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Suzuki Y, Ferris JS, Chen L, Dioun S, Usseglio J, Matsuo K, Xu X, Hershman DL, Wright JD. Levonorgestrel-releasing intrauterine device therapy vs oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia: a systematic review and meta-analysis. J Natl Cancer Inst 2024; 116:653-664. [PMID: 38305500 DOI: 10.1093/jnci/djae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/14/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis to examine outcomes of patients with endometrial intraepithelial neoplasia treated with oral progestins or a levonorgestrel-releasing intrauterine device (IUD). METHODS We conducted a systematic review across 5 databases to examine outcomes of progestational treatment (oral progestins or levonorgestrel-releasing IUD) for patients with endometrial intraepithelial neoplasia. The primary outcome was the best complete response rate within 12 months of primary progestational treatment. Sensitivity analyses were performed by removing studies with extreme effect sizes. Secondary outcomes included the pooled pregnancy rate. RESULTS We identified 21 eligible studies, including 824 premenopausal patients with endometrial intraepithelial neoplasia, for our meta-analysis. Among these, 459 patients received oral progestin, and 365 patients received levonorgestrel-releasing IUD as a primary progestational treatment. The pooled best complete response proportion within 12 months was 82% (95% confidence interval [CI] = 69% to 91%) following oral progestin treatment and 95% (95% CI = 81% to 99%) following levonorgestrel-releasing IUD treatment. After removing outlier studies, the pooled proportion was 86% (95% CI = 75% to 92%) for the oral progestin group and 96% (95% CI = 91% to 99%) for the levonorgestrel-releasing IUD group, with reduced heterogeneity. The pooled pregnancy rate was 50% (95% CI = 35% to 65%) after oral progestin and 35% (95% CI = 23% to 49%) after levonorgestrel-releasing IUD treatment. CONCLUSIONS This meta-analysis provides data on the effectiveness of oral progestins and levonorgestrel-releasing IUD treatment within 12 months of treatment among premenopausal patients with endometrial intraepithelial neoplasia. Although based on small numbers, the rate of pregnancy after treatment is modest. These data may be beneficial for selecting progestational therapies that allow fertility preservation for patients with endometrial intraepithelial neoplasia.
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Affiliation(s)
- Yukio Suzuki
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jennifer S Ferris
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ling Chen
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shayan Dioun
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - John Usseglio
- Augustus C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Matsuo
- University of Southern California, Los Angeles, CA, USA
| | - Xiao Xu
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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Ye X, Li T. Effects of hysteroscopic surgery combined with progesterone therapy on fertility and prognosis in patients with early endometrial cancer and atypical endometrial hyperplasia or endometrial intraepithelial neoplasia: a meta-analysis. Arch Gynecol Obstet 2024; 309:259-268. [PMID: 37540307 DOI: 10.1007/s00404-023-07173-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This meta-analysis aimed to evaluate the effects of hysteroscopic surgery combined with progesterone therapy on fertility and prognosis in patients with early endometrial cancer (EC), atypical endometrial hyperplasia (AEH), or endometrial intraepithelial neoplasia (EIN). METHODS Studies on hysteroscopic surgery combined with progesterone therapy for patients with early-stage EC, AEH, or EIN were searched from Embase, Web of Science, PubMed, and Cochrane Library databases. The included studies contained one or more of the following outcome variables: pregnancy rate, live birth rate, complete response (CR) rate, and recurrence rate after conservative treatment. The meta-analysis was performed using Stata. RESULTS 13 pieces of literature containing 239 patients with EC and 199 patients with AEH/EIN were included. As per the results of meta-analysis, the pregnancy rates of EC patients and AEH/EIN patients were 49% (95% CI 33-65%) and 47% (95% CI 31-64%), respectively, and the live birth rates were 45% (95% CI 32-58%) and 44% (95% CI 34-54%), respectively. CR rates of EC patients and AEH/EIN patients were 90% (95% CI 85-94%) and 100% (95% CI 97-100%), respectively, and the disease recurrence rates were 17% (95% CI 8-28%) and 11% (95% CI 3-23%), respectively. CONCLUSION Hysteroscopic surgery combined with progesterone was linked to an improved overall response rate, reduced disease recurrence rate, and increased pregnancy and live birth rates among patients with EC and AEH/EIN.
