群)と未施行75例(B群)に分類した。検討項目は肥満症例(BMIが25以上)と非肥満症例における患者背景(年齢、未産婦数、糖尿病の頻度、高血圧の頻度、病理組織型、手術進行期、治療成績(手術時間、推定出血量、術後入院期間、リンパ節郭清群の摘出リンパ節個数)、術中・術後合併症、術後治療の有無、無増悪生存割合、全生存割合で、2群間で比較した。また、過去の開腹下子宮体癌手術49例の摘出リンパ節数を肥満症例と非肥満症例で比較した。その結果、A群において肥満症例が非肥満手術例に比べ手術時間、摘出リンパ節個数が有意に多かった。しかし、その他の項目に有意差はなく、肥満は腹腔鏡下子宮体癌手術に影響を及ぼさないと考えられた。

目的:子宮体癌の腹腔細胞診陽性の背景因子を明らかにし、子宮鏡検査が腹腔細胞診陽性に与える影響を検討することを目的とした。方法:当院にて子宮鏡検査を施行した後に、開腹もしくは腹腔鏡下に手術療法を施行した414例に関して、腹腔細胞診の結果と臨床病理学的因子との関連を後方視的に検討した。成績:414例中13例(3%)で腹腔細胞診陽性であった。腹腔細胞診陽性の有意なリスク因子として、単変量解析では類内膜癌Grade 3+特殊組織型、付属器転移、大網転移、腹膜播種が挙げられ(p<0.001)、多変量解析では類内膜癌Grade 3+特殊組織型(p=0.01)と大網転移が挙げられた(p<0.001)。またリスク因子別では大網転移陽性例で腹腔細胞診陽性例が最も多かった(7/10例、70%)。12例で腹腔細胞診陽性のリスク因子である類内膜癌Grade 3+特殊組織型もしくは大網転移を認めた。1例のみリスク因子を有さず腹腔細胞診が陽性となった症例を認め、多発子宮筋腫や子宮腺筋症によって、子宮鏡の検査時間や還流圧を通常より要したことが原因と推定されたが、術後再発を認めず経過している。結論:術前に子宮鏡検査を施行したにもかかわらず腹腔細胞診陽性となった例は少なく、そのほとんどが腹腔細胞診陽性のリスク因子を有する症例であったため、術前子宮鏡検査による腹腔細胞診への影響は軽微であろうと考えられた。(著者抄録)

The Fourth Edition of the Guidelines for Treatment of Uterine Body Neoplasm was published in 2018. These guidelines include 9 chapters: 1. Overview of the guidelines, 2. Initial treatment for endometrial cancer, 3. Postoperative adjuvant therapy for endometrial cancer, 4. Post-treatment surveillance for endometrial cancer, 5. Treatment for advanced or recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment of uterine carcinosarcoma and uterine sarcoma, 8. Treatment of trophoblastic disease, 9. Document collection; and nine algorithms: 1-3. Initial treatment of endometrial cancer, 4. Postoperative adjuvant treatment for endometrial cancer, 5. Treatment of recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment for uterine carcinosarcoma, 8. Treatment for uterine sarcoma, 9. Treatment for choriocarcinoma. Each chapter includes overviews and clinical questions, and recommendations, objectives, explanation, and references are provided for each clinical question. This revision has no major changes compared to the 3rd edition, but does have some differences: 1) an explanation of the recommendation decision process and conflict of interest considerations have been added in the overview, 2) nurses, pharmacists and patients participated in creation of the guidelines, in addition to physicians, 3) the approach to evidence collection is listed at the end of the guidelines, and 4) for clinical questions that lack evidence or clinical validation, the opinion of the Guidelines Committee is given as a "Recommendations for tomorrow".

