臨床婦人科産科78巻9号

2024年09月発行

今月の臨床 ―外来担当医として知っておきたい―婦人科腫瘍の卵巣機能・妊孕性温存療法

子宮体がん編

高用量MPA療法以外の妊孕性温存療法の選択肢

著者： 西尾真¹ 鈴木幸雄²³

所属機関： ¹久留米大学医学部産婦人科学講座 ²横浜市立大学医学部産婦人科学講座 ³神奈川県立がんセンター婦人科

ページ範囲：P.798 - P.802

文献概要

●高用量MPA療法以外の妊孕性温存療法として，レボノルゲストレル含有IUDとそれにGnRHアゴニストやメトホルミンを併用する方法がある．

●しかし，レボノルゲストレル含有IUDの治療成績は以前から報告されているが，いずれも少数例での検討であり，実地臨床への情報の外挿が困難であった．

●今年（2024年）に入って，厳密なシステマティックレビューとメタアナリシスによるレボノルゲストレル含有IUDの妊孕性温存療法の報告があった．

参考文献

1）Pennant ME, et al : Premenopausal abnormal uterine bleeding and risk of endometrial cancer. BJOG 124 : 404-411, 2017

2）Jarboe EA, et al : Endometrial intraepithelial neoplasia. Semin Diagn Pathol 27 : 215-225, 2010

3）American College of Obstetricians and Gynecologists : Management of endometrial intraepithelial neoplasia or atypical endometrial hyperplasia : ACOG Clinical Consensus No. 5. Obstet Gynecol 142 : 735-744, 2023

4）Kelley RM, et al : Progestational agents in the treatment of carcinoma of the endometrium. N Engl J Med 264 : 216-222, 1961

5）Greenwald ZR, et al : Does hormonal therapy for fertility preservation affect the survival of young women with early-stage endometrial cancer? Cancer 123 : 1545-1554, 2017

6）Wildemeersch D, et al : Treatment of nonatypical and atypical endometrial hyperplasia with a levonorgestrel-releasing intrauterine system. Am J Obstet Gynecol 188 : 1297-1298, 2003

7）Montz FJ, et al : Intrauterine progesterone treatment of early endometrial cancer. Am J Obstet Gynecol 186 : 651-657, 2002

8）Mathews TJ, et al : Mean age of mothers is on the rise : United States, 2000-2014. NCHS Data Brief （232） : 1-8, 2016

9）Suzuki Y, et al : Systemic progestins and progestin-releasing intrauterine device therapy for premenopausal patients with endometrial intraepithelial neoplasia. Obstet Gynecol 141 : 979-987, 2023

10）Suzuki Y, et al : Levonorgestrel-releasing intrauterine device therapy versus oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia : a systematic review and meta-analysis. J Natl Cancer Inst 116 : 653-664, 2024

11）Orbo A, et al : Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia : a national multicentre randomised trial. BJOG 121 : 477-486, 2014

12）Chen J, et al : Oncological and reproductive outcomes for gonadotropin-releasing hormone agonist combined with aromatase inhibitors or levonorgestrel-releasing intra-uterine system in women with endometrial cancer or atypical endometrial hyperplasia. Int J Gynecol Cancer 32 : 1561-1567, 2022

13）Chae-Kim J, et al : Outcomes of women treated with progestin and metformin for atypical endometrial hyperplasia and early endometrial cancer : a systematic review and meta-analysis. Int J Gynecol Cancer 31 : 1499-1505, 2021

14）Meireles CG, et al : Effects of metformin on endometrial cancer : systematic review and meta-analysis. Gynecol Oncol 147 : 167-180, 2017

15）Acosta-Torres S, et al : The addition of metformin to progestin therapy in the fertility-sparing treatment of women with atypical hyperplasia/endometrial intraepithelial neoplasia or endometrial cancer : little impact on response and low live-birth rates. Gynecol Oncol 157 : 348-356, 2020

16）Yang BY, et al : Metformin plus megestrol acetate compared with megestrol acetate alone as fertility-sparing treatment in patients with atypical endometrial hyperplasia and well-differentiated endometrial cancer : a randomised controlled trial. BJOG 127 : 848-857, 2020

17）Koskas M, et al : Prognostic factors of oncologic and reproductive outcomes in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma : systematic review and meta-analysis. Fertil Steril 101 : 785-794, 2014

18）Crosbie E, et al : The emerging epidemic of endometrial cancer : time to take action. Cochrane Database Syst Rev 2014 : ED000095, 2014

19）Morice P, et al : Endometrial cancer. Lancet 387 : 1094-1108, 2016

20）Wartko PD, et al : Association of endometrial hyperplasia and cancer with a history of gestational diabetes. Cancer Causes Control 28 : 819-828, 2017

21）Raffone A, et al : Diabetes mellitus and responsiveness of endometrial hyperplasia and early endometrial cancer to conservative treatment. Gynecol Endocrinol 35 : 932-937, 2019

22）Mandelbaum RS, et al : Progestin therapy for obese women with complex atypical hyperplasia : levonorgestrel-releasing intrauterine device vs systemic therapy. Am J Obstet Gynecol 223 : 103.e1-103.e13, 2020

23）Yuk JS, et al : Levonorgestrel-releasing intrauterine systems versus oral cyclic medroxyprogesterone acetate in endometrial hyperplasia therapy : a meta-analysis. Ann Surg Oncol 24 : 1322-1329, 2017