要旨:卵巣粘液性

（mucinous borderline ovarian tumor ; MBOT）は，再発することの少ない予後良好な疾患として知られている。まれに再発を経験することはあるが，腹腔内における再発がほとんどである。今回我々は，初回手術から1年後に肺転移で再発した，希少な経過を辿ったMBOTの症例を経験したので報告する。症例は60歳代の2経妊2経産の女性で，1ヶ月続く労作時呼吸苦を主訴に近医診療所を受診し，骨盤内腫瘍と胸水貯留を指摘され，さらなる精査のため福島県立医科大学附属病院産婦人科に紹介となった。画像検査で15cm大の多房性嚢胞性腫瘍が認められたことから卵巣がんが疑われ，腹式単純子宮全摘術，両側付属器切除術，大網部分切除術が行われた。組織診断はMBOTでpT1cN0M0，ステージICと診断した。術後補助化学療法は行わずに経過観察をしていたが，術後1年で撮影したCTで両下肺野に1箇所ずつ小結節影を認めた。胸腔鏡下両肺下葉切除術がおこなわれ，肺病変の組織像は卵巣腫瘍，すなわちMBOTとの形態学的類似性がみられていた。また，肺病変と卵巣腫瘍の免疫組織学的プロファイルが一致していたことや，原発性肺腺癌で高率に陽性となるTTF-1（Thyroid transcription factor-1）が陰性であったことから，MBOTの肺転移再発と診断した。MBOTの肺転移は非常にまれであるが，早期進行期での再発例や，初回手術後に長期間経過してからの再発例が報告されており，進行期の程度によらず肺も含めた長期間のサーベイランスが必要であることが示唆された。

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Background; MR images are considered to be highly effective to examine ovarian tumors. However, in some case, it is difficult to differentiate malignant ovarian tumors from benign ones.
Methods; Five hundred eighty-nine cases of ovarian tumors were managed by laparoscopic surgery during a period of six years. Of these cases, 15 cases were diagnosed as borderline ovarian tumors after surgery, and MR images of these cases were retrospectively reviewed.
Results; The mean age was 35 years old and the mean follow-up period was 36 months. Pathological results revealed ten cases of mucinous borderline tumors (67%), three cases of serous borderline tumors (20%), and the other two cases. In reviewing preoperative MR images, six cases showed solid parts within the tumor walls enhanced by contrast agents or huge tumor size (over 20 cm in diameter). Of ten cases of pathologically proven mucinous borderline tumors, five cases were interpreted as endometrial cysts before surgery.
Conclusion; For the gynecologic laparoscopists, it is necessary to thoroughly understand the characteristic features of MR images for ovarian tumors. If MR images show any possibility of malignancy, proper strategies such as frozen section diagnosis should be considered.

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Objective: Endometrioid borderline ovarian tumor accounts for 0.2％ of all ovarian epithelial tumors, and 63％ of them are associated with endometriosis. In this report, we present a case of an infertile woman with ovarian endometrioma, which was diagnosed as an endometrioid borderline tumor postoperatively.

Case: The patient was a 37-year-old infertile woman with an ovarian cyst. Pelvic magnetic resonance imaging showed a 65-mm ovarian cyst with high signal on T1-weighted imaging and low signal on T2-weighted imaging. Serum CA125 and CA19-9 levels were 17.3 U/mL and 778 U/mL, respectively. We performed laparoscopic cystectomy with a diagnosis of ovarian endometrioma. A 6-cm-sized left ovarian endometrioma was removed, and superficial endometriotic lesions on the pelvic peritoneum and right adnexa were ablated. The score on the revised American Society for Reproductive Medicine classification was 33 points. The histopathological examination revealed that the ovarian cyst was an endometrioid borderline tumor. We discussed the treatment plan with the patient and decided to try to achieve pregnancy as soon as possible instead of performing additional surgery. The patient is currently undergoing assisted reproduction.

Conclusion: We encountered a case of an infertile woman with an endometrioid borderline ovarian tumor who wished to bear a child. Endometrioid borderline tumors are rare, and few reports have described assisted reproduction for patients with this tumor; these patients have lower pregnancy rates than those with other histologic types of ovarian borderline tumor. More studies are required to determine the safety and efficacy of assisted reproductive technology in infertile patients with endometrioid borderline ovarian tumors.

