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国立がん研究センター 中央病院

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Department of Gynecology

Tomoyasu Kato, Shunichi Ikeda, Mitsuya Ishikawa, Takashi Uehara

Introduction

The Department of Gynecology 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 considered in close cooperation with therapeutic radiation oncologists and medical oncologists. The incidences of three common gynecologic cancers, that is, cervical, endometrial and ovarian cancer, are now on the rise in Japan.

Routine activities

  1. The staff members of the Department of Gynecology comprise four gynecologic oncologists. A new staff member, Dr. Uehara, has been in our Department since October 2015. In addition, our Division includes six residents in training. Current topics in the diagnosis and treatment of gynecologic malignancies are periodically discussed after the Monday general meeting. All patients under treatment are the subjects of presentations and discussions at the weekly joint conference on Wednesdays. A clinicopathological conference is held on the fourth Tuesday of each month.
  2. Treatment strategy for uterine cervical cancer: Either conization or simple total hysterectomy is the treatment of choice for persistent Cervical intraepithelial neoplasia (CIN) III, carcinoma in situ, or cervical cancer stage IA1. Patients with stages IA2 to IIB usually undergo radical hysterectomy and pelvic lymphadenectomy. Autonomic nerves during radical hysterectomy should be preserved as much as possible to prevent severe neurogenic bladder. Postoperative whole pelvic irradiation following radical hysterectomy is only considered for patients with metastasis to the pelvic nodes or parametrial tissue as confirmed by pathological examination. Furthermore, in 2011, intensitymodulated radiation therapy (IMRT) started to be employed for postoperative adjuvant radiotherapy. Thereafter, none had severe radiation enterocolitis. Radiotherapy alone or concurrent chemo-radiotherapy is given to patients at any stage. Chemotherapy is occasionally used for the treatment of distant metastasis.
  3. 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 a high risk of metastasis. Para-aortic node dissection is limited to those with biopsyproven nodal metastasis. Postoperative adjuvant chemotherapy is performed for patients with extra-uterine disease under management of the Department of Medical Oncology.
  4. Treatment strategy for ovarian cancer: A simple total hysterectomy, bilateral salpingooophorectomy and omentectomy with or without combined resection of the involved intestine are the standard procedures for the treatment of ovarian cancer. When an intraperitoneal tumor can be optimally debulked and node metastasis is confirmed by pathologic sampling during the operation, combined pelvic and para-aortic lymph node dissection is indicated. For patients with advanced-stage cancer, surgery is followed by combination chemotherapy containing Carboplatin and Paclitaxel (TC or dose dense TC). Patients with more advanced stage III and IV disease, who are unlikely to be optimally debulked, are treated with Neoadjuvant chemotherapy (NAC). After three of four courses of chemotherapy, an interval debulking surgery (IDS) is usually performed for three patients. Surgery alone can offer the chance of a cure for patients with recurrence, but only when the disease is completely resectable. The type of patient number and surgical procedure are shown in Tables 1 and 2, respectively.

Research activities

  1. The Japan Clinical Oncology Group (JCOG) 0806-A: This report describes a determination of indications for less invasive modified radical hysterectomy for patients with the International Federation of Gynecology and Obsterics (FIGO) stage IB1 cervical cancer. We expected that patients with <2-3% parametrial involvement and ≥95% five-year OS would be good candidates for less invasive surgery. The primary target population was patients with a tumor diameter ≤2 cm as preoperatively assessed by magnetic resonance (MR) imaging and/or cone biopsy. They had lower risk of parametrial involvement (1.9%) and more favorable fiveyear OS (95.8%). This population is considered a good candidate for less invasive surgery such as modified radical hysterectomy. This paper would shed new light on candidates of less invasive surgery for cervical cancer stage IB1.
  2. Ascites cell block system: To investigate the diagnostic utility of the ascites cell block system (CB), 48 patients with diagnosed carcinomatous peritonitis were reviewed retrospectively between 2010 and 2014. Ascites CB sections were stained with hematoxylin and eosin (HE) and immunohistochemistry. Of the 48 patients, 32 had peritoneal cancer or ovarian cancer, three had endometrial cancers, four had breast cancers, six had digestive system malignancies, and three had peritoneal mesotheliomas. A total of seven patients (14.5%) were different between clinical diagnosis (symptom, image and tumor marker) and the diagnosis by CB. A specific immunochemistry panel was helpful for the estimation of primary lesion, especially in the diagnosis of digestive system origin.
  3. Adjuvant radiotherapy for vulvar cancer stage IIIA: The groin nodes are the most important prognostic factors in squamous cell carcinoma of the vulva. Adjuvant radiotherapy is indicated for patients with node-positive disease. The most common complication is the development of lower extremity lymphedema. Lymph drainage from the vulva rarely bypasses the superficial groin nodes, and from these superficial groin nodes the disease spreads to the deep groin nodes. We regard the absence of deep groin node metastasis as a low risk for pelvic lymph node metastasis, so we have omitted adjuvant radiotherapy for patients with node metastasis limited to the superficial groin region. We showed that five patients with stage IIIA are alive without postoperative radiotherapy, even though two of the five are those with two or more positive nodes.

