Ovarian function preservation in the cancer patient

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

Safety of [177Lu]Lu-NeoB treatment: a preclinical study characterizing absorbed dose and acute, early, and late organ toxicity

Purpose

The radiolabeled gastrin-releasing peptide receptor (GRPR)-targeting antagonist NeoB is a promising radioligand for imaging and therapy of GRPR-expressing malignancies. In the current study, we aimed to discover the target organs of toxicity and the radiotoxic effects to these organs, when repeated dosages of [¹⁷⁷Lu]Lu-NeoB are administered to healthy female and male mice.

Methods

Animals received either 3 injections, with a 7-day interval, of vehicle (control group 1), 1200 pmol [¹⁷⁵Lu]Lu-NeoB (control group 2) or 40 MBq/400 pmol, 80 MBq/800 pmol, and 120 MBq/1200 pmol [¹⁷⁷Lu]Lu-NeoB (treatment groups 1, 2, and 3, respectively). At week 5, 19, and 43 after the first injection acute, early, and late organ toxicity, respectively, was determined. For this, histopathological and blood analyses were performed. To correlate the observed toxicity to absorbed dose, we also performed extensive biodistribution and dosimetry studies.

Results

The biodistribution study showed the highest absorbed doses in GRPR-expressing pancreas, the liver, and the kidneys (the main organs of excretion). Both control groups and almost all animals of treatment group 1 did not show any treatment-related toxicological effects. Despite the high absorbed doses, no clear microscopic signs of toxicity were found in the pancreas and the liver. Histological analysis indicated kidney damage in the form of hydronephrosis and nephropathy in treatment groups 2 and 3 that were sacrificed at the early and late time point. In the same groups, increased blood urea nitrogen levels were found.

Conclusion

In general, repeated administration of [¹⁷⁷Lu]Lu-NeoB was tolerated. The most significant radiotoxic effects were found in the kidneys, similar to other clinically applied radioligands. The results of this study underline the potential of [¹⁷⁷Lu]Lu-NeoB as a promising option for clinical therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-022-05926-2.

Ovarian Function Preservation in Patients With Cervical Cancer Undergoing Hysterectomy and Ovarian Transposition Before Pelvic Radiotherapy

To examine the factors associated with ovarian failure (OF) and assess the effectiveness of ovarian transposition (OT) before pelvic irradiation for preserving ovarian function in patients with cervical cancer (CC) undergoing hysterectomy. During 2003 to 2017, patients who underwent hysterectomy with preservation of one or both ovaries were retrospectively enrolled. Patients were divided into 4 groups, depending on whether radiotherapy (RT) and OT were performed: group 1, RT(+) and OT(+); group 2, RT(+) and OT(−); group 3, RT(−) and OT(+); group 4, RT(−) and OT(−). OF was defined as serum follicle-stimulating hormone levels of ≥30 mIU/mL. Sixty-six patients (59 [89.4%] invasive CC and 7 [10.6%] cervical intraepithelial neoplasia) were included. The 2-year OF-free survival rate was 61.4% (95% confidence interval [CI] 37.8-86.0), 0%, 91.7% (95% CI 76.0-100), and 75.8% (95% CI 58.2-93.4) for groups 1, 2, 3, and 4, respectively. In groups 1 and 2 receiving RT, OT, and combination of external beam radiotherapy and vaginal brachytherapy were associated with OF on multivariate analysis (MVA) (P-value  =  .002 and .046, respectively). In groups 3 and 4 without RT, older age (40 years old) and OT did not affect OF; however, the number of remaining ovaries was independently associated with OF in MVA (P  =  .035). OT could effectively preserve ovarian function in patients treated with adjuvant RT, while OT procedure itself did not affect ovarian failure. OT should be considered in the management of premenopausal cervical cancer patients.

Practical consensus recommendations on fertility preservation in patients with breast cancer

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Expert oncologists along with reproductive medicine specialists discuss fertility preservation options in this chapter since fertility preservation is becoming a priority for young women with breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Neoadjuvant chemotherapy plus surgery versus concurrent chemoradiotherapy in stage IB2-IIB cervical cancer: A systematic review and meta-analysis

