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Ogunbiyi MO, Oxley S, Graham R, Olaitan A. The oncological and reproductive outcomes of fertility-preserving treatments for stage 1 grade 1 endometrial carcinoma: a systematic review and meta-analysis. J OBSTET GYNAECOL 2024; 44:2294329. [PMID: 38126736 DOI: 10.1080/01443615.2023.2294329] [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: 02/18/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The number of patients desiring fertility-preserving treatment for endometrial cancer rather than standard surgical management continues to increase. OBJECTIVE We aimed to evaluate the efficacies of fertility-preserving treatments on the live birth rate, remission and relapse rates for women with stage 1a grade 1 endometrial carcinoma to support patient counselling. METHODS We performed a meta-analysis for our primary outcomes of overall remission and relapse rate, and for secondary analysis, we divided papers into treatment type: systemic progestins, intrauterine progestins or hysteroscopic resection and adjuvant hormonal treatment. RESULTS Thirty-five observational studies met inclusion criteria, with a total of 624 patients. Overall, conservative treatment of endometrial cancer showed a remission rate of 77% (95% CI: 70-84%), a relapse rate of 20% (95% CI: 13-27%) and a live birth rate of 20% (95% CI: 15-25%) with more favourable outcomes for the hysteroscopic resection group. CONCLUSIONS Hysteroscopic resection and adjuvant hormonal treatment had the most favourable fertility and oncological outcomes. Further high-quality prospective multi-centre trials are warranted to determine the optimal treatment regimen and dosage and risk stratification for these patients.
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Affiliation(s)
| | - Samuel Oxley
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Radha Graham
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Adeola Olaitan
- University College London Hospitals NHS Foundation Trust, London, UK
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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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Dagher C, Manning-Geist B, Ellenson LH, Weigelt B, Rios-Doria E, Barry D, Abu-Rustum NR, Leitao MM, Mueller JJ. Molecular subtyping in endometrial cancer: A promising strategy to guide fertility preservation. Gynecol Oncol 2023; 179:180-187. [PMID: 37992549 PMCID: PMC10843754 DOI: 10.1016/j.ygyno.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES To investigate the association of molecular subtype with progesterone response in patients with endometrial cancer (EC) or atypical endometrial hyperplasia (AEH). METHODS Premenopausal patients aged ≤48 years with tumor-normal sequencing data who received progesterone for EC/AEH from 1/1/2010-6/30/2021 were identified. Tumors were classified as POLE-ultramutated, microsatellite instability-high (MSI-H), copy number-high (CN-H), or copy number-low (CN-L) molecular subtype. Best response to progesterone was compared by subtype. Appropriate statistical tests were performed. RESULTS Of 20 patients, 7 (35%) had AEH and 13 (65%) had EC. Sixteen tumors (80%) were CN-L, 3 (15%) were MSI-H, and 1 (5%) was POLE-ultramutated. Median time on progesterone was 22 months (range, 3-115). Ten patients (50%) had complete response (CR); median time to CR was 9 months (range, 3-32). Four patients (20%) had stable disease (SD) and 6 (30%) had progressive disease (PD). For CN-L tumors, 10 patients (62%) had CR, 3 (19%) had SD, and 3 (19%) had PD. For MSI-H tumors, 1 patient (33%) had SD and 2 (66%) had PD. For POLE-ultramutated tumors, 1 patient had PD. Median follow-up was 48 months (range, 12-123). Four of 10 patients (40%) with CR recurred; median time from CR to recurrence was 16 months (range, 5-102). CONCLUSION Molecular subtype may be associated with progesterone response in patients with EC/AEH. CN-L tumors had the best response, and MSI-H tumors had the poorest. Recurrence after CR is common, and close surveillance is warranted. Larger studies investigating the role of molecular classification in medical management of EC/AEH are needed.
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Affiliation(s)
- Christian Dagher
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Beryl Manning-Geist
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lora H Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Rios-Doria
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Danika Barry
- Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, IL, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Chaudhari SR, Lai TS, Zakhour M, Myung Shin S, Baltayan A, Tan H, Cohen JG. Comparison of Mirena and Liletta levonorgestrel intrauterine devices for the treatment of endometrial intraepithelial neoplasia and grade 1 endometrioid endometrial cancer. Gynecol Oncol Rep 2023; 49:101257. [PMID: 37691755 PMCID: PMC10485590 DOI: 10.1016/j.gore.2023.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023] Open
Abstract
Objective Current standard nonsurgical management of endometrial intraepithelial neoplasia (EIN) and grade 1 endometrioid endometrial cancer (g1EEC) is the Mirena levonorgestrel intrauterine device (M-IUD). This retrospective study was designed primarily to determine noninferiority of the Liletta IUD (L-IUD) for pathologic regression of EIN and g1EEC compared to the M-IUD at 6 months of continuous use. Secondary objectives include to determine noninferiority as above at 3, 9, and 12 months of continuous use and to identify factors including DNA mismatch repair (MMR) status associated with pathologic regression after LNG-IUD use. Methods A retrospective observational study was performed with patients treated for EIN or g1EEC and managed continuously with M- or L-IUD. Patients with recent (within 6 months) or concurrent progesterone use were excluded. For the EIN group, the noninferiority margin of odds ratio was predetermined to be 0.58, and for the g1EEC group it was 0.64. Results 62 patients from an academic center and a safety-net hospital were identified with continuous M-IUD (n = 44) or L-IUD (n = 18) use for EIN or g1EEC. 85% of patients treated with L-IUD were from a safety-net hospital, which had 63% with public insurance. At 3/6/9 months, 54/71/73% of patients with M-IUD and 80/83/100% with L-IUD had pathologic regression of EIN (95% confidence interval of estimated odds ratio 1.00-2.07/0.84-2.03/0.69-2.10). Lifetime smoking status, not MMR status, was significantly associated with pathologic regression. Conclusions L-IUD is an effective fertility-sparing treatment for EIN. L-IUD is noninferior to M-IUD for pathologic regression of EIN after 3,6, and 9 months. Further larger studies are warranted to validate findings in EIN and g1EEC.
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Affiliation(s)
- Sonal R. Chaudhari
- University of California, Los Angeles, Division of Gynecologic Oncology, Department of Surgery, USA
- Olive View-UCLA Medical Center, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Tiffany S. Lai
- University of California, Los Angeles, Division of Gynecologic Oncology, Department of Surgery, USA
- Olive View-UCLA Medical Center, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Mae Zakhour
- Corewell Health Gynecology Oncology, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Sim Myung Shin
- University of California, Los Angeles, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Armine Baltayan
- Olive View-UCLA Medical Center, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Hongying Tan
- Olive View-UCLA Medical Center, Division of Gynecologic Oncology, Department of Surgery, USA
| | - Joshua G. Cohen
- City of Hope, Division of Gynecologic Oncology, Department of Surgery, USA
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2023; 288:90-107. [PMID: 37499278 DOI: 10.1016/j.ejogrb.2023.07.001] [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: 03/09/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.
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Affiliation(s)
- J L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165 chemin du Grand Revoyet, 69495 Pierre-Benite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital europeen Georges-Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hotel Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40 avenue Serge Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
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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: 1] [Impact Index Per Article: 1.0] [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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Murakami I, Machida H, Morisada T, Terao Y, Tabata T, Mikami M, Hirashima Y, Kobayashi Y, Baba T, Nagase S. Effects of a fertility-sparing re-treatment for recurrent atypical endometrial hyperplasia and endometrial cancer: a systematic literature review. J Gynecol Oncol 2023:34.e49. [PMID: 36929578 DOI: 10.3802/jgo.2023.34.e49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/02/2023] [Accepted: 01/18/2023] [Indexed: 03/14/2023] Open
Abstract
To examine the effectiveness of progestin re-treatment for recurrent endometrial intraepithelial neoplasia (EIN), atypical endometrial hyperplasia (AH) and endometrial cancer (EC) following initial fertility-sparing treatment. A comprehensive systematic review and meta-analysis were conducted by an Expert Panel of the Japan Society of Gynecologic Oncology Endometrial Cancer Committee. Multiple search engines, including PubMed/MEDLINE and the Cochrane Database, were searched in December 2021 using the keywords "Endometrial neoplasms," "Endometrial hyperplasia," "Endometrial intraepithelial neoplasia," "Fertility preservation," "Progestins," AND "Recurrence." Cases describing progestin re-treatment for recurrent EIN, AH and EC were compared with cases that underwent conventional hysterectomy. The primary outcomes were survival and disease recurrence, and the secondary outcome was pregnancy. After screening 238 studies, 32 with results for recurrent treatment were identified. These studies included 365 patients (270 received progestin re-treatment and 95 underwent hysterectomy). Most progestin re-treatment involved medroxyprogesterone acetate or megestrol acetate (94.5%). Complete remission (CR) following progestin re-treatment was achieved in 219 (81.1%) cases, with 3-, 6- and 9-month cumulative CR rates of 22.8%, 51.7% and 82.6%, respectively. Progestin re-treatment was associated with higher risk of disease recurrence than conventional hysterectomy was (odds ratio [OR]=6.78; 95% confidence interval [CI]=1.99-23.10), and one patient (0.4%) died of disease. Fifty-one (14.0%) women became pregnant after recurrence, and progestin re-treatment demonstrated a possibility of pregnancy (OR=2.48; 95% CI=0.94-6.58). This meta-analysis suggests that repeat progestin therapy is an effective option for women with recurrent EIN, AH and EC, who wish to retain their fertility.