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Affiliation(s)
- Xiabin Ye
- Obstetrics and Gynecology Department, LiShui City People's Hospital, No. 1188, Liyang Street, Lishui City, 323000, Zhejiang Province, China
| | - Tonghuai Li
- Obstetrics and Gynecology Department, LiShui City People's Hospital, No. 1188, Liyang Street, Lishui City, 323000, Zhejiang Province, China.
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Dellino M, Cerbone M, Laganà AS, Vitagliano A, Vimercati A, Marinaccio M, Baldini GM, Malvasi A, Cicinelli E, Damiani GR, Cazzato G, Cascardi E. Upgrading Treatment and Molecular Diagnosis in Endometrial Cancer-Driving New Tools for Endometrial Preservation? Int J Mol Sci 2023; 24:ijms24119780. [PMID: 37298731 DOI: 10.3390/ijms24119780] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
One emerging problem for onco-gynecologists is the incidence of premenopausal patients under 40 years of age diagnosed with stage I Endometrial Cancer (EC) who want to preserve their fertility. Our review aims to define a primary risk assessment that can help fertility experts and onco-gynecologists tailor personalized treatment and fertility-preserving strategies for fertile patients wishing to have children. We confirm that risk factors such as myometrial invasion and The International Federation of Gynecology and Obstetrics (FIGO) staging should be integrated into the novel molecular classification provided by The Cancer Genome Atlas (TCGA). We also corroborate the influence of classical risk factors such as obesity, Polycystic ovarian syndrome (PCOS), and diabetes mellitus to assess fertility outcomes. The fertility preservation options are inadequately discussed with women with a diagnosis of gynecological cancer. A multidisciplinary team of gynecologists, oncologists, and fertility specialists could increase patient satisfaction and improve fertility outcomes. The incidence and death rates of endometrial cancer are rising globally. International guidelines recommend radical hysterectomy and bilateral salpingo-oophorectomy as the standard of care for this cancer; however, fertility-sparing alternatives should be tailored to motivated women of reproductive age, establishing an appropriate cost-benefit balance between childbearing desire and cancer risk. New molecular classifications such as that of TCGA provide a robust supplementary risk assessment tool that can tailor the treatment options to the patient's needs, curtail over- and under-treatment, and contribute to the spread of fertility-preserving strategies.
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Affiliation(s)
- Miriam Dellino
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Marco Cerbone
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Amerigo Vitagliano
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Antonella Vimercati
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Marco Marinaccio
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | | | - Antonio Malvasi
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Ettore Cicinelli
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Obstetrics and Gynaecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Gerardo Cazzato
- Department of Emergency and Organ Transplantation, Pathology Section, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
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Lv M, Chen P, Bai M, Huang Y, Li L, Feng Y, Liao H, Zheng W, Chen X, Zhang Z. Progestin Resistance and Corresponding Management of Abnormal Endometrial Hyperplasia and Endometrial Carcinoma. Cancers (Basel) 2022; 14:cancers14246210. [PMID: 36551694 PMCID: PMC9776943 DOI: 10.3390/cancers14246210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/05/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
With a younger tendency in morbidity age, endometrial cancer (EC) incidence has grown year after year. Worse, even more commonly occurring is endometrial hyperplasia (EH), which is a precancerous endometrial proliferation. For young women with early EC and EH who want to preserve fertility, progestin therapy has been utilized as a routine fertility-preserving treatment approach. Nevertheless, progestin medication failure in some patients is mostly due to progestin resistance and side effects. In order to further analyze the potential mechanisms of progestin resistance in EH and EC, to provide theoretical support for effective therapeutic strategies, and to lay the groundwork for searching novel treatment approaches, this article reviews the current therapeutic effects of progestin in EH and EC, as well as the mechanisms and molecular biomarkers of progestin resistance, and systematically expounds on the potential therapeutic methods to overcome progestin resistance.
