An evaluation of lateral and medial transposition of the ovaries out of radiation fields

Ovarian Transposition Before Pelvic Radiation Therapy: Spatial Distribution and Dose Volume Analysis

Purpose

Methods and Materials

Results

Conclusions

Molecular Mechanism and Prevention Strategy of Chemotherapy- and Radiotherapy-Induced Ovarian Damage

Fertility preservation is an emerging discipline, which is of substantial clinical value in the care of young patients with cancer. Chemotherapy and radiation may induce ovarian damage in prepubertal girls and young women. Although many studies have explored the mechanisms implicated in ovarian toxicity during cancer treatment, its molecular pathophysiology is not fully understood. Chemotherapy may accelerate follicular apoptosis and follicle reservoir utilization and damage the ovarian stroma via multiple molecular reactions. Oxidative stress and the radiosensitivity of oocytes are the main causes of gonadal damage after radiation treatment. Fertility preservation options can be differentiated by patient age, desire for conception, treatment regimen, socioeconomic status, and treatment duration. This review will help highlight the importance of multidisciplinary oncofertility strategies for providing high-quality care to young female cancer patients.

Ovarian transposition and cervical cancer

Cervical cancer is the fourth most common female malignancy worldwide. As the focus of treatment is shifting towards balancing oncological outcomes with reproductive benefit, women are becoming increasingly aware of their fertility options. Cervical cancer is one of the primary malignancies where transposition of the ovaries may be indicated. Ovarian transposition should be performed in pre-menopausal women, undergoing pelvic irradiation to preserve ovarian function and prevent early menopause. The review discusses the available literature and synthesises a concise summary for gynaecologic oncology surgeons to counsel affected women. The paradoxical controversy, leading to its under use is acknowledged, due to the scarcity of published data with regard to functional outcomes, and the lack of clinical trials. In cervical cancer, ovarian transposition remains a safe fertility preservation (FP) option, which is associated with high ovarian function preservation, an acceptable rate of ovarian cysts and a negligible risk for metastases in the transposed ovaries.

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.

Fertility issues in cancer survivorship

Breakthroughs in cancer diagnosis and treatment have led to dramatic improvements in survival and the need to focus on survivorship issues. Chemotherapy and radiotherapy can be gonadotoxic, resulting in impaired fertility. Techniques to help cancer survivors reproduce have been improving over the past decade. Discussion of the changes to a patient's reproductive health after cancer treatment is essential to providing comprehensive quality care. The purpose of this review is to aid in pre- and posttreatment counseling, focusing on fertility preservation and other strategies that may mitigate risks to the patient's reproductive, sexual, and overall health.

Female fertility loss and preservation: threats and opportunities

BACKGROUND

Ovarian aging and cytotoxic treatments are the most common causes for fertility loss in women. With increasing numbers of young female survivors following cytotoxic cancer treatments, the issue of fertility preservation has assumed greater importance.

METHODS

We review the literature on the causes of female fertility loss as well as the recent advances in fertility preservation options and strategies that might be of interest to oncologists. Currently, several methods and techniques exist for fertility preservation of female patients with cancer including embryo freezing, ovarian protection techniques, oocyte cryopreservation, ovarian tissue cryopreservation followed by autotransplantation, and recently in vitro culture of ovarian tissue, follicles, and oocytes. Each method or technique has advantages and disadvantages related to current success rate, required delay in cancer treatment, sperm requirement, and risk of reintroducing cancer cells.

RESULTS

To date, embryo freezing is the only established method successfully and widely used for fertility preservation of female patients with cancer. The other methods are promising but still considered experimental.

CONCLUSION

Patient awareness, physician knowledge, early counseling, costs management, international registry, interdisciplinary networks, and research development are necessary to improve the current care in the field of female fertility preservation.

Effects of cancer treatment on ovarian function

Causes of primary ovarian failure are reviewed, focusing specifically on cancer treatment-related modalities. Strategies and future directions for protection of the ovaries during cancer therapy, including ovarian transposition, and conformal radiation techniques are presented.

