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Isao Murakami,Hiroko Machida,Tohru Morisada,Yasuhisa Terao,Tsutomu Tabata,Mikio Mikami,Yasuyuki Hirashima,Yoichi Kobayashi,Tsukasa Baba,Satoru Nagase 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.4
Objective: To examine the effectiveness of progestin re-treatment for recurrent endometrial intraepithelial neoplasia (EIN), atypical endometrial hyperplasia (AH) and endometrial cancer (EC) following initial fertility-sparing treatment. Methods: A comprehensive systematic review and meta-analysis were conducted by an Expert Panel of the Japan Society of Gynecologic Oncology Endometrial Cancer Committee. Multiple search engines, including PubMed/MEDLINE and the Cochrane Database, were searched in December 2021 using the keywords “Endometrial neoplasms,” “Endometrial hyperplasia,” “Endometrial intraepithelial neoplasia,” “Fertility preservation,” “Progestins,” AND “Recurrence.” Cases describing progestin re-treatment for recurrent EIN, AH and EC were compared with cases that underwent conventional hysterectomy. The primary outcomes were survival and disease recurrence, and the secondary outcome was pregnancy. Results: After screening 238 studies, 32 with results for recurrent treatment were identified. These studies included 365 patients (270 received progestin re-treatment and 95 underwent hysterectomy). Most progestin re-treatment involved medroxyprogesterone acetate or megestrol acetate (94.5%). Complete remission (CR) following progestin re-treatment was achieved in 219 (81.1%) cases, with 3-, 6- and 9-month cumulative CR rates of 22.8%, 51.7% and 82.6%, respectively. Progestin re-treatment was associated with higher risk of disease recurrence than conventional hysterectomy was (odds ratio [OR]=6.78; 95% confidence interval [CI]=1.99–23.10), and one patient (0.4%) died of disease. Fifty-one (14.0%) women became pregnant after recurrence, and progestin re-treatment demonstrated a possibility of pregnancy (OR=2.48; 95% CI=0.94–6.58). Conclusion: This meta-analysis suggests that repeat progestin therapy is an effective option for women with recurrent EIN, AH and EC, who wish to retain their fertility.
Lymphadenectomy issues in endometrial cancer
Yosuke Konno,Hiroshi Asano,Ayumi Shikama,Daisuke Aoki,Michihiro Tanikawa,Akinori Oki,Koji Horie,Akira Mitsuhashi,Akira Kikuchi,Hideki Tokunaga,Yasuhisa Terao,Toyomi Satoh,Kimio Ushijima,Mitsuya Ishika 대한부인종양학회 2021 Journal of Gynecologic Oncology Vol.32 No.2
Objectives: This review aims to introduce preoperative scoring systems to predict lymphnode metastasis (LNM) and ongoing clinical trials to investigate the therapeutic role oflymphadenectomy for endometrial cancer. Methods: We summarized previous reports on the preoperative prediction models forLNM and evaluated their validity to omit lymphadenectomy in our recent cohorts. Next, wecompared characteristics of two ongoing lymphadenectomy trials (JCOG1412, ECLAT) toexamine the survival benefit of lymphadenectomy in endometrial cancer, and described thedetails of JCOG1412. Results: Lymphadenectomy has been omitted for 64 endometrial cancer patients who met low risk criteria to omit lymphadenectomy using our scoring system (LNM score) and no lymphaticfailure has been observed. Other two models also produced comparable results. Two randomizedphase III trials to evaluate survival benefit of lymphadenectomy are ongoing for endometrialcancer. JCOG1412 compares pelvic lymphadenectomy alone with pelvic and para-aorticlymphadenectomy to evaluate the therapeutic role of para-aortic lymphadenectomy for patients atrisk of LNM. For quality assurance of lymphadenectomy, we defined several regulations, includinglower limit of the number of resected nodes, and submission of photos of dissected area toevaluate thoroughness of lymphadenectomy in the protocol. The latest monitoring report showedthat the quality of lymphadenectomy has been well-controlled in JCOG1412. Conclusion: Our strategy seems reasonable to omit lymphadenectomy and could begeneralized in clinical practice. JCOG1412 is a high-quality lymphadenectomy trial in terms ofthe quality of surgical procedures, which would draw the bona-fide conclusions regarding thetherapeutic role of lymphadenectomy for endometrial cancer.