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  Ovarian clear cell borderline tumors are extremely rare, accounting for less than 1% of all borderline ovarian malignancies. The preoperative diagnosis of ovarian borderline malignancy is difficult in some cases, and although the number of cases diagnosed incidentally after laparoscopy is increasing, the optimal treatment for each histological type is unclear. In this case report, we describe a 65-year-old woman who was diagnosed with a cystic ovarian clear cell borderline malignancy without adenofibromatous components after laparoscopy. She presented at our hospital due to an abnormal medical examination, and an MRI revealed a polycystic lesion in the left appendage area. No obvious malignant findings were observed, and laparoscopic bilateral salpingo-oophorectomy was performed. The pathology was determined to be cystic ovarian clear cell borderline malignancy. No additional postoperative treatment was given, and the patient was carefully monitored and has not experienced postoperative recurrence for 1.5 years.

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卵巣上皮性

は全上皮性卵巣腫瘍の10～15％程度を占めている．その多くがStage Iで診断され，全体の再発率は4～12.4％で10年生存率はおよそ95％と報告されているが，悪性腫瘍より若年者に好発するため，妊孕性温存を希望する場合も多い．本研究では，当院で手術を施行した卵巣上皮性54症例のプロファイルを解析し，妊孕性温存手術後の経過および術前検査や術中迅速病理組織検査の精度について検討した．年齢の中央値は43.5歳，23例が40歳未満で，うち18例は未産婦であった．術前PET/CTは19例で施行され，SUV maxの中央値は2.2であった．進行期はI期が52例，III期が2例で，組織型は粘液性が32例，漿液性が17例，類内膜が1例，明細胞が１例，混合上皮性が3例であった．術中迅速病理検査は46例で行われ，6例で最終病理組織診断と乖離があり，2例で再手術が行われた．妊孕性温存手術を施行した24例中観察期間に妊娠を希望したのは9人で，6人に9例の妊娠が成立した．術後追跡期間の中央値は46カ月で，腫瘍摘出術を行った粘液性の１例のみ術後35カ月後に患側卵巣に再発を認めて追加で付属器摘出術を施行したが，再々発なくその後生児を得た．の鑑別にPET/CTの有用性が示唆されているが，術前診断精度の一層の向上が望まれる．また妊孕性温存手術を選択する場合は，再発リスクを考慮したインフォームドコンセントと慎重なフォローアップが必要である．〔産婦の進歩69（2）：77-84，2017（平成29年5月）〕

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近年，卵巣腫瘍合併妊娠に対する腹腔鏡下手術は良性腫瘍であれば低侵襲性から選択されることが多い．しかし，卵巣上皮性

に対する腹腔鏡下手術は慎重な対応が求められる．今回，当院で経験した卵巣合併妊娠に対して腹腔鏡併用下で手術を施行した2例を経験したので報告する．症例1は26歳の初産婦で両側腫瘍に対して妊娠14週6日に腹腔鏡補助下左付属器摘出術，右卵巣嚢腫摘出術，大網部分切除術を施行した．手術は出血少量で終了し，術後経過良好で術後4日目に退院となった．術後病理診断は両側卵巣漿液性，pT1b Nx M0，stage IBの診断であった．妊娠経過は順調で，妊娠40週0日に陣痛発来し，自然経腟分娩となった．卵巣上皮性に関しては現在術後18カ月が経過するが，再発なく経過している．症例2は30歳の初産婦で右卵巣腫瘍に対して妊娠15週4日に腹腔鏡下右付属器摘出術および大網部分切除術を施行した．手術は出血少量で終了し，術後経過良好であったため，術後4日目に退院となった．術後病理診断の結果は，右卵巣漿液粘液性 pT1A Nx M0，stageIAの診断であった．以降の妊娠経過は前医で行い経過順調であったが，妊娠40週3日に胎児機能不全の疑いで帝王切開となった．卵巣上皮性は術後30カ月と短期間であるが現在のところ再発所見なく経過している．〔産婦の進歩71（1）：37-44，2019（平成31年2月）〕