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Affiliation(s)
- Mu Lv
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Peiqin Chen
- Department of Obstetrics and Gynecology, The International Peace Maternity & Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Mingzhu Bai
- Reproductive Medicine Center, Maternal and Child Health Hospital in Xuzhou, Xuzhou 215002, China
| | - Yan Huang
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, 270 Dong-an Road, Shanghai 200032, China
| | - Linxia Li
- Department of Obstetrics and Gynecology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, 358 Datong Road, Shanghai 200137, China
| | - Youji Feng
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Hong Liao
- Department of Clinical Laboratory Medicine, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200090, China
- Correspondence: (X.C.); (Z.Z.)
| | - Zhenbo Zhang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
- Correspondence: (X.C.); (Z.Z.)
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Ding Y, Fan Y, Li X, Wang Y, Wang J, Tian L. Metabolic syndrome is an independent risk factor for time to complete remission of fertility-sparing treatment in atypical endometrial hyperplasia and early endometrial carcinoma patients. Reprod Biol Endocrinol 2022; 20:134. [PMID: 36064542 PMCID: PMC9442985 DOI: 10.1186/s12958-022-01006-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/23/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Fertility-sparing treatment of atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EC) patients has recently emerged important social health topic. This study is designed to explore the risk factors for time to complete remission (CR) of fertility-sparing treatment in woman with AEH and early EC. METHODS A retrospective study was designed with clinical data from 106 patients admitted between January 2012 to December 2019. Univariate and multivariate logistic analysis were used to explore independent risk factors for time to CR. These factors were employed in receiver operator characteristic (ROC) curve and the decision curve analysis (DCA) to evaluate predictive accuracy of time to CR. Stratified analysis and interactive analysis was also performed for more in-depth perspective. RESULTS Univariate analysis showed that fasting blood glucose levels (FBG, OR = 1.6, 95%CI: 0.6-2.5, P = 0.020), metabolic syndrome (MetS, OR = 3.0, 95%CI: 1.1-5.0, P = 0.003), and polycystic ovary syndrome (PCOS, OR = 2.0, 95%CI: 0.5-3.4, P = 0.009) were associated with time to CR. Among these factors, multivariate analysis confirmed MetS (OR = 3.1, 95%CI: 1.0-5.2, P = 0.005) was an independent risk factor. The area under the ROC curve (AUC) of MetS was higher than FBG and PCOS (AUC = 0.723 vs 0.612 and 0.692). The AUC of FBG combined with PCOS was 0.779, and it was improved to 0.840 when MetS was included (P < 0.05). Additionally, MetS played different roles in time to CR in various groups. Moreover, we found high-density lipoprotein (HDL) and MetS had an interactive effect for time to CR. CONCLUSION MetS is an independent risk factor for time to CR and should be taken seriously in fertility-sparing management of AEH and early EC patients.
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Affiliation(s)
- Yingqiao Ding
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yuan Fan
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Li Tian
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
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Ran X, Hu T, Li Z. Molecular Classification in Patients With Endometrial Cancer After Fertility-Preserving Treatment: Application of ProMisE Classifier and Combination of Prognostic Evidence. Front Oncol 2022; 12:810631. [PMID: 35664732 PMCID: PMC9160735 DOI: 10.3389/fonc.2022.810631] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 04/14/2022] [Indexed: 12/21/2022] Open
Abstract
The Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) is a molecular classification system that identifies endometrial cancer (EC) into four prognostically distinct subtypes: POLE-mutated, mismatch repair deficiency (MMR-D), p53 wild-type (p53wt), and p53 abnormal (p53abn). However, few reports have applied the ProMisE classifier to EC patients who underwent fertility-preserving treatment (FPT) so far. This study evaluated whether the ProMisE classifier predicted in early-stage EC patients after FPT. We first summarized the three reported outcomes of ProMisE applied to EC patients who received FPT. The hormone-treated patients with EC from 2010 to 2020 in our facility were then analyzed. By sequential immunohistochemistry and Sanger sequencing of POLE according to the ProMisE system, formalin-fixed paraffin-embedded blocks of patients before treatment were collected and classified into POLE-mutated, MMR-D, p53wt, and p53abn subtypes. The primary outcome was a complete response rate after FPT. Thirteen patients were enrolled from our facility, with 3 (3/13) MMR-D, 0 (0/13) POLE, 8 (8/13) p53wt, 1 (1/13) p53abn, and 1 (1/13) failed with DNA amplification. Six (6/8) patients with p53wt, 2 (2/3) patients with MMR-D, and 1 (1/1) patient with p53abn achieved a complete response in 6 months after treatment. The results of our study and the reported outcomes were finally combined. A total of 106 patients who underwent FPT were included. Of these, 23 (21.7%) were classified as MMR-D, 3 (2.8%) as POLE-mutated, 3 (2.8%) as p53abn, and 77 (72.6%) as p53wt. There was no significant difference in the complete response rate (P = 0.152) and recurrence rate (P = 0.174) between MMR-D and p53wt subtypes after FPT. Based on current data, we observed no prognostic significance of the ProMisE classifier in EC patients who underwent FPT. Larger prospective studies are needed to elucidate the precise prognostic meaning of this molecular classifier in these cases.
