Synopsis: Brain metastasis has a substantial impact on survival and quality of life. Brain metastasis stemming from gynecological malignancies is rare compared to that from other cancers. In this study, we retrospectively examined the clinical characteristics, treatment for brain metastasis stemming from gynecological malignancies, and prognosis of 14 patients diagnosed and treated at our hospital from January 2008 to December 2020. The primary disease was cervical cancer in three cases, uterine cancer in five, uterine sarcoma in one, and ovarian cancer in five. The brain metastasis was a single brain metastasis in 4 cases and multiple metastases in 10 cases. For patients with a single metastasis, surgery was the treatment of choice, whereas radiation was the treatment of choice for those with multiple metastases. The median survival after diagnosis of brain metastasis was 2.3 months for cervical cancer, 3.7 months for uterine cancer, and 32.5 months for ovarian cancer. The survival time was 27.7 months in the single metastasis group and 3.4 months in the multiple metastases group. Brain metastases generally yield a poor prognosis, but aggressive treatment may be considered because patients may survive for multiple years.

Synopsis: Preoperative diagnosis of gastric-type adenocarcinoma in multiple cystic lesions of the cervix is difficult. This study investigated the optimal screening of gastric-type adenocarcinoma in 123 patients who underwent cervical mucin test using the HIK1083 mAb. Nineteen patients exhibited gastric-type mucin-producing lesions, with a positivity rate of 63.1%for the HIK1083 test. Among these, seven had malignant tumors (including four cases of minimal deviation adenocarcinoma; two of HPV-independent gastric type adenocarcinoma; and one of gastric type adenocarcinoma in situ) and 12 had benign lesions diagnosed as lobular endocervical glandular hyperplasia. Univariate analysis revealed yellowish mucin on cytology and decreased diffusion on MRI imaging as significant factors distinguishing benign from malignant gastric-type mucin-producing lesions. In a multivariate analysis of 38 patients with final pathologic diagnosis and preoperative MRI imaging, a positive HIK1083 test, yellowish mucin, and decreased diffusion emerged as significant factors for screening gastric-type adenocarcinoma. Consequently, in cases of multiple cystic lesions of the cervix, the combination of clinical data—such as positive HIK1083 test, yellowish mucin, and decreased diffusion—indicates the likely presence of gastric-type adenocarcinoma.

Synopsis: Tissue Factor Pathway Inhibitor 2 (TFPI2) is a tumor marker demonstrating high specificity in distinguishing ovarian clear cell carcinoma from other types of ovarian tumors. In Japan, TFPI2 became a part of insurance coverage since April 2021. As fewer cases were presented after the insurance coverage, we investigated the usefulness of TFPI2 in the diagnosis of ovarian cancer. We studied 124 cases, including 67 (54.0%) benign tumors, 12 (9.7%) borderline tumors, and 45 (36.3%) malignancies. Comparing the benign tumors group with the combined borderline tumors and malignancies groups, the combined benign and borderline tumors groups and malignancies group, and the ovarian clear cell carcinoma group and the non-clear cell carcinoma group, both CA125 and TFPI2 showed significant differences, effectively distinguishing the groups. However, when comparing the ovarian clear cell carcinoma group with the ovarian endometrial cyst group, TFPI2 demonstrated a significant difference, while CA125 did not. These findings indicate that TFPI2 can be used alongside conventional tumor markers in real world as well.

Synopsis: Epithelioid sarcoma is a rare soft-tissue sarcoma which is classified into proximal type and distal type. We report a case of advanced proximal epithelioid sarcoma of the Douglas pouch that was successfully treated with first-line chemotherapy. The patient was a 39-year old woman, gravida 2, para 2. She felt buttock pain ten months after the delivery of her second child. She visited her primary care physician, who noted a mass in the Douglas' pouch on transvaginal ultrasound sonography. Subsequent examination revealed a rectal tumor, multiple liver metastases, peritoneal dissemination, and diaphragmatic dissemination. We performed an omental biopsy under diagnostic laparoscopy. Microscopically, poorly cohesive tumor cells were densely arranged in sheets, and rhabdoid-like cells were observed. Immunohistochemistry showed a complete absence of INI1 expression. We diagnosed proximal-type epithelioid sarcoma. Comprehensive genomic profiling revealed a SMARCB1/INI1 deficiency, which supported the epithelioid sarcoma diagnosis. She received docetaxel and gemcitabine and achieved a complete response.