© Yoshihama et al. Purpose: To find genetic variants that predicted toxicity and/or efficacy of paclitaxel plus carboplatin combination therapy (TC therapy). Patients and methods: In a retrospective case-control study, we analyzed 320 patients who had received TC therapy for gynecological cancers (ovarian, fallopian tube, peritoneal, uterine, and cervical cancers) and collected their germline DNA. We performed a comprehensive pharmacogenomic analysis using a targeted resequencing panel of 100 pharmacogenes. For 1,013 variants passing QC, case-control association studies and survival analyses were conducted. Results: GSTP1 rs1695 showed the smallest p value for hematotoxicity association, and the 105Ile wild type allele had a significantly higher risk of severe hematotoxicity (neutropenia G4, thrombocytopenia ≥ G3 and anemia ≥ G3) than the 105Val allele (p=0.00034, odds ratio=5.71 (95% confidence interval:1.77-18.44)). Next, we assessed 5-year progression-free survival (PFS) and overall survival (OS) in 56 advanced ovarian cancer patients who received tri-weekly TC as a first-line chemotherapy. Patients with the 105Ile/105Ile genotype showed significantly better PFS (p=0.00070) and OS (p=0.0012) than those with the 105Ile/105Val or 105Val/105Val genotype. Conclusion: Our study indicates that the GSTP1 rs1695 105Ile/105Ile genotype is associated with both severe hematotoxicity and high efficacy of TC therapy, identifying a possible prognostic indicator for patients with TC therapy.

© 2017, The Author(s). Background: Vulvar cancer and vaginal cancer are relatively rare tumors, and there had been no established treatment principles or guidelines to treat these rare tumors in Japan. The first version of the Japan Society of Gynecologic Oncology (JSGO) guidelines for the treatment of vulvar cancer and vaginal cancer was published in 2015 in Japanese. Objective: The JSGO committee decided to publish the English version of the JSGO guidelines worldwide, and hope it will be a useful guide to physicians in a similar situation as in Japan. Methods: The guideline was created according to the basic principles in creating the guidelines of JSGO. Results: The guidelines consist of five chapters and five algorithms. Prior to the first chapter, basic items are described including staging classification and history, classification of histology, and definition of the methods of surgery, radiation, and chemotherapy to give the reader a better understanding of the contents of the guidelines for these rare tumors. The first chapter gives an overview of the guidelines, including the basic policy of the guidelines. The second chapter discusses vulvar cancer, the third chapter discusses vaginal cancer, and the fourth chapter discusses vulvar Paget’s disease and malignant melanoma. Each chapter includes clinical questions, recommendations, backgrounds, objectives, explanations, and references. The fifth chapter provides supplemental data for the drugs that are mentioned in the explanation of clinical questions. Conclusion: Overall, the objective of these guidelines is to clearly delineate the standard of care for vulvar and vaginal cancer with the goal of ensuring a high standard of care for all women diagnosed with these rare diseases.

© 2018. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology. Objective: Reports on the repeated administration of medroxyprogesterone acetate (MPA) for intrauterine recurrence after fertility-preserving therapy for atypical endometrial hyperplasia (AEH) and early grade 1 endometrioid carcinoma (G1) are lacking. We aimed to clarify the outcomes of repeated MPA therapy in cases of intrauterine recurrence after fertility-preserving therapy with MPA against AEH/early G1. Methods: Patients with AEH or stage IA well-differentiated endometrioid carcinoma without myometrial invasion who underwent first-line MPA therapy for primary lesions or intrauterine recurrence were divided into initial treatment and repeated treatment groups (162 and 82 patients, respectively). Oral MPA administration (400−600 mg/day) was continued until pathological tumor disappearance. Data regarding clinicopathological factors, adverse events, and outcomes following the initial and repeated hormonal treatments were extracted from medical records and analyzed. Results: Complete response rates in the initial and repeated treatment groups were 98.5% and 96.4%, respectively, among patients with AEH, and were 90.7% and 98.1%, respectively, among patients with G1. In the initial treatment group, 5-year recurrence-free survival (RFS) rates were 53.7% and 33.2% among patients with AEH and G1, respectively. In the repeated treatment group, RFS rates were 14.0% and 11.2% among patients with AEH and G1, respectively. Among patients with AEH, the pregnancy rate tended to be lower in the repeated treatment group than in the initial treatment group (11.1% vs. 29.2%; p=0.107), while no significant group difference was observed among patients with G1 (20.8% vs. 22.7%). Conclusion: Repeated treatment is sufficiently effective for intrauterine recurrence after hormonal therapy for AEH/early G1.

