西尾 永司

【目的】39歳以下の若年子宮頸癌の臨床的特徴を再検討した。【方法】1999〜2011年に当院で治療したIB期以上の275例を対象とし、39歳以下(A群)と40歳以上(B群)における以下の臨床病理学的所見を比較した。(1)頻度、(2)組織型(扁平上皮癌;以下SCC、腺癌;以下AD、腺扁平上皮癌;以下AS、その他)、(3)ステージ、(4)I+II期で手術施行例の臨床病理学的因子と予後、(5)III、IV期癌の予後。【結果】(1)A群:69例(25.1%)、B群:206例(74.9%)で、A群の頻度は2005年以前と以降で差はなかった。(2)組織型はA群:SCC45例(65.2%)、AD+AS20例(29.0%)、その他4例(5.8%)、B群:SCC152例(73.8%)、AD+AS50例(24.3%)、その他4例(1.9%)で差はなかった。(3)ステージはA群:I期50例、II期12例、III期3例、IV期4例、B群:I期77例、II期69例、III期35例、IV期25例で、A群で有意にI+II期が多く認められた(p=0.001)。(4)I+II期で手術を施行したA群59例とB群116例の比較では、組織型、筋層浸潤の程度、脈管侵襲の有無、リンパ節転移頻度、リンパ節転移個数、術後補助療法に差はなく、A群vsB群の無増悪生存(progression-free survival;以下PFS)、全生存(overall survival;以下OS)はそれぞれ78.8%vs74.1%、85.4%vs79.5%と同等であった。(5)III+IV期の予後は両群同等であったが、IIIB期に関してはA群vsB群のPFS、OSはそれぞれ0%vs34.9%(p=0.142)、0%vs59.5%(p=0.028)と症例数は少ないものの、A群の全生存は有意に予後不良であった。【結論】若年子宮頸癌はI、II期癌が有意に多く、その予後は40歳以上の症例と同等、むしろ良好であるが、その一方で進行癌の予後は不良である可能性が示唆された。(著者抄録)

症例1(31歳、0経妊0経産婦)。症例2(35歳、1経妊1経産婦)。症例3(28歳、1経妊1経産婦)。3症例とも子宮筋腫に対する腹腔鏡下手術目的に受診となった。いずれの症例も術前検査にて子宮は正常形態を保ち、漿膜下および筋層内に筋腫は認められなかった。だが、腫瘤は子宮に近接しており、周囲臓器と強固な癒着を形成していたため臓器圧迫症状があった。以後、腹腔鏡下手術を行なったところ、腫瘤の癒着剥離操作により腫瘤は速やかに虚血性変化を示した。尚、病理検査では中心性壊死が認められ、臨床経過と総合し、PM(骨盤内腫瘤)の自然発生が考えられた。

We encountered a 46-year-old woman with synchronous quintuple primary cancers. She did not present with any symptoms, and her tumors were discovered at a gynecological screening. She had clear cell adenocarcinoma of the right ovary, moderately differentiated endometrioid adenocarcinoma of the endometrium, moderately differentiated adenocarcinoma of the ascending colon, well-differentiated adenocarcinoma of the rectum, and poorly differentiated papillary adenocarcinoma of the left lung. A fluorodeoxyglucose-positron emission tomography and other imaging techniques were extremely useful for the diagnosis of multiple primary cancers. Moreover, MSH2 protein expression was absent in the tumors of the ovary, endometrium, ascending colon, and rectum, while the rectal cancer also lacked MLH1 protein. These findings suggested that an abnormality of DNA mismatch repair genes was responsible for carcinogenesis. Copyright (C) 2012 S. Karger AG, Basel

Primary uterine cervical neuroendocrine tumors are rare, but affect relatively young women and the prognosis is poor despite multidisciplinary treatment. The incidence of meningeal carcinomatosis arising from malignant tumors of the uterine cervix is extremely low, only two patients with meningeal carcinomatosis arising from a uterine cervical neuroendocrine tumor have been reported in the English literature. Moreover, there have been no reports in which this was confirmed at autopsy. We encountered a pregnant woman aged 33 years who was diagnosed as having atypical carcinoid of the uterine cervix after radical surgery. Despite multidrug chemotherapy (paclitaxel + etoposide + cisplatin and irinotecan + carboplatin), the patient developed multiple organ metastases. Although there was no metastasis to the brain parenchyma or the spinal cord parenchyma, the patient also developed meningeal carcinomatosis. Whole-brain radiation therapy was performed, but was ineffective. The patient died at 19 months after her initial operation and 10 days after diagnosis of meningeal carcinomatosis. The presence of meningeal carcinomatosis was confirmed at autopsy.

