Kazuhiko Ochiai

Preoperative diagnosis of malignant transformation arising from mature cystic teratoma of the ovary

OBJECTIVE Mature cystic teratoma of the ovary (MCT) is the most common ovarian cystic disease in young women. Although it is a rare occurrence, some cases develop malignant transformation (MT), which results in serious consequences. However, MT is currently diagnosed only by postoperative pathology in most cases. We have conducted a retrospective study in an attempt to seek the factor to diagnose MT from MCT prior to surgery. STUDY DESIGN Eighty-one patients with MCT and 39 patients with MT were entered in this study. Patients age, tumor size, serum CEA levels, and serum SCC levels were tested by the Mann-Whiteney U test. Sensitivity and specificity were calculated, and the most suitable point was searched from the receiver operating characteristic (ROC) curve. RESULTS A significant difference was recognized in both patients age and serum SCC level (P < 0.0001). For a patient less than 40 years old, the sensitivity to MT was 95%, and then the specificity to MT was 63%. When the standard value of the SCC level of the serum was established as 2.5 ng/ml, the sensitivity to MT was 80% and the specificity to MT was 94%. We apply two criteria at the same time (serum SCC levels less than 2.5 ng/ml and patients age less than 40 years old). The sensitivity for MT was 77% and specificity was 96%. CONCLUSION The combination of the two criteria which are patients age (under 40 years old) and serum SCC level (under 2.5 ng/ml) was considered a suitable marker for differential diagnosis between MCT and MT. Further the possibility for MT is quite low when the patient is 39 years old or younger and the serum SCC level is under 2.5 ng/ml. When any patient satisfies this condition, laparoscopic surgery will be able to be planned safely.

Serum levels of inhibin in maternal and umbilical blood during pregnancy

Inhibin levels were measured by a double antibody heterologous radioimmunoassay in the peripheral serum of 75 pregnant women throughout gestation and in serum from the umbilical vein and artery, which was obtained at the time of delivery. For reference, samples were obtained from 20 nonpregnant women in the early (days 0 to 3), mid (days 4 to 8), and late (days 9 to 14) luteal or follicular phase. Maternal serum levels of inhibin (mean +/- SEM) in early (6 to 12 weeks) gestation (36.4 +/- 2.6 U/ml, n = 36) were significantly (p less than 0.01) higher than those in serum from nonpregnant women in the mid (23.9 +/- 2.5 U/ml, n = 19) or late (11.3 +/- 0.6 U/ml, n = 19) luteal phase. Inhibin levels in maternal serum fell to 15.9 +/- 1.4 U/ml (n = 24) in mid (14 to 20 weeks) gestation and then gradually increased during late (21 to 40 weeks) gestation to peak levels of 49.4 +/- 5.1 U/ml (n = 9) at 36 to 37 weeks. Inhibin levels declined in parallel with human chorionic gonadotropin concentrations during the first trimester (r = 0.587 at p less than 0.01). Significant positive correlations (p less than 0.001) were observed between serum levels of inhibin and 17 beta-estradiol (r = 0.560), progesterone (r = 0.648), and human placental lactogen (r = 0.715) during mid and late (20 to 40 weeks) gestation. Inhibin levels in umbilical vein serum (38.5 +/- 1.3 U/ml, n = 5) were not different from those in umbilical artery serum (39.4 +/- 3.6 U/ml) but were significantly (p less than 0.01) lower than those in maternal serum (50.9 +/- 5.3 U/ml), which was obtained at the time of delivery. By day 5 of puerperium, serum levels of inhibin in the maternal vein were extremely low (2.3 +/- 0.1 U/ml, n = 7); these levels were nearly one fifth lower than follicular phase levels of 10.9 +/- 3.4 U/ml (n = 38). We propose that maternal inhibin in early gestation is secreted from the corpus luteum of pregnancy but that increasing inhibin levels during mid and late gestation result from inhibin that is produced by the placenta. The lack of an umbilical arterial-venous gradient for inhibin and the higher levels of inhibin in maternal serum argue against a fetal source of inhibin in the maternal circulation. The physiologic function of inhibin that is produced by the corpus luteum and by the placenta remains to be determined.

Effect of Estriol on Bone Loss in Postmenopausal Japanese Women: A Multicenter Prospective Open Study

Objectives: To assess the effects of oral estriol on the bone mineral density (BMD) and bone metabolism in postmenopausal women.

Alpha-fetoprotein (AFP)-producing ovarian tumor in an elderly woman

Apart from typical yolk sac tumors, ovarian tumors with elevated alfa-fetoprotein (AFP) are uncommon and the differential diagnosis needs to consider the hepatoid pattern of a yolk sac tumor, hepatocellular carcinoma metastatic to the ovary, hepatoid carcinoma, and other epithelial ovarian tumors. We report here an AFP-producing ovarian tumor with uncertain pathological diagnosis, which was extremely responsive to chemotherapy. A 59-year-old Japanese woman presented with lower abdominal distension and was found to have a left ovarian mass on pelvic examination and magnetic resonance imaging (MRI) scan. Laboratory tests showed serum AFP, 73 687 ng/ml; carbohydrate antigen 125 (CA125), 1599 U/ml; and carcinoembryonic antigen (CEA), 13.9 ng/ml. Total hysterectomy with bilateral salpingo-oophorectomy, partial omentectomy, and low anterior resection of the rectum was performed, without any residual macroscopic tumor. Microscopically, the tumor was characterized by a hepatoid carcinomatous component composed of solid sheets of large eosinophilic cells with pleomorphic nuclei. The pathological stage was pT2N0M0. Tumor cells were diffusely immunoreactive for AFP and cytokeratin (CAM5.2), but monoclonal CEA and CA19-9 were focally positive in the cytoplasm, while CA125 was negative. The patient was treated postoperatively with three cycles of chemotherapy consisting of bleomycin, etoposide, and cisplatin; with this regimen, serum AFP decreased to 16 ng/ml from 12 600 ng/ml just before the initiation of chemotherapy. The patient received secondary cytoreductive surgery of systemic lymphadenectomy, which revealed no evidence of residual tumor.