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Affiliation(s)
- Xuting Ran
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Tingwenyi Hu
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Zhengyu Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Herrera Cappelletti E, Humann J, Torrejón R, Gambadauro P. Chances of pregnancy and live birth among women undergoing conservative management of early-stage endometrial cancer: a systematic review and meta-analysis. Hum Reprod Update 2022; 28:282-295. [PMID: 34935045 PMCID: PMC8888991 DOI: 10.1093/humupd/dmab041] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/08/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Endometrial cancer is common and usually occurs after menopause, but the number of women diagnosed during reproductive age is increasing. The standard treatment including hysterectomy is effective but causes absolute uterine factor infertility. In order to avoid or postpone surgery, conservative management of endometrial cancer (CMEC) has been proposed for younger women who want to retain their fertility. OBJECTIVE AND RATIONALE The main objective of this study was to estimate the chances of pregnancy and live birth for women with early-stage endometrial cancer (EEC) who are managed conservatively for fertility preservation. SEARCH METHODS The PRISMA recommendations for systematic reviews and meta-analyses were followed. Structured searches were performed in PubMed, Embase and the Cochrane Library, from inception until 13 June 2021. Inclusion was based on the following criteria: group or subgroup of women with Clinical Stage IA, well-differentiated, endometrioid endometrial cancer (from now on, EEC); CMEC for fertility preservation; and reported frequencies of women achieving pregnancy and/or live birth after CMEC. The following exclusion criteria applied: impossibility to isolate/extract outcome data of interest; second-line CMEC for persistent/recurrent disease; CMEC in the presence of synchronous tumours; case reports; non-original or duplicated data; and articles not in English. Qualitative synthesis was performed by means of tabulation and narrative review of the study characteristics. Study quality was assessed with an ad hoc instrument and several moderator and sensitivity analyses were performed. OUTCOMES Out of 1275 unique records, 133 were assessed in full-text and 46 studies were included in the review. Data from 861 women with EEC undergoing CMEC were available. Progestin-based treatment was reported in all but three studies (93.5%; 836 women). Complete response to treatment was achieved in 79.7% of women, with 35.3% of them having a disease recurrence during follow-up. Of 286 pregnancies obtained after CMEC; 69.4% led to live birth (9% of them multiple births) and 66.7% were achieved through fertility treatment. Based on random-effects meta-analyses, women treated with progestin-based CMEC have a 26.7% chance of achieving pregnancy (95% CI 21.3-32.3; I2 = 53.7%; 42 studies, 826 women) and a 20.5% chance to achieve a live birth (95% CI 15.7-25.8; I2 = 40.2%; 39 studies, 650 women). Sample size, average age, publication year, study design and quality score were not associated with the outcomes of progestin-based CMEC in moderator analyses with meta-regression. However, mean follow-up length (in months) was positively associated with the chances of pregnancy (regression coefficient [B] = 0.003; 95% CI 0.001-0.005; P = 0.006) and live birth (B = 0.005; 95% CI 0.003-0.007; P < 0.001). In sensitivity analyses, the highest chances of live birth were estimated in subsets of studies including only women of age 35 or younger (30.7%), the combination of progestins with hysteroscopic resection (30.7%), or at least 3 years of follow-up (42.4%). WIDER IMPLICATIONS Progestin-based CMEC is viable for women with well-differentiated, Clinical Stage 1A, endometrioid endometrial cancer who want to preserve their fertility, but there is room for improvement as only one-fifth of them are estimated to achieve live birth according to this meta-analysis. Further investigations on prognosis-driven selection, hysteroscopic resection and long-term surveillance are arguably needed to improve the reproductive outcomes of CMEC.
