Local Treatment Efficacy for Single-Area Squamous Cell Carcinoma of the Unknown Primary Site

The prognosis for cancer of unknown primary site (CUP) is poor, and squamous cell carcinoma of the unknown primary site (SCCUP) is a rare histological type. CUP is often treated with aggressive multimodal treatments, while the treatment of single-area localized CUP remains controversial. We retrospectively reviewed the medical records of patients with CUP. SCCUP in women was classified according to several definitions. Based on the histologic type and site, they were classified into favorable and unfavorable subsets. We further divided SCCUP into two types (single and multiple areas) and reviewed treatment and efficacy. Among the 227 female CUP patients, 36 (15%) had SCCUP. The median age was 59.9 years (range, 31-90 years). Most patients (61.1%) had a good performance status. Of the SCCUP patients, 22 had cancer in a single area, and 14 in multiple areas. Single-area SCCUP was further divided into favorable (16 cases) and unfavorable subsets (6 cases). In the favorable subset, local treatment was predominant, and almost all cases had a good prognosis. Even in the unfavorable subset, local therapy was combined with systemic chemotherapy in only two cases, and four cases showed no recurrences. Local treatment may be effective for single-area SCCUP, even in the unfavorable subset.

Impact of the coverage of risk-reducing salpingo-oophorectomy by the national insurance system for women with BRCA pathogenic variants in Japan

To determine the impact of the coverage of risk-reducing salpingo-oophorectomy (RRSO) and mastectomy (RRM) as well as genetic testing for BRCA pathogenic variants by the national insurance system in Japan. We compared the clinical background of women who underwent RRSO at our institution before and after its coverage by the national insurance system. Those who underwent RRSO between January 2017 and December 2019 and between April 2020 and March 2022 were classified as Period. A and B, respectively. Overall, 134 women underwent RRSO during the study period. In Period A and B, 45 and 89 women underwent RRSO for the study period was 36 and 24 months, respectively. Compared with Period A, the number of women who underwent RRSO per month increased by threefold in Period B (p < 0.01). In addition, the number of women who underwent surgery for breast cancer along with RRSO increased in Period B (p < 0.01). Although the number of women who underwent concurrent RRM with RRSO in Period B increased, the difference was not statistically significant. Compared with Period A, the number of women diagnosed with BRCA pathogenic variant increased by 3.9-fold, and the proportion of women who underwent concurrent hysterectomy at the time of RRSO decreased from 66 to 7.9% in Period B (p < 0.01). Owing to the introduction of the national insurance system, the number of women who underwent RRSO and concurrent surgery for breast cancer at the time of RRSO increased in Japan.

A case of tongue cancer manifesting from oral leukoplakia after long-term administration of pegylated liposomal doxorubicin

We present a case of tongue cancer manifestation from oral leukoplakia after administration of pegylated liposomal doxorubicin (PLD). A 56-year-old woman was diagnosed with ovarian cancer. After preoperative chemotherapy with paclitaxel and carboplatin (TC), she underwent interval debulking surgery. Five cycles of TC therapy were carried out as adjuvant chemotherapy; however, recurrence was observed. Despite administration of gemcitabine-carboplatin therapy, the patient's condition was judged as advancing to a progressive disease. PLD treatment was completed at a total dose of 1140 mg/m². Two months after the end of treatment, the patient was diagnosed with leukoplakia. The leukoplakia lesion became thicker at each 3-month follow-up. She was diagnosed with tongue cancer and underwent a partial resection 2 years and 3 months after the completion of PLD treatment. Our report suggests that the risk of malignant transformation to tongue cancer persists even after the completion of treatment with PLD.

Clinical Management of Atypical Endometrial Cells of Undetermined Significance Followed by Negative Cytology

INTRODUCTION

In Japan, endometrial cytology is widely performed to evaluate the status of the endometrium in women with suspected endometrial cancer. A new classification system for endometrial cytology has recently been used: the Yokohama system, based on a descriptive reporting format. This study aimed to clarify the triage for patients with atypical endometrial cells of undetermined significance (ATEC-US) when followed by negative endometrial cytology.

METHODS

We enrolled patients diagnosed with ATEC-US at the Cancer Institute Hospital between January 2016 and December 2017, based on the following inclusion criteria: (1) ATEC-US diagnosed by office endometrial cytology, with or without office endometrial biopsy; (2) follow-up endometrial cytology was performed 3-6 months after initial sampling, with a negative result for malignancy; and (3) no prior history of conservative treatment with progestin for endometrial cancer or atypical endometrial hyperplasia (ATEC-A). Among eligible patients, we analyzed those later diagnosed by endometrial biopsy with ATEC-A or carcinoma.

RESULTS

Among 187 patients, 65 met the inclusion criteria. Forty-two patients (64.6%) were observed for more than 24 months. Two patients (3.1%) developed ATEC-A during a median observation time of 26.5 months; the times to diagnosis were 32 months and 22 months.

DISCUSSION/CONCLUSION

No patient developed ATEC-A or worse within 1 year. For patients with ATEC-US, if negative cytology is obtained at the next examination, a close follow-up is not necessary.

