生水 真紀夫

We report a case of spontaneous parasitic leiomyoma in a 30-year-old post-partum woman. A subserosal leiomyoma had been noted at the first trimester screening, and she had experienced persistent abdominal pain during her previous pregnancy. She was referred to hospital with severe abdominal pain at 7 months after delivery. We detected a homogenous solid tumor that resembled the subserosal leiomyoma but was completely detached from the uterus. On laparoscopy the vascularization of the tumor was supplied from the omentum, which was tightly adherent to the tumor. Histopathologically, the tumor was surrounded by a fibrous vascular capsule, and broadly hyalinized and partially calcified, consistent with a degenerated uterine leiomyoma. Detachment of a pedunculated subserosal leiomyoma from the uterus following adhesion to other pelvic structures throughout pregnancy may result in a parasitic leiomyoma, a rare subtype of uterine leiomyoma.

OBJECTIVE: To report the results of local injection of diluted vasopressin followed by suction curettage as a conservative treatment for women with cervical ectopic pregnancy, who wish to preserve their future fertility. STUDY DESIGN: This was a retrospective chart review in a university hospital and a municipal hospital. We injected diluted vasopressin (Pitressin R, total amount of 4-10 units) transvaginally into the cervix surrounding the gestational sac, but not directly into the gestational sac, and/or the lower segment of the uterine body under transvaginal ultrasonographic guidance. After cessation of fetal heartbeats, we aspirated the conceptus by performing suction curettage. We injected additional vasopressin into the gestational sac in cases with a viable fetus after the initial injection. Forced contraction of the cervical smooth muscle facilitated removal of the conceptus with minimal blood loss during curettage. We measured operative time, total blood loss, complications, and the need for additional treatment. RESULTS: We included 11 women. Mean patient age, gestational age, and serum human chorionic gonadotrophin (hCG) at the intervention were 31.2±6.4years, 6.0±0.6 weeks, and 18,370±21,570 IU/L, respectively. Mean size of the gestational sac was 19.6±9.5mm. The uterus was successfully preserved without any complications in all patients. All procedures were completed within 15min except for the first case (range: 5-33min). In 4 cases, the conceptus containing a gestational sac was spontaneously extruded en bloc from the external os after the injection. Additional systematic methotrexate administration was required in one case because of remaining villi at the implantation site with persistence of serum hCG levels after the procedure. CONCLUSION: Local injection of diluted vasopressin and subsequent suction curettage is a feasible conservative treatment for cervical ectopic pregnancy.

The purpose of this study was to evaluate the efficacy and toxicities of carbon-ion radiotherapy (C-ion RT) for locally advanced cervical cancer with bladder invasion by a subset analysis of pooled data from eight prospective clinical trials at the National Institute of Radiological Sciences. Between June 1995 and January 2014, 29 patients with locally advanced cervical cancer with bladder invasion were identified. The median age was 56 years old (range 31-79 years old). The median tumor size at diagnosis on magnetic resonance imaging was 6.7 cm (range 3.5-11.0 cm). Histologically, 20 patients had squamous cell carcinoma and 9 had adenocarcinoma. C-ion RT was performed as a dose-escalation study in the initial trials. All patients received prophylactic whole-pelvic or extended-field irradiation and local boost. The total dose to the cervical tumor was 52.8-74.4 Gy (relative biological effectiveness) in 20 or 24 fractions. Weekly cisplatin (40 mg/m2/week, five cycles) was concurrently given to four patients. The median follow-up of all patients was 28.6 months (range 8.8-238.6 months). Grade 2 or higher late complications in the bladder were observed in eight patients, with seven developing vesicovaginal fistula. Six patients had Grade 2 or higher complications in the rectosigmoid colon. The 3-year overall survival rate was 47%, the 3-year local control rate was 66%, and the 3-year disease-free survival rate was 28%. In this study, C-ion RT showed favorable local control with reasonable toxicities, but the results were still unsatisfactory. We have the expectation of improvement of therapeutic effects by using C-ion RT with concurrent chemotherapy.