Fertility preservation options for women with malignancies

Cancer is not rare in younger women. There has been a remarkable improvement in the survival rates due to progress in cancer treatment. The necessary treatment for most of the common cancer types occurring in younger women implies either removal of the reproductive organs or cytotoxic treatment that could partially or definitively affect reproductive function. Early loss of ovarian function not only puts the patients at risk for menopause-related complications at a very young age, but is also associated with loss of fertility. Further, women in the western hemisphere have been delaying initiation of childbearing to later in life. The results of these changes have led to an increase in patients facing the risk of premature ovarian failure, and therefore seeking help in preserving their fertility. This increase in demand has resulted in a proliferation of techniques to preserve fertility. Indeed, the number of options is increasing; some are more established procedures, such as embryo cryopreservation, and some are still experimental, such as ovarian cryopreservation. Because of the variations in type and dose of chemotherapy, the type of cancer, the time available before onset of treatment, the patient's age and the partner status, each case is unique and requires a different strategy of fertility preservation.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the potential early loss of ovarian function secondary to radiotherapy and/or chemotherapy for cancer at a young age; explain the increasing demands for fertility preservation; and summarize the limited number of proven, safe, and efficacious methods.

Radiation dose to laterally transposed ovaries during external beam radiotherapy for cervical cancer

The purpose of this study was to estimate the radiation dose to laterally transposed ovaries from external beam radiotherapy for cervical cancer. Dose measurements were performed in a modified humanoid phantom using a 6 MV photon beam. The dependence of the ovarian dose upon the field size, the distance from the primary irradiation field and the presence of wedges or gonadal shielding was determined. For a tumor dose of 45 Gy, ovarian dose was 0.88-8.51 Gy depending on the field size employed and the location of the transposed ovary in respect to the treatment field. Positioning of 7 cm thick shielding reduced the dose to ovary by less than 19%. The use of wedges increased the ovarian dose by a factor up to 1.5. Accurate radiographic localization of the ovaries allows the use of the presented dosimetric results to obtain a reasonable prediction of the ovarian dose.

Fertility preservation in cancer patients

Fertility preservation is an important but often neglected need of cancer patients. There are several options available but many are considered experimental or are unproven. Most require interventions that can postpone the initiation of cancer treatment. The options include surgical procedures to move the ovaries out of the path of a radiation field, prophylactic medical therapy with gonadotropin-releasing hormone agonists and storage of gametes, embryos or gonadal tissue. Embryo freezing after conventional in vitro fertilization has a high success rate. Experimental fertility preservation procedures such as oocyte freezing and ovarian tissue cryopreservation/transplantation should be offered to cancer patients only under institutional review board oversight. Laparoscopic ovarian transposition is a viable option if radiotherapy is to be used alone. Oncologists, reproductive endocrinologists and other healthcare professionals should be part of a multidisciplinary team that offers cancer patients options to preserve their reproductive potential if they desire to do so.

Adnexal torsion in pediatric and adolescent girls

PURPOSE OF REVIEW

This review provides timely information to assist in solving the diagnostic dilemma of adnexal or ovarian torsion. Knowledge and awareness of current literature is essential to help clinicians improve diagnostic accuracy and avoid potentially catastrophic consequences, including loss of ovarian tissue and function.

RECENT FINDINGS

This article reviews recent evidence regarding radiologic tools used for efficient, timely diagnosis and management strategies for adnexal torsion, including detorsion. The role of oophoropexy in the pediatric and adolescent population is also reviewed.

SUMMARY

The discussion reinforces the role of detorsion in lieu of oophorectomy or adnextomy in an effort to preserve reproductive capacity in a young population. Long-term follow-up, including reproductive outcomes, is needed to determine the role of oophoropexy.