Clinical trials

  1. A nonrandomized confirmatory trial of modified radical hysterectomy for patients with FIGO Stage Ib1 (< 2 cm) uterine cervical cancer (JCOG1101) is ongoing as planned.
  2. A non-randomized verification study regarding selection of fertility-sparing surgery for patients with epithelial ovarian cancer (JCOG1203) is ongoing as planned.
  3. A randomized phase II/III trial conventional paclitaxel and carboplatin versus dosedense paclitaxel and carboplatin in stage IVB, recurrent, or persistent cervical carcinoma (JCOG 1311) has started.
Table 1. Number of patients

Table 2. Type of procedure

List of papers published in 2015

Journal

  1. Kato T, Takashima A, Kasamatsu T, Nakamura K, Mizusawa J, Nakanishi T, Takeshima N, Kamiura S, Onda T, Sumi T, Takano M, Nakai H, Saito T, Fujiwara K, Yokoyama M, Itamochi H, Takehara K, Yokota H, Mizunoe T, Takeda S, Sonoda K, Shiozawa T, Kawabata T, Honma S, Fukuda H, Yaegashi N, Yoshikawa H, Konishi I, Kamura T, Gynecologic Oncology Study Group of the Japan Clinical Oncology Group. Clinical tumor diameter and prognosis of patients with FIGO stage IB1 cervical cancer (JCOG0806-A). Gynecol Oncol, 137:34-39, 2015
  2. Satoh T, Tsuda H, Kanato K, Nakamura K, Shibata T, Takano M, Baba T, Ishikawa M, Ushijima K, Yaegashi N, Yoshikawa H, Gynecologic Cancer Study Group of the Japan Clinical Oncology Group. A non-randomized confirmatory study regarding selection of fertility-sparing surgery for patients with epithelial ovarian cancer: Japan Clinical Oncology Group Study (JCOG1203). Jpn J Clin Oncol, 45:595-599, 2015
  3. Ikeda S, Ishikawa M, Kato T. Spontaneous ureteral rupture during concurrent chemoradiotherapy in a woman with uterine cervical cancer. Gynecol Oncol Rep, 13:18-19, 2015
  4. Togami S, Sasajima Y, Kasamatsu T, Oda-Otomo R, Okada S, Ishikawa M, Ikeda S, Kato T, Tsuda H. Immunophenotype and human papillomavirus status of serous adenocarcinoma of the uterine cervix. Pathol Oncol Res, 21:487-494, 2015
  5. Arimoto T, Kawana K, Adachi K, Ikeda Y, Nagasaka K, Tsuruga T, Yamashita A, Oda K, Ishikawa M, Kasamatsu T, Onda T, Konishi I, Yoshikawa H, Yaegashi N, Gynecologic Cancer Study Group of the Japan Clinical Oncology Group. Minimization of curative surgery for treatment of early cervical cancer: a review. Jpn J Clin Oncol, 45:611-616, 2015
  6. Yoshida A, Yoshida H, Yoshida M, Mori T, Kobayashi E, Tanzawa Y, Yasugi T, Kawana K, Ishikawa M, Sugiura H, Maeda D, Fukayama M, Kawai A, Hiraoka N, Motoi T. Myoepithelioma- like Tumors of the Vulvar Region: A Distinctive Group of SMARCB1-deficient Neoplasms. Am J Surg Pathol, 39:1102-1113,2015
  7. Shimizu C, Kato T, Tamura N, Bando H, Asada Y, Mizota Y, Yamamoto S, Fujiwara Y. Perception and needs of reproductive specialists with regard to fertility preservation of young breast cancer patients. Int J Clin Oncol, 20:82-89, 2015