松岡 歩

Background/Aim: Upper gastrointestinal obstruction is an extremely rare complication of primary ovarian cancer. We present a case of primary advanced ovarian cancer with gastroduodenal obstruction successfully managed with neoadjuvant chemotherapy (NAC) and conservative treatment. Case Report: A 60-year-old woman was referred to our hospital for advanced ovarian cancer with upper gastrointestinal obstruction. Computed tomography and endoscopy revealed severe duodenal obstruction caused by dissemination. NAC was initiated with conservative management using a nasogastric tube and total parenteral nutrition (TPN). She was able to eat and TPN was stopped after three months. Complete resection was achieved with interval debulking surgery (IDS) not involving pancreatoduodenectomy, which would have been necessary for primary debulking surgery. There were no serious postoperative complications. Conclusion: NAC with conservative management can improve upper gastrointestinal obstruction in patients with primary advanced ovarian cancer. Furthermore, IDS is expected to allow complete resection, avoiding highly invasive surgeries.

OBJECTIVE: Therapy-related myeloid neoplasms (t-MNs) are often fatal and arise as late complications of previous anticancer drug treatment. No single-center case series has examined t-MNs in epithelial ovarian cancer (EOC). METHODS: All patients with EOC treated at Chiba University Hospital between 2000 and 2021 were included. We retrospectively analyzed the characteristics, clinical course, and outcomes of patients who developed t-MNs. RESULTS: Among 895 cases with EOC, 814 cases were treated with anticancer drugs. The median follow-up period was 45 months (interquartile range, 27-81) months. Ten patients (1.2%) developed t-MNs (FIGO IIIA in one case, IIIC in three, IVA in one, and IVB in five). Nine patients were diagnosed with myelodysplastic syndrome and one with acute leukemia. One patient with myelodysplastic syndrome developed acute leukemia. The median time from the first chemotherapy administration to t-MN onset was 42 months (range, 21-94 months), with t-MN diagnoses resulting from pancytopenia in four cases, thrombocytopenia in three, and blast or abnormal cell morphology in four. The median number of previous treatment regimens was four (range, 1-7). Paclitaxel + carboplatin therapy was administered to all patients, gemcitabine and irinotecan combination therapy to nine, bevacizumab to eight, and olaparib to four. Six patients received chemotherapy for t-MN. All patients died (eight cancer-related deaths and two t-MN-related deaths). None of the patients was able to restart cancer treatment. The median survival time from t-MN onset was 4 months. CONCLUSIONS: Patients with EOC who developed t-MN were unable to restart cancer treatment and had a significantly worse prognosis.

BACKGROUND/AIM: Upper gastrointestinal obstruction is an extremely rare complication of primary ovarian cancer. We present a case of primary advanced ovarian cancer with gastroduodenal obstruction successfully managed with neoadjuvant chemotherapy (NAC) and conservative treatment. CASE REPORT: A 60-year-old woman was referred to our hospital for advanced ovarian cancer with upper gastrointestinal obstruction. Computed tomography and endoscopy revealed severe duodenal obstruction caused by dissemination. NAC was initiated with conservative management using a nasogastric tube and total parenteral nutrition (TPN). She was able to eat and TPN was stopped after three months. Complete resection was achieved with interval debulking surgery (IDS) not involving pancreatoduodenectomy, which would have been necessary for primary debulking surgery. There were no serious postoperative complications. CONCLUSION: NAC with conservative management can improve upper gastrointestinal obstruction in patients with primary advanced ovarian cancer. Furthermore, IDS is expected to allow complete resection, avoiding highly invasive surgeries.

【緒言】広範な腹腔内播種や腹水貯留があり,原発巣が不明な場合にはまず卵管癌や腹膜癌が疑われる.今回,腹腔内播種や腹水貯留があり進行卵管癌・腹膜癌を疑ったが,腹膜サルコイドーシスであった症例を経験したため報告する.【症例】患者は50歳女性.右下腹部および排尿時痛,発熱が出現し,腹水と腹膜播種を指摘され当科に紹介受診となった.CA125 387U/mlで,胸腹骨盤部CT検査では,腹水貯留と腹膜の肥厚,縦隔リンパ節腫大を認めたが,腹水細胞診は陰性であった.原発不明癌と術前診断し,試験開腹術を施行したところ,腹膜全体に1～3mm程度の結節が多数集簇していた.両側付属器は正常大で,表面に1～2mmの結節を認めた.病理組織検査では,右付属器,左卵管および大網に多数の非乾酪性類上皮肉芽腫を認め,肉芽腫性炎症性疾患が疑われた.病理,血液検査より,腹膜サルコイドーシスと診断した.試験開腹術後,自覚症状は軽快し,無治療で現在は経過観察している.【結語】本症例では,病理学的に腹膜サルコイドーシスの診断に至り,試験開腹術が診断に有効であった.腹水細胞診が陰性かつ腹膜の均一な肥厚を認めた症例は,腹膜サルコイドーシスや結核性腹膜炎を鑑別に挙げながら検査を進めていく必要があると考えられる.(著者抄録)