Female gamete preservation

The use of multiple agent chemotherapy and combined modality treatment of childhood and adolescent cancers has markedly increased survival rates. Thus, the majority of young cancer patients survive into adulthood and the potential long-term consequences of the therapies are of ongoing concern. Alkylating agents have proven to be the most toxic to the ovaries; however radiation is also extremely gonadotoxic. In addition, combination of these modalities will produce additive effects in terms of ovarian damage (follicle depletion). As a result, there are increasing numbers of young cancer survivors with impaired or absent gonadal function. Advances in the field of assisted reproductive technology (ART) provide hope that the reproductive impact of cancer therapy can be reduced. Those technologies that may be applicable prior to gonadotoxic therapy are pretreatment ovarian protection with oral contraceptives or gonadotropin releasing hormone agonist; ART using pretreatment cryopreservation of embryos or gametes; posttreatment ART with donor gametes or embryos; or adoption. However, ovarian protection is not of proven benefit and oocyte/ovary cryopreservation has had only limited success to date. Information regarding cancer treatment's possible effects on fertility and ways to potentially circumvent these should be part of routine counseling to allow the patient to make an informed decision.

Laparoscopic medial oophoropexy prior to radiation therapy in an adolescent with Hodgkin's disease

BACKGROUND

Advances in radiation therapy have led to long term survival in young patients with Hodgkin's disease. Oophoropexy may reduce ovarian damage and preserve hormonal production and future fertility. When ovarian ligaments are shortened, incising the serosa parallel to the infundibulopelvic ligaments at laparoscopy permits the completion of a medial oophoropexy.

CASE

An adolescent female underwent a laparoscopic medial oophoropexy prior to radiation therapy for Stage IIIB Hodgkin's disease. Due to shortened ovarian ligaments the ovaries could not be placed behind the uterus without excessive tension. The infundibulopelvic ligaments were sharply dissected off of the lateral pelvic sidewalls eliminating tension on the ligaments and allowing completion of the medial oophoropexy. Twenty-two months after completion of her radiation therapy the patient was normally menstruating and conceived spontaneously.

CONCLUSION

Laparoscopic dissection of the infundibulopelvic ligaments allowed for a medial oophoropexy to be performed in an adolescent patient and was associated with return of ovarian function after radiation therapy.

Therapeutic external irradiation in women of reproductive age: risk estimation of hereditary effects

Exposure of women of childbearing age to ionizing radiation may result in induction of genetic disorders in future generations. This study aims to estimate the risk of hereditary effects attributable to therapeutic external irradiation in women. An anthropomorphic phantom was used to simulate radiotherapy in female patients and ovarian dose was measured for irradiation of brain, breast and lung cancer, and for treatment of Hodgkin's disease. These malignancies are among the most common tumours presenting in women of reproductive age. Dose measurements were undertaken using thermoluminescent dosemeters and all exposures were made with 6 MV X-ray beams. The dose to ovaries was found to be 2-3 cGy, 8-11 cGy and 11-15 cGy depending on the distance from the primary irradiation field during radiotherapy of brain, breast and lung cancer, respectively. The corresponding ovarian dose resulting from treatment of supradiaphragmatic and infradiaphragmatic Hodgkin's disease was 18-25 cGy and 128-356 cGy, respectively. A small excess risk of genetic diseases of (1-15) x 10(-4) was estimated for radiotherapy above the diaphragm. Pelvic irradiation resulted in an increased risk of hereditary effects of (77-214) x 10(-4).

Asynchronous bilateral ovarian torsion

BACKGROUND

Pediatric ovarian torsion (OT) is a serious condition, especially in cases of asynchronous bilateral ovarian torsion (ABOT). The authors sought to evaluate the predisposing factors for ABOT and to evaluate the most appropriate treatment for ovarian torsion.

METHODS

The authors retrospectively reviewed the charts of patients with ovarian torsion between 1980 and 2002. Data collected included age at presentation, type and duration of symptoms, ultrasound scan findings, interval to surgery, procedures, pathology report, and follow-up.

RESULTS

Seventy-six patients had adnexal torsion confirmed at surgery, 4 of whom had ABOT. The mean age was 10 years. The mean duration of complaints before hospitalisation and interval to surgery were 56 and 33 hours, respectively. Thirty-five patients had simple tubo-ovarian torsion (46%), including all the patients with ABOT (11.4%), and 41 had an ovarian pathology (54%). All patients with ABOT underwent salpingo-oophorectomy at the first episode. They presented earlier for the second episode and had a shorter interval to surgery where detorsion with oophoropexy was performed. Follow-up ultrasound scan showed perfusion and follicles in the remaining ovary.