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Affiliation(s)
- Isao Murakami
- Department of Obstetrics and Gynecology, Toho University Ohashi Medical Center, Tokyo, Japan.
| | - Hiroko Machida
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | - Tohru Morisada
- Department of Obstetrics and Gynecology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | | | - Yoichi Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Tsukasa Baba
- Department of Obstetrics and Gynecology, Iwate Medical University, Iwate, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
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Wei H, Pan N, Zhang W, Xiong G, Guo W, Dong Z, Ma C. Levonorgestrel-releasing intrauterine system-based therapies for early-stage endometrial cancer: a systematic review and meta-analysis. J Gynecol Oncol 2023; 34:e36. [PMID: 36731895 PMCID: PMC9995869 DOI: 10.3802/jgo.2023.34.e36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/23/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of studies evaluating the oncological and fertility outcomes of early-stage endometrial cancer (EC) treated with the levonorgestrel-releasing intrauterine system (LIUS)-based regimens. METHODS The Meta-analyses Of Observational Studies in Epidemiology statement for meta-analyses was followed. Searches were conducted on MEDLINE, Embase, PubMed, Preprints, and the Cochrane Central Register of Controlled Trials from January 1990 to August 4, 2022. The Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment. The primary endpoint was the complete response (CR) rate and the secondary endpoints were relapse, pregnancy, and live birth rate. RESULTS A total of 25 studies (821 women) were included. The CR rate of LIUS-based regimens was 63.4% (95% confidence interval [CI]=52.3%-73.2%), with 29.6% (95% CI=23.3%-36.8%) of cases experiencing recurrence during follow-up. In sensitivity analyses, patients younger than 45 years of age with a body mass index <30 kg/m² who were treated with LIUS-based regimens achieved a high CR rate of 84.6% (95% CI=80.3%-88.1%) over a median follow-up of more than 24 months. Overall pregnancy and live birth rates were 37.9% (95% CI=24.1%-53.9%) and 39.3% (95% CI=24.0%-57.0%), respectively. No statistical differences were apparent in CR or relapse rates among the LIUS+GnRH agonist, LIUS+oral progesterone, or hysteroscopic resection followed by LIUS subgroups. CONCLUSION LIUS-based therapies are viable for the conservative management of early-stage endometrioid EC on CR and fertility outcome. TRIAL REGISTRATION PROSPERO Identifier: CRD42022352890.
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Affiliation(s)
- Hongyi Wei
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Ningning Pan
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Wen Zhang
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Guangwu Xiong
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Wenping Guo
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Zhe Dong
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Caihong Ma
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 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. Oncological and reproductive outcomes for gonadotropin-releasing hormone agonist combined with aromatase inhibitors or levonorgestrel-releasing intra-uterine system in women with endometrial cancer or atypical endometrial hyperplasia. Int J Gynecol Cancer 2022; 32:1561-1567. [PMID: 36368706 PMCID: PMC9763228 DOI: 10.1136/ijgc-2022-003882] [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: 07/29/2022] [Accepted: 10/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of gonadotropin-releasing hormone agonist (GnRHa) combined with a levonorgestrel-releasing intrauterine device (LNG-IUD) or aromatase inhibitor (letrozole) in women with endometrial carcinoma or atypical endometrial hyperplasia who wished to preserve fertility. METHODS Patients at the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital between January 2013 and December 2020 were retrospectively reviewed. A total of 179 patients who were unsuitable to undergo treatment with high-dose oral progestin, including those with progestin allergies, body mass index ≥30 kg/m2, liver and/or renal dysfunction, hypercoagulable state, and thrombosis were included. Patient data were retrieved from medical records and a prospectively maintained database that represented the standard protocol was followed for all patients. Clinical characteristics, treatment outcomes, adverse events, and reproductive outcomes were collected and analyzed. Logistic regression models were constructed to determine the associations between complete remission, recurrence, and fertility. RESULTS Overall, 169 patients (94.4%) achieved complete remission; 58 (96.7%) had atypical endometrial hyperplasia and 111 (93.3%) had endometrial carcinoma. The complete remission rates for the GnRHa plus LNG-IUD and GnRHa plus letrozole groups were 93.5% and 95.8%, respectively. The median time to complete remission was 6 (range 3-18) months: 4 (range 3-10) months for atypical endometrial hyperplasia and 8 (range 3-18) months for endometrial carcinoma. After a median follow-up of 27.5 (range 3-92) months, 41 (24.3%) women developed recurrence, with a median recurrence time of 17 (range 6-77) months. Of the patients with complete remission, 134 patients desired to conceive and 42 (32.3%) became pregnant, 24 (17.9%) were successfully delivered, 5 (3.7%) were still pregnant, while 13 miscarried. CONCLUSION GnRHa combined treatment provides favorable oncological and reproductive outcomes. Larger multi-institutional studies are required to confirm these preliminary findings.
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Affiliation(s)
- Junyu Chen
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Division of Gynecology oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mei Yu
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huimei Zhou
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ninghai Cheng
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinhui Wang
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Peng
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer in Childbearing Age Women. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091256. [PMID: 36143933 PMCID: PMC9504942 DOI: 10.3390/medicina58091256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
Total hysterectomy and bilateral adnexectomy is the standard treatment for atypical endometrial hyperplasia and early-stage endometrial cancer. However, the recommended surgical treatment precludes future pregnancy when these conditions are diagnosed in women in their fertile age. In these patients, fertility-sparing treatment may be feasible if the desire for childbearing is consistent and specific conditions are present. This review summarizes the available evidence on fertility-sparing management for atypical endometrial hyperplasia and early-stage endometrial cancer. Historically, oral progestins have been the mainstay of conservative management for atypical endometrial hyperplasia and stage IA endometrioid endometrial cancer with no myometrial invasion, although there is no consensus on dosage and treatment length. Intrauterine progestin therapy has proved a valid alternative option when oral progestins are not tolerated. GnRH analogs, metformin, and hysteroscopic resection in combination with progestins appear to increase the overall efficacy of the treatment. After a complete response, conception is recommended; alternatively, maintenance therapy with strict follow-up has been proposed to decrease recurrence. The risk of disease progression is not negligible, and clinicians should not overlook the risk of hereditary forms of the disease in young patients, in particular, Lynch syndrome. Hysterectomy is performed once the desire for childbearing desire has been established. The conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer is feasible, provided a strong desire for childbearing and permitting clinical–pathological conditions. However, patients must be aware of the need for a strict follow-up and the risk of progression with a possible consequent worsening of the prognosis. More homogenous and well-designed studies are necessary to standardize and identify the best treatment and follow-up protocols.
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Hirata T, Kondo E, Magawa S, Kubo-Kaneda M, Nii M, Yoshida K, Maezawa T, Tabata T, Ikeda T. Safety and efficacy of levonorgestrel-releasing intrauterine device in the treatment of atypical endometrial hyperplasia and early endometrial cancer. J Obstet Gynaecol Res 2022; 48:3219-3225. [PMID: 36054237 DOI: 10.1111/jog.15408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Abstract
AIM To investigate the recurrence rate, live-birth rate, and treatment outcomes of levonorgestrel-releasing intrauterine device (LNG-IUD) for the management of atypical endometrial hyperplasia (AEH) or Grade-1 endometrial cancer (EC) in patients who desire fertility-sparing treatment and those seeking conservative treatment without fertility preservation. METHODS We prospectively enrolled nine patients from a single institution between April 2009 and September 2013 who were followed up for 60 months after LNG-IUD insertion. RESULTS The median patient age was 35 (range: 29-39) years. The overall recurrence rate was 56% (5/9). The median interval between removal of the LNG-IUD and recurrence was 20.5 (range: 2-30) months. Three of the nine patients had Grade-1 EC, and six had AEH. The response rates to the LNG-IUD in patients with Grade-1 EC and AEH were 66% and 100%, respectively. Four patients (three with AEH, one with Grade-1 EC) experienced recurrence 6 months after MPA treatment and all 4 (100%) had complete response. Eight patients desired fertility preservation, of which 37% (3/8) conceived after receiving fertility treatment and 25% (2/8) had a live birth; the remaining three had previously received MPA for 6 months and had a recurrence; of these, 1 had a live birth. CONCLUSION LNG-IUD is effective for the management of AEH and EC in young patients who desire fertility-sparing treatment, including those ineligible for MPA owing to the presence of comorbidities and those with recurrence after MPA treatment (6-month treatment), and patients seeking conservative treatment without fertility preservation.