Asymptomatic hydronephrosis following hysterectomy is generally transient. Here, we present the case of a 52-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for benign indications. Computed tomography (CT) to examine bleeding on the second postoperative day incidentally revealed bilateral grade II hydronephrosis. Asymptomatic hydronephrosis was not reevaluated, and gynecological outpatient follow-up was terminated with a normal creatinine level on postoperative day 43. On postoperative day 107, the patient noticed weight gain of 10 kg, decreased urine output, and generalized edema. The serum creatinine level was elevated to 5.4 mg/dL, and CT revealed bilateral grade III hydronephrosis. Urgent bilateral ureteral stenting was performed to treat stenosis of the distal ureters that caused postrenal failure. Ureteroneocystostomy was performed for strict stenosis of the right ureter at 10 months postoperatively. Histological examination of the resected distal ureter showed inflammation and fibrosis. Asymptomatic hydronephrosis developing after hysterectomy progress to delayed postrenal failure.

Several cancers harbor "enhancer-type" mutations of the telomerase reverse transcriptase (TERT) promoter for immortalization. Here, we report that 8.6% (8/93) of ovarian clear cell carcinomas (OCCCs) possess the "suppressor-type" TERT promoter mutation. The recurrence rate of OCCCs with "suppressor-type" TERT promoter mutations was 62.5% (5 of 8) and was significantly higher than that of the "unaffected-type" with no mutation (20.8%, 15 of 72) or "enhancer-type" TERT promoter mutations (7.7%, 1 of 13). Our findings show that the acquired suppression of TERT is closely associated with OCCC development and recurrence, indicating the need for further research on telomerase suppression in cancers.

2022年2月に卒後3～10年目の若手医師33名を対象に、産婦人科領域における内視鏡手術手技修練方法に関する意識調査を記名式webアンケートにて行った。9名は良性子宮腫瘍に対して腹腔鏡手術を行っていない施設に所属し、腹式子宮全摘(TAH)執刀経験数50例以上は14名であった一方、25名は腹腔鏡下子宮全摘術(TLH)を執刀したことがなく、執刀経験のある手術の自信度はTAHの方がTLHよりも有意に高かった。技術認定医取得を希望していたのは27名(82%)であったが、認定医取得に必要な要件である日本産婦人科内視鏡学会へ入会していたのは8名であった。28名は縫合練習の重要性を理解していたが、13名はドライボックスでの練習の頻度が2～3ヵ月に1回以下もしくは練習の習慣がなく、10名は手術手技の上達に何を始めたらいいか分からないと回答した。他施設への研修を考慮していたのは16名であった。

膵癌が原発巣の転移性卵巣癌は稀であり,その特徴はあまり知られていない.今回,膵癌の卵巣転移を3症例経験した.症例1は68歳,膵体尾部癌IIB期のため標準治療を施行し寛解していた.膵癌発症から1年4ヵ月後,右卵巣多房性嚢胞性腫瘤を認めた.化学療法を開始したが,腹部膨満感と腹痛の緩和目的に両側付属器切除術(bilateral salpingo-oophorectomy:BSO)を施行した.症例2は69歳,膵体部癌IV期で切除不能のため化学療法を施行した.膵癌発症1年3ヵ月目,骨盤内に多房性嚢胞性腫瘤を認め,腹痛の緩和目的でBSOを施行した.症例3は81歳,子宮筋腫で単純子宮全摘術と右付属器切除術後である.膵体部癌IV期のため膵体部切除術と右肺部分切除術後,化学療法を施行し寛解していた.膵癌発症から3年10ヵ月後,左卵巣多房性嚢胞性腫瘤を認めた.左卵巣腫瘍は増大傾向のため,左付属器切除術を施行した.膵癌の卵巣転移は多房性嚢胞性であることが比較的多いが,原発性粘液性卵巣癌も多房性嚢胞性であり,それだけで両者の鑑別は困難である.今回の3症例に共通して,超音波検査で認めた多房性腫瘤を呈し血流を伴う薄い隔壁は,膵癌卵巣転移の特徴的な所見の1つと考えられた.膵癌の治療歴を有する卵巣腫瘍は,この超音波所見と合わせることで,膵癌の卵巣転移と術前に診断できる可能性が示唆された.(著者抄録)