Synopsis: A patient is a 52-year-old female with squamous cell carcinoma of uterine cervix. She underwent radical hysterectomy and turned out to be stage IIIC1 with left obturator lymph node metastasis. During her adjuvant chemotherapy, Pegfilgrastim was administered because of the duration of myelosuppression. 11 days after administration of anticancer agents, she had a fever and was admitted with urinary tract infection. Although her blood and urine cultures were negative, she was still febrile and her CRP level elevated. Contrast-enhanced CT revealed thickened wall of aortic arch. Autoimmune disease was ruled out and she was diagnosed as Pegfilgrastim induced aortitis. 14 days after administration of Pegfilgrastim, she became afebrile and her CRP level was normalized in natural course.

Granulocyte-colony stimulating factor (G-CSF) is used for treatment and prevention of febrile neutropenia. G-CSF induced aortitis was first reported in 2004 and added to a medical package insert as a severe adverse event in Japan. Infection is commonly suspected when a patient undergoing chemotherapy gets a fever, but it is important to consider aortitis if G-CSF was administered to them.

Synopsis: Pelvic exenteration is one of the treatment modalities for central recurrence within the irradiated uterine cervical cancer field. We report on two cases with different outcomes.

Case 1 was a stage IIA2 adenocarcinoma of the uterine cervix. Eleven months after completion of concurrent chemoradiotherapy, a recurrence was detected in the uterine cervix, and pelvic exenteration was performed. Numerous perioperative complications required hospitalization for 50 days postoperatively. Although the histopathological resection margins were positive, the patient has favorable outcome without recurrence.

Case 2 was a stage IB1 adenocarcinoma of the uterine cervix with recurrence at the vaginal vault 1 year and 10 months after radical hysterectomy. After repeating systemic chemotherapy for recurrent disease, laparoscopic pelvic exenteration was performed for the third recurrence. Perioperative ileus was observed, requiring hospitalization for 40 days postoperatively. Although histopathological diagnosis was negative for resection margins, 5 months after surgery, a disseminated lesion was found in the pelvis, which was diagnosed as recurrence.

In pelvic exenteration after treatment of vaginal wall invasion, it is important to determine the extent of resection, taking microscopic tumor residuals into consideration. It is also important to avoid dispersing tumor cells because cervical adenocarcinoma often recurs in peritoneal dissemination.

Synopsis: We report a rare case of endometrioid borderline ovarian tumor that underwent conservative surgery, and a baby was delivered. The patient was a 24-year-old woman. Initially, a laparoscopic right ovarian cystectomy was performed due to the rapture of an endometrial cyst. Six months later, a solid left ovarian tumor raised concerns of malignancy, resembling a tumor-like clear cell carcinoma. Subsequently, a left salpingo-oophorectomy was conducted during laparotomy for diagnosis, confirming an endometrioid borderline ovarian tumor upon pathological examination. Radical surgery was avoided due to the patient's desire to have a baby. She received in vitro fertilization and embryo transfer (IVF-ET), and an endometrial polyp was identified by hysteroscopy during fertility assessment, necessitating Transcervical resection (TCR). After two TCR procedures, a successful pregnancy ensued, and she delivered a baby. Long-term follow-up has revealed no tumor recurrence. Generally, endometrioid borderline ovarian tumors exhibit good prognoses. However, achieving pregnancy can be challenging due to coexisting endometriosis and endometrial lesions. Therefore, a proactive approach to fertility management and meticulous evaluations of endometrial lesion is imperative in such cases.