Prognosis and adjuvant chemotherapy for patients with positive peritoneal cytology in stage IA endometrial cancer

This study evaluated the influence of positive peritoneal cytology (PPC) on the prognosis of patients with stage IA endometrial cancer, and the usefulness of adjuvant chemotherapy in their treatment. We retrospectively analyzed the data of patients with stage IA endometrial cancer admitted in our hospital between 2005 and 2015. Among 989 patients who underwent peritoneal cytology, 135 (13.7%) had PPC. Multivariate analysis extracted several independent risk factors for recurrence in stage IA patients, including those with PPC. Adjuvant chemotherapy did not cause a significant difference in the 5-year relapse-free survival rate in patients with PPC (p = 0.78). Similarly, the 5-year recurrence-free survival rate with or without chemotherapy was not different among type II cancer patients (p = 0.11). However, the baseline risk of 5-year relapse-free survival without chemotherapy in patients with PPC and type II was very low (66.7%). While PPC was an independent risk factor for recurrence in stage IA endometrial cancer, adjuvant chemotherapy did not influence the survival rate in patients with PPC. While it is controversial whether adjuvant chemotherapy should be administered in stage IA uterine cancer with only PPC as a prognostic factor, it should be considered for early-stage patients who have multiple risk factors for recurrence.

Volume index is a risk factor for recurrence even in patients with clinical stage IA endometrial cancer undergoing either laparotomy or laparoscopy: A retrospective study

Objectives:

The objective of the study was to investigate the long-term outcomes, in particular, recurrence risk, especially tumor volume, for Stage IA endometrial cancer and to identify the risk factors for recurrence.

Materials and Methods:

This single-center retrospective study analyzed women who underwent primary surgical treatment for the International Federation of Gynecology and Obstetrics Stage IA (Grade 1 or 2) endometrioid carcinoma at our institute between January 2010 and July 2018. Patients' demographic characteristics, including age, operative time, number of lymph nodes, final stage, volume index as tumor volume, and final histological type, were reviewed. A total of 168 patients were enrolled, with 95 and 73 patients in the laparotomy and laparoscopy groups, respectively. The Cox proportional hazards model was used to adjust for prognostic factors in the analysis including upstaged patients, tumor histology, lymphovascular invasion, and volume index.

Results:

There was no difference in the recurrence rate between laparoscopic and open surgeries for Stage IA endometrial cancer. The operative time was longer, and the amount of blood loss was lesser in the laparoscopy group than in the laparotomy group. For all patients undergoing either laparoscopy or open surgery, upstaged ≥IB, nonendometrioid Grade 1 or 2, lymphovascular invasion, and volume index ≥36 were significant independent recurrence risk factors.

Conclusion:

Laparoscopic surgery for Stage IA endometrial cancer is technically and oncologically safe. Patients with a high-volume index have a higher recurrence risk. Furthermore, the volume index can be a recurrence predictor in low-risk endometrial cancer patients.

Feasibility and Outcomes of "No-Look No-Touch" Laparoscopic Radical Trachelectomy for Early-Stage Cervical Cancer

Intraoperative tumor manipulation and dissemination may compromise the survival of women with early-stage cervical cancer who undergo laparoscopic surgery. This study aimed to examine survival and obstetrical outcomes related to laparoscopic radical trachelectomy (LRT) with a “no-look no-touch” technique in 40 women. This technique incorporates five measures to prevent tumor spillage and damage to the uterine artery perfusion. Five LRTs were aborted because of positive nodes or positive surgical margins. Compared with those of type III laparoscopic radical hysterectomy, the surgical outcomes of LRT in 35 patients were acceptable: operative time (380 min), estimated blood loss (140 mL), length of hospital stay (15 days), and lengths of excised parametrium and vagina. During follow-up (median, 41.3 months), the 5-year disease-free survival and overall survival were 95.0% (95% CI: 69.5–99.3%) and 100%, respectively. Of the nine patients (26%) who attempted pregnancy, seven conceived (nine pregnancies, 76%). Eight were delivered by term cesarean section, while one was miscarried in the first trimester. Our study suggests that the no-look no-touch technique may be effective in reducing the risk of recurrence and improving obstetrical outcomes during LRT for early-stage cervical cancer.

Clinical and pathological outcomes of risk-reducing salpingo-oophorectomy for Japanese women with hereditary breast and ovarian cancer

BACKGROUND

To clarify the clinical as well as pathological outcomes in Japanese women with germline pathogenic BRCA1/2 variants who underwent risk-reducing salpingo-oophorectomy (RRSO).

METHODS

This prospective study examined the rate of occult cancer and primary peritoneal cancer after RRSO at our institution in the period from 2011 to 2020. Clinical records of genetically confirmed patients with germline pathogenic BRCA1/2 variants who desired to undergo RRSO were reviewed. Specimens obtained during RRSO were pathologically diagnosed as per SEE-FIM protocol. All the participants underwent magnetic resonance imaging (MRI) about 1 month preoperatively.