© 2019 AAGL Study Objective: To examine the diagnostic accuracy of hysteroscopic photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5ALA) in patients with endometrial cancer and premalignant atypical endometrial hyperplasia. Design: A single-center, open-label, exploratory intervention study. Setting: University Hospital in Japan. Patients: Thirty-four patients who underwent hysteroscopic resection in the Department of Obstetrics and Gynecology at Keio University Hospital. Interventions: Patients were given 5ALA orally approximately 3 hours before surgery and underwent observation of the uterine cavity and endometrial biopsy using 5ALA-PDD during hysteroscopic resection. Specimens were diagnosed histopathologically and the diagnostic sensitivity and specificity of hysteroscopic 5ALA-PDD for malignancy in the uterine cavity was determined. Red (R), blue (B), and green (G) intensity values were determined from PDD images, and the relationships of histopathological diagnosis with these values were used to develop a model for objective diagnosis of uterine malignancy. Measurements and Main Results: Three patients were excluded from the study because of failure of the endoscope system. A total of 113 specimens were collected endoscopically. The sensitivity and specificity of 5ALA-PDD for diagnosis of malignancy in the uterine cavity were 93.8% and 51.9%, respectively. The R/B ratio in imaging analysis was highest in malignant lesions, followed by benign lesions and normal uterine tissue, with significant differences among these groups (p <.05). The R/B and G/B ratios were used in a formula for prediction of malignancy based on logistic regression and the area under the receiver operating characteristic curve for this formula was 0.838. At a formula cutoff value of 0.220, the sensitivity and specificity for diagnosis of malignant disease were 90.6% and 65.4%, respectively. Conclusion: To our knowledge, this is the first study of the diagnostic accuracy of 5ALA-PDD for malignancies in the uterine cavity. Hysteroscopic 5ALA-PDD had higher sensitivity and identifiability of lesions. These findings suggest that hysteroscopic 5ALA-PDD may be useful for diagnosis of minute lesions.

© 2018. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology. Objective: We aimed to propose a set of quality indicators (QIs) based on the clinical guidelines for cervical cancer treatment published by The Japan Society of Gynecologic Oncology, and to assess adherence to standard-of-care as an index of the quality of care for cervical cancer in Japan. Methods: A panel of clinical experts devised the QIs using a modified Delphi method. Adherence to each QI was evaluated using data from a hospital-based cancer registry of patients diagnosed in 2013, and linked with insurance claims data, between October 1, 2012, and December 31, 2014. All patients who received first-line treatment at the participating facility were included. The QI scores were communicated to participating hospitals, and additional data about the reasons for non-adherence were collected. Results: In total, 297 hospitals participated, and the care provided to 15,163 cervical cancer patients was examined using 10 measurable QIs. The adherence rate ranged from 50.0% for ‘cystoscope or proctoscope for stage IVA’ to 98.8% for ‘chemotherapy using platinum for stage IVB’. Despite the variation in care, hospitals reported clinically valid reasons for more than half of the non-adherent cases. Clinically valid reasons accounted for 75%, 90.9%, 73.4%, 44.5%, and 88.1% of presented non-adherent cases respectively. Conclusion: Our study revealed variations in pattern of care as well as an adherence to standards-of-care across Japan. Further assessment of the causes of variation and non-adherence can help identify areas where improvements are needed in patient care.