The optimal treatment strategy for stage IB2-IIB cervical cancer is controversial. This systematic review with meta-analysis evaluated the efficacy of concomitant chemoradiotherapy (CCRT) and neoadjuvant chemotherapy followed by radical surgery (NACT+S). Studies that evaluated NACT+S versus CCRT for patients with Federation of Gynecology and Obstetrics stage IB2-IIB cervical cancer were searched in MEDLINE, EMBASE, and the Cochrane Library database. Hazard ratios (HRs) with their respective 95% confidence intervals (CIs) were calculated using a random-effects model. Toxicity was also evaluated. Six qualified retrospective studies and one randomized controlled trial (2270 patients) were included in this review. The results suggested that compared with CCRT, NACT+S did not improve overall survival in all patients (HR 0.73, 95% CI 0.52-1.02) or stage IIB patients (HR 0.83, 95% CI 0.61-1.15). NACT+S did not improve disease-free survival (DFS) in stage IIB patients (HR 1.10, 95% CI 0.70-1.71). In the analysis of DFS in all patients, a high degree of heterogeneity was detected (I2 = 84%). Sensitivity analysis that eliminated these heterogeneous data suggested that CCRT could improve DFS over NACT+S (HR 1.47, 95% CI 1.12-1.93). Diarrhea and rectal and bladder complications occurred at a lower rate in the NACT+S group than in the CCRT group. NACT+S had no survival advantage for patients with stage IB2-IIB cervical cancer compared with CCRT but was associated with fewer side effects. Further prospective studies with a larger sample size of treatment protocols for locally advanced cervical cancer are needed.

MicroRNA profiling and identification of let-7a as a target to prevent chemotherapy-induced primordial follicles apoptosis in mouse ovaries

Cancer treatments as cyclophosphamide and its active metabolites are highly gonadotoxic leading to follicle apoptosis and depletion. Considering the risk of subsequent infertility, fertility preservation is recommended. Beside the germ cells and gametes cryopreservation options, ovarian pharmacological protection during treatment appears to be very attractive. Meanwhile, the advances in the field of oncology have brought microRNAs into spotlight as a potential feature of cancer treatment. Herein, we investigated miRNAs expressions in response to chemotherapy using postnatal-day-3 (PND3) mouse ovaries. Our results revealed that several miRNAs are differently expressed during chemotherapy exposure. Amongst them, let-7a was the most profoundly downregulated and targets genes involved in crucial cellular processes including apoptosis. Thus we developed a liposome-based system to deliver the let-7a mimic in whole PND3 ovaries in vitro. We showed that let-7a mimic prevented the upregulation of genes involved in cell death and reduced the chemotherapy-induced ovarian apoptosis, suggesting that it can be an interesting target to preserve ovarian function. However, its impact on subsequent follicular development has to be further elucidated in vivo using an appropriate delivery system. In this study, we demonstrated that miRNA replacement approaches can be a useful tool to reduce chemotherapy-induced ovarian damage in the future.

Anti-apoptotic Regulation Contributes to the Successful Nuclear Reprogramming Using Cryopreserved Oocytes

Cryopreservation has a negative effect on the quality of oocytes and may be closely associated with increased levels of reactive oxygen species (ROS) and apoptotic events. The purpose of the present study was to evaluate the detrimental effects on the developmental competence of somatic cell nuclear transferred (SCNT) mouse embryos using vitrified (cryopreserved) oocytes and to evaluate the recovery effects of melatonin on cryo-damage in cloned embryos. Development of SCNT embryos using cryopreserved oocyte cytoplasm (SCNT-CROC) was inferior to those using fresh cytoplasm (SCNT-FOC). Using RNA-sequencing analysis, we found upregulation of eight pro-apoptotic-related genes (Cyct, Dapk2, Dffb, Gadd45g, Hint2, Mien1, P2rx7, and Pmaip) in the SCNT-CROC group. Furthermore, the addition of melatonin, an agent that reduces apoptosis and ROS production, enhanced blastocyst formation rates in the SCNT-CROP group when compared with the melatonin-untreated group. Additionally, melatonin treatment increased the derivation efficiency of pluripotent stem cells from cloned embryos using cryopreserved oocyte.

•

Cloned mouse embryos using cryopreserved oocytes have shown increased apoptosis

•

The addition of melatonin reduces apoptosis and ROS production

•

Melatonin enhances development of the SCNT embryos using cryopreserved oocytes

•

This system will be helpful in the derivation and application of human SCNT-ESC line

Ovarian preservation techniques for female pelvic radiotherapy techniques: a critical review

Introduction

Advances in treatment over recent years have increased the long-term survival of young, female cancer patients; unfortunately these treatments bring a significant risk of ovarian failure and infertility. This literature review aimed to determine the optimal technique for ovarian preservation in pre-menopausal women receiving pelvic radiotherapy (IMRT). The traditional method comprises surgical transposition; IMRT and other emerging techniques may offer alternative non-invasive means of sparing ovaries and minimising dose.

Methods

A critical review of the evidence pertaining to pelvic radiotherapy and ovarian sparing was performed. Evidence was subjected to critical appraisal using the Critical Appraisal Skills Programme tool and thematic analysis of the findings identified key issues.