24歳。月経過多と倦怠感を主訴とした。経腟超音波で子宮体部後壁に子宮内膜変形を伴う84×76×84mmの低輝度の腫瘤を認め、子宮筋腫の診断で腹腔鏡下筋腫核出術を施行した。子宮後壁筋層に切開を加えた途端、動脈性の強出血を認め、止血に難渋した。筋腫核出時に子宮内膜の一部が穿破し、術中出血が多いため1層での全層縫合を行い、その後子宮筋層の2層縫合を行った。術後経過は良好であったが、25日目の経腟超音波で筋腫核出部に最大径23mmの嚢胞性病変があり、カラードップラーで拍動性の噴水状血流を認めた。検査直後に突発的な大量性器出血を来たし、嚢胞性病変の破綻と考え緊急開腹術を施行した。嚢胞性病変内背側より直径1mmほどの動脈が数ミリ突出しており、拍動性出血を認め、単離結紮で完全止血可能であった。その後、嚢胞壁の穿孔部を含め筋層の3層縫合を行った。術後経過は良好で、77日目の超音波では子宮後壁の筋層切開部付近に異常血流を認めた。現在まで再発は認めていない。

Recently, as laparoscopic myomectomy (LM) has become increasingly common, reports of intraoperative or postoperative complications have arisen. We experienced a case of massive hemorrhage resulting from a ruptured uterine arteriovenous fistula after LM.<BR>  A 24-year-old woman, nulligravid, presented with hypermenorrhea. She was diagnosed with an 8-cm intramyometrial leiomyoma of the posterior uterus with endometrial deformation. LM was performed. The myoma was soft, its boundaries were not clear, and there was extensive contact with endometrium. Operative time, blood loss, and enucleate weight were 181 minutes, 1,000 ml, and 298g. On a transvaginal ultrasound 25 days after the operation, a cystic lesion was noted in the area of the myomectomy. Color Doppler ultrasonography showed a fountain of blood streaming from a single artery into the cyst, while the size of the cyst was not changed. However, a massive hemorrhage erupted even as we were conferring with the patient in the medical examination room. She underwent emergency laparotomy on the same day. Pulsatile bleeding from a 1mm diameter artery in the wound of the myomectomy was observed. We examined the cyst in detail after ligating the artery. The wall of cyst was a structured fibrous myomatous capsule of a white color with a perforation of the intrauterine part. Blood infiltration and hematoma were not seen at all in the myometrium of the cyst.<BR>  We have performed LM on 406 patients in our hospital. This case was the first of its kind, so we are reporting it as a warning for consideration in the LM of the future.

Ectopic ovary is a rare gynecologic entity. A variety of synonymous terms such as ectopic ovary, supernumerary ovary, accessory ovary, and autoamputation of the ovary have been used to describe this condition. The etiology for ectopic ovary has not been elucidated, but several mechanisms have been proposed. They are categorized as either congenital (embryologically derived) or acquired. This report presents two cases of ectopic ovary resulting from different causes and one case of potential ectopic ovary. © 2010 Japan Society for Reproductive Medicine.

In recent years, improvements in diagnostic technology have enabled the early detection of ectopic pregnancy, and the opportunities for preserving the oviduct have increased, particularly as laparoscopic surgery has become the first-line choice for treatment of ectopic pregnancy in an increasing number of institutions. At our institution we use laparoscopic techniques to attempt oviduct preservation in patients with ectopic pregnancy who wish to become pregnant again. In this report, we examined the rates of persistent ectopic pregnancy and repeat ectopic pregnancy over a ten year period in patients who were treated laparoscopically with oviduct preservation. When compared with other treatments, we found a lower rate of persistent and recurrent ectopic pregnancy in women who were treated with oviduct-persevering laparoscopy. We conclude that laparoscopic surgery with oviduct preservation should be the therapy of choice for ectopic pregnancy when the patient still desires to get pregnant. However, a thoroughly informed consent detailing the risks of persistent and recurrent ectopic pregnancies must be a priority because of the high emotional toll of these complications.

Objective: We conducted postoperative follow-up of patients with bilateral ovarian chocolate cysts, focusing on rates of recurrence, potential to conceive, and degree of ovarian reserve. <BR>Methods: A total of 128 patients diagnosed with bilateral ovarian chocolate cysts were studied during a 9-year period. Any patient seen postoperatively for six months or more was included in the study. Of this cohort, 21 underwent bilateral cystectomy, while bilateral fenestration and coagulation was performed for the remainder (n=107). <BR>Results: The recurrence rate was 4.7% (6/128), with all instances of recurrence limited to the bilateral fenestration and coagulation technique The mean period from surgery to recurrence was 12.5 months (range, 10-31 months). The recurrence rate by surgical procedure was 0% (0/21) for bilateral cystectomy and 5.6% (6/107) for bilateral fenestration and coagulation. Seventeen of 40 (42.5%) patients became pregnant in the study time frame (12 spontaneous cycles, 3 clomiphene cycles, and 2 IVF-ET cycles). We also selectively examined subjects under the age of 40 years (115/128) whose menstrual cycles had been normal prior to surgery. The rate of postoperative menstrual disorders was 22.2% (4/18 cases) for bilateral cystectomy and 4.1% (4/97 cases) for bilateral fenestration and coagulation (p=0.0055). <BR>Discussion: Laparoscopic fenestration and coagulation, rather than cystectomy, may be a preferable treatment for bilateral chocolate ovarian cysts in terms of preserving fertility and ovarian reserve.