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Affiliation(s)
- Erica Herrera Cappelletti
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Area of Obstetrics and Gynaecology, University of Cádiz, Cádiz, Spain
| | - Jonas Humann
- Area of Obstetrics and Gynaecology, University of Cádiz, Cádiz, Spain
| | - Rafael Torrejón
- Area of Obstetrics and Gynaecology, University of Cádiz, Cádiz, Spain
| | - Pietro Gambadauro
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Area of Obstetrics and Gynaecology, University of Cádiz, Cádiz, Spain
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- Res Medica Sweden, Uppsala, Sweden
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Zisi M, Zygouris D, Tsonis O, Papadimitriou S, George M, Kalantaridou S, Paschopoulos M. Uterine sparing management in patients with endometrial cancer: a narrative literature review. J OBSTET GYNAECOL 2022; 42:823-829. [PMID: 34989284 DOI: 10.1080/01443615.2021.2006164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Endometrial cancer is the most common malignancy of the female genital tract. Approximately 25% of cases occur in premenopausal women, and up to 5% of cases occur in women who are younger than 40 years old. The survival rate in these cases is 99%; therefore, uterine-sparing management could be considered under strict criteria selection and the strong desire of the woman to preserve uterus and fertility. Diagnosis should be performed after a hysteroscopic biopsy instead of dilatation and curettage. The highest remission rate was achieved after combining a hysteroscopic resection with hormonal therapy compared to single hormonal treatment. The most common regiments are the following progestins: megestrol acetate (MA) and medroxyprogesterone acetate (MPA) taken orally with a daily dosage of 160 mg-320 mg for MA and 250 mg-600 mg for MP. Evaluations at three and six months could be performed by office endometrial biopsy and/or hysteroscopic directed biopsy especially in the presence of levonorgestrel intrauterine system, and in cases of remission, either a pregnancy attempt or maintenance therapy should be considered. After childbearing, hysterectomy with bilateral salpingo-oophorectomy is recommended, whereas ovarian preservation could be considered depending on the patient's age and whether they fulfil the strict criteria selection.
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Affiliation(s)
- Maria Zisi
- Department of Obstetrics and Gynecology, Medical School, University of Ioannina, Ioannina, Greece
| | - Dimitrios Zygouris
- Department of Obstetrics and Gynecology, Medical School, University of Ioannina, Ioannina, Greece
| | - Orestis Tsonis
- Department of Obstetrics and Gynecology, Medical School, University of Ioannina, Ioannina, Greece
| | | | - Mastorakos George
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens Medical School, Aretaieio Hospital, Athens, Greece
| | - Sophia Kalantaridou
- 3rd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens Medical School, Attikon Hospital, Athens, Greece
| | - Minas Paschopoulos
- Department of Obstetrics and Gynecology, Medical School, University of Ioannina, Ioannina, Greece
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Jing CY, Li SN, Shan BE, Zhang W, Tian WJ, Ren YL, Wang HY. Hysteroscopic Curettage Followed by Megestrol Acetate Plus Metformin as a Fertility-Sparing Treatment for Women with Atypical Endometrial Hyperplasia or Well-Differentiated Endometrioid Endometrial Carcinoma. CLINICAL MEDICINE INSIGHTS: ONCOLOGY 2022; 16:11795549221110522. [PMID: 35875417 PMCID: PMC9297462 DOI: 10.1177/11795549221110522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background: In reproductive-aged women, the incidence of atypical endometrial hyperplasia (AEH) or endometrioid endometrial carcinoma (EEC) is rising globally. The study aimed to investigate the effectiveness of hysteroscopic curettage followed by megestrol acetate (MA) plus metformin as conservative treatment in AEH and early EEC. Methods: We retrospectively studied AEH and stage