RESULTS

One hundred and seventeen women underwent RRSO during this period. Of these, the numbers of women with germline pathogenic BRCA1 and BRCA2 variants were 72 and 45, respectively. The mean observational time after RRSO was 35.8 months. Despite negative preoperative screening results, three (2.6%) serous tubal intraepithelial carcinoma and three (2.6%) invasive carcinomas were identified. Of the three invasive carcinomas cases, two were International Federation of Gynecology and Obstetrics (FIGO) stage I primary fallopian tube cancer, and the third case was double cancer (ovarian cancer and fallopian tube cancer) with FIGO stage IC3.

CONCLUSIONS

The rate of occult neoplasms was similar to those reported by studies performed in other countries. Although women with occult cancer were diagnosed with FIGO stage I, the MRI performed 1 month preoperatively did not show any such malignant findings. Thus, RRSO is the only promising method that can improve the prognosis in women with germline pathogenic BRCA1/2 variants.

Positive surgical margin is an independent predictor of overall survival of patients with vulvar squamous cell carcinoma

AIM

It is uncertain whether curative surgical treatment or a less radical surgery with adjuvant treatment should be provided to preserve function in patients with vulvar squamous cell carcinoma (SCC) that is adjacent to the urethra, anus, and vagina. The aim of this study was to investigate the surgical margin in patients with vulvar SCC with regard to local recurrence and overall survival.

METHODS

Thirty-four patients were identified as having a diagnosis of vulvar SCC without distant metastasis. They had been treated surgically with curative intent at the Cancer Institute Hospital. Clinical data were analyzed retrospectively.

RESULTS

Rates of 5-year local recurrence-free survival among patients with positive, <3-mm, <5-mm, <8-mm, and ≥8-mm surgical margins were 32%, 30.3%, 42.5%, 55.5%, and 73%, respectively. Rates of 5-year overall survival of patients with positive, <3-mm, <5-mm, <8-mm, and ≥8-mm surgical margins were 15.5%, 53.8%, 58.8%, 67.6%, and 83.3%, respectively. In the multivariable analysis, a tumor size of more than 2-cm (hazard ratio [HR] = 17.7, 95% confidence interval [CI] = 1.39-226) and a positive surgical margin (HR = 0.0092, 95% CI = 0.011-0.53) were risk factors for local recurrence, and a lymph node involvement (HR = 1.41, 95% CI = 0.31-6.43) and a positive surgical margin (HR = 0.0046, 95% CI = 0.011-0.53) were significant risk factors for overall mortality.

CONCLUSIONS

To improve the prognosis, thorough resection with an adequate surgical margin is needed. But narrow surgical margin may be acceptable, particularly to preserve the function of adjacent organs.

Nedaplatin use in patients with hypersensitivity reaction episodes to carboplatin

OBJECTIVE

To evaluate the benefits of nedaplatin treatment in patients with a history of hypersensitivity reactions to carboplatin.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with ovarian, fallopian, and peritoneal cancers and with a history of hypersensitivity to carboplatin between January 2010 and December 2016 at the Department of Gynecology in the Saitama Medical Center associated with Jichi Medical University. We studied the response rate to treatment with a nedaplatin-based regimen compared to that of a carboplatin regimen. Fisher's exact test was used to determine statistical significance.

RESULTS

Thirty-one patients with a past hypersensitivity to carboplatin were treated with nedaplatin-based regimen, while ten patients were treated with other drugs. The response rates in the nedaplatin- and non-nedaplatin-treated patient groups were 71.4% and 30.0%, respectively (P = 0.021). Among all the patients, only one experienced hypersensitivity reaction to nedaplatin.

CONCLUSION

The nedaplatin regimen following hypersensitivity to carboplatin was safe, feasible, and effective in achieving complete or partial response.

Laparoscopic pelvic exenteration and laterally extended endopelvic resection for postradiation recurrent cervical carcinoma: Technical feasibility and short-term oncologic outcome

OBJECTIVE

Surgery is the only treatment for cervical cancer recurrence in a previously irradiated field. Pelvic exenteration (PE) and laterally extended endopelvic resection (LEER) are indicated for select patients; however, morbidity and mortality rates remain high, and new treatment modalities are required. Laparoscopy optimizes visualization and allows meticulous dissection while also reducing intraoperative blood loss and postoperative complications without worsening the outcomes. We aimed to clarify the feasibility and outcomes of laparoscopic PE and LEER for previously irradiated recurrent cervical cancer.

METHODS

We prospectively investigated the outcomes of laparoscopic PE and LEER in 28 patients with recurrent cervical carcinoma after radiotherapy.

RESULTS

Seventeen laparoscopic PEs for central recurrences and 11 laparoscopic LEERs for lateral recurrences were performed. The median operation time and blood loss were 454mins and 285 mL in the PE group, and 562mins and 325 mL in the LEER group, respectively, with no conversions to laparotomy. R0 resection was achieved in all patients in the PE group and 73% in the LEER group. The morbidity and mortality rates were 41% and 0% in PE group, and 55% and 0% in LEER group, respectively. The 2-year disease-free survival and overall survival were 68.9% and 76% in the PE group, and 27.3% and 29.6% in the LEER group, respectively.