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Affiliation(s)
- Toru Hirata
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan.,Department of Obstetrics and Gynecology, Kuwana City Medical Center, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Shoichi Magawa
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Michiko Kubo-Kaneda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Kenta Yoshida
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Tadashi Maezawa
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
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De Rocco S, Buca D, Oronzii L, Petrillo M, Fanfani F, Nappi L, Liberati M, D'Antonio F, Scambia G, Leombroni M, Dessole M, Lucidi A. Reproductive and pregnancy outcomes of fertility-sparing treatments for early-stage endometrial cancer or atypical hyperplasia: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 273:90-97. [PMID: 35526471 DOI: 10.1016/j.ejogrb.2022.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/09/2022] [Accepted: 04/20/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To report the pregnancy outcomes of women with prior endometrial cancer and endometrial hyperplasia managed with fertility-sparing treatments. METHODS Medline and Embase databases were searched. Inclusion criteria were studies reporting the pregnancy outcomes of women who had undergone fertility-sparing treatments for endometrial hyperplasia or early endometrioid endometrial cancer. Outcomes explored were pregnancy, miscarriage and livebirth rates according to the type of progestin treatment used. Subgroup analyses according to the type of diagnostic follow-up were also performed. Meta-analyses of proportions using a random effects model were used to combine data. RESULTS Twenty-nine studies (1036 women) were included, and 82.8% [95% confidence interval (CI) 72.3-91.2] of women achieved complete remission. Pregnancy rates were 56.3% (95% CI 41.6-70.5) with megestrol (MA) or medroxyprogesterone acetate (MPA), 63.1% (95% CI 37.0-85.6) with levonorgestrel-releasing intrauterine device (LNG-IUD), 57.9% (95% CI 37.7-76.8) with MA or MPA and metformin, 59.8% (95% CI 48.3-70.7) with MPA and LNG-IUD, 15.4% (95% CI 4.3-42.2) with gonadotropin-releasing hormone analogue (GnRHa) combined with LNG-IUD or letrozole, and 40.7% (95% CI 24.5-59.3) with LNG-IUD and GnRHa. Miscarriage rates were 17.4% (95% CI 12.2-23.4), 14.3% (95% CI 6.4-24.7), 57.9% (95% CI 37.7-76.8), 26.9% (95% CI 14.6-39.3), 100% (95% CI 34.0-100) and 18.2% (95% CI 5.1-47.7), respectively, and livebirth rates were 68.8% (95% CI 56.0-80.3), 80.8% (95% CI 69.5-90.0), 69.9% (95% CI 56.1-82.0), 25.97 (95% CI 14.6-39.3), 0% (95% CI 0-66.0) and 81.8% (95% CI 52.3-94.8), respectively. Finally, stratifying the analysis considering the endometrial sampling method alone, the pregnancy rate was 68.6% (95% CI 51.2-83.6; 10 studies, I2 = 83.5%) in women who underwent hysteroscopy and 60.5% (95% CI 53.4-67.5; 13 studies, I2 = 39.8%) in women managed with dilatation and curettage biopsy; the miscarriage and livebirth rates were 13.2% (95% CI 8.0-19.5; I2 = 0%) and 81.2% (95% CI 67.4-91.8; I2 = 67.3%), respectively, for hysteroscopy, and 25.2% (95% CI 17.8-33.3; I2 = 15.5%) and 67.5% (95% CI 58.8-75.5; I2 = 0%), respectively, for dilatation and curettage biopsy. CONCLUSION Fertility-sparing treatment in women with endometrial cancer or hyperplasia is associated with an overall good response to therapy, good chance of achieving pregnancy and a good livebirth rate. Diagnostic follow-up with hysteroscopy was associated with a higher pregnancy rate, although this requires confirmation in adequately powered randomized trials.
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Affiliation(s)
- Silvia De Rocco
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Danilo Buca
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Ludovica Oronzii
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Marco Petrillo
- Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Sardegna, Italy
| | - Francesco Fanfani
- Dipartimento della salute della donna, del bambino e di sanità pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Marco Liberati
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Giovanni Scambia
- Dipartimento della salute della donna, del bambino e di sanità pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martina Leombroni
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Margherita Dessole
- Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Sardegna, Italy
| | - Alessandro Lucidi
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy.
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. [Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:345-373. [PMID: 35248756 DOI: 10.1016/j.gofs.2022.02.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.
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Affiliation(s)
- J-L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4, rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hôtel-Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40, avenue Serge-Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
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14
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Pino I, Iacobone AD, Vidal Urbinati AM, Di Giminiani M, Radice D, Guerrieri ME, Preti EP, Martella S, Franchi D. Fertility-Sparing Treatment for Endometrial Cancer: Oncological and Obstetric Outcomes in Combined Therapies with Levonorgestrel Intrauterine Device. Cancers (Basel) 2022; 14:cancers14092170. [PMID: 35565299 PMCID: PMC9101107 DOI: 10.3390/cancers14092170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/25/2023] Open
Abstract
Simple Summary This article discusses a retrospective study describing sixteen years of experience in the fertility-sparing treatment (FST) of endometrial cancer (EC) in a tertiary referral center for oncology. The aim of the study is to compare oncological and reproductive outcomes of different combined therapy with LNG-IUD in FST of presumed FIGO STAGE IA endometrioid G1 EC. We assessed outcomes for 75 patients treated with three different approaches: GnRH analogue (GnRHa) + LNG-IUD vs. Megestrol acetate (MA) + LNG-IUD vs. MA + LNG-IUD + Metformin (MET). We reported, although not statistically significant, an increasing rate of CR from the regimen with GnRHa to one with MA+MET (65% vs. 83%) and showed a statistically significant lower risk of recurrence in women treated with MA+ LNG-IUD+MET when compared to GnRHa+ LNG-IUD regimen. There were no differences in obstetric outcomes among different therapeutic regimens. Abstract Background: The prevalence of reaches up to 5% in women younger than 40 years. Therefore, the fertility preservation should be the goal of the clinical practice in women with desire of pregnancy and low-risk features. The aim of this study is to compare oncological and reproductive outcomes of different hormonal therapies in FST of EC. Methods: A retrospective single-center study recruiting patients with presumed FIGO STAGE IA endometrioid G1 EC from 2005 to 2020 was performed. We assessed outcomes for three different therapeutic options: GnRHa + LNG-IUD vs. MA + LNG-IUD vs. MA + LNG-IUD + MET. Results: In total, 75 patients were enrolled and followed up for a median of 45 months. Complete response (CR) was achieved in 75% of patients at 12 months. Although not statistically significant, we reported an increasing rate of CR from the regimen with GnRHa to the one with MA + MET (65% vs. 83%). We showed a statistically significant lower risk of recurrence in women treated with MA + LNG-IUD + MET, when compared to GnRHa + LNG-IUD regimen. The pregnancy rate was 74% and live birth rate was 42%, with no differences among regimens. Conclusions: FST is a safe and effective option in women who desire to preserve fertility.
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Affiliation(s)
- Ida Pino
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
- Correspondence: ; Tel.: +39-02-57489120
| | - Anna Daniela Iacobone
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
| | - Ailyn Mariela Vidal Urbinati
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
| | - Maria Di Giminiani
- Unit of Obstetrics and Gynecology, ASST Fatebenefratelli-Sacco, Department of Biological and Clinical Sciences L. Sacco, University of Milan, 20157 Milan, Italy;
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Maria Elena Guerrieri
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
| | - Eleonora Petra Preti
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
| | - Silvia Martella
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
| | - Dorella Franchi
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (M.E.G.); (E.P.P.); (S.M.); (D.F.)