Results

Surgical transposition appears to be a successful method of preserving ovarian function depending on the position of the ovaries outside of the radiation field, the age of the patient and the total dose received by the ovaries. There is limited modern evidence concerning its usage in relation to emerging techniques and technology. The use of IMRT is certainly widespread in the treatment of female pelvic cancers, however, there is no evidence supporting its use for reduction of ovarian dose. Several other studies have attempted to demonstrate new techniques to preserve ovarian function, but no functional outcome measures have reinforced their results.

Conclusions

Ovarian transposition has a proven track record for preservation of ovarian function, but the potential value of IMRT as a viable alternative to date remains unexplored. New work should be encouraged to determine the potential value of IMRT as a non-surgical alternative.

Gonadotropin-Releasing Hormone Agonists for Ovarian Function Preservation in Premenopausal Women Undergoing Chemotherapy for Early-Stage Breast Cancer: A Systematic Review and Meta-analysis

IMPORTANCE

Chemotherapy may result in a detrimental effect on ovarian function and fertility in premenopausal women undergoing treatment for early-stage breast cancer (EBC). To minimize risk of harm to ovarian function and fertility for patients in this setting, careful considerations should be made. Gonadotropin-releasing hormone agonists (GnRHa) have been suggested as an alternative to prevent the loss of ovarian function due to exposure to cytotoxic agents, but GnRHa use for ovarian protection in EBC patients is not fully resolved.

OBJECTIVE

To determine the effectiveness of GnRHa administered concurrently with chemotherapy for ovarian function preservation.

DATA SOURCES

PubMed, SCOPUS, and Cochrane databases were searched for studies published between January 1975 and March 2015. The abstracts of the American Society of Clinical Oncology Annual Meeting between 1995 and 2014 and the San Antonio Breast Cancer Symposium between 2009 and 2014 were searched as well.

STUDY SELECTION

Prospective, randomized, clinical trials addressing the role of ovarian suppression with GnRHa in preventing early ovarian dysfunction in premenopausal women undergoing treatment for EBC were selected.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed independently by 2 authors. The methodology and the risk of bias were assessment based on the description of randomization method, withdrawals, and blinding process.

MAIN OUTCOMES AND MEASURES

Rate of resumption of regular menses after a minimal follow-up period of 6 months following chemotherapy was used as a surrogate to assess the incidence of ovarian dysfunction. Additional secondary outcomes included hormone levels and number of pregnancies. Risk ratio estimates were calculated based on the number of evaluable patients. Analyses were conducted using a random effect model.

RESULTS

Seven studies were included in this analysis, totaling 1047 randomized patients and 856 evaluable patients. The use of GnRHa was associated with a higher rate of recovery of regular menses after 6 months (odds ratio [OR], 2.41; 95% CI, 1.40-4.15; P = .002) and at least 12 months (OR, 1.85; 95% CI, 1.33-2.59; P < .001) following the last chemotherapy cycle. The use of GnRHa was also associated with a higher number of pregnancies (OR, 1.85; 95% CI, 1.02-3.36; P = .04), although this outcome was not uniformly reported and fertility or rate of pregnancy was not the primary outcome in any of the trials.

CONCLUSIONS AND RELEVANCE

Gonadotropin-releasing hormone agonists given with chemotherapy was associated with increased rates of recovery of regular menses in this meta-analysis. Evidence was insufficient to assess outcomes related to GnRHa and ovarian function and fertility and needs further investigation.

Anticancer treatment and fertility: Effect of therapeutic modalities on reproductive system and functions

The significant improvement of cancer treatments entailed a longer life in cancer survivors and raised expectations for higher quality of life with minimized long-term toxicity. Infertility and gonadal dysfunction are adverse effects of anticancer therapy or may be related to specific tumors. In female cancer survivors, premature ovarian failure is common after antineoplastic treatments resulting in infertility and other morbidities related to oestrogen deficiency such as osteoporosis. In male cancer survivors, infertility and persistent a zoospermia is a more common long-term adverse effect than hypogonadism because germ cells are more sensitive to chemotherapy and radiotherapy than leydig cells. Gonadal toxicity and compromise of reproductive functions will be more efficiently prevented and treated if addressed before treatment initiation. This review focuses on these issues in young cancer survivors of childbearing age, where methods of protecting or restoring endocrine function and fertility need to be considered.