OBJECTIVE: To determine whether oocyte retrieval from nondominant small follicles supplies mature oocytes and increases live births in natural cycle IVF and embryo transfer (IVF-ET). DESIGN: Retrospective cohort study. SETTING: Private assisted reproductive technology practice. PATIENT(S): Seven hundred seventy-one infertile women who underwent natural cycle IVF between 2011 and 2013. INTERVENTION(S): The LH surge was triggered via nasal buserelin when the dominant follicle reached 16-18 mm during nonstimulated cycles, and as many oocytes as possible were retrieved from nondominant small follicles (a diameter of 3-10 mm) after retrieval from the large (dominant) follicle. The embryos were cryopreserved once they had yielded good-quality blastocysts and then transferred (one per cycle) during subsequent cycles. MAIN OUTCOME MEASURE(S): Number of mature oocytes (metaphase II) and resulting live births yielded via oocyte retrieval from the initial cycle of treatment. RESULT(S): Among 771 women, nondominant small follicle puncture yielded 902 metaphase II oocytes and 78 live births, whereas large dominant follicle puncture yielded 466 metaphase II oocytes and 90 live births. Successes in oocyte retrieval and live births resulting from small follicle puncture were positively correlated with ovarian reserve but did not depend on the outcomes of the dominant follicle puncture. CONCLUSION(S): Nondominant small follicles are a promising supplementary source of mature oocytes for natural cycle IVF.

OBJECTIVE: The aim of the study was to evaluate the association between tumor histology and serum sex hormone levels in postmenopausal women with ovarian tumors. METHODS: We preoperatively measured serum levels of gonadotropins and sex steroids, including estradiol, progesterone, and testosterone, in 69 postmenopausal women who underwent surgical resection for ovarian tumors. Tumors were classified as surface epithelial-stromal tumors, sex cord-stromal tumors, germ cell tumors, and metastatic tumors. Surface epithelial-stromal tumors were divided into mucinous, serous, clear cell, and endometrioid tumor subgroups. Patients were divided into two groups depending on tumor type: mucinous and nonmucinous, and any association between these tumor types and serum sex hormone levels were evaluated. RESULTS: Univariate analyses revealed that serum sex steroid levels were significantly higher in women with mucinous ovarian tumors compared with women with other tumor types. Serum gonadotropin levels, age, body mass index, tumor size, and tumor malignancy status did not affect the sex steroid levels. Multivariate analysis evaluating sex steroid levels and tumor histology revealed that high serum progesterone levels were significantly and independently associated with mucinous ovarian tumors. A serum progesterone cut-off level of at least 1.3 nmol/L was the most accurate for differentiating mucinous tumors from other tumor types (area under the curve, 0.81; sensitivity, 75%; and specificity, 86%). CONCLUSIONS: Serum progesterone levels were significantly elevated in postmenopausal women with mucinous ovarian tumors. In these women, serum progesterone levels may thus represent a useful biomarker for predicting tumor histology preoperatively, which would aid treatment planning.

Background: Metformin, widely used in the treatment of type 2 diabetes mellitus, reduces the risk of cancer and relapse after treatment. Fertility-sparing treatment for endometrial cancer (EC) with progestin is associated with a high chance of disease regression, and the high relapse rate continues to be a problem. We assessed the efficacy of metformin in preventing recurrence after medroxyprogesterone acetate (MPA) as fertility-sparing treatment for atypical endometrial hyperplasia (AEH) and EC. Patients and methods: This phase II study enrolled 17 patients with AEH and 19 patients with EC limited to the endometrium (age, 20-40 years). MPA (400 mg/day) and metformin (750-2250 mg/day) were administered for 24-36 weeks to achieve a complete response (CR). Metformin was administered until conception, even after MPA discontinuation. The primary end point was relapse-free survival (RFS) after remission.We analyzed all efficacy end points in the full analysis set. Results: The body mass index was ≥25 kg/m2 in 27 patients (mean, 31 kg/m2 range, 19-51 kg/m2), and the homeostasis model assessment for insulin resistance index was ≥2.5 in 24 patients (mean, 4.7 range, 0.7-21). Two patients showed progression at 12 weeks [6% 95% confidence interval (CI) 2-18]. At 36 weeks, 29 (81% 95% CI 65-90) patients achieved CR, and 5 (14% 95% CI 6-29) patients achieved partial response. During a median follow-up of 38 months (range, 9-66 months) after remission, relapse was confirmed in three of the patients who had achieved CR (relapse rate, 10%). The 3-year estimated RFS rate was 89%. No patients experienced severe toxicity. Conclusions: Metformin inhibited disease relapse after MPA therapy. The combination of metformin and MPA in EC treatment should be studied further.