Investigator
Nippon Medical School
Dysgerminoma of the ovary presenting as acute abdomen with intratumoural gas image: a diagnostic challenge suspected as a gastrointestinal stromal tumour
A woman in her 20s presented with acute abdomen, manifesting as a palpable abdominal mass, left lower quadrant pain and vomiting. Imaging revealed a large pelvic mass containing multiple linear air pockets, which complicated the differentiation from gastrointestinal tumours (such as gastrointestinal stromal tumour) or abscesses. Emergency surgery revealed a left ovarian tumour with 360-degree torsion and associated congested change. Pathological diagnosis confirmed dysgerminoma, characterised by positive immunohistochemistry for Sal-like protein 4, placental alkaline phosphatase and octamer-binding transcription factor 4 (OCT-4). We hypothesise that the intratumoural gas was intravascular gas associated with the torsion, entrapped within the dysgerminoma’s characteristic fibrovascular septa, thereby mimicking an enterogenous mass. This case highlights the importance of considering ovarian torsion as an aetiology of unusual gas images and underscores the challenge in diagnosing rare ovarian malignancies presenting acutely.
Prognostic Significance of Actinin‐4 Protein Expression and Gene Amplification in Endometrial Carcinoma
ABSTRACT Objective This study aimed to investigate the clinical significance of actinin‐4 in endometrial carcinoma. Actinin‐4, an actin‐binding protein involved in cytoskeletal dynamics, has been implicated in the progression of various cancers; however, its precise role in endometrial carcinoma is not fully understood. This research sought to evaluate actinin‐4 protein expression and gene amplification and correlate these findings with clinicopathological parameters and patient survival to determine its prognostic value. Methods A retrospective analysis was conducted on endometrial carcinoma patients who underwent surgical resection. Actinin‐4 protein expression was assessed using immunohistochemical staining (IHC), and ACTN4 gene amplification was evaluated by fluorescence in situ hybridization (FISH). The intensity of actinin‐4 staining was graded, and gene amplification of ACTN4 was defined using the ACTN4 / CEP19 ratio. Statistical analysis, including Kaplan–Meier survival analysis and Cox proportional hazards modeling, was performed to correlate actinin‐4 expression with clinicopathological features and survival outcomes. Results Overexpression of actinin‐4 protein by IHC was significantly associated with advanced clinical stage and histological subtypes. While no significant difference was observed in overall survival (OS), patients with high actinin‐4 IHC demonstrated significantly poorer progression‐free survival (PFS). ACTN4 gene amplification by FISH was significantly associated with poorer prognosis for both OS and PFS compared to the group without amplification. Conclusion This study suggests that actinin‐4 plays a role in the progression of endometrial carcinoma, particularly influencing tumor aggressiveness and progression‐free survival.
A Survey of Current Practice and Perspectives on Lymphadenectomy in Minimally Invasive Surgery for Endometrial Cancer in Japan
ABSTRACT Objective This study investigated the reasons behind the decreasing trend of lymph node dissection for endometrial cancer (EC) in Japan, focusing on the impact of minimally invasive surgery (MIS) adoption, evolving clinical guidelines, and physician work‐style reform. Methods A cross‐sectional survey of the Japan Society of Gynecologic Oncology and Endoscopy (JSGOE) members was conducted to investigate facility demographics, MIS adoption, lymphadenectomy practices, factors influencing omission, impact of work‐style reform, and perspectives on future EC management, such as molecular classification and sentinel lymph node biopsy (SLNB). Results In total, 424 responses were received, representing a response rate of 67.8%. MIS adoption for EC is widespread in Japan, with laparoscopy preferred over robotic surgery. Lymphadenectomy is commonly performed; however, the criteria for omission varied among institutions, with clinical guidelines published by the Japanese Society of Gynecologic Oncology having the greatest impact. Physician work‐style reform significantly affected surgical practices such as surgical scheduling, adherence to time limits, and the number of surgeons participating in surgeries, while it had little impact on the criteria for lymphadenectomy omission. The adoption of molecular classifications is increasing with approximately half of the institutions planning to implement or having partially implemented them, while SLNBs remained relatively low. Conclusion This study highlights the significant impact of evolving clinical guidelines on lymphadenectomy practices for MIS for EC in Japan, and the limited impact of physician work‐style reform.
High-grade endometrial stromal sarcoma presenting with multiple brain metastases: a case report
High-grade endometrial stromal sarcoma is a rare and aggressive subtype of uterine sarcoma, characterized by a poor prognosis. While typical initial manifestations include gynecological symptoms such as abnormal vaginal bleeding (for example, postmenopausal bleeding, intermenstrual bleeding, or menorrhagia), abdominal pain, and abdominal distension, an initial presentation involving distant metastases, particularly to the brain, is exceptionally uncommon. This case highlights a highly atypical initial presentation of this rare and challenging disease. This report details a unique clinical scenario of high-grade endometrial stromal sarcoma in a 58-year-old Japanese woman. She presented with left hemiparesis and unexplained weight loss, leading to the discovery of multiple brain tumors on cranial computed tomography. Following craniotomy and tumor resection, pathology suggested metastatic sarcoma. Positron emission tomography-computed tomography subsequently identified the uterus as the most probable primary site. Despite initial negative endometrial biopsy results, a targeted transabdominal computed tomography-guided biopsy ultimately confirmed the diagnosis of high-grade endometrial stromal sarcoma. Furthermore, detailed imaging and pathological findings raised the intriguing possibility that the high-grade endometrial stromal sarcoma may have originated from pre-existing adenomyosis. Despite initial chemotherapy and Gamma Knife radiosurgery for brain metastases, the patient's condition rapidly deteriorated, leading to her death approximately 4 months after initial presentation, highlighting the aggressive nature and poor prognosis of this disease. The inherent rarity of high-grade endometrial stromal sarcoma, combined with its highly unusual initial presentation as neurological symptoms, significantly contributed to the diagnostic delay in this case. This report critically underscores the vital importance for clinicians to maintain a high index of suspicion for high-grade endometrial stromal sarcoma in the differential diagnosis of patients presenting with brain metastases, even when typical gynecological complaints are absent.
Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross‐sectional survey for JSGOE members
AbstractAimMinimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross‐sectional questionnaire survey to ascertain the status of MIS for endometrial cancer.MethodsThe survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed.ResultsThe total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board‐certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan.ConclusionThis study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra‐fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.
Preoperative screening endometrial cytology discovered incidental gynaecological malignancy in two patients undergoing risk-reducing salpingo-oophorectomy
Pelvic ultrasonography and measurement of serum cancer antigen 125 (CA-125) are recommended for preoperative evaluation before performing risk-reducing salpingo-oophorectomy (RRSO). We report our experience with two patients in whom an incidental gynaecological malignancy was found using endometrial cytology as a preoperative screening test for RRSO. Patient 1 was an early 50s woman with a pathologic variant of BRCA1. Transvaginal ultrasonography showed no endometrial abnormalities, but preoperative endometrial cytology revealed high-grade serous carcinoma. The patient underwent total hysterectomy, bilateral adnexectomy, pelvic and para-aortic lymph node dissection, and omentectomy. Patient 2 was a late 40s woman with a pathological variant of BRCA1. Transvaginal ultrasonography showed mild enlargement of the left ovary, and her CA-125 level was elevated. Preoperative endometrial cytology revealed high-grade serous cancer. She underwent total hysterectomy, bilateral adnexectomy and omentectomy. These case reports illustrate the importance of preoperative screening—including endometrial cytology—before performing RRSO.
Significance of positive peritoneal cytology for recurrence and survival in patients with endometrial cancer
AbstractAimThis study aims to examine the association between malignant peritoneal cytology and prognosis in women with endometrial cancer.MethodsWe retrospectively analyzed the records of patients with endometrial cancer who underwent surgery with intraoperative peritoneal cytology at our hospital between January 1988 and December 2012. All results were reclassified according to the 2009 International Federation of Gynecology and Obstetrics (FIGO) system, and the relation between intraoperative peritoneal cytology results and recurrence and prognosis was examined.ResultsOf the 908 patients analyzed, 205 (22.6%) had positive peritoneal cytology. Patients with positive peritoneal cytology had significantly lower rates of recurrence‐free survival (RFS) and overall survival (OS) than those in the negative cytology group (both p < 0.001). Subgroup analysis of patients with FIGO stage I/II showed significantly lower RFS in the positive‐cytology group (p = 0.005), but there was no significant difference in OS (p = 0.637). In the patients with FIGO stage III/IV or patients classified as “high risk,” the RFS and OS were significantly lower in the positive‐cytology group (both p < 0.001). Cox regression analysis identified positive peritoneal cytology as a significant predictor of recurrence in patients with FIGO stage I/II disease.ConclusionsPatients with positive peritoneal cytology for endometrial cancer have a high risk of recurrence, regardless of histopathologic type or FIGO stage. Peritoneal cytology has already been removed from the 2009 FIGO classification of endometrial cancer, but it may deserve reconsideration.
Small bowel intussusception as a rare presentation of metastatic uterine leiomyosarcoma
Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer, commonly metastasising to the lungs and liver. However, small bowel metastasis, especially causing intussusception, is exceedingly rare. We report a woman in her 60s who developed acute small bowel obstruction 22 months after her initial uLMS diagnosis and treatment for bone metastases. Despite being stable on adjuvant therapy, her CT scan confirmed bowel obstruction with intussusception-suggestive findings, though a clear neoplastic lead point was not initially identified. Emergency laparotomy subsequently revealed intussusception with a tumour as the lead point, which histopathology confirmed as metastatic leiomyosarcoma. This case underscores the importance for clinicians to maintain a high index of suspicion for metastatic disease, even at uncommon sites, in patients with a uLMS history presenting with acute abdominal symptoms, regardless of the time elapsed since the primary diagnosis.
Uterine carcinosarcoma showing immature teratoid-like differentiation
A carcinosarcoma is a rare form of cancer characterised by the presence of both carcinomatous and sarcomatous components. Here, we present our experience with an extremely rare case of an uterine carcinosarcoma with immature teratoid-like differentiation. The patient was a woman in her 60s. She was referred for the evaluation of a uterine tumour. She underwent total abdominal hysterectomy with bilateral adnexectomy and received postoperative treatment with paclitaxel and carboplatin. On microscopic examination, the tumour had a heterogeneous appearance with a combination of carcinomatous and sarcomatous elements, and teratoid features. The tumour included immature squamous epithelial cells and immature epithelial glands, and focal atypical fused glands, which are consistent with endometrioid carcinoma, were identified in the endometrium. Pathological differentiation from extrarenal Wilms’ tumour and teratocarcinosarcoma was challenging. The final pathological diagnosis was uterine carcinosarcoma with immature teratoid-like differentiation. At 14 months after the surgery, the patient has not experienced recurrence.