CONCLUSION

Laparoscopic PE is feasible for previously irradiated central recurrent cervical cancer and has acceptable outcomes. Laparoscopic LEER is also feasible for lateral recurrence, but oncologic outcome may be modest in this limited preliminary study. Further studies using a larger sample size with a longer follow-up period is warranted to determine the indications for laparoscopic LEER.

Continuous Administration of Bevacizumab After Disease Progression in Recurrent Ovarian Cancer: A Retrospective Observational Study

BACKGROUND/AIM

Chemotherapy with additional bevacizumab is the standard treatment for primary and recurrent ovarian cancer. We aimed to investigate the clinical utility and safety of bevacizumab when used in combination with chemotherapy after disease progression.

PATIENTS AND METHODS

This retrospective, observational study recruited patients treated for recurrent ovarian cancer from 2014 to 2016. We evaluated the effects of bevacizumab with chemotherapy in patients whose disease had progressed following treatment with bevacizumab. We assessed progression-free survival and adverse events.

RESULTS

Thirty-three patients received post-progression treatment with bevacizumab. The median progression-free survival was 8.7 months (95% confidence interval=5.5-11). The progression-free survival was compared pre- and post-progression treatment, and was longer in platinum-resistant than platinum-sensitive cases after treatment (p=0.06). The most common non-hematological toxicity was proteinuria. The incidence of serious adverse events was low.

CONCLUSION

Continuous administration of bevacizumab may be beneficial for ovarian cancer patients after disease progression.

Surgical outcomes of early-stage primary vaginal nonsquamous cell carcinoma

OBJECTIVE

Definitive radiation therapy (RT), using external beam RT and/or brachytherapy, is a standard treatment option for primary vaginal carcinoma. However, this treatment has poor prognosis when applied to vaginal nonsquamous cell carcinoma (non-SCC). We aimed to clarify treatment outcome and surgical safety in early-stage primary vaginal non-SCC.

METHODS

After receiving approval from the institutional review board, we retrospectively reviewed the clinical records and pathological samples of patients treated at our hospital between 1991 and 2018. Among 49 patients with primary vaginal carcinoma, 12 with histologically confirmed early-stage primary vaginal non-SCC were included in this study.

RESULTS

In total, 40% of patients with primary vaginal carcinoma treated at our hospital had primary vaginal non-SCC. The average observation time was 34 months (median 53.3 months). Three patients had local recurrence: 2 in pelvic lymph nodes and 1 in the vagina. Furthermore, 2 patients died of their disease. Five-year local control rate of stage I and stage II non-SCC was 75% and 100%, respectively. Disease-specific survival rate of stage I and stage II non-SCC was 81.8% and 100%, respectively. No major morbidity was observed. Three patients required allogeneic blood transfusion, whereas 1 underwent autotransfusion. None of the 12 patients were discharged with self-catheterization.

CONCLUSION

Five-year local control and disease-specific survival rates of patients surgically treated for vaginal non-SCC were favorable. Therefore, surgery could be a safe and reasonable option for early-stage primary vaginal non-SCC.

Spontaneous endometriosis in cynomolgus monkeys as a clinically relevant experimental model

STUDY QUESTION

Does spontaneous endometriosis in cynomolgus monkeys have the characteristics required of a good experimental model?

SUMMARY ANSWER

Spontaneous endometriosis in cynomolgus monkeys exhibited similar clinicopathological characteristics to the human disease and was useful as an experimental model.

WHAT IS KNOWN ALREADY

The prevalence of endometriosis in autopsied cynomolgus monkeys (Macaca fascicularis) in a breeding colony was reported to be 28.7% in 1993. The histopathological findings we reported recently showed that components of spontaneous endometriosis were not only endometriotic epithelium and stromal cells (CD10-positive) with hemorrhage and inflammation, but also smooth muscle metaplasia and nerve fibers.

STUDY DESIGN, SIZE, DURATION

During routine medical examinations at a research facility from 2008 to 2012, 614 female cynomolgus monkeys of reproductive age (6-25 years) were screened for endometriosis by the presence of regular menstrual bleeding, serum CA125 levels and palpation of the abdomen. In total, 29 monkeys were selected as subjects for the following study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 29 monkeys selected, 15 were diagnosed with endometriosis by laparoscopy and/or open surgery. The monkeys were monitored by observing their general condition, and eight of these were monitored using laparoscopy and MRI. In addition, to investigate appropriate screening parameters and endometriosis-associated biological parameters in monkeys, we retrospectively examined general laboratory parameters that correlate to the menstrual cycle and disease status.