Tamoxifen prevents apoptosis and follicle loss from cyclophosphamide in cultured rat ovaries

Recent studies documented that the selective estrogen receptor modulator tamoxifen prevents follicle loss and promotes fertility following in vivo exposure of rodents to irradiation or ovotoxic cancer drugs, cyclophosphamide and doxorubicin. In an effort to characterize the ovarian-sparing mechanisms of tamoxifen in preantral follicle classes, cultured neonatal rat ovaries (Day 4, Sprague Dawley) were treated for 1-7 days with active metabolites of cyclophosphamide (i.e., 4-hydroxycyclophosphamide; CTX) (0, 1, and 10 μM) and tamoxifen (i.e., 4-hydroxytamoxifen; TAM) (0 and 10 μM) in vitro, and both apoptosis and follicle numbers were measured. CTX caused marked follicular apoptosis and follicular loss. TAM treatment decreased follicular loss and apoptosis from CTX in vitro. TAM alone had no effect on these parameters. IGF-1 and IGF-1 receptor were assessed in ovarian tissue showing no impact of TAM or CTX on these endpoints. Targeted mRNA analysis during follicular rescue by TAM revealed decreased expression of multiple genes related to inflammation, including mediators of lipoxygenase and prostaglandin production and signaling (Alox5, Pla2g1b, Ptgfr), cytokine binding (Il1r1, Il2rg ), apoptosis (Tnfrsf1a), second messenger signaling (Mapk1, Mapk14, Plcg1), as well as tissue remodeling and vasodilation (Bdkrb2, Klk15). The results suggest that TAM protects the ovary from CTX-mediated toxicity through direct ovarian actions that oppose follicular loss.

Challenges and Potential for Ovarian Preservation with SERMs

Tamoxifen (TAM) is a selective estrogen receptor modulator with tissue-specific effects on estrogen signaling used predominantly for treatment and chemoprevention of breast cancers. Recent studies have shown that TAM prevents infertility and decreases follicular loss from common cancer chemotherapy and radiation therapy in preclinical models. Here we review current and novel uses of selective estrogen receptor modulator s and advantages and challenges for translation of TAM for human fertility preservation.

Fibrin-mediated delivery of an ovarian follicle pool in a mouse model of infertility

The cryopreservation and autotransplantation of ovarian tissue is emerging as a powerful approach for preserving fertility. However, for cancer patients, it may not be possible to transplant ovarian tissue due to the risk of re-seeding disease. We investigated strategies for transplantation of individually isolated follicles to minimize the risk of re-introducing cancer cells present within the vasculature of ovarian stroma. Procedures for large-scale isolation of early-stage follicles and their encapsulation into fibrin hydrogels were developed. For in vivo validation studies, mice were ovariectomized and transplanted with encapsulated follicles into the ovarian bursa. A substantial increase in the number of secondary follicles was observed in the graft at 9 days after transplantation, and antral follicles by day 21, demonstrating primordial follicle recruitment into the growing pool. Initially, elevated follicle-stimulating hormone levels declined substantially by day 21, indicating feedback from the graft; presence of corpora lutea showed the graft's capability of restoring hormone cyclicity. Taken together, the transplanted follicles were able to engraft, mature, and restore ovarian function in an infertile mouse. This biomaterial may, thus, provide a platform for follicle transplantation with a low risk of cancer contamination and for developing strategies that preserve fertility for women facing a cancer diagnosis.

Maintaining the reproductive potential of cancer patients during cancer treatment

Cancer therapies are known to alter the reproductive potential in cancer patients. Due to improved survival rates in cancer patients of reproductive age, considerations of the long-term effects of cancer therapy have become more significant. Oncofertility is a new discipline in medicine that deals with maintaining the reproductive potential of cancer patients while they are receiving gonadotoxic cancer treatment. The purpose of this review is to explore how cancer treatment impairs reproductive functioning and present the current options for preservation of fertility in women. All patients with reproductive potential should be made aware of the possible treatment-related infertility and be offered appropriate fertility preservation options before cancer treatment is instituted. The hope is that, in the future, mechanism(s) can be developed to preserve immature germ cells in the ovary, so that they can be used for fertilization in vivo or in vitro.

The need for laparoscopic ovarian transposition in young patients with cervical cancer undergoing radiotherapy

Maintaining the quality of life by preserving ovarian function in premenopausal patients with cervical cancer undergoing radiation is crucial. This can be accomplished with a simple and safe laparoscopic ovarian transposition procedure. This procedure aims to move the ovary out of the irradiation field, protecting it from direct radiation and irreversible damage and preserving its function. However, this procedure is often forgotten and seldom offered to patients. This review aims to lay stress on and reconsider the importance of laparoscopic ovarian transposition as a simple, safe, and extremely useful procedure. The biological effects of radiation are described briefly and several studies are evaluated, which reveal that this procedure has more benefits than risks.