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卵巣原発のは，良性腫瘍と悪性腫瘍の中間的な組織像，増殖能を示し，予後の良い疾患とされている。しかし，腹腔内播種，腹膜偽粘液腫を生じる場合，治療に難渋し不幸な転帰をとることも少なくない。
我々は卵巣の治療を経験した。術前のMRIでは腫瘍は腹壁に限局し腹腔内に腫瘤を認めなかった。腫瘍マーカーの上昇も認めなかったため，腫瘍は腹壁に限局するものと考え，摘出手術を施行した。術中所見では腹腔内に広範囲の播種を認めたため，腹壁腫瘍のみを摘出し手術を終了した。
本疾患は婦人科領域の疾患であるが，腹壁に生じた場合には，切除，再建に関して皮膚軟部腫瘍を扱う医師が治療を行う可能性がある。術前の画像検査で腹腔内に腫瘤を認めず，腫瘍マーカーの異常も認めない場合，腹膜偽粘液腫を生じていても予測することは難しい。

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　A 26-year-old pregnant woman was referred to our hospital for examination of a right adnexal mass. Transvaginal ultrasound revealed a cystic tumor (approximately 8×7 cm) arising from the right adnexa. MRI revealed a suspected benign simple cyst of right ovary without any sign of nodules. We performed laparoscopic right ovarian cystectomy at 14 weeks and ６ days of gestational age (GA) to excise the tumor. The fluid inside appeared yellowish and mucinous, and the surface of the resected cyst was rough. Pathological diagnosis of the resected right ovarian cyst was right ovarian sero-mucinous borderline tumor. We recommended right adnexectomy and partial omentectomy as a secondary surgery. She consented, and laparoscopic right adnexectomy and partial omentectomy were performed at 16 weeks and ２ days GA with no operative complications. She was discharged ６ days after the operation. There was no evidence of residual tumor or metastasis. Her pregnancy course was generally good until emergency c-section surgery was performed because of placental abruption at 36 weeks and ２ days of GA. There has been no evidence of recurrence or metastasis until now.

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漿液粘液性卵巣腫瘍（seromucinous tumor）は，2014年のWHO分類第4版で新たに設けられた組織学的分類である．歴史が浅いことから，臨床上の取り扱いについてはあまり知られていない．本研究では，漿液粘液性卵巣腫瘍の臨床病理学的特徴を明らかにすることを目的とし，当院で2015年から2019年の間に手術を実施し，漿液粘液性卵巣腫瘍と診断された症例を対象に後方視的に検討した．対象症例は12例で，そのうち

が11例（91.7％）で同期間の全体の26.8％を占めていた．悪性腫瘍は1例（8.3％）のみで同期間の悪性腫瘍全体の1.1％であった．良性腫瘍の症例はなかった．年齢の中央値は44.5歳（23-71歳）と若年者が多く，未経産6例（50.0％）であった．MRI所見では10例（83.3％）で囊胞内に乳頭状の壁在結節を伴い，壁在結節はT2強調像で高信号を呈しADC mapで拡散低下を認めなかった．6例（50.0％）で背景に子宮内膜症性病変を認め，そのうち3例では術前にホルモン療法を実施していた．進行期についてはIA期7例，IC1期4例，IC2期1例であった．観察期間の中央値は24.5カ月（10-67カ月）で，全例術後に再発を認めず経過していた．40歳未満の5例では全て妊孕性温存手術を選択しており，そのうち1例が術後に妊娠，分娩に至った．漿液粘液性卵巣腫瘍は背景に子宮内膜症を合併することが多く，卵巣子宮内膜症性囊胞との鑑別が重要である．また，予後良好なI期のが多いことから，若年者には妊孕性温存手術が選択肢となり得る．〔産婦の進歩74（3）：309-317，2022（令和4年8月）〕