A feasibility study on maintenance of docetaxel after paclitaxel-carboplatin chemotherapy in patients with advanced ovarian cancer

Objective To test the concept of taxane sequencing, this feasibility trial evaluated maintenance of docetaxel after paclitaxel and carboplatin combination chemotherapy in patients with stage IC-IV ovarian cancer. Methods All patients received debulking surgery followed by paclitaxel and carboplatin chemotherapy. Attainment of clinically defined complete or partial response was confirmed by image scanning. Maintenance of docetaxel started at an initial dose of 70 mg/m2 every 4 weeks for 6 cycles and was extended to 10 cycles unless disease progression and/or recurrence during the protocol therapy or unacceptable toxicities were seen. Results Stage subsets in 20 eligible patients were as follows: IIIB, 2 patients (10%); IIIC, 13 patients (65%); IV, 5 patients (25%). Neutropenia was common (40% with grade 3 or 4) and was most frequent during first or second cycle although the disabling peripheral neuropathy was not observed. Twelve patients completed protocol therapy (6≤cycles), while 8 patients failed to complete 6-cycle chemotherapy, because of progressive disease (5 patients) or grade 4 toxicities (3 patients). Median PFS was 20 months and 3-year PFS rate was 12%. Median overall survival was 39 months and 3-year OS rate was 69%. Conclusion Six cycles of single-agent docetaxel maintenance chemotherapy is feasible and generally tolerable to women with advanced ovarian cancer who attained a clinically defined response to initial paclitaxel and carboplatin based chemotherapy.

Two cases of epidural anesthesia-associated postoperative decubitus

Very few cases of postoperative decubitus have been reported. We report two cases of hip decubitus after myomectomy. Case 1 is a 32‐year‐old Japanese woman who underwent an uncomplicated myomectomy under the combination of general and epidural anesthesia. Twelve hours after surgery, a palpable soft tissue mass developed in the sacral region. On day 3, the soft tissue mass had disappeared and the patient was discharged on day 8. Case 2 is a 33‐year‐old woman. Under a combination of spinal and epidural anesthesia, a myomectomy was carried out. On day 1 after surgery, a hard mass with redness was detected. On day 8, decubitus improved and she was discharged. We evaluated the temporal changes in anesthetic level in four independent cases. Eighteen hours after surgery, the anesthetic effect still continued below the L2 level. We conclude that the extended effect of epidural anesthesia might be one of the mechanisms causing postoperative decubitus.

Retrospective analysis of sites of recurrence in stage I epithelial ovarian cancer

Objective The aim of the study is to investigate recurrence of stage I epithelial ovarian cancer. Methods Six hundred two patients diagnosed with stage I epithelial ovarian cancer at 4 hospitals between 2000 and 2013 were retrospectively analyzed. Age, surgical procedure, substage, histologic type, adjuvant chemotherapy, recurrence, initial recurrence site (peritoneal dissemination [P], hematogenous recurrence [H], lymphogenous recurrence [L], and others [O]), and frequency of recurrence at each site were investigated retrospectively. Results Median age was 54 years and median follow-up was 60 months. The stage was IA in 180 cases (30%), IB in 8 (1%), IC1 in 247 (41%), IC2 in 63 (10%), and IC3 in 104 (17%). Systematic lymph node dissection including both pelvic and para-aortic lymph nodes was performed in 224 patients (37%), and 412 patients (68%) received adjuvant chemotherapy. Recurrence occurred in 70 patients (11.6%). The median time to recurrence was 18 months, and the stage was IA in 13 (19%), IB in 1 (1%), IC1 in 24 (34%), IC2 in 9 (13%), and IC3 in 23 (33%) cases. The numbers of recurrence at the P, H, L, and O sites, including overlapping cases, were 49 (70%), 18 (26%), 9 (13%), and 6 (9%), respectively, and recurrence by peritoneal dissemination in the pelvis occurred in 43 cases (61%). Conclusion Recurrence of stage I epithelial ovarian cancer by peritoneal dissemination was frequent, especially in the pelvis. There is a need to elucidate the pathogenesis of peritoneal recurrence and to prepare a treatment strategy to prevent pelvic peritoneal recurrence.

A case of hormone-producing tumor detected colposcopsically and cytolosically.

子宮癌集団検診にてコルポスコープおよび子宮腟部細胞診を施行し, ホルモン産生腫瘍の存在を疑いえた症例を経験したので, 細胞標本のホルモン評価を加え報告した.症例は, 76歳の閉経後31年を経た婦人で, コルポスコープにて多量の頸管粘液と偽ビランを認め, 子宮腟部細胞診にてMIが右方移動を示し, なおかつ内膜細胞診では子宮内膜増殖症が疑われ, 何らかのestrogen活性の存在が示唆された. 術前のホルモン検査では, E252.1pg/mlと高値を示した. ホルモン産生腫瘍の診断のもとに手術が施行されたが, 左卵巣は多房性のendometrial cystが大半を占め, 一部間質の増殖が認められるのみで, いわゆるfunctioning tumorの所見とは異なっていた. また, 子宮内膜はcystic hyperplasiaの像を示し, estrogenの効果と思われた. 術後のホルモン検査ではE216.3pg/mlと低下しestrogenはやはり卵巣腫瘍より産生されていたと思われた.細胞標本のホルモン評価では, 本症例においてKPIとEIが高値を示し, 表層細胞の大きさは, 有意に小さかった.