5-Azacytidine induces early stage apoptosis and promotes in vitro maturation by changing chromosomal construction in murine oocytes

As an anticancer drug, 5-azacytidine (5-AzaC) has been widely used to treat various cancers. To investigate the effect of 5-AzaC on mouse oocytes cultured in vitro, we have performed morphological and molecular biology studies to examine the behavior of chromosomes and oocyte development. In 5-AzaC-treated oocytes, chromosomes were decondensed and unstable. The mRNA levels of Caspase3, Caspase8, and Caspase9 increased with the occurrence of early stage apoptosis in oocytes following 5-AzaC treatment. Furthermore, the mRNA levels of Gdf9 and Bmp15 also increased with the corresponding morphological changes in 5-AzaC-treated oocytes. In conclusion, 5-AzaC not only induced early apoptosis through both extrinsic and intrinsic pathways, but also had a positive effect on the developmental competence of mouse oocytes during in vitro maturation. These effects may be due to changes in chromosomal construction induced by DNA hypomethylation.

Fertility sparing in cancer patients

Infertility can arise as a consequence of treatment of oncological conditions. As cancer survival rates continue to improve, many women will face infertility after successful treatment of their malignant diseases. This review summarizes the current state of different fertility preservation options in these patients. This review will discuss the premature ovarian failure and other adverse reproductive outcomes in female patients who receive chemotherapy and radiation. In addition, cancer-specific fertility preservation methods are presented. Embryo cryopreservation is a well established technique to preserve fertility. However, it requires delaying cancer treatment for two to six weeks and a partner or willingness to use donor sperm. When these criteria cannot be met, more experimental options include oocyte cryopreservation for later IVF and ovarian tissue cryopreservation. In-vitro maturation is a promising technology and can be applied in combination with oocyte or ovarian tissue cryopreservation. Ovarian transposition remains the standard option for women undergoing pelvic radiation. Lastly, the efficacy of GnRH analoga in ovarian protection during chemotherapy has still not been proved. As fertility preservation choices include both established and experimental methods, a highly individualized approach is required in the management of patients looking for fertility preservation options.

Granulocyte colony-stimulating factor in conjunction with vascular endothelial growth factor maintains primordial follicle numbers in transplanted mouse ovaries

OBJECTIVE

To determine whether granulocyte colony-stimulating factor (G-CSF), stem cell factor (SCF), or vascular endothelial growth factor (VEGF) improve the outcome of ovarian grafting.

DESIGN

Experimental animal study.

SETTING

Tertiary care hospital, animal facilities.

ANIMAL(S)

Young adult (6- to 8-week-old) C57BL/6 female mice.

INTERVENTION(S)

Orthotopic transplantation of the frozen-thawed ovary. Group 1 (n = 6) received VEGF (8 g/kg/day); group 2 (n = 6) received VEGF and G-CSF (50 g/kg/day), group 3 (n = 6) received G-CSF and SCF (100 g/kg/day), and group 4 (n = 5) received saline (vehicle controls). All injections were given once daily for 5 days starting the day after surgery. Ovaries were collected 2 weeks after transplantation.

MAIN OUTCOME MEASURE(S)

Number of nonatretic immature (primordial, primary, and small preantral) follicles.

RESULT(S)

Transplanted ovaries in mice injected with VEGF concurrently with G-CSF maintained a statistically significantly larger pool of primordial follicles compared with transplanted ovaries in saline-injected controls. Follicle numbers (total immature and primordial) in transplanted ovaries showed no statistically significant difference in mice injected with VEGF alone or G-CSF plus SCF compared with saline-injected controls.

CONCLUSION(S)

After ovarian transplantation, mice treated with VEGF and G-CSF maintain a significantly greater number of primordial follicles compared with the transplanted ovaries in control animals, suggesting that the combination of G-CSF and VEGF minimizes ischemic damage and thus improves the viability and function of the ovarian graft.

[Is there any medical treatment to preserve fertility during chemotherapy in women?]

Intensive use of radio-chemotherapy has greatly improved the prognosis associated with cancer in young girl or women patients. However, improvement of the vital prognosis is frequently associated with impairment of fertility and premature ovarian failure. In vitro fertilization (IVF) followed by embryo cryopreservation is an available method, which needs a partner and a pretreatment stimulation. Ovarian and oocyte cryopreservation are techniques showing great promise. However, the nec plus ultra would be to be able to protect ovaries during chemotherapy. Since more than 10 years Gonadotropin releasing hormone (GnRH) analogues have been investigated as possible means to preserve fertility in young women. However, even recent prospective, randomized studies do not demonstrate clearly their effectiveness. To prevent primordial follicle apoptosis, an inhibitor of tysosine kinase, imatinib, has recently been proposed and positively evaluated in mice. It could represent an interesting hope to preserve female fertility during chemotherapy.