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15
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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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Lago V, Marina T, Laseca Modrego M, Gil-Ibañez B, Rodriguez JR, Domingo J, Minig L, Padilla-Iserte P, Arencibia Sánchez O, Sala Ferichola M, Munmanny M, Martín Salamanca B, Iacoponi S, Cabrera S, Coronado P, Utrilla-Layna J, Bataller Á, Fiol G, Corbalán S, Espinosa E, Gil-Moreno A, Domingo S. Fertility sparing treatment in patients with endometrial cancer (FERT-ENC): a multicentric retrospective study from the Spanish Investigational Network Gynecologic Oncology Group (SPAIN-GOG). Arch Gynecol Obstet 2022; 306:821-828. [PMID: 35122158 DOI: 10.1007/s00404-021-06375-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/20/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment. MATERIAL AND METHODS This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study. RESULTS The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion > 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases. CONCLUSIONS Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.
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Affiliation(s)
- Víctor Lago
- Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain.
| | - Tiermes Marina
- Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain.,Obstetrics and Gynecology Department, Clinic University Hospital, Barcelona, Spain
| | - María Laseca Modrego
- Gynecologic Oncology Department, Maternal and Child University Hospital of the Canarias, Canari Island, Spain
| | - Blanca Gil-Ibañez
- Gynecologic Oncology Department, University Hospital, 12 de Octubre, Madrid, Spain
| | - José Ramón Rodriguez
- Obstetrics and Gynecology Department, Clinic and University Hospital Virgen de la Arrixaca, Murcia, Spain
| | | | - Lucas Minig
- Department of Gynecology, CEU Cardenal Herrera University, Valencia, Spain
| | | | - Octavio Arencibia Sánchez
- Gynecologic Oncology Department, Maternal and Child University Hospital of the Canarias, Canari Island, Spain
| | - Manuela Sala Ferichola
- Obstetrics and Gynecology Department, General University Hospital of Alicante, Alicante, Spain
| | - Merixell Munmanny
- Obstetrics and Gynecology Department, Clinic University Hospital, Barcelona, Spain
| | | | - Sara Iacoponi
- Gynecologic Oncology Department, Hospital Quironsalud Madrid, Madrid, Spain
| | - Silvia Cabrera
- Gynecologic Oncology Department, University Hospital Vall d´Hebron, Barcelona, Spain
| | - Pluvio Coronado
- Obstetrics and Gynecology Department, Clinic University Hospital San Carlos, Madrid, Spain
| | | | - Águeda Bataller
- Obstetrics and Gynecology Department, University Hospital of La Rivera, Alzira, Spain
| | - Gabriel Fiol
- Gynecologic Oncology Department, University Hospital Torrecárdenas, Almeria, Spain
| | - Shiana Corbalán
- Obstetrics and Gynecology Department, University Hospital Los Arcos, Murcia, Spain
| | | | - Antonio Gil-Moreno
- Gynecologic Oncology Department, University Hospital Vall d´Hebron, Barcelona, Spain
| | - Santiago Domingo
- Gynecologic Oncology Department, University Hospital La Fe, Valencia, Spain
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17
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O'Hara M, Janda M, McCarthy AL, Nicklin J, Walker G, Obermair A. Patient experiences of conservative treatment for early stage endometrial cancer and endometrial hyperplasia with atypia using levonorgestrel intrauterine device: A qualitative study. Gynecol Oncol Rep 2022; 39:100914. [PMID: 35005158 PMCID: PMC8718559 DOI: 10.1016/j.gore.2021.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022] Open
Abstract
Most participants in the qualitative interviews expressed appreciation for being given a conservative treatment option. Women with early-stage EAC and EHA have extensive unmet information and support needs. Physical and emotional impact of overweight, obesity and multiple unsuccessful weight loss attempts were reported.
Objective The aim of the study was to obtain an in-depth understanding of the experience of women who received non-surgical treatment for endometrial adenocarcinoma (EAC) or endometrial hyperplasia with atypia (EHA). Enhanced understanding of women’s experiences of non-surgical treatment is essential to inform counselling of the growing number of patients in this field. Methods Individual semi-structured interviews were conducted with 21 women who received conservative (non-surgical hormonal) treatment for early stage EAC or EHA using the levonorgestrel intrauterine device (LNG-IUD) as part of the feMMe trial (NCT01686126). All interviews were audiotaped and transcribed verbatim prior to content analysis. Results Of the 21 women interviewed, ten received conservative treatment for early stage EAC and 11 received conservative treatment for EHA. Five overarching themes were identified: i) extensive information and support needs (e.g. understanding of how the LNG-IUD treatment worked); ii) gratitude for treatment choice and non-surgical options (e.g. avoidance of potential risks associated with surgery); iii) onco-fertility (e.g. desire to maintain reproductive potential); iv) patient experience of overweight and obesity related to EAC development (e.g. history of trauma and disordered eating, multiple unsuccessful weight loss attempts); and v) patient experience of treatment options and actual non-surgical treatment (e.g. desire for early referral to counselling services). Conclusions This qualitative investigation enabled novel insights into the treatment preferences and decision-making process of women with newly diagnosed EHA and EAC when offered non-surgical treatment options. These insights facilitate the development of pragmatic guidance and decision support tools that could be tested in future clinical trials.
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Affiliation(s)
- Montana O'Hara
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - Monika Janda
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alexandra L McCarthy
- School of Nursing, Midwifery and Social Work, The University of Queensland and Mater Research Institute, Brisbane, Queensland, Australia
| | - James Nicklin
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Graeme Walker
- Gold Coast University Hospital, Queensland, Australia
| | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
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18
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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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19
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Zhao XL, Du ZQ, Zhang X, Yao Z, Liang YQ, Zhao SF. Fertility-preserving treatment in patients with early-stage endometrial cancer: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27961. [PMID: 35049199 PMCID: PMC9191341 DOI: 10.1097/md.0000000000027961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/14/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Endometrial cancer (EC) is the second most common malignancy of the female reproductive system worldwide, and the standard treatment for early-stage EC potentially leads to permanent infertility. The objective of this study was to investigate the efficacies of different methods on fertility preservation in patients with early-stage EC. METHODS We searched the major online databases (PubMed, Embase, The Cochrane Library, and Web of Science) to collect the research literature on fertility preservation therapy in patients with early-stage well-differentiated EC aged ≤ 40 years from January 1999 to October 2019. The inclusion was performed using the R software (version R3.5.3) meta-analysis of a single rate. The efficacy of the following three fertility preservation treatments was evaluated from four aspects, the complete remission rate (CRR), recurrence rate (ReR), pregnancy rate (PregR), and live birth rate (LBR): a) taking oral progestin only therapy, b) hysteroscopic resection combined with progestin/levonorgestrel-releasing intrauterine system (LNG-IUS)/GnRH-a, c) LNG-IUS or combined with progestin/GnRH-a. RESULTS A total of 23 articles were included in this study, including 446 patients with early-stage EC. In the group that took oral progestin only (n = 279), CRR, ReR, PregR, and LBR were 82% (95% confidence interval [CI], 74%-92%, P = .01), 38% (95% CI, 31%-45%, P = .35), 70% (95% CI, 62%-79%, P = .68), and 63% (95% CI, 55%-73%, P = .55), respectively. Hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a therapy group (n = 96) achieved a CRR, ReR, PregR, and LBR of 95% (95% CI, 90%-100%, P = .42), 16% (95% CI, 6%-39%, P = .03), 84% (95% CI, 73%-96%, P = .39), and 72% (95% CI, 59%-87%, P = .28), respectively. LNG-IUS or combined with progestin/GnRH-a therapy group (n = 91) achieved a CRR, ReR, PregR, and LBR of 69% (95% CI, 54%-89%, P < .01), 30% (95% CI, 19%-49%, P = .36), 48% (95% CI, 18%-100%, P < .01), and 36% (95% CI, 10%-100%, P < .01), respectively. CONCLUSION It is safe and effective for young patients with early-stage EC to receive oral progestin, hysteroscopic resection combined with progestin/LNG-IUS/GnRH-a, LNG-IUS, or progestin/GnRH-a. INPLASY REGISTRATION NUMBER DOI 10.37766/inplasy2020.12.0137.
