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 close cooperation with therapeutic radiation oncologists and medical oncologists.
The incidences of three common gynecologic cancers, cervical, endometrial and ovarian cancer, are now on the increase in Japan. In our institution, the numbers of endometrial and ovarian cancer patients have increased about four-fold during the last 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 invasive cervical cancer is still the most common gynecologic cancer in Japan.

Routine Activities
Four gynecologic oncologists belong to the Gynecology Division as staff members. In addition, there are one chief resident and three residents under training in our division.
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 Ia1 cervical cancer. Patients with stage Ia2-IIIa usually undergo radical hysterectomy and pelvic lymphadenectomy. Post-operative 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 hysterectomy with bilateral salpingo-oophorectomy. Pelvic lymph node dissection is also performed for patients with high risk of metastasis. Para-aortic node dissection is only performed, if there is a biopsy proven nodal metastasis. Positive peritoneal cytology is not a poor prognostic factor for patients with a well-differ-entiated tumor. Postoperative total pelvic irradiation is performed for 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 resection of the involved intestine are the standard procedure for the treatment of ovarian cancer. For patients who do not have peritoneal dissemination, pelvic and para-aortic lymph node dissection is indicated if the metastasis has been confirmed by frozen section. For patients with advanced stage, surgery is followed by combination adjuvant chemotherapy containing Carboplatin and either Paclitaxel or Docetaxel. Patients with advanced stage III and IV disease are unlikely to achieve optimally tumor debulking, are treated with primary chemotherapy. After four courses of chemotherapy, laparotomy is usually 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
Biopsy specimens of cervical squamous cell carcinoma treated with radiotherapy were reviewed by Okada et al. They devised a histological criteria for the predictability of response to radiotherapy.
To identify selection criteria for nonradical surgery for adenocarcinoma of the cervix, Kasamatsu et al analysed seventy-nine patients with early cervical adenocarcinoma, and concluded that patients with stage Ia1 cervical adenocarcinoma might be treated with simple hysterectomy without lymphadenectomy and oophorectomy .
The results of a multi-institutional phase I-II study of a combination chemotherapy with cisplatin, paclitaxel and doxorubicin for patients with advanced ovarian cancer were reported by Onda et al.

Clinical Trials
A randomized controlled trial of a neoadjuvant chemotherapy for advanced cervical cancer (stage Ib2 or stage II having a large tumor with one dimension over 4 cm) was started in 2001 and is now ongoing, by the study group supported by the MHWL (JACOG102). A randomized controlled trial of a neoadjuvant chemotherapy for advanced epitherial ovarian cancer (stage IIIc or IV) will be started in 2003, by the study group supported by the MHWL (JAGOG0206MF). 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.

R. TSUNEMATSU

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