Michiyasu Kawai

Diagnosis of squamous cell carcinoma arising from mature cystic teratoma of the ovary

The prognoses of patients with squamous cell carcinoma of the ovary are quite poor. However, preoperative diagnosis is difficult due to the rarity of this tumor and its similarity to mature cystic teratoma (MCT). The objective of this study was to assess the value of tumor markers and clinical characteristics in making a differential diagnosis between MCT and squamous cell carcinoma arising from MCT.

Placenta previa increta/percreta in Japan: A retrospective study of ultrasound findings, management and clinical course

Aim:  Placenta accreta is an abnormally firm attachment of placental villi to the uterine wall, which may cause postpartum hemorrhage resulting in maternal morbidity and mortality. The purpose of the present study was to clarify the incidence, clinical background and prognosis of placenta previa increta/percreta treated with different modalities in Japan.

Prognostic factors in yolk sac tumors of the ovary. A clinicopathologic analysis of 29 cases

Twenty‐nine ovarian cancer patients with yolk sac tumors and germ cell tumors with yolk sac tissue as a component of their disease (16 endodermal sinus tumor, 11 mixed germ cell tumors, one embryonal carcinoma, and one polyembryoma) were treated with cytoreductive surgery and combination chemotherapy. Prognostic factors were investigated in this group. Patients with Stage I disease had a more favorable prognosis (P < 0.003) than those with Stages II and IV disease. The difference in prognosis was significant in cases where residual tumor was absent (P < 0.003) and in cases where ascites was either absent or less than 100 ml in volume (P < 0.05). Endodermal sinus tumor with either an intestinal (P < 0.05) or microcystic pattern (P < 0.01) was more common in survivors than in those who died. The age, preoperative serum alpha‐fetoprotein level, maximum tumor size, and tumor weight had no significant correlation with prognosis. In advanced cases, chemotherapy regimens including cisplatin gave better results than those containing vincristine, dactinomycin, and cyclophosphamide (P < 0.05). The optimal treatment of yolk sac tumors or tumors with yolk sac tissue as a component of the ovary is discussed in light of these results.

Seven Tumor Markers in Benign and Malignant Germ Cell Tumors of the Ovary

Seven tumor markers were analyzed clinically in 135 patients with germ cell tumors of the ovary who were treated in Tokai Ovarian Tumor Study Group, an association comprising Nagoya University and its affiliated hospitals, between January 1979 and September 1990. Positive rate of AFP was 100% (36/36) in yolk sac tumor, 61.9% (13/21) in immature teratoma, and 11.8% (2/17) in dysgerminoma, but there were no positive cases of mature cystic teratoma with malignant transformation (0/7) and mature cystic teratoma (0/31). Positive rate of CA125 was over 50% in all tumor types except mature cystic teratoma, which showed a positive rate of 23.7%. CA125 was useful for the screening of malignant germ cell tumors. CA19-9 showed a high positive rate in teratomatous tumors, which were immature teratoma, mature cystic teratoma with malignant transformation, and mature cystic teratoma. Dysgerminoma and yolk sac tumor, especially dysgerminoma, had a high positive rate of LDH. TPA and CEA were not considered useful tumor markers for germ cell tumors of the ovary.

Long-Term Prognosis of Stage I Ovarian Carcinoma

Objective: There are a few long-term follow-up studies of patients with stage I ovarian carcinoma. The objective of this study was to evaluate prognostic factors for long-term survival. Methods: Two hundred fourteen stage I ovarian carcinomas (registered by the Tokai Ovarian Tumor Study Group from 1988 to 1999) were analyzed. Staging according to the International Federation of Gynecology and Obstetrics was set without considering the pathologic findings of the lymph nodes. Stage Ic was divided into Ic(b) and other Ic. Results: Seventy-four patients were stage Ia, 2 were stage Ib, and 138 were stage Ic, consisting of 75 Ic(b) and 63 other Ic patients. The ratios of stage Ic to Ia and stage Ic(b) to Ic were highest in clear-cell adenocarcinoma among histologies analyzed. There were significant differences in disease-free survival curves between each group. In clear cell adenocarcinoma, there was a significant difference in disease- free survival curves between stage Ic(b) and other Ic (p = 0.0373), while this tendency was also observed in other histologies except for mucinous carcinoma. Multivariate analysis demonstrated that substage was a significant prognostic factor of both disease-free and overall survival. Conclusions: Stage Ic(b) patients showed poorer survival than stage Ia patients but better than survival in other Ic. Thus, cautious treatment of ovarian tumor during surgery is quite important to avoid rupture.

Fertility-sparing surgery in young women with invasive epithelial ovarian cancer

OBJECTIVES The purpose of this study was to clarify the clinical outcome of patients with stage IA or more advanced epithelial ovarian cancer (EOC) treated with fertility-sparing surgery (FSS). METHODS After a central pathological review and search of the medical records from multiple institutions, a total of 60 stage I EOC patients treated with FSS were retrospectively evaluated in the current study. RESULTS The median age was 30 years (range: 12-40 years). The median follow-up time was 54.7 months (range: 4.8-243.8 months). The stage was IA in 30, IB in one, and IC in 29 patients. Fifty-two patients were alive without relapse and 8 patient experienced recurrences {IA, 2; IB, 1; IC(surface involvement), 1; and IC(positive cytology), 4}. However, all patients with stage IC(capsule rupture) (n=17) were alive without recurrence. Collectively, there was no significant difference in the overall survival between the stage IA and IC groups (P=0.256). Moreover, there was no significant difference in DFS and OS between patients with stage IC(capsule rupture) and those with stage IA. In contrast, DFS and OS of the patients with stage IC(surface involvement/positive cytology) were poorer than those of patients with stage IA {OS; P=0.030, and DFS; P=0.005, respectively}. Thirteen pregnancies were observed in 9 patients. CONCLUSIONS FSS may be considered a treatment option in women with stage I EOC, even in those with stage IC(capsule rupture) or more wishing to bear children.