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Affiliation(s)
- Xiao-Li Zhao
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Gynecology, The Fourth Hospital of Shijiazhuang (Obstetric and Maternal Hospital Affiliated to Hebei Medical University), Shijiazhuang, China
| | - Ze-Qing Du
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuan Zhang
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi Yao
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ying-Qiu Liang
- Department of Gynecology, The Fourth Hospital of Shijiazhuang (Obstetric and Maternal Hospital Affiliated to Hebei Medical University), Shijiazhuang, China
| | - Su-Fen Zhao
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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20
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Lucchini SM, Esteban A, Nigra MA, Palacios AT, Alzate-Granados JP, Borla HF. Updates on conservative management of endometrial cancer in patients younger than 45 years. Gynecol Oncol 2021; 161:802-809. [PMID: 33892887 DOI: 10.1016/j.ygyno.2021.04.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/12/2021] [Indexed: 02/01/2023]
Abstract
Endometrial cancer is the most common gynecologic malignancy in developed country. Women under the age of 40 represent 5% of all endometrial cancer and the majority are nulliparous at the time of diagnosis. The aim of this review was to compare oncologic and fertility outcomes among different fertility-preserving therapies in patients under 45 years of age with grade 1 or 2 endometrial cancer. A systematic review was conducted, the MEDLINE, EMBASE, and CINAHL databases were searched for articles published during the period from January 2010 through January 2020 in accordance with PRISMA guidelines, using the terms endometrial cancer, fertility sparing treatment and conservative treatment. A total of 661 patients in 38 studies were included. The median age was 32.3 years (range 13--43). Regardless of the primary treatment, it is always accompanied by systemic or local hormonal treatment. The median follow-up time was 47.92 months (range 1-412), 54.9 months (range 3.4-412) for the progesterone group, 38.97 months (range 3-172) for the hysteroscopic resection group and 23.11 months (range 1-115.5) for the Levonorgestrel Intrauterine Device group. The overall complete response rate was 79.4%, [Hysteroscopic Resection: 90%, hormonal treatment: 77.7%, and Levonorgestrel Intrauterine Device: 71.3%] The p = 0.02 when the primary treatment is Hysteroscopic resection, always followed by hormonal therapy either oral progesterone or Levonorgestrel Intrauterine Device. Patients who had tumor resection had lower progression than those who received hormonal treatment or Levonorgestrel Intrauterine Device 3.5% vs. 12.1% vs. 19.5% respectively (p = 0.03). The complete response time was higher in the Hysteroscopic Resection group (p = 0.04) with fewer patients undergoing hysterectomy (p = 0.0001). Patients who underwent Hysteroscopic Resection had higher pregnancy rates compared to medical treatment or Levonorgestrel Intrauterine Device, 34.5%, 27.6% and 18.4%, respectively (p = 0.002). CONCLUSION: Patients who underwent Hysteroscopic Resection followed progestogens agent was associated to a better complete response, high pregnancy rates and minor numbers of hysterectomies.
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Affiliation(s)
- Sergio M Lucchini
- Department of Gynecologic Oncology, Sanatorio Allende, Córdoba, Argentina.
| | - Agustin Esteban
- Department of Gynecologic Oncology, Sanatorio Allende, Córdoba, Argentina
| | - Mariana A Nigra
- Department of Gynecology and Obstetrics, Sanatorio Allende, Córdoba, Argentina
| | - Ana T Palacios
- Department of Gynecologic Oncology, Fundación Universitaria Ciencias de la Salud, Hospital de San José, Bogotá, Colombia
| | - Juan P Alzate-Granados
- FUCS - Division of investigation, Fundación Universitaria Ciencias de la Salud, Bogotá, Colombia; Direction of planning, evaluation and knowledge management, SANITAS EPS, Bogotá, Colombia
| | - Hernan F Borla
- Department of Gynecology and Obstetrics, Sanatorio Allende, Córdoba, Argentina
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Janda M, Robledo KP, Gebski V, Armes JE, Alizart M, Cummings M, Chen C, Leung Y, Sykes P, McNally O, Oehler MK, Walker G, Garrett A, Tang A, Land R, Nicklin JL, Chetty N, Perrin LC, Hoet G, Sowden K, Eva L, Tristram A, Obermair A. Complete pathological response following levonorgestrel intrauterine device in clinically stage 1 endometrial adenocarcinoma: Results of a randomized clinical trial. Gynecol Oncol 2021; 161:143-151. [PMID: 33762086 DOI: 10.1016/j.ygyno.2021.01.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/24/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Intrauterine levonorgestrel (LNG-IUD) is used to treat patients with endometrial adenocarcinoma (EAC) and endometrial hyperplasia with atypia (EHA) but limited evidence is available on its effectiveness. The study determined the extent to which LNG-IUD with or without metformin (M) or weight loss (WL) achieves a pathological complete response (pCR) in patients with EAC or EHA. PATIENTS AND METHODS This phase II randomized controlled clinical trial enrolled patients with histologically confirmed, clinically stage 1 FIGO grade 1 EAC or EHA; a body mass index > 30 kg/m2; a depth of myometrial invasion of less than 50% on MRI; a serum CA125 ≤ 30 U/mL. All patients received LNG-IUD and were randomized to observation (OBS), M (500 mg orally twice daily), or WL (pooled analysis). The primary outcome measure was the proportion of patients developing a pCR (defined as absence of any evidence of EAC or EHA) after 6 months. RESULTS From December 2012 to October 2019, 165 patients were enrolled and 154 completed the 6-months follow up. Women had a mean age of 53 years, and a mean BMI of 48 kg/m2. Ninety-six patients were diagnosed with EAC (58%) and 69 patients with EHA (42%). Thirty-five participants were randomized to OBS, 36 to WL and 47 to M (10 patients were withdrawn). After 6 months the rate of pCR was 61% (95% CI 42% to 77%) for OBS, 67% (95% CI 48% to 82%) for WL and 57% (95% CI 41% to 72%) for M. Across the three treatment groups, the pCR was 82% and 43% for EHA and EAC, respectively. CONCLUSION Complete response rates at 6 months were encouraging for patients with EAC and EHA across the three groups. TRIAL REGISTRATION U.S. National Library of Medicine, NCT01686126.
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Affiliation(s)
- Monika Janda
- Centre for Health Services Research, The University of Queensland, QLD, Australia
| | - Kristy P Robledo
- University of Sydney NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Val Gebski
- University of Sydney NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jane E Armes
- Sunshine Coast University Hospital Laboratory, Birtinya, QLD, Australia
| | | | - Margaret Cummings
- University of Queensland Centre for Clinical Research, Brisbane, QLD, Australia; Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Chen Chen
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Yee Leung
- Division of Obstetrics and Gynaecology, The University of Western Australia, WA, Australia
| | - Peter Sykes
- Christchurch Women's Hospital, Canterbury District Health Board, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand
| | - Orla McNally
- Department of Oncology and Dysplasia, Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | | | | | - Andrea Garrett
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Amy Tang
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Russell Land
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - James L Nicklin
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Naven Chetty
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Mater Health Services, Brisbane, Australia
| | - Lewis C Perrin
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Mater Health Services, Brisbane, Australia
| | - Greet Hoet
- The Townsville Hospital, Townsville, QLD, Australia
| | | | - Lois Eva
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | | | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, QLD, Australia; Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
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22
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Corrado G, Marchetti C, Trozzi R, Scambia G, Fagotti A. Fertility preservation in patients with BRCA mutations or Lynch syndrome. Int J Gynecol Cancer 2021; 31:332-338. [PMID: 33649002 DOI: 10.1136/ijgc-2020-002071] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 12/20/2022] Open
Abstract
Guidelines and expert consensus are lacking on fertility preservation in BRCA mutation carriers and in patients with Lynch syndrome. The safety of fertility preservation in this setting is still a topic of debate and multiple factors need to be carefully considered. The aim of this review was to analyze the reproductive potential of women harboring a genetic mutation affecting the DNA repair system and explore the efficacy and safety of existing fertility preservation strategies in these patients.