Incorporating fertility preservation into the care of young oncology patients

As the number of cancer survivors continues to increase, oncologists are faced with the challenge of providing cancer therapy to patients who may 1 day want to have children. Yet, gonadotoxic cancer treatments can compromise future fertility, either temporarily or permanently. There are established means of preserving fertility before cancer treatment; specifically, sperm cryopreservation for men and in vitro fertilization and embryo cryopreservation for women. Several innovative techniques are being actively investigated, including oocyte and ovarian follicle cryopreservation, ovarian tissue transplantation, and in vitro follicle maturation, which may expand the number of fertility preservation choices for young cancer patients. Fertility preservation may also require some modification of cancer therapy; thus, patients' wishes regarding future fertility and available fertility preservation alternatives should be discussed before initiation of therapy. This commentary provides an overview of the range of fertility preservation options currently available and under development, using case-based discussions to illustrate ways in which fertility preservation can be incorporated into oncology care. Cases involving breast cancer, testicular cancer, and rectal cancer are described to illustrate fertility issues experienced by male and female patients, as well as to provide examples of strategies for modifying surgical, medical, and radiation therapy to spare fertility. Current guidelines in oncology and reproductive medicine are also reviewed to underscore the importance of communicating fertility preservation options to young patients with cancer.

Maintaining fertility in young women with breast cancer

OPINION STATEMENT

Breast cancer effects nearly 200,000 American women each year, with 9% of these women still in their childbearing years. For this subset of future survivors, the issue of fertility may be a significant quality-of-life concern. Both the causes and treatments for infertility in young breast cancer patients must be thoroughly understood by the multidisciplinary team caring for these women in order for the caregivers to be effective advocates for their patients. Radiation, cytotoxic chemotherapy, and hormonal therapy all effect ovarian function to greater or lesser degrees, with the incidence of permanent post-treatment amenorrhea following systemic treatment for breast cancer in women age 50 or younger estimated as between 33% and 76%. The science of fertility preservation continues to experience significant advances in terms of the success of oocyte, embryo, and ovarian tissue preservation, and it is crucial that physicians and patients are aware of the available fertility preservation options. The optimal time to address the possibility of treatment-related infertility and strategies to combat this with younger patients is prior to treatment, rather than after cancer therapy has begun, and a full knowledge of the available technologies is a prerequisite for an informed discussion. Causes of ovarian suppression and options for treatment, including consideration of preimplantation genetic diagnosis and alternative parenting approaches are also discussed to assist the clinician caring for young patients with cancer.

Heavy ion radiotherapy during pregnancy

OBJECTIVE

To provide a safe particle therapy treatment for a pregnant woman with skull-base cancer.

DESIGN

Case report.

SETTING

University clinic.

PATIENT(S)

A 27-year-old woman diagnosed for a skull-base chordoma and whose pregnancy was found during the course of radiotherapy with accelerated carbon ions.

INTERVENTION(S)

Therapy was continued as scheduled, and fetal dose produced by photons and neutrons was measured at each radiotherapy fraction using passive and active monitors.

MAIN OUTCOME MEASURE(S)

Radiation dose to the uterus. Health of the mother and the newborn.

RESULT(S)

Total dose to the uterus was <0.2 mSv. About 30% of this dose was caused by neutrons. Magnetic resonance imaging of the skull base showed no evidence of recurrent disease in the mother. The child was healthy with normal development.

CONCLUSION(S)

Heavy ion cancer therapy produces a very low dose in distal organs.

Duration of fertility after fresh and frozen ovary transplantation

OBJECTIVE

To evaluate the function of human ovarian transplants.

DESIGN

Follow a series of fresh ovarian transplants for up to 5 years, and compare fresh and frozen ovarian tissue transplantation.

SETTING

Tertiary referral community hospital.

PATIENT(S)

Nine women with premature ovarian failure who received an ovary donated from a monozygotic twin sibling, and 16 young cancer patients undergoing ovarian cryopreservation. Two of the transplant recipients were cancer survivors rendered sterile by their therapy.

INTERVENTION(S)

Fresh ovary transplantation between monozygotic twin sisters, as well as transplantation of previously frozen ovarian tissue, and study of cryopreserved tissue in cancer patients.

MAIN OUTCOME MEASURE(S)

Return of normal menstrual cycling, hormone levels, pregnancy, healthy babies, duration of transplant function, and ovarian tissue evaluation.

RESULT(S)

Normal serum FSH and regular menstrual cycles returned by 5 months after surgery in all cases, both fresh and frozen. Fourteen spontaneous pregnancies were established leading to eight healthy live births and two healthy ongoing conceptions. All three frozen tissue transplants conceived spontaneously, one delivered, and two were ongoing. Oocyte survival with slow freezing was 42% and after vitrification 89%.

CONCLUSION(S)

Ovarian transplantation in humans is a robust procedure, even after cryopreservation, and vitrification might prove to be more effective than slow freezing.

[Oncofertility: a new focus in women health-care...]

