Gynecology Division

Introduction
The Gynecologic Oncology Division deals with tumors originating from the female genital and reproductive organs. Surgery is the main treatment modality for most gynecologic cancers, but multidisciplinary treatments, consisting of radiotherapy and chemotherapy, are routinely carried out in this division. We work closely with therapeutic radiation oncologists and medical oncologists.
The incidence of cancer of the uterine body is on the rise in Japan. In our institution, the numbers of endometrial cancer patients have increased markedly, about fourfold during the past thirty years. The number of patients with invasive squamous cell carcinoma of the cervix had decreased by half in that same period, but the trend has reversed since the late-1990s. Consequently the numbers of patients with invasive cervical and corpus cancer have become equal since 1997.

Routine Activities
Four gynecologic oncologists and one medical oncologist belong to the Gynecology Division as staff members. In addition, there are one chief resident and one resident under training in our division.
The outpatient routine consists of rectovaginal examination, colposcopy, Papanicolaou smear, directed biopsy for examination of the cervix, curettage for examination of endometrium, and transabdominal or transvaginal ultrasonography for uterus and pelvic masses. Routine preoperative examinations are planned before admission.
Current topics in the diagnosis and treatment of gynecologic malignancies are periodically discussed after the Monday general meeting. All cases under treatment are presented at the joint conference every Wednesday. A clinicopathological conference is held monthly on 2nd Tuesday.
(1) Treatment strategy for uterine cervical cancer
Either conization or simple total hysterectomy is the treatment of choice for persistent high grade dysplasia, Stage 0 or Stage Ia1 uterine cervical cancer. Patients with stage Ia2-IIIa usually undergo radical hysterectomy and pelvic lymphadenectomy. Postoperative total pelvic irradiation following radical hysterectomy is only considered in patients with metastasis to pelvic nodes or parametrial tissue confirmed by pathological examination. Radiotherapy is given to patients with stage IIIb-IV, or poor risk patients at any stage. Chemotherapy is sometimes employed for the treatment of distant metastasis. Concurrent chemo-radiotherapy became a routine method for bulky stage tumors.
(2) Treatment strategy for endometrial cancer
The primary treatment choice is a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. Para-aortic lymph node dissection is also performed, if there is a biopsy proven nodal metastasis. However, lymph node is not removed, if the tumor is well differentiated and has less than 50% myometrial invasion. Positive peritoneal cytology is not a poor prognostic factor for patients with a welldifferentiated tumor. Postoperative total pelvic irradiation is given to patients with metastasis to pelvic node. For patients with distant metastasis, chemotherapy is added to the treatment regimen.
(3) Treatment strategy for ovarian cancer A simple total hysterectomy, bilateral salpingo-oophorectomy and omentectomy with or without combined resection of the involved intestine are the standard procedure for the treatment of ovarian cancer. For patients who do not have any peritoneal dissemination, pelvic and para-aortic lymph node dissection is indicated National Cancer Center Hospital Annual Report if the metastasis is confirmed by frozen section. For patients with advanced stage, surgery is followed by combination chemotherapy containing Carboplatin and Taxol (TJ). Patients with advanced stage III and IV disease that are believed unlikely to be optimally debulked, are treated with primary chemotherapy. After six course of chemotherapy, an initial surgery is performed for these patients. Surgery alone can offer the chance of cure for cases of recurrence, if the disease is completely resectable.

Research Activities and Clinical Trials
A randomized controlled trial of neoadjuvant chemotherapy for advanced cervical cancer (stage Ib2 or stage II having a large tumor with one dimension over 4 cm) was started on December, 2001, by the study group supported by the Ministry of Health, Labour and Welfare.
A phase I/II study of Heavy Ion Radiotherapy for advanced cervical adenocarcinoma using the Heavy Ion Medical Accelerator in Chiba (HIMAC) that was developed by the National Institute of Radiological Science (NIRS) was instituted in 1997 and is now ongoing.
A randomized controlled trial of neoadjuvant chemotherapy for advanced epitherial ovarian cancer (stage IIIc or IV) will be started in 2002, by a study group supported by the Ministry of Health, Welfare and Labor. First line chemotherapy with carboplatin plus docetaxel and second line chemotherapy with CPT-11 plus carboplatin for advanced or recurrent ovarian cancer are under phase II trial.

R. TSUNEMATSU

Table of Contents