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Affiliation(s)
- Giacomo Corrado
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Claudia Marchetti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Rita Trozzi
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Istituto di Ostetricia e Ginecologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Universita Cattolica del Sacro Cuore Facolta di Medicina e Chirurgia, Rome, Italy
| | - Anna Fagotti
- Istituto di Ostetricia e Ginecologia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Universita Cattolica del Sacro Cuore Facolta di Medicina e Chirurgia, Rome, Italy
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23
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Ayhan A, Tohma YA, Tunc M. Fertility preservation in early-stage endometrial cancer and endometrial intraepithelial neoplasia: A single-center experience. Taiwan J Obstet Gynecol 2021; 59:415-419. [PMID: 32416890 DOI: 10.1016/j.tjog.2020.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The purpose of this study was to define the pregnancy and oncologic outcomes after fertility-sparing treatment of atypical hyperplasia (AH)/endometrial intraepithelial neoplasia (EIN) and early-stage endometrioid endometrial cancer (EEC). MATERIALS AND METHODS The retrospective cohort study included patients who had applied to Başkent University's Ankara Hospital between January 2007 and October 2018 with either AH/EIN (n: 27; Group A) or EEC (n: 30; Group B), and who had the desire to preserve their fertility. The medical records of all patients included in the study were reviewed retrospectively from the hospital records. RESULTS There were 2 (7.4%) and 5 (16.7%) recurrences, whereby one patient from Group A and two patients from Group B underwent staging surgery. In Group A, 8 patients attempted pregnancy after their treatment and 4 of them (50%) became pregnant, while 3 of them (37.5%) had a live birth. In Group B, there were 17 patients who wanted to become pregnant following treatment of the disease; 8 of them (47%) became pregnant after treatment, 5 of them (16.6%) had a live birth, 1 experienced intrauterine exitus (at 21st gestational week, 350 g), and 2 currently have ongoing pregnancies. CONCLUSION Hysteroscopic resection of visible lesions and full endometrial curettage prior to hormonal therapy as a fertility-preserving approach for women of reproductive age with endometrial malignancies can achieve promising oncologic and obstetric responses.
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Affiliation(s)
- Ali Ayhan
- Department of Gynecologic Oncology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Yusuf Aytac Tohma
- Department of Reproductive Endocrinology and Infertility, Faculty of Medicine, Baskent University, Ankara, Turkey.
| | - Mehmet Tunc
- Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
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24
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The Role of Gonadotropin-Releasing Hormone (GnRH) in Endometrial Cancer. Cells 2021; 10:cells10020292. [PMID: 33535622 PMCID: PMC7912811 DOI: 10.3390/cells10020292] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/23/2022] Open
Abstract
Endometrial cancer (EC) is one of the most common gynecological malignancies. Gonadotropin releasing hormone (GnRH) is a decapeptide first described to be secreted by the hypothalamus to regulate pituitary gonadotropin secretion. In this systematic review, we analyze and summarize the data indicating that most EC express GnRH and its receptor (GnRH-R) as part of an autocrine system regulating proliferation, the cell cycle, and apoptosis. We analyze the available data on the expression and function of GnRH-II, its putative receptor, and its signal transduction. GnRH-I and GnRH-II agonists, and antagonists as well as cytotoxic GnRH-I analogs, have been shown to inhibit proliferation and to induce apoptosis in human EC cell lines in pre-clinical models. Treatment with conventional doses of GnRH-agonists that suppress pituitary gonadotropin secretion and ovarian estrogen production has become part of fertility preserving therapy of early EC or its pre-cancer (atypical endometrial hyperplasia). Conventional doses of GnRH-agonists had marginal activity in advanced or recurrent EC. Higher doses or more potent analogs including GnRH-II antagonists have not yet been used clinically. The cytotoxic GnRH-analog Zoptarelin Doxorubicin has shown encouraging activity in a phase II trial in patients with advanced or recurrent EC, which expressed GnRH-R. In a phase III trial in patients with EC of unknown GnRH-R expression, the cytotoxic GnRH doxorubicin conjugate was not superior to free doxorubicin. Further well-designed clinical trials exploiting the GnRH-system in EC might be useful.
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25
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Prospective phase II trial of levonorgestrel intrauterine device: nonsurgical approach for complex atypical hyperplasia and early-stage endometrial cancer. Am J Obstet Gynecol 2021; 224:191.e1-191.e15. [PMID: 32805208 DOI: 10.1016/j.ajog.2020.08.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of complex atypical hyperplasia and early-stage endometrioid endometrial cancer is increasing, in part owing to the epidemic of obesity, which is a risk factor tightly linked to the development of endometrial hyperplasia and cancer. The standard upfront treatment for complex atypical hyperplasia and early-stage endometrial cancer is hysterectomy. However, nonsurgical treatment of early-stage endometrial neoplasia may be necessary owing to medical comorbidities precluding surgery or desired future fertility. OBJECTIVE This study aimed to evaluate the efficacy of the levonorgestrel intrauterine device to treat complex atypical hyperplasia and grade 1 endometrioid endometrial carcinoma. STUDY DESIGN A single-institution, single-arm, phase II study of the levonorgestrel intrauterine device (52 mg levonorgestrel, Mirena) was conducted in patients with complex atypical hyperplasia or grade 1 endometrioid endometrial cancer. The primary endpoint was pathologic response rate at 12 months, including complete or partial response. Quality of life and toxicity were assessed. Molecular analyses for proliferation markers, hormone-regulated genes, and wingless-related integration site pathway activation were performed at baseline and 3 months. RESULTS A total of 57 patients were treated (21 endometrial cancer, 36 complex atypical hyperplasia). The median age was 48.0 years, and the median body mass index was 45.5 kg/m2. Of the 47 evaluable patients, 12-month response rate was 83% (90% credible interval, 72.7-90.3)-37 were complete responders (8 endometrial cancer; 29 complex atypical hyperplasia), 2 were partial responders (2 endometrial cancer), 3 had stable disease (2 endometrial cancer; 1 complex atypical hyperplasia), and 5 had progressive disease (3 endometrial cancer; 2 complex atypical hyperplasia). After stratification for histology, the response rate was 90.6% for complex atypical hyperplasia and 66.7% for grade 1 endometrioid endometrial cancer. Notably, 4 patients (9.5%) experienced relapse after the initial response. Adverse events were mild, primarily irregular bleeding and cramping. Quality of life was not negatively affected. At 3 months, exogenous progesterone effect was present in 96.9% of responders (31 of 32) vs 25% of nonresponders (2 of 8) (P=.001). Nonresponders had higher baseline proliferation (Ki67) and lower dickkopf homolog 3 gene expression than responders (P=.023 and P=.030). Nonresponders had significantly different changes in secreted frizzled-related protein 1, frizzled class receptor 8, and retinaldehyde dehydrogenase 2 compared with responders. CONCLUSION The levonorgestrel intrauterine device has a substantial activity in complex atypical hyperplasia and grade 1 endometrioid endometrial cancer, with a modest proportion demonstrating upfront progesterone resistance. Potential biomarkers were identified that may correlate with resistance to therapy; further exploration is warranted.
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26
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Live births and maintenance with levonorgestrel IUD improve disease-free survival after fertility-sparing treatment of atypical hyperplasia and early endometrial cancer. Gynecol Oncol 2021; 161:152-159. [PMID: 33461741 DOI: 10.1016/j.ygyno.2021.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Our objectives were to (1) compare different regimens of hormonal therapy (HT) in young women with atypical endometrial hyperplasia (AEH) and early endometrial cancer (EC), (2) assess reproductive and oncologic outcomes and (3) explore possible predictors of complete response (CR) and disease free survival (DFS). METHODS Reproductive age women with AEH and Grade 1-2 endometrioid EC with no or minimal myometrial invasion on MRI treated with different regimens of HT were prospectively analyzed. Treatment protocols included levonorgestrel intrauterine device (LNG IUD), gonadotropin-releasing hormone agonist (aGnRH) or high-dose oral medroxyprogesteron acetate (MPA) separately and in combinations. RESULTS Total of 418 patients with AEH (n = 228) and EC (n = 190) aged 19-46 years received HT. Overall CR rate was 96% in AEH and 88% in EC patients (р < 0.001). None of the regimens used in AEH (LNG IUD + 2 D&C vs. LNG IUD + aGnRH vs. LNG IUD + 3 D&C) was found inferior to the others (CR of 98%, 95%, 100%, respectively, p > 0.05) except for MPA alone (CR 87%, р = 0.009). Out of four HT regimens used in EC LNG IUD + aGnRH+3 D&C was superior to all others (CR 96%, р = 0.026) where 2 D&Cs were performed or oral MPA was prescribed. The median follow-up for 339 patients was 33 months (range: 3-136), 68% of patients (n = 232) attempted conception, 38% (n = 89) of them used ART. The birth rate was 42% (n = 97). The rate of recurrence was 26% (50/196) in AEH group and 36% (51/143) in EC group (p = 0.05). Birth after treatment (HR = 0.24) or LNG IUD maintenance (HR = 0.18) were associated with superior DFS (p < 0.001 for both). ART use did not influence DFS. CONCLUSION Hormonal therapy of AEH and early EC with LNG IUD is superior to MPA-containing regimens, however still carries high risk of recurrence. Post-treatment pregnancy rates are satisfactory and can be further improved by broader ART use which was proven safe. Initial diagnosis of AEH, post-treatment child birth and LNG IUD maintenance were associated with decreased rates of recurrence.