Although treatment and survival are the primary focus of health-care patients, with cancer survivors living longer it is now appropriate to consider their quality of life after treatment, including the possibility of becoming parents. There are several options for fertility preservation in cancer patients. Even though most of them are still experimental and their efficacy and reliability have not been determined, especially in women. The most successful alternative for female survivors is embryo cryopreservation, an approach not suitable for many single or virgin women or even possible for prepubertal girls. Reports of live birth after transplantation of human ovarian tissue have reinforced the clinical potential of ovarian tissue banking for fertility preservation. Many exciting studies are underway to improve the efficacy and solve the problems with current fertility preservation strategies, especially for in vitro culture of cryopreserved tissue or follicles. Continuous efforts to improve current strategies and to develop new strategies will benefit many women and children who are facing premature ovarian failure and sterility.

Medical and psychosocial aspects of fertility after cancer

Survival for cancer has improved significantly in the last 25 years with excellent overall 5- and 10-year survival rates. Hence, the majority of young women diagnosed with cancer can expect to live for decades, making quality of life issues such as fertility increasingly important. Risks of infertility vary based on the chemotherapy and treatments employed, as well as a woman's age. In general, younger women are less likely to experience permanent amenorrhea than older women, but even women who continue to menstruate have a greatly increased risk of premature menopause. Options for patients with cancer entering chemotherapy treatment, who wish to preserve fertility range from clinically well-established techniques such as embryo cryopreservation to more experimental techniques such as ovarian tissue cryopreservation. Pregnancy does not appear to increase the risk of cancer recurrence. Discussions of fertility issues in premenopausal women diagnosed with cancer present important challenges to the provider and to the patient. However, failure to discuss these options adequately can have lasting negative consequences on a woman's quality of life. Physician education interventions should seek to improve the knowledge of fertility preservations options, and of locally and nationally available resources.

Multidisciplinary care for patients with breast cancer

The care of patients with breast cancer has become increasingly complex with advancements in diagnostic modalities, surgical approaches, and adjuvant treatments. A multidisciplinary approach to breast cancer care is essential to the successful integration of available therapies. This article addresses the key components of multidisciplinary breast cancer care, with a special emphasis on new and emerging approaches over the past 10 years in the fields of diagnostics, surgery, radiation, medical oncology, and plastic surgery.

[Primary myeloid sarcoma of uterine cervix and prevention of fertility. Report of a case]

The isolated myeloid sarcomas of the cervix are tumors whose forecast was dark for a long time. However, an effective but invasive treatment associating chemotherapy and radiotherapy allows for local remission. This treatment generally causes an ovarian failure and especially infertility. We report the case of a 29-year-old woman suffering from a myeloid sarcoma isolated from the uterine cervix and wishing a pregnancy. A prevention of the deficit ovarian was carried out. This patient presented normal menstrual cycles and a biochemical pregnancy three years after the beginning of the treatment.

Female fertility preservation: practical and ethical considerations of an underused procedure

PURPOSE

Cancer treatments for young women can permanently or temporarily affect fertility. The purpose of this retrospective analysis was to present the clinical experience and ethical considerations of fertility preservation in female oncology patients in a tertiary gynaecological department.

METHODS

Since 2002, in 37 patients fertility preservation was performed according to an institutional review board approved protocol in a University hospital in the Netherlands; 33 patients were not treated.

RESULTS

Embryo cryopreservation was performed in 10 patients, ovarian tissue cryopreservation in 24, and an ovarian transposition was performed in 3 patients; in one patient combined with an ovarian transplantation and in one patient with ovarian tissue cryopreservation.

DISCUSSION

Approved protocols and timing are essential in performing female fertility preservation. Referral for ovarian tissue and embryo cryopreservation is minimal in the Netherlands. Future research focuses on the psychosocial aspects of fertility preservation and explores patients' and professionals' expectations and attitudes regarding fertility preservation and aims to be in line with technical developments.

Lactoferrin is associated with a decrease in oocyte depletion in mice receiving cyclophosphamide

OBJECTIVE

To investigate new important molecules involved in the regulation of chemotherapy-induced ovarian damage and, based on those results, to examine the effect of lactoferrin on cyclophosphamide (CPM)-induced ovarian failure.

DESIGN

Complementary DNA microarray and the administration of lactoferrin.

SETTING

Experimental animal study.

ANIMAL(S)

Female imprinting control region mice.

INTERVENTION(S)

Administration of CPM to mice, isolation of ovaries, isolation of RNA, microarray hybridization, and statistical analysis. According to the results of the microarray assay, administration of lactoferrin to CPM-treated mice, isolation of ovaries, isolation of RNA, and evaluation using quantitative polymerase chain reaction and histomorphometric analyses.

MAIN OUTCOME MEASURE(S)

A list of nine down-regulated and two up-regulated genes with reliable hybridization signals was obtained. Several target molecules were then investigated.