膵癌が原発巣の転移性卵巣癌は稀であり,その特徴はあまり知られていない.今回,膵癌の卵巣転移を3症例経験した.症例1は68歳,膵体尾部癌IIB期のため標準治療を施行し寛解していた.膵癌発症から1年4ヵ月後,右卵巣多房性嚢胞性腫瘤を認めた.化学療法を開始したが,腹部膨満感と腹痛の緩和目的に両側付属器切除術(bilateral salpingo-oophorectomy:BSO)を施行した.症例2は69歳,膵体部癌IV期で切除不能のため化学療法を施行した.膵癌発症1年3ヵ月目,骨盤内に多房性嚢胞性腫瘤を認め,腹痛の緩和目的でBSOを施行した.症例3は81歳,子宮筋腫で単純子宮全摘術と右付属器切除術後である.膵体部癌IV期のため膵体部切除術と右肺部分切除術後,化学療法を施行し寛解していた.膵癌発症から3年10ヵ月後,左卵巣多房性嚢胞性腫瘤を認めた.左卵巣腫瘍は増大傾向のため,左付属器切除術を施行した.膵癌の卵巣転移は多房性嚢胞性であることが比較的多いが,原発性粘液性卵巣癌も多房性嚢胞性であり,それだけで両者の鑑別は困難である.今回の3症例に共通して,超音波検査で認めた多房性腫瘤を呈し血流を伴う薄い隔壁は,膵癌卵巣転移の特徴的な所見の1つと考えられた.膵癌の治療歴を有する卵巣腫瘍は,この超音波所見と合わせることで,膵癌の卵巣転移と術前に診断できる可能性が示唆された.(著者抄録)

Background: We evaluated whether the serum hormone levels are useful in the differential diagnosis of granulosa cell tumors (GCTs), regardless of menopausal status. Methods: Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, estradiol, and progesterone were measured preoperatively in all patients (n = 471) who underwent surgery for ovarian tumors at Chiba University Hospital between 2009 and 2021. These were compared in two groups, a GCT group (n = 13) and a group with other histological types (non-GCT) (n = 458). Results: The GCT group had significantly lower serum LH and FSH (p = 0.03 and p < 0.001, respectively) and significantly higher testosterone, estradiol, and progesterone (p < 0.001, p < 0.001, and p = 0.045, respectively) than the non-GCT group. Multivariate analysis revealed that serum FSH and estradiol were significantly associated with GCT (FSH, odds ratio (OR) = 0.0046, 95% confidence interval (CI) = 0.0026–0.22, p = 0.004; estradiol, OR = 0.98, 95% CI = 0.96–0.998, p = 0.046). Receiver-operating characteristic curve analysis for GCTs showed that the area under the curve of serum FSH was 0.99, with a sensitivity of 100% and a specificity of 98%, when the cutoff level was set at 2.0 IU/L. Conclusions: Preoperative serum FSH level is an extremely useful marker for differentiating GCTs from all ovarian tumors.

BACKGROUND/AIM: We investigated whether highly aggressive surgery has survival and perioperative complication benefit in patients with advanced ovarian cancer. PATIENTS AND METHODS: This retrospective study included 209 patients with stage III/IV ovarian cancer who underwent aggressive surgery [surgical complexity score (SCS) ≥8] between January 2008 and December 2018. Patients were categorized into the SCS 8-12 (less aggressive surgery, 83 patients) and SCS ≥13 (highly aggressive surgery, 126 patients) groups. Survival outcomes and perioperative complications between the groups were compared. Patient suitability for primary debulking surgery or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) was based on the evaluation of performance status, tumor load, and ascites. If patients were suitable for NACT/IDS, the residual tumor margins were marked at the initial laparotomy. The previously marked lesions were removed during IDS, even in patients with macroscopic tumor resolution. RESULTS: Prevalence rates of stage IV disease, poor performance status, presence of omental cake, peritoneal cancer index ≥15, and IDS performed were significantly higher in the highly aggressive surgery group than in the less aggressive surgery group. The median progression-free survival (PFS) and overall survival (OS) were not significantly different between the groups (PFS, 32 and 31 months, respectively; p=0.622; OS, 99 and 75 months, respectively; p=0.390). The incidence of severe perioperative complications was not significantly different between the less aggressive group (4.8%) and the highly aggressive surgery group (6.4%) (p=0.767). CONCLUSION: Highly aggressive surgery with appropriate selection regardless of the timing of cytoreduction benefits patients with advanced ovarian cancer.

BACKGROUND/AIM: Brain metastases from ovarian cancer remain rare and the appropriate treatment is unknown. We investigated survival outcomes following salvage chemotherapy before and after bevacizumab approval to evaluate the efficacy of bevacizumab in patients with brain metastasis from ovarian cancer. PATIENTS AND METHODS: We investigated 23 consecutive patients with brain metastasis from ovarian cancer at our hospital between 2001 and 2020. Bevacizumab was administered for treating ovarian cancer after approval in Japan in November 2013. Survival after brain metastasis was compared between 9 patients treated before bevacizumab approval (2000-2013) and 14 patients treated after approval (2014-2020). Seven patients treated in the latter period received bevacizumab-salvage chemotherapy for brain metastasis. RESULTS: Median survival in all patients was 9.1 months [95% confidence interval (CI)=4.2-33.5]. In addition, patients treated during the latter period presented better survival outcomes than those treated in the former period (former, 2.9 months vs latter, 33.5 months, log-rank test, p=0.015; Wilcoxon test, p=0.009). Multivariate analysis revealed that bevacizumab addition (p=0.020), interval to brain metastasis (p=0.005), number of brain lesions (p=0.001), number of recurrences (p=0.001), and platinum sensitivity (p=0.028) were independently associated with survival in all cohorts. CONCLUSION: Bevacizumab-based salvage chemotherapy may improve survival outcomes in patients with brain metastasis.