IA, grade 1 EEC patients treated with hysteroscopic curettage followed by MA (160 mg/d) plus metformin (1500 mg/d) from January 2010 to December 2020 at Fudan University Shanghai Cancer Center. Treatment outcomes were assessed by complete response (CR) rate, recurrence rate, and pregnancy outcomes. Univariate and multivariate analyses were performed via the logistic regression model. Results: The study included 79 patients, 31 (39.2%) with AEH and 48 (60.8%) with EEC. The medians of age (years) and follow-up time (months) were 30 and 39.5, respectively. Seventy-six patients (96.2%) finally achieved CR. The median time to CR was 3.6 (3.0-20.6) months. The CR rate after 3 months, 6 months, and 1 year was 55 (69.6%), 67 (84.8%), and 72 (91.1%), respectively. Recurrence occurred in 26 (34.2%) patients. Treatment duration ⩾9 months was associated with a lower recurrence rate after CR (P = .012). Fourteen (93.3%) of the 15 recurrent patients who received progestin re-treatment achieved CR again. Finally, 29 patients delivered live births. Conclusions: Hysteroscopy followed by MA plus metformin can achieve CR in short time and is overall safe. Consolidation treatment should be prolonged to decrease the recurrence rate, despite a shorter time to CR.
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Affiliation(s)
- Chu-Yu Jing
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sheng-Nan Li
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bo-Er Shan
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Wei Zhang
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Wen-Juan Tian
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu-Lan Ren
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Hua-Ying Wang
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
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Chen J, Cao D, Yang J, Yu M, Zhou H, Cheng N, Wang J, Zhang Y, Peng P, Shen K. Management of Recurrent Endometrial Cancer or Atypical Endometrial Hyperplasia Patients After Primary Fertility-Sparing Therapy. Front Oncol 2021; 11:738370. [PMID: 34568074 PMCID: PMC8458864 DOI: 10.3389/fonc.2021.738370] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023] Open
Abstract
Objective To evaluate the efficacy and prognosis of fertility-sparing re-treatment on patients with recurrent endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) who wish to preserve their uterus after complete remission (CR) for primary conservative therapy. Methods We performed a retrospective study on recurrent EC or AEH patients who received fertility-sparing re-treatment after achieving CR. Data regarding clinicopathological factors, adverse events, treatment efficacy, tumor prognosis, and reproductive outcome were analyzed. Results Of the 98 recurrent patients with a median disease-free interval period of 19 (3–96) months, 18 patients decided to receive hysterectomy directly, and 80 patients received fertility-preserving re-treatment. Seventy-one (88.6%) cases achieved CR, 96.0% in AEH and 75.8% in EC patients, with the 6 (3–16) months’ median CR time. Seven (8.8%) patients failed to achieve CR and then underwent the hysterectomy: one partial response (PR), four stable disease (SD), and two progressive disease (PD). Forty-nine women attempted to get pregnant after CR, 13 (26.5%) became pregnant, seven (14.3%) successfully delivered, and six (12.2%) miscarried. During the follow-up period, 22 (31.0%) women had developed a second relapse with the median recurrence time of 12 (4–90) months, and 10 patients decided to receive the third round of fertility-sparing treatment. Seven (70.0%) patients, 33.3% in EC and 85.7% in AEH, achieved CR again. Hysterectomy was performed in two (20.0%) patients due to SD. After the third-round treatment, six women had the desire to conceive but no one became pregnant successfully. Conclusion For patients with recurrent EC and AEH after primary conservative treatment, fertility-preserving re-treatment can still achieve a promising response, and patients have possibilities of completing childbirth.