Diagnostic Efficacy of Tumor Markers, Sonography, and Intraoperative Frozen Section for Ovarian Tumors

Using sonography, we classified the adnexal masses of 292 patients into 4 patterns. Pattern A was benign cystic tumors; B was benign mixed tumors (cysts with a smooth solid component); C was malignant mixed tumors (cysts with an irregular solid component or thickened septum), and D was solid tumors. We diagnosed tumors showing patterns A and B as benign, while patterns C and D represented tumors with low malignant potential or actual malignancy. The sensitivity and specificity of sonography was 82.2 and 82.1%, respectively, and these values were superior to those for tumor markers (CA125, CA19-9, CA72-4). Both the sensitivity and specificity of intraoperative frozen sections were the highest, showing that this is the most reliable examination. However, 15 of 191 patients undergoing frozen section were upgraded by the final pathological diagnosis. If sonography is performed by an experienced gynecologic oncologist, this examination is more reliable than tumor markers. However, intraoperative frozen section should still be performed during surgery for patients with ovarian tumors.

Survival impact of capsule rupture in stage I clear cell carcinoma of the ovary in comparison with other histological types

OBJECTIVE We analyzed a large number of stage I clear cell carcinoma of the ovary (CCC) patients to estimate the survival impact of the capsule status in stage I CCC patients, particularly in comparison with non-CCC patients. METHODS Clinicopathologic data on 564 patients with stage I epithelial ovarian cancer (EOC) collected under the central pathological review system were subjected to uni- and multivariable analyses to evaluate the disease-free survival (DFS) and overall survival (OS). RESULTS There was no significant difference in both the OS and DFS of CCC patients between IA and IC(ir) (intraoperative capsule rupture) {IA vs. IC(ir); OS: P=0.1402, DFS: P=0.2701}. In contrast, CCC patients at IC(non-ir) {IC excluding for IC(ir), such as preoperative capsule rupture, positive ascites/washing, and surface involvement} showed a poorer OS and DFS than those at IC(ir), or those at the corresponding stage in non-CCC. In multivariable analysis, the capsule status was an independent prognostic factor of a poor OS and DFS {OS: HR, 2.832; 95% CI 1.156-6.938; P=0.023; DFS: HR, 4.327; 95% CI, 1.937-9.667; P=0.0004)} {In contrast, non-CCC: N.S. (OS/DFS)}. Furthermore, in CCC patients, intraperitoneal recurrences were more frequently observed in IC(non-ir) CCC than IA or IC(ir) CCC (P=0.0083) {In contrast, non-CCC: N.S.}. CONCLUSION This study suggests that CCC patients other than those with intraoperative capsule rupture show a considerable risk for mortality despite adjuvant chemotherapy.

Is there any association between retroperitoneal lymphadenectomy and survival benefit in ovarian clear cell carcinoma patients

BACKGROUND To estimate the survival impact of systemic retroperitoneal lymphadenectomy in patients diagnosed with International Federation of Gynecology and Obstetrics pTI-IIb clear cell carcinoma of the ovary (CCC). PATIENTS AND METHODS Demographic and clinicopathologic data were obtained from the Tokai Ovarian Tumor Study Group between 1986 and 2006. Survival curves were calculated using the Kaplan-Meier method. Differences in survival rates were analyzed using the log-rank test. RESULTS A total of 205 patients had clinical pTI-IIb CCC (median age: 52 years, range: 30-75). One hundred and four (50.7%) patients underwent systemic retroperitoneal lymphadenectomy. Lymphadenectomy was not associated with improved disease-free and overall survival in all patients (P = 0.353 and P = 0.645, respectively). Moreover, lymphadenectomy did not improve the overall survival in those with pTIc CCC (P = 0.433). Similarly, on univariate analysis, age, volume of ascites, preoperative CA 125 values, and regimen of chemotherapy were not significant factors. In addition, there was no significant difference in the ratio of positive lymph node metastases regardless of the completion of lymphadenectomy (P = 0.955). CONCLUSION Our data suggest that patients with pTI-IIb CCC who underwent lymphadenectomy did not show a significant improvement in survival. There was no significant difference in the overall and disease-free survival rates in pTI-IIb CCC patients regardless of the completion of surgical staging lymphadenectomy.

α-Fetoprotein in malignant germ cell tumors of the ovary

To investigate the clinical significance of alpha-Fetoprotein (AFP) in malignant germ cell tumors of the ovary, we studied 46 patients who were treated by the Tokai Ovarian Tumor Study Group. The 46 patients had the following tumors: immature teratoma (IT), 17 cases; endodermal sinus tumor (EST), 16 cases; mixed germ cell tumor containing EST, 11 cases; embryonal carcinoma, 1 case; polyembryoma, 1 case. In all 29 non-IT cases, AFP was positive, and in 27 cases (93%) the level was above 1000 ng/ml. In 11 of 17 cases of IT (64.7%), AFP levels were elevated and in 1 case the level was above 1000 ng/ml. Elevation of the AFP level above 1000 ng/ml suggested the presence of EST. AFP levels were monitored in 27 of 29 cases without IT during treatment and follow-up. It was found that AFP levels should be monitored closely for at least 1 year after induction of remission. No recurrence was observed when AFP continued to be negative longer than 1 year. The mean interval to clinical recurrence from the reelevation of AFP was 4 months (1.4-9 months). An increase in the AFP to a positive level, even without clinical signs of recurrence, should be regarded as a recurrence. AFP was found to be a useful tumor marker for the diagnosis and management of malignant germ cell tumors of the ovary.