RESULT(S)

Among the listed genes, we focused on the mouse lactoferrin gene, because of its CPM-induced expression pattern and its multiple novel functions. Oral administration of bovine lactoferrin prevented down-regulation of the ovulation-related, Adamts1 and partial recovery of follicle depletion induced by CPM treatment.

CONCLUSION(S)

The present report suggests that lactoferrin helps to rescue the ability to ovulate and partially to prevent oocyte depletion in mouse ovaries.

Difficulties improving ovarian functional recovery by microvascular transplantation and whole ovary vitrification

OBJECTIVE

To evaluate recovery of endocrine function and fertility after transplantation and vitrification of whole ovaries.

DESIGN

Animal study.

SETTING

Lyon Veterinary School, France.

ANIMAL(S)

Ewes.

INTERVENTION(S)

In group 1 (n = 5), the left ovary was removed with its vascular pedicle and was transplanted onto the contralateral pedicle. In group 2 (n = 5), the left ovary with its pedicle was cryopreserved after a vitrification procedure. After thawing, transplantation was performed by microvascular anastomosis to the contralateral ovarian pedicle.

MAIN OUTCOME MEASURE(S)

Median ischemia time, progesterone levels, histologic examination.

RESULT(S)

Successful microsurgical transplantation was performed in both groups. The median ischemia time was statistically significantly longer in group 2 (287 minutes, range: 226 to 349] versus 129 minutes [range: 125 to 130]) in group 1. In group 1, four sheep recovered spontaneous ovarian endocrine function about 2.5 (range: 2.00 to 3.75) months after transplantation. Two ewes gave healthy live births at 12 and 25 months, respectively, after transplantation. In group 2, one ewe recovered ovarian endocrine function 6 months after transplantation. However, histologic evaluation showed a follicular survival rate of 6% in group 1, and total follicle loss in group 2.

CONCLUSION(S)

Autograft of whole sheep ovaries with microvascular anastomosis seems technically feasible but resulted in a very poor follicle survival rate (6%), in spite of endocrine function recovery and birth of two lambs. Attempts at cryopreservation with vitrification resulted in no follicle survival at all.

Morphology and function of cryopreserved whole ovine ovaries after heterotopic autotransplantation

BACKGROUND

The objective of this study was to perform complex characterization of cryopreserved and then autotransplanted ovaries including determination of the ability to respond to in vivo follicle stimulating hormone (FSH)-treatment, fertilizability of retrieved oocytes, and morphology, vascularization, cellular proliferation and apoptosis in sheep.

METHODS

Mature crossbred ewes were divided into two groups; an intact (control) group (n = 4), and autotransplanted group (n = 4) in which oophorectomy was performed laparoscopically and ovaries with intact vascular pedicles frozen, thawed and transplanted back into the same animal at a different site. Approximately five months after autotransplantation, estrus was synchronized, ewes were treated with FSH, and ovaries were collected. For all ovaries, number of visible follicles was determined, and collected cumulus oocyte complexes (COC) were matured and fertilized in vitro. Remaining ovarian tissues were fixed for evaluation of morphology, expression of factor VIII (marker of endothelial cells), vascular endothelial growth factor (VEGF; expressed by pericytes and smooth muscle cells), and smooth muscle cell actin (SMCA; marker of pericytes and smooth muscle cells), and cellular proliferation and apoptosis. Two fully functional ovaries were collected from each control ewe (total 8 ovaries).

RESULTS

Out of eight autotransplanted ovaries, a total of two ovaries with developing follicles were found. Control ewes had 10.6 +/- 2.7 follicles/ovary, oocytes were in vitro fertilized and developed to the blastocyst stage. One autotransplanted ewe had 4 visible follicles from which 3 COC were collected, but none of them was fertilized. The morphology of autotransplanted and control ovaries was similar. In control and autotransplanted ovaries, primordial, primary, secondary, antral and preovulatory follicles were found along with fully functional vascularization which was manifested by expression of factor VIII, VEGF and SMCA. Proliferating cells were detected in follicles, and the rate of apoptosis was minimal in ovaries of control and autotransplanted ovaries.

CONCLUSION

These data demonstrate successful autotransplantation of a portion of frozen/thawed ovaries manifested by restoration of selected ovarian function including in vitro maturation of collected oocytes, presence of follicles from several stages of folliculogenesis and blood vessels expressing specific markers of vascularization, and proliferation and apoptosis of ovarian cells. Thus, heterotopic autotransplantation of a whole frozen/thawed ovary allows for development of preovulatory follicles, oocyte growth, and for restoration of vascularization and cellular function. However, additional improvements are required to enhance the efficiency of autotransplantation of frozen/thawed ovaries to produce more oocytes.