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Affiliation(s)
- Junyu Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Mei Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Huimei Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Ninghai Cheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jinhui Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Peng Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
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11
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Carugno J, Wong A. Fertility-sparing approach for endometrial cancer: the role of office hysteroscopy. MINIM INVASIV THER 2021; 30:296-303. [PMID: 34292797 DOI: 10.1080/13645706.2021.1949353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endometrial cancer is the most common gynecologic malignancy in developed countries, with increasing incidence among younger, nulliparous patients. These epidemiological shifts are attributed to increasing rates of obesity, in combination with delayed childbearing. This highlights a need for fertility-sparing options for individuals who wish to delay standard surgical management with hysterectomy, bilateral salpingoophorectomy, and assessment of pelvic/para-aortic lymph nodes. Careful consideration should be taken to select which patients are suitable candidates for fertility-sparing methods. Typically, these are patients found to have FIGO grade 1 tumors of the endometrioid subtype without myometrial invasion. Currently, conservative treatment options include the use of oral progestins and levonorgestrel-releasing intrauterine devices, with an emerging role for hysteroscopy for direct visualization of the uterine cavity, targeted tissue sampling, and tumor resection. This paper aims to highlight the role of office hysteroscopy for diagnosis, hysteroscopic tumor resection, and follow-up in suitable endometrial cancer patients who wish to preserve their uterus until childbearing is complete.
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Affiliation(s)
- José Carugno
- Minimally Invasive Gynecology Division, Department of Obstetrics, Gynecology and Reproductive Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Adriana Wong
- Department of Obstetrics and Gynecology, University of California Davis Medical Center, Sacramento, CA, USA
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12
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Puechl AM, Spinosa D, Berchuck A, Secord AA, Drury KE, Broadwater G, Wong J, Whitaker R, Devos N, Corcoran DL, Strickland KC, Previs RA. Molecular Classification to Prognosticate Response in Medically Managed Endometrial Cancers and Endometrial Intraepithelial Neoplasia. Cancers (Basel) 2021; 13:cancers13112847. [PMID: 34200374 PMCID: PMC8201008 DOI: 10.3390/cancers13112847] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether molecular classification prognosticates treatment response in women with endometrial cancers and endometrial intraepithelial neoplasia (EIN) treated with levonorgestrel intrauterine system (LNG-IUS). METHODS Patients treated with LNG-IUS for endometrial cancer or EIN from 2013 to 2018 were evaluated. Using immunohistochemistry and single gene sequencing of POLE, patients were classified into four groups as per the Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE): POLE-mutated, mismatch repair-deficient (MMRd), p53 wild type (p53wt), and p53-abnormal (p53abn). Groups were assessed relative to the primary outcome of progression or receipt of definitive treatment. RESULTS Fifty-eight subjects with endometrioid endometrial cancer or EIN treated with LNG-IUS were included. Of these, 22 subjects (37.9%) had endometrial cancer and 36 subjects (62.1%) had EIN. Per the ProMisE algorithm, 44 patients (75.9%) were classified as p53wt, 6 (10.3%) as MMRd, 4 (6.9%) as p53abn, and 4 (6.9%) as POLE-mutated. Of the 58 patients, 11 (19.0%) progressed or opted for definitive therapy. Median time to progression or definitive therapy was 7.5 months, with p53abn tumors having the shortest time to progression or definitive therapy. CONCLUSIONS Molecular classification of endometrial cancer and EIN prior to management with LNG-IUS is feasible and may predict patients at risk of progression.
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Affiliation(s)
- Allison M. Puechl
- Atrium Health, Division of Gynecologic Oncology, Levine Cancer Institute, Charlotte, NC 29204, USA
- Correspondence: ; Tel.: +1-980-442-2000
| | - Daniel Spinosa
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | - Andrew Berchuck
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Angeles Alvarez Secord
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Kerry E. Drury
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | | | - Janice Wong
- Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC 27710, USA; (D.S.); (K.E.D.); (J.W.)
| | - Regina Whitaker
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
| | - Nicolas Devos
- GCB, Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA;
| | - David L. Corcoran
- Duke Center for Genomics and Computational Biology, Durham, NC 27710, USA;
| | - Kyle C. Strickland
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA;
| | - Rebecca A. Previs
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA; (A.B.); (A.A.S.); (R.W.); (R.A.P.)
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