MAIN RESULTS AND THE ROLE OF CHANCE

The combination of CA125 serum levels (this was a useful marker for chocolate cysts), palpation of the abdomen, and fecal abnormalities was the most efficient screening method for diagnosing monkeys with endometriosis. Each animal could be diagnosed and assigned a disease stage by laparoscopy. While monitoring the disease stage by laparoscopy and/or MRI, disease status in individual monkeys was mainly stable or was progressive for 2-7 months. The detection rate by screening was low (15/614) but age-specific analysis suggests that screening would be more efficient if a colony for an endometriosis model is maintained with 11-20-year olds. As an endometriosis-associated biological parameter, the decrease in food consumption that coincided with menstruation was selected and correlated well (R2 value = 0.8239) with disease status (according to a modified adhesion revised American Fertility Society score).

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Peritoneal fluid was not analyzed because a smaller amount is produced in cynomolgus monkeys than in baboons. Although clinical endometriosis-associated pain is evaluated in women using a visual analog scale, pain could not be directly evaluated in this non-human primate model.

WIDER IMPLICATIONS OF THE FINDINGS

Although cynomolgus monkeys are relatively small (2-5 kg) primates, laparoscopy and MRI make it possible to evaluate spontaneous endometriosis in these monkeys and to monitor its development over time. Spontaneous endometriosis in cynomolgus monkeys is a useful model for evaluating disease progress and drug efficacy because they have similar lesions to those in humans, and conventional laboratory methods and parameters for assessment are well established.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were used for this study. A.N.-K., K.T., H.T., A.K. and M.S. are full-time employees of Chugai Pharmaceutical Co., Ltd. R.K. received a consultancy fee from Chugai Pharmaceutical Co., Ltd. and lecture fees from Chugai Pharmaceuticals, Japan Vaccine Co. Ltd., Merck & Co., Mochida Co. Ltd., Roche Diagnostics, and BD, unrelated to the submitted work. S.N., S.O. and T.S. have nothing to declare.

Efficacy of a Self-timed Trial of Laparoscopic Surgical Training Using a Dry Box

Objective: This study evaluated the self-timed trial training for laparoscopic suturing. Methods: The set task involved grasping the suture, aligning the needle with a needle holder, passing the suture, making 3 knots, holding the 2 tails of the suture with one grasper, and cutting them. Trainees were given an instruction for suturing and reducing their suturing time. The same instruction was given 3 months later. Suturing times for the first and second trials and the last trial after the second instruction of the 9 trainees were measured. Results: Their mean suturing times were statistically significantly shorter after instruction (before instruction: 276.7 ± 43.4 seconds, after instruction: 177.4 ± 46.1 seconds; P = .0035). Four trainees were trained twice during the second instruction. Their suturing times were shorter than those of the other trainees, and the standard deviation decreased (120.5 ± 21.2 seconds, P = .017). Conclusion: A self-timed trial training for laparoscopic suturing using a dry box makes training interesting and motivates trainees.

Increase in the cervical length after the loop electrosurgical excision procedure for grade III cervical intraepithelial neoplasia

This study aimed to determine whether the cervical length increases over a period of six months, after the loop electrosurgical excision procedure (LEEP) for grade III cervical intraepithelial neoplasia (CIN), and to identify the factors associated with an increase in the cervical length. We retrospectively reviewed the medical records of 183 patients who underwent the LEEP between April 2011 and March 2014, at the Department of Gynaecology, Kyosai Hospital. Transvaginal ultrasonography was performed at two, three and six months after the LEEP, and the mean increase in the cervical length between two and three months, two and six months, and three and six months were 2.07, 5.23 and 2.92 mm, respectively. The increase in the cervical length was not associated with age, gravidity, parity and the width of CIN. In conclusion, the cervical length may increase gradually over a period of six months after the LEEP.

Characteristics of histologically confirmed endometriosis in cynomolgus monkeys

STUDY QUESTION

What are the characteristics of spontaneous endometriosis in cynomolgus monkeys?

SUMMARY ANSWER

Spontaneous endometriosis in cynomolgus monkeys exhibited similar characteristics to the human disease.

WHAT IS KNOWN ALREADY

One previous report described the prevalence and the basic histopathology of spontaneous endometriosis in cynomolgus monkeys.

STUDY DESIGN, SIZE, DURATION

Endometriotic lesions that had been histologically confirmed in 8 female cynomolgus monkeys between 5 and 21 years old were subjected to study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The monkeys died of, or were sacrificed because of, sickness consequent on endometriosis. Specimens were evaluated histopathologically with haematoxylin and eosin staining, iron staining and immunohistochemistry (CD10, CD31, α-SMA and PGP9.5), and by observing them under a microscope.

MAIN RESULTS AND THE ROLE OF CHANCE

Endometriotic and stromal cells (CD10-positive) with haemorrhage and inflammation were observed. Smooth muscle metaplasia and nerve fibres were also noted in the endometriotic lesions. Endometriotic lesions in lymph nodes were incidentally found.

LIMITATIONS AND REASONS FOR CAUTION

Since laparoscopic analysis for monitoring the disease state was not set as a parameter of the current study, time course changes (progression) of the disease were not assessed.