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27
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Zhou S, Xu Z, Yang B, Guan J, Shan W, Shi Y, Chen X. Characteristics of progestin-insensitive early stage endometrial cancer and atypical hyperplasia patients receiving second-line fertility-sparing treatment. J Gynecol Oncol 2021; 32:e57. [PMID: 34085795 PMCID: PMC8192233 DOI: 10.3802/jgo.2021.32.e57] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/14/2021] [Accepted: 03/13/2021] [Indexed: 12/20/2022] Open
Abstract
Objective This study investigated the characteristics of progestin-insensitive endometrioid endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH) patients receiving fertility-sparing treatments and assessed the therapeutic effects of second-line fertility-preserving treatments. Methods Three hundred and thirty-eight patients with EEC (n=75) or AEH (n=263) receiving fertility-preserving treatment were retrospectively analyzed. ‘Progestin-insensitive’ was defined as meeting one of the following criteria: 1) presented with progressed disease at any time during conservative treatment, 2) remained with stable disease after 7 months of treatment, and/or 3) did not achieve complete response (CR) after 10 months of treatment. Clinical characteristics and treatment results of progestin-insensitive patients receiving second-line treatment and those of progestin-sensitive patients were compared. Results Eight-two patients (59 AEH and 23 EEC) were defined as progestin-insensitive and 256 as progestin-sensitive. In multivariate analysis, body mass index ≥28.0 kg/m2 (odds ratio [OR]=1.898) and lesion size >2 cm (OR=2.077) were independent predictors of progestin-insensitive status. Compared to AEH patients, progestin-insensitive EEC patients had poorer second-line treatment responses (28-week cumulative CR rate after changing second-line treatment, 56.3% vs. 85.4%, p=0.011). No statistical difference was found in CR rate among different second-line treatments. Conclusion Obesity and larger lesion size were independent risk factors associated with progestin-insensitive status. In progestin-insensitive patients receiving second-line treatment, EEC patients had lower CR rate comparing with AEH patients. Further study with larger sample size is needed to evaluate efficacy of different second-line treatments for progestin insensitive patients.
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Affiliation(s)
- Shuang Zhou
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Zhiying Xu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Bingyi Yang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Jun Guan
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Weiwei Shan
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Yue Shi
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.
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28
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Garzon S, Uccella S, Zorzato PC, Bosco M, Franchi MP, Student V, Mariani A. Fertility-sparing management for endometrial cancer: review of the literature. Minerva Med 2020; 112:55-69. [PMID: 33205638 DOI: 10.23736/s0026-4806.20.07072-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Primary surgery is effective in low-risk endometrial cancer (EC). However, in young women, this approach compromises fertility. Therefore, fertility-sparing management in the case of atypical endometrial hyperplasia, or grade 1 EC limited to the endometrium can be considered. EVIDENCE ACQUISITION We performed a literature review to identify studies involving women with EC or atypical hyperplasia who underwent fertility-sparing management. We conducted multiple bibliographic databases research from their inception to May 2020. EVIDENCE SYNTHESIS Oral therapy with medroxyprogesterone acetate and megestrol acetate is recommended based on extensive experience, although without consensus on dosages and treatment length. The pooled complete response rate, recurrence rate, and pregnancy rate of EC were 76.3%, 30.7% and 52.1%, respectively. Endometrial hyperplasia was associated with better outcomes. LNG-IUSs appears an alternative treatment, particularly in patients who do not tolerate oral therapy. In a randomized controlled trial, megestrol acetate plus metformin guaranteed an earlier complete response rate than megestrol acetate alone for endometrial hyperplasia. Hysteroscopic resection followed by progestogens is associated with a higher complete response rate, live birth rate, and lower recurrence rate than oral progestogens alone. Pooled complete response, recurrence, and live birth rates were 98.1%, 4.8% and 52.6%. CONCLUSIONS Fertility preservation appears feasible in young patients with grade 1 EC limited to the endometrium or atypical endometrial hyperplasia. Progestins are the mainstay of such management. The addition of Metformin and hysteroscopic resection seems to provide some improvements. However, fertility preservation is not the standard approach for staging and treatment, potentially worsening oncologic outcomes.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA -
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Massimo P Franchi
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Vladimir Student
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA
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29
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Won S, Kim MK, Seong SJ. Fertility-sparing treatment in women with endometrial cancer. Clin Exp Reprod Med 2020; 47:237-244. [PMID: 33181010 PMCID: PMC7711095 DOI: 10.5653/cerm.2020.03629] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/14/2020] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer (EC) in young women tends to be early-stage and low-grade; therefore, such cases have good prognoses. Fertility-sparing treatment with progestin is a potential alternative to definitive treatment (i.e., total hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and/or lymphadenectomy) for selected patients. However, no evidence-based consensus or guidelines yet exist, and this topic is subject to much debate. Generally, the ideal candidates for fertility-sparing treatment have been suggested to be young women with grade 1 endometrioid adenocarcinoma confined to the endometrium. Magnetic resonance imaging should be performed to rule out myometrial invasion and extrauterine disease before initiating fertility-sparing treatment. Although various fertility-sparing treatment methods exist, including the levonorgestrel-intrauterine system, metformin, gonadotropin-releasing hormone agonists, photodynamic therapy, and hysteroscopic resection, the most common method is high-dose oral progestin (medroxyprogesterone acetate at 500–600 mg daily or megestrol acetate at 160 mg daily). During treatment, re-evaluation of the endometrium with dilation and curettage at 3 months is recommended. Although no consensus exists regarding the ideal duration of maintenance treatment after achieving regression, it is reasonable to consider maintaining the progestin therapy until pregnancy with individualization. According to the literature, the ovarian stimulation drugs used for fertility treatments appear safe. Hysterectomy should be performed after childbearing, and hysterectomy without oophorectomy can also be considered for young women. The available evidence suggests that fertility-sparing treatment is effective and does not appear to worsen the prognosis. If an eligible patient strongly desires fertility despite the risk of recurrence, the clinician should consider fertility-sparing treatment with close follow-up.
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Affiliation(s)
- Seyeon Won
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea
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30
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Fertility-sparing treatment in early endometrial cancer: current state and future strategies. Obstet Gynecol Sci 2020; 63:417-431. [PMID: 32689770 PMCID: PMC7393748 DOI: 10.5468/ogs.19169] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 04/03/2020] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer (EC) is the fifth most common cancer in women worldwide. Global estimates show rising incidence rates in both developed and developing countries. Most women are diagnosed postmenopausal, but 14–25% of patients are premenopausal and 5% are under 40 years of age. Established risk factors include age and hyperestrogenic status associated with nulliparity, obesity, and metabolic syndrome. Standard treatment for EC, which involves total hysterectomy and bilateral salpingo-oophorectomy, has excellent survival outcomes, particularly for low-grade endometrioid tumors. However, it leads to permanent loss of fertility among women who wish to preserve their reproductive potential. With current trends of reproductive-age women delaying childbearing, rising EC incidence rates, and a growing epidemic of obesity, particularly in developed countries, research on conservative non-surgical treatment approaches remains a top priority. Fertility-sparing treatment predominantly involves the use of oral progestins and levonorgestrel-releasing intrauterine devices, which have been shown to be feasible and safe in women with early stage EC and minimal or no myometrial invasion. However, data on the efficacy and safety of conservative management strategies are primarily based on retrospective studies. Randomized clinical trials in younger women and high-risk obese patients are currently underway. Here, we have presented a comprehensive review of the current literature on conservative, fertility-sparing approaches, defining the optimal candidates and evaluating tumor characteristics, reproductive and oncologic outcomes, and ongoing clinical trials. We have also summarized current guidelines and recommendations based on the published literature.
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31
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Doherty MT, Sanni OB, Coleman HG, Cardwell CR, McCluggage WG, Quinn D, Wylie J, McMenamin ÚC. Concurrent and future risk of endometrial cancer in women with endometrial hyperplasia: A systematic review and meta-analysis. PLoS One 2020; 15:e0232231. [PMID: 32343732 PMCID: PMC7188276 DOI: 10.1371/journal.pone.0232231] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 04/09/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND To inform treatment decisions in women diagnosed with endometrial hyperplasia, quantification of the potential for concurrent endometrial cancer and the future risk of progression to cancer is required. METHODS We identified studies up to September 2018 that reported on the prevalence of concurrent cancer (within three months of endometrial hyperplasia diagnosis), or the incidence of cancer, identified at least three months after hyperplasia diagnosis. Random-effects meta-analyses produced pooled estimates and 95% confidence intervals (CIs). RESULTS A total of 36 articles were identified; 15 investigating concurrent and 21 progression to cancer. In pooled analysis of 11 studies of atypical hyperplasia, the pooled prevalence of concurrent endometrial cancer was 32.6% (95% CI: 24.1%, 42.4%) while no studies evaluated concurrent cancer in non-atypical hyperplasia. The risk of progression to cancer was high in atypical hyperplasia (n = 5 studies, annual incidence rate = 8.2%, 95% CI 3.9%, 17.3%) and only one study reported on non-atypical hyperplasia (annual incidence rate = 2.6%, 95% CI: 0.6%, 10.6%). CONCLUSIONS Overall, a third of women with atypical hyperplasia had concurrent endometrial cancer, although the number of studies, especially population-based, is small. Progression to cancer in atypical hyperplasia was high, but few studies were identified. Population-based estimates are required, in both atypical and non-atypical hyperplasia patients to better inform treatment strategies.