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Objectives: Clinical management of borderline ovarian tumors (BOTs) during reproductive age has shifted from radical surgery to fertility-sparing surgery. The aim of this study was to evaluate the feasibility of the laparoscopic approach for fertility-sparing surgery for BOTs.
Methods: From August 2012 through March 2014, laparoscopic surgery for ovarian tumors was performed for 557 cases, and a total of 11 cases were diagnosed as BOTs. Six patients were premenopausal, and five selected fertility-sparing surgery. We retrospectively reviewed the clinical and surgical parameters of undergoing laparoscopic surgery for reproductive-age women with BOTs at our institution.
Results: Four cases had mucinous BOTs and one had granulosa-cell tumor. The mean age was 30.8 (20–43) years and mean diameter was 10.1cm (6–22 cm). Two cases had multi-cystic tumor, and all tumors showed no enhancement by contrast magnetic resonance imaging. Laparoscopic ovarian cystectomy was performed in all cases. All cases underwent a secondary laparoscopic surgery as a fertility-sparing surgery and surgical staging including salpingo-oophorectomy of the affected side, partial omentectomy, and peritoneal observation. Appendectomy was performed for one case. The incidence of perioperative morbidities included one case of suspected ureter stenosis. After surgical staging, no case was up-staged, but a residual tumor was found in the affected ovary of one case. After a mean follow-up of 10.3 months (3–19), none had a recurrence or died of the disease. One case had delivered after the two-stage surgery.
Conclusions: Laparoscopic surgery might be feasible and an acceptable intervention for reproductive-age women with BOTs.

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Introduction: Borderline ovarian tumors (BOTs) account for 10-20% of ovarian epithelial tumors. Despite its moderate incidence and increase in laparoscopic surgery, the literature contains scant reports regarding the laparoscopic management of these tumors. This may be due to the difficulty in making a preoperative diagnosis.
Objectives and methods: This study was focused on investigating the characteristics of laparoscopic surgery for a BOT. We retrospectively reviewed the medical charts of 32 patients who were pathologically diagnosed with a BOT from April 2009 through March 2013. We compared age and observation period, tumor size, surgery time, amount of bleeding, length of hospital stay, frozen section, intraoperative tumor rupture, emergency surgery, fertility surgery, clinical stage, recurrence, and recurrence-free-survival (RFS) between 19 patients who underwent laparoscopy and 13 patients who underwent a laparotomy.
Results: The laparoscopic group had shorter hospital stays (4 days (range: 2-13) vs. 7 days (range: 6-19); P < 0.01), less frequent frozen section (2/19 (11%) vs. 7/13 (54%); P = 0.011), more frequent rupture (12/19 (63%) vs. 2/13 (15%; P = 0.009), fertility sparing surgery (13/19 (68%) vs. 1/13 (8%); P = 0.008) .
Conclusions: Laparoscopic surgery for a BOT should be performed with meticulous care in order to avoid rupture. However, laparoscopic surgery for a BOT appears to be safe since no significant difference in RFS between the two groups was found.

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　遺伝性乳癌卵巣癌症候群（hereditary breast and ovarian cancer syndrome；HBOC）における卵巣癌のほとんどは高異型度漿液性癌（high grade serous carcinoma；HGSC）であり，低異型度漿液性癌（low grade serous carcinoma；LGSC）やその発生母体となる漿液性

（serous tubal intraepitherial carcinoma；SBT）はまれである．今回，BRCA2に病的バリアントを認めたSBTの症例を経験したので報告する．

　症例は66歳，女性．40歳代で卵巣腫瘍の診断で手術を行い，組織診断はSBTであったが，細胞異型や間質反応が強く，卵巣癌Ⅰa期（FIGO 1988）に準じて治療をした後，定期検診を行っていた．本人がBRCA1/2遺伝学的検査を希望したため実施したところ，BRCA2に病的バリアントを認めた．HBOCにおける卵巣腫瘍としてSBTは非常にまれだが，SBT症例においてもBRCA1/2病的バリアント保持者が一定の頻度で存在するとの報告が複数あり，卵巣

に対しても，HBOCに関する遺伝診療の観点に基づいた介入が必要と考える．

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  We performed a two-stage laparoscopic surgery in granulosa cell tumor of juvenile type. It was controversial that borderline tumors of the ovary were safely treated by laparoscopy.

  A 12-year-old woman was referred to our hospital for irregular menses. Magnetic resonance imaging (MRI) of the pelvis revealed a 6cm-sized solid and cystic mass, and uterine endometrium was thick. Serum estradiol was high level, and LDH and AFP were within normal limits. The laparoscopic procedure was done. The tumor was soft, and we could strip the tumor from right ovary easily. Microscopically, tumor cells which were composed hyperchromatic nuclei, eosinophilic or clear cytoplasm showed in a diffuse sheet-like pattern or in loose short fascicles or a trabecular growth fashion. Mitotic figures were encountered in some areas. The feature was compatible with granulosa cell tumor of juvenile type. A two-stage laparoscopic surgery performed was right salpingo-oophorectomy.

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