外来診断を可能にするモバイルテクノロジーを用いた細径子宮鏡の使用実績と診断精度の検討

Office hysteroscopy is a minimally invasive procedure and provides a direct view of the endometrial cavity. This study presents the first report of a novel smartphone‑based ultrathin flexible hysterofiberscopy system (currently known as office diagnostic smart hysterofiberscopy, or Hysmartscopy), for the diagnosis of intrauterine abnormalities. The Hysmartscopy system captures images using a flexible fiberscope (0.8 mm in diameter) coupled with an Apple iPhone 6S™. This study was conducted at the Department of Gynecology of Nara Medical University Hospital from February, 2015 to February, 2019. In total, 22 patients requiring a diagnostic Hysmartscopy for the investigation of intrauterine pathology were included in this study. In the first cohort, Hysmartscopy was performed in the operating room with anesthesia in 17 patients to assess the overall physician's experience during image acquisition, subjective image quality and the ease of use on a 5‑point Likert scale. In the second cohort, 5 subjects further underwent Hysmartscopy without anesthesia to evaluate the feasibility and safety of this system. Images were assessed by two expert gynecological endoscopists blinded to the pathological reports. The Hysmartscopy system revealed good resolutions in the ex vivo image and color resolution. From the beginning of the procedure, the time required to capture a video was <1 min. The ergonomic advantage of this technique enabled the examiners to use direct visualization for image‑guided diagnosis in a hand‑held manner. On average, the quality of the images (4.0/5.0 on a 5‑point Likert scale) may be largely sufficient to detect emergent findings. The diagnostic accuracy of Hysmartscopy was found to be 100% (2/2) for the normal endometrium, 71.4% (5/7) for endometrial polyps, 62.5% (5/8) for submucosal fibroids and 100% (5/5) for endometrial cancer. The diagnostic accuracy of Hysmartscopy was 77.3%. None of the cases had any complications during and after the diagnostic procedures. Thus, the results indicate that Hysmartscopy is a patient‑friendly technique without the need for anesthesia and cervical dilation in an office setting. To the best of our knowledge, this study is first proof of concept pilot study of Hysmartscopy. Hysmartscopy may prove to be a simple, convenient, non‑invasive, accurate and well‑tolerated procedure for the diagnosis of intrauterine abnormalities that can be performed within an outpatient clinic.博士（医学）・乙第1453号・令和2年3月16日Copyright: © Iwai et al. This is an open access article distributed under theterms of CreativeCommons Attribution License (https://creativecommons.org/licenses/by-nc-nd/4.0/)

卵巣明細胞癌と類内膜癌の鑑別に関するMRIについての知見

BACKGROUND: Common cancerous histological types associated with endometriosis are clear cell carcinoma (CCC) and endometrioid carcinoma (EC). CCC is regarded as an aggressive, chemoresistant histological subtype. Magnetic resonance imaging (MRI) offers some potential advantages to diagnose ovarian tumors compared with ultrasonography or computed tomography. This study aimed to identify MRI features that can be used to differentiate between CCC and EC. METHODS: We searched medical records of patients with ovarian cancers who underwent surgical treatment at Nara Medical University Hospital between January 2008 and September 2018; we identified 98 patients with CCC or EC who had undergone preoperative MRI. Contrasted MRI scans were performed less than 2 months before surgery. Patients were excluded from the study if they had no pathology, other pathological subtype of epithelial ovarian cancer, and/or salvage treatment for recurrence and metastatic ovarian cancer at the time of study initiation. Clinically relevant variables that were statistically significant by univariate analysis were selected for subsequent multivariate regression analysis to identify independent factors to distinguish CCC from EC. RESULTS: MRI of CCC and EC showed a large cystic heterogeneous mixed mass with mural nodules protruding into the cystic space. Univariate logistic regression analysis revealed that the growth pattern (broad-based nodular structures [multifocal/concentric sign] or polypoid structures [focal/eccentric sign]), surface irregularity (a smooth/regular surface or a rough/irregular/lobulated surface), "Width" of mural nodule, "Height-to-Width" ratio (HWR), and presence of preoperative ascites were factors that significantly differed between CCC and EC. In the multivariate logistic regression analysis, the growth pattern of the mural nodule (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.013-0.273, p = 0.0004) and the HWR (OR = 3.71, 95% CI: 1.128-13.438, p = 0.036) were independent predictors to distinguish CCC from EC. CONCLUSIONS: In conclusion, MRI data showed that the growth pattern of mural nodules and the HWR were independent factors that could allow differentiation between CCC and EC. This finding may be helpful to predict patient prognosis before operation.博士（医学）・乙第1433号・令和元年9月27日© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated

Current status of tertiary debulking surgery and prognosis after secondary debulking surgery for recurrent Müllerian epithelial cancer in Japan: a retrospective analysis of 164 patients (KCOG-G1402)

BackgroundThis study aimed to evaluate the current status of secondary debulking surgery (SDS) and tertiary debulking surgery (TDS; performed for recurrence after SDS) and to assess the overall survival after recurrence of Müllerian epithelial cancer in Japan. We also evaluated the data of patients who underwent a fourth debulking surgery (i.e., quaternary debulking surgery (QDS)).MethodsWe conducted a retrospective study of 164 patients with recurrent Müllerian epithelial cancers (i.e., ovarian, tubal, and peritoneal cancers). The SDS was performed between January 2000 and September 2014 in 20 Japanese hospitals. Clinicopathological data were collected and analyzed.ResultsOf the 164 patients, 66 patients did not have a recurrence or died after SDS. Ninety-eight patients had a recurrence after SDS. Forty-three of the 98 patients underwent TDS; 55 of the 98 patients did not undergo TDS and were classified into the non-TDS group. The overall survival (OS) after SDS was significantly better in the TDS group than in the non-TDS group. The median OS after SDS was 123 and 42 months in the TDS group and non-TDS group, respectively. Of the 43 patients who received TDS, 11 patients were further treated with QDS. The median OS after SDS was 123 months for patients who underwent QDS.ConclusionsThis multicenter study on the prognosis of post-SDS is apparently the first report on QDS in Japan. Patients undergoing TDS have a good prognosis, compared to patients in the non-TDS group. Novel drugs are being evaluated; however, debulking surgery remains a necessary treatment for recurrence