WIDER IMPLICATIONS OF THE FINDINGS

Further investigation of spontaneous endometriosis in cynomolgus monkeys may contribute to better understanding of the disease pathobiology.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were used for this study. A.N.K., S.M., S.H., T.I., O.K., A.K. and M.S. are full-time employees of Chugai Pharmaceutical Co., Ltd. R.K. received lecture fees from Chugai Pharmaceutical Co., Ltd., unrelated to the submitted work. S.N., S. O., L.Y., K.Y. and T.S. have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Delayed diagnosis of single compartment muscle contusion after radical hysterectomy in the lithotomy position: A case report

•

In lithotomy position, surgeries performed can result in muscle contusion.

•

MRI can help to detect light muscle contusion.

•

Routine physical examination may be needed for identification of muscle contusions.

Introduction

Muscle contusions usually occur as a result of blunt trauma, which damages the muscle fibers and connective tissue without breaking the skin. Rapid bleeding can cause an increase in pressure that requires surgical intervention, commonly referred to as compartment syndrome. Here, we report a case with delayed diagnosis of single compartment muscle contusion in which compartment syndrome did not develop.

Presentation of case

A 50-year-old woman underwent radical hysterectomy. She complained of edema and tenderness in the lower left leg on postoperative day 6. The serum creatine phosphokinase level was slightly elevated at 177 IU/L (normal range: 6–142 IU/L). T2-weighted magnetic resonance imaging revealed swelling of the muscle in the deep posterior compartment of the lower left leg, edematous fascia, and subcutaneous adipose tissue. She recovered naturally without other complications.

Discussion

In the lithotomy position during surgery, muscle contusion might occur, without general symptoms.

Conclusion

Magnetic resonance imaging is useful for diagnosis. For patients who complain of edema and tenderness in the lower leg after surgery in the lithotomy position, muscle contusions should be considered.

Outcomes of concurrent radiotherapy and weekly paclitaxel/carboplatin therapy in cervical cancer: a retrospective study

PURPOSE OF INVESTIGATION

To determine if concurrent chemoradiotherapy (CCRT) with paclitaxel and carboplatin is effective, convenient, and tolerable for cervical cancer treatment.

MATERIALS AND METHODS

The authors retrospectively reviewed the medical records of 49 patients. Primary outcomes included progression-free survival (PFS) and overall survival (OS). The Cox proportional hazards model was adjusted for all prognostic factors in the multivariable analysis.

RESULTS

Over the median follow-up time of 32 months in a sample consisting of 87.8% (43/49) squamous cell carcinoma and 12.2% (6/49) adenocarcinoma, two-year PFS and OS rates were 67.2% and 80.9%, respectively. In univariate analyses, stage, histology, performance status, tumor size, and age were significant vari- ables for OS; only histology was significant in the multivariable analysis. Acute toxicity grade 3 or 4 neutropenia (85.7%), diarrhea (32.7%), and late toxicity grade 3 or 4 (12.2%) were detected.

CONCLUSIONS

For cervical cancer treatment, CCRT with paclitaxel/car- boplatin is satisfactory.

Expectant management of a case of uterine arteriovenous malformation with an ovarian artery aneurysm

Uterine arteriovenous malformations are rare and their true prevalence is unknown. Selective arterial embolization is used as first-line therapy for acute severe vaginal hemorrhage associated with uterine arteriovenous malformations. However, some patients with no vaginal bleeding have been treated conservatively, so the optimal treatment modality for arteriovenous malformations is unclear. We describe a 58-year-old woman with uterine arteriovenous malformation and an ovarian artery aneurysm who was successfully treated with an expectant management approach along with an assessment of age, symptoms, and imaging findings.

Intractable Coronary Spastic Angina Improvement after Continuous Combined Estrogen-progestin Hormonal Contraception Use in a Premenopausal Woman

A 44-year-old woman, who had been previously diagnosed with coronary spastic angina and treated with standard medical therapy including calcium channel blockers, was admitted to our hospital due to chest pain at rest. Her chest pain attacks were concentrated just before and during menstruation. Despite the administration of an intravenous infusion of nitroglycerin and nicorandil, strong heart attacks with ST elevation occurred frequently after this admission. However, following continuous combined estrogen-progestin hormonal contraception use (estradiol plus dienogest), her attacks disappeared completely. Reduced estrogen levels before and during menstruation were speculated to be associated with her angina attacks.

Surgical excision of umbilical endometriotic lesions with laparoscopic pelvic observation is the way to treat umbilical endometriosis

Primary umbilical endometriosis is extremely rare, although cases secondary to previous surgery have occasionally been reported. Here, we report three cases of umbilical endometriosis: two cases with previous cesarean section and one case of primary umbilical endometriosis. The treatment of choice for umbilical endometriosis is the excision of the lesions, and we believe laparoscopic pelvic observation is a beneficial addition, as 13%-15% of umbilical endometriosis cases are accompanied by pelvic endometriosis.