CONCLUSIONS

The diagnosis of ovarian torsion often is delayed, especially when a solid tumor is suspected. Conservative management should be strongly considered when there is no underlying ovarian pathology. Furthermore, oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a potentially devastating recurrence.

Ovarian function preservation in the cancer patient

OBJECTIVE

To review the clinical modalities that are available to women receiving potentially sterilizing cancer therapy.

DESIGN

The MEDLINE database was reviewed for all publications on medication, surgery, or assisted reproductive technology that could potentially preserve fertility in women who are receiving cancer therapy.

CONCLUSION(S)

There are many options available to a patient undergoing a treatment that will negatively impact her fertility. Many procedures and medical interventions have been proven successful both in terms of ovarian function and pregnancy rates. Other techniques have great potential but do not have long-term clinical data. It is important that the patient's primary care physician understand the methods available to preserve fertility in cancer patients and communicate this information to the patient.

Conservative management of bilateral asynchronous adnexal torsion with necrosis in a prepubescent girl

Conservative management of ovarian torsion consisting of detorsion and surgical stabilization of the involved ovary, and possibly including the uninvolved ovary, has been described in the adult population. A 6-year-old girl with a history of prior ovarian torsion resulting in oophorectomy presented with 72 hours of intermittent abdominal pain, anorexia, and 1 episode of vomiting. The patient had torsion of her remaining ovary diagnosed surgically and was managed with detorsion and oophoropexy, despite the severely necrotic appearance of the ovarian tissue. Postoperative serial ultrasound scans confirmed the viability and position of the ovary. In the prepubertal girl, ovaries may torse despite the absence of enlarging lesions such as tumors or cysts. To maximize the potential success of conservative therapy, torsion always must be included in the differential diagnosis of abdominal pain. Surgical management should attempt to salvage the torsed ovary, despite possible necrotic appearance, and also consider interventions to prevent recurrence, because bilateral torsion is a rare but potentially devastating complication.

Hodgkin's disease

OBJECTIVES

To review current approaches to the diagnosis and treatment of Hodgkin's disease (HD).

DATA SOURCES

Review articles, research studies, and book chapters related to HD.

CONCLUSIONS

The treatment of HD has progressed to be one of the most successful therapies in oncology. Researchers currently seek to improve the positive outcomes of therapy while decreasing the toxicity associated with therapy.

IMPLICATIONS FOR NURSING PRACTICE

Nursing care of the patient with HD requires physical, educational, and psychological support. Within this scope of nursing care, the patient receives essential information to participate as a partner in care.

Laparoscopic unilateral ovarian transposition prior to irradiation: prospective study of 20 cases

BACKGROUND

The objective of this study was to evaluate the feasibility, morbidity, and efficacy of unilateral laparoscopic ovarian transposition on the preservation of hormonal function in premenopausal patients requiring pelvic irradiation (external and/or intracavity by brachytherapy).

METHODS

This prospective study was based on 20 patients: 17 presenting with cervical cancer, 2 with Hodgkin's disease, and 1 with ependymoma of the cauda equina. The operative technique consisted of releasing the right ovary from its pelvic attachments, and placing it as high and as laterally as possible in the right paracolic gutter, after creating a pedicle on the infundibulopelvic ligament. The follow-up of ovarian function was more than 1 year for 14 patients.

RESULTS

The therapeutic protocol was not modified as a result of ovarian transposition. No intraoperative or postoperative complications were observed. The mean dose of irradiation received by the transposed ovary was 1.75 gray (Gy) (range 0.4-3.7). Mean follow-up was 2 years. Two cases of menopause (14.7%), in the only 2 patients older than 40 years, were observed among the 14 patients followed for more than 1 year. The success rate was 100% for patients younger than age 40 years.

CONCLUSIONS

Laparoscopic ovarian transposition is a simple and reliable method, which does not complicate subsequent therapeutic protocol. Its short term efficiency is comparable to results obtained by laparotomy, with a lesser morbidity. Although long term evaluation is necessary, laparoscopic surgery should be considered as an alternative to laparotomy for ovarian transposition.