High HPV vaccination uptake rates for adolescent girls after regional governmental funding in Shiki City, Japan

BACKGROUND

In Japan, the bivalent HPV vaccine was approved in October, 2009 and became available as a non-routine vaccine from December, 2009. While routine vaccinations are free, the cost and responsibility for non-routine vaccinations are left to the individual. In exceptional circumstances regional governments fund non-routine vaccinations. This was the case in Shiki City, Saitama Prefecture, where a high uptake rate for individual (non-school based) HPV vaccination was obtained.

MATERIALS

On January 20, 2010, the mayor of Shiki City announced to the media his decision to vaccinate adolescent girls in Shiki City against HPV. A project team for HPV vaccination was set up in the city's Health Promotion Center. To gain mutual consent for HPV vaccination, senior health professionals, city officials, the head of the board of education, school principals and health-care teachers met several times. The cohort to be vaccinated was 1254 girls aged 12-15 years. Individual notifications were mailed to each girl on April 23, 2010, along with information about the HPV vaccine.

CONCLUSIONS

As of April 10th, 2011, the uptake rate for girls aged 15 years old was 90.7% for the 1st dose. The vaccine registry is managed by the health care system of the city. The success of the HPV vaccination program and high uptake rates in Shiki City is a good model for the nationwide HPV vaccination program that started in February, 2011.

[Human papillomavirus vaccination for prevention of cervical cancer]

Persistent infection of human papillomavirus (HPV) is the necessary cause for developing cervical cancer. Now cervical cancer is getting attention as not only early-detectable but also preventable cancer by developing vaccine for HPV. In Japan, the first HPV vaccine, "Cervarix, GlaxoSmithKline (GSK)" was licensed on October 2009 and vaccination was started on December 2009. This is the bivalent vaccine specifically targeting HPV-16 and -18 types. Domestic clinical trial is also about to demonstrate the efficacy, safety, and possibility to keep enough antibody levels. The widespread use of this vaccine will help cervical cancer eliminated.

Meningeal dissemination from an ovarian carcinoma with effective response to intrathecal chemotherapy

Meningeal dissemination is rare in the clinical course of ovarian carcinoma, and its prognosis is poor. Although it is treated by the intrathecal administration of methotrexate (MTX) and/or total brain irradiation, these treatments are usually ineffective. We report a 58-year-old woman with stage IIIc ovarian cancer who had received nine courses of adjuvant chemotherapy after surgery. But her carbohydrate antigen (CA) 125 serum level had increased further (38.9 U/ml) after five courses of biweekly paclitaxel (Taxol; Bristol-Myers Squibb, Tokyo, Japan; BT) maintenance therapy. Fainting occurred, with a few seconds of unconsciousness, as did severe headaches. However, results of head computed tomography (CT), head magnetic resonance imaging, and electroencephalogram were normal. Lumbar puncture (LP) was performed. The opening pressure was 30 cmH2O or greater. Meningeal dissemination of the ovarian cancer was diagnosed, as adenocarcinoma cells were found by cerebrospinal fluid (CSF) cytology. We started chemotherapy with intrathecal injections of MTX and hydrocortisone acetate. Establishing a diagnosis of carcinomatous meningitis may be difficult. Clinical signs and biological data are not conclusive. In this patient, CSF cytology was very effective in establishing the diagnosis, and the intrathecal administration of MTX and hydrocortisone was very effective.

Oral eicosapentaenoic acid supplementation as possible therapy for endometriosis

OBJECTIVE

To investigate the anti-inflammatory effect of n-3 eicosapentaenoic acid (EPA) compared with n-6 linoleic acid (LA) in an endometriosis rat model. We focused on the relationship between lipid metabolism and inflammatory reactions in endometriosis based on the hypothesis that a lipid intake imbalance is one of the factors responsible for the recent increase of endometriosis.

DESIGN

Prospective, randomized experimental study.

SETTING

Animal surgery laboratory in a university hospital.

ANIMAL(S)

Sprague-Dawley rats (female, 6 weeks old).

INTERVENTION(S)

Rats were fed a diet with EPA (n = 9) or with LA (n = 9) for 2 weeks. Two weeks after feeding, the uterus was autotransplanted to the peritoneum to construct an endometriosis model. Feeding was continued for a total of 6 weeks. Two and 4 weeks after autotransplantation, three rats of each group were killed and evaluated.

MAIN OUTCOME MEASURE(S)

Endometriotic lesions were morphologically evaluated and their fatty acid composition was examined. Gene expression in these tissues was evaluated by cDNA microarray analysis and quantative real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULT(S)

In the EPA group, the n-3:n-6 ratio in each tissue significantly increased and the thickening of the interstitium, an active site for inflammation in endometriosis, was significantly suppressed (0.30 +/- 0.09 mm [EPA group] vs. 0.77 +/- 0.23 mm [LA group]). The mRNA of metalloproteinases, interleukin-1beta, interleukin-1r, prostaglandin E synthase (Ptges), and nuclear factor (NF)-kappaB were reduced in the EPA group.

CONCLUSION(S)

EPA supplementation might be a valid strategy for the treatment of endometriosis.

Gene expression profiling of the rat endometriosis model

PROBLEM

To investigate the molecular mechanism of endometriosis, gene expression profiling was analyzed in a rat endometriosis model.

METHOD OF STUDY

An endometriosis model was induced by uterine autotransplantation in the peritoneal cavity on a female-SD rat (8 weeks old). As control samples, the normal uterine tissues were used. The gene expression was compared between endometriotic lesions and normal uterine tissues by cDNA microarray analysis, quantitative real time RT-PCR and immunohistochemistry.

RESULTS

The expression of 71 genes was upregulated and that of 45 genes was downregulated in the endometriotic lesions compared to normal uterine tissues. The upregulated genes included genes encoding cytokines, chemokines, growth factors and cell adhesion molecules. The levels of transcripts of osteopontin, Lyn, Vav1, Runx1, and l-selectin in the endometriotic lesions were 130, 10, 10, 12 and 46-fold higher than the respective levels in the eutopic endometrial samples.

CONCLUSION

The results suggest that osteopontin, Lyn, Vav1, Runx1, and l-selectin play important roles in the pathogenesis of endometriosis.

Immunohistochemical study of osteopontin and l-selectin in a rat endometriosis model and in human endometriosis

OBJECTIVE

To investigate the localization of the proteins osteopontin (OPN) and L-selectin (SELL).

DESIGN

Retrospective nonrandomized immunohistochemical study in a surgically induced rat model of peritoneal endometriosis and in samples of human endometriotic lesions of ovaries.

SETTING

Department of gynecology in a university hospital.

PATIENT(S)

A rat endometriosis model was induced in 10 8-week-old SLC-Sprague-Dawley rats by surgical autotransplantation of uterus. Fourteen premenopausal women with histologically diagnosed endometriosis were selected (mean age, 39 y; range, 25-53 y). Twenty endometriotic specimens were obtained from 14 patients who underwent laparoscopic surgery for enlarged endometriotic cysts.

INTERVENTION(S)

Histopathological examination of endometriotic ovarian specimens for OPN and SELL expression by immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Demonstration of the immunoreactive staining of OPN and SELL expressions in tissues of a rat endometriosis model and of human endometriosis.

RESULT(S)

In both tissues from a rat endometriosis model and from human endometriosis, OPN was stained more prominently in glandular epithelium than in interstitial space, whereas SELL stained more prominently in interstitial space (macrophages and lymphocytes) than in epithelium. The staining pattern of OPN in ectopic endometriotic lesions was very similar to that in eutopic normal human endometrium in the secretory phase.

CONCLUSION(S)

These results suggested important roles for OPN and SELL in the pathogenesis of endometriosis.

[Prognostic factors of uterine cervical cancer]

The large majority of gynecologic malignancies are comprised of uterine cervical cancer, endometrial cancer and ovarian cancer. Prognostic factors for each disease are based on various clinical pathological features, including clinical stage, tumor size, and lymph node metastatis for uterine cervical cancer. In addition to these factors, recent studies have investigated the role of various molecules including tumor markers and Hb level, apoptosis-related molecules as well as various genetic abnormalities as prognostic factor or indicators for uterine cervical cancer. This molecular background of uterine cervical cancer will shape future directions in the increasingly individualized basis of treatment.

Localization of Mast Cells in Endometrial Cysts

PROBLEM

Although the presence of mast cells in endometriosis lesions has been reported, there have been no reports of their pathological localization in ovarian endometrial cysts.

METHODS OF STUDY

The localization of mast cells in ovarian endometrial cysts were investigated using hematoxyline and eosin and toluidine blue staining with light microscopy, immunohistochemical c-kits, and electron microscopy.

RESULTS

Mast cells were identified in endometrial cyst tissues. Few mast cells were localized in the endometrial stroma, which is characteristic of endometrial gland-like regions. Many mast cells were noted around blood vessels and the interstitium with fibrosis, that is, the fibrotic interstitium of endometrial cysts.

CONCLUSIONS

Mast cells may be involved in the development and progression of endometriosis. Localization of mast cells suggests a particularly close relationship with fibrosis and adhesion.

[A case of pregnant woman with severe obsessive-compulsive disorder successfully treated by modified-electroconvulsive therapy]

Obsessive-compulsive disorder (OCD) is rare psychiatric disorder during pregnancy, and is often therapy-resistant. We report a 36-year-old pregnant woman with severe obsessive-compulsive disorder successfully treated by modified-electroconvulsive therapy. During the pregnancy, severe mysophobia and compulsive washing appeared, so severely that she was unable to lie down, endangering the life of the fetus. Since the pharmacotherapy was ineffective, modified electroconvulsive therapy (m-ECT) was performed in cooperation with the obstetrician and the anesthesiologist, along with monitored cardiotocography throughout the procedure. During the second therapy late deceleration on the fetal cardiotocogram occurred, but rapid intravenous administration of ritodrine led to the cessation of abnormal uterine contraction. Two courses of m-ECT markedly diminished her symptoms, and she delivered a healthy infant without complications. M-ECT can be an alternative treatment for pregnant patients with OCD.