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Affiliation(s)
- Michelle T. Doherty
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Omolara B. Sanni
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Helen G. Coleman
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Chris R. Cardwell
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - W. Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, Northern Ireland, United Kingdom
| | - Declan Quinn
- Department of Obstetrics and Gynaecology, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, Northern Ireland, United Kingdom
| | - James Wylie
- Department of Obstetrics and Gynaecology, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, Northern Ireland, United Kingdom
| | - Úna C. McMenamin
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
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Stein EB, Hansen JM, Maturen KE. Fertility-Sparing Approaches in Gynecologic Oncology. Radiol Clin North Am 2020; 58:401-412. [DOI: 10.1016/j.rcl.2019.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Deligdisch-Schor L. Hormone Therapy Effects on the Uterus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1242:145-177. [PMID: 32406032 DOI: 10.1007/978-3-030-38474-6_8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The uterus and especially the endometrium are sensitive targets for steroid sex hormones, capable to modify structure and function with promptitude and versatility in order to secure reproductive functions. Hormone therapy is used to counteract deprivation, abnormal, and deleterious functions of "natural" hormones. It is widely prescribed, being used by millions of women all over the world. It seems that most women would use at least some hormone therapy at some point of their life, as contraceptives, ovarian stimulation, replacement therapy, or hormone antitumoral therapy. The diagnosis of uterine tissue, mostly of the frequently performed endometrial biopsies taken from women undergoing hormone therapy, is often confusing and difficult to interpret due to the complexity of histologic changes. Permanently changing hormonal pharmaceutical products, regimens, dosages, as well as new concepts of therapy are challenges for both users and medical prescribers. This chapter addresses the most commonly issues arising from the gynecological pathology interpretation of hormonal therapy effects on the uterus.
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Affiliation(s)
- Liane Deligdisch-Schor
- Professor Emeritus, Department of Pathology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Department of Obstetrics-Gynecology and Reproductive Science, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Trojano G, Olivieri C, Tinelli R, Damiani GR, Pellegrino A, Cicinelli E. Conservative treatment in early stage endometrial cancer: a review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:405-410. [PMID: 31910163 PMCID: PMC7233769 DOI: 10.23750/abm.v90i4.7800] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022]
Abstract
Endometrial Cancer (EC) is the commonest gynecological cancer and its incidence is increasing. The diagnosis of endometrial carcinoma in young women of childbearing age is rare. Indeed, only 4% of patients with endometrial carcinoma are <40 years of age. It's typically diagnosed in postmenopausal women. The standard approach for the management of endometrial cancer in young women of childbearing age is hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy but is not ideal for women interested in future fertility. We reviewed the published literature to clarify in fertile women who have not yet fulfilled their desire for motherhood, what are the strategies, the risks of a conservative treatment of early stage of Endometrial Cancer and what are the obstetric outcomes in this patients. Recently, several studies have reported encouraging results on fertility-sparing management of EC with high dose of progestins in selected women associated or not with hysteroscopic resection.
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Affiliation(s)
- Giuseppe Trojano
- Department of Obstetrics and Gynecology AOU Policlinico University Hospital Bari, Italy.
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Guillon S, Popescu N, Phelippeau J, Koskas M. A systematic review and meta‐analysis of prognostic factors for remission in fertility‐sparing management of endometrial atypical hyperplasia and adenocarcinoma. Int J Gynaecol Obstet 2019; 146:277-288. [DOI: 10.1002/ijgo.12882] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/19/2019] [Accepted: 06/12/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Sarah Guillon
- Division of Gynecologic OncologyBichat University HospitalParis Diderot University Paris France
| | - Nathalie Popescu
- Division of Gynecologic OncologyBichat University HospitalParis Diderot University Paris France
| | - Juliette Phelippeau
- Division of Gynecologic OncologyBichat University HospitalParis Diderot University Paris France
| | - Martin Koskas
- Division of Gynecologic OncologyBichat University HospitalParis Diderot University Paris France
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Li M, Guo T, Cui R, Feng Y, Bai H, Zhang Z. Weight control is vital for patients with early-stage endometrial cancer or complex atypical hyperplasia who have received progestin therapy to spare fertility: a systematic review and meta-analysis. Cancer Manag Res 2019; 11:4005-4021. [PMID: 31190979 PMCID: PMC6512613 DOI: 10.2147/cmar.s194607] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/17/2019] [Indexed: 12/15/2022] Open
Abstract
Objectives: This study aimed to identify potential prognostic factors for patients with complex atypical hyperplasia (CAH) or early-stage endometrial cancer (EC) who received progestin therapy to spare fertility and, thus, improve the management of this patient group. Materials and methods: The PubMed, PMC, EMBASE, Web of Science, and Cochrane databases were searched for correlational studies published in English. Studies that evaluated the prognosis of patients with CAH or early-stage EC were pooled for a systematic review and meta-analysis. Results: In total, 31 eligible studies, including 8 prospective and 23 retrospective studies involving 1099 patients, were included in this analysis. The most commonly used progestin agents were medroxyprogesterone acetate (MPA, 47.0%) and megestrol acetate (MA, 25.5%). The total complete response (CR) rate was 75.8% (833/1099), and the median time to CR with first-line progestin therapy was 6 months. In total, 294 (26.8%) patients who achieved CR became pregnant spontaneously (28 cases) or through assisted reproductive technology (127 cases). During the median follow-up of 39 months, 245 (22.3%) women developed recurrence. Only one patient (0.09%) died of the disease. The meta-analysis showed that compared to a BMI<25 kg/m2 and CAH, a body mass index (BMI) ≥25 kg/m2 (P=0.0004, odds ratios (OR), 0.4; 95% confidence interval, 0.3-0.6) and EC (P=0.0000, OR, 0.3; 95% confidence interval, 0.2-0.6) were significantly associated with a higher likelihood of a CR. Patients with a BMI≥25 kg/m2 (P=0.0007, OR, 2.5; 95% confidence interval, 1.4-4.3), PCOS (P=0.0006, OR, 3.4; 95% confidence interval, 1.5-7.9), and EC (P=0.0344, OR, 2.8; 95% confidence interval, 1.4-5.3) had a significantly higher risk of recurrence. Conclusion: In general, patients with CAH or early-stage EC who were treated with progesterone therapy had a favorable prognosis. However, the recurrence risk was not insignificant. Weight control is crucial for improving the clinical management of this patient group.
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Affiliation(s)
- Miaomiao Li
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tao Guo
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ran Cui
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ying Feng
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huimin Bai
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhenyu Zhang
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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Zhang Z, Huang H, Feng F, Wang J, Cheng N. A pilot study of gonadotropin-releasing hormone agonist combined with aromatase inhibitor as fertility-sparing treatment in obese patients with endometrial cancer. J Gynecol Oncol 2019; 30:e61. [PMID: 31074242 PMCID: PMC6543109 DOI: 10.3802/jgo.2019.30.e61] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 11/30/2022] Open
Abstract
Objective This study aims to evaluate the effects and pregnancy outcomes of gonadotropin-releasing hormone agonist (GnRH agonist) combined with aromatase inhibitor (AI) in preserving the fertility of obese women with grade 1 endometrial cancer (EC). Methods This study recruited obese EC patients who wished to preserve their fertility. The treatment regimen consisted of intramuscular GnRH agonist 3.75 mg every 4 weeks and oral AI 2.5 mg daily. The maintenance regimen was the same as the initial treatment regimen. Primary outcomes included response rate, time to complete response (CR), and time to recurrence; pregnancy outcomes included the time to pregnancy, pregnancy rate and live birth rate. Results Six obese patients with EC were included in this study, with the age (mean±standard deviation [SD]) of 30.5±3.3 years and body mass index (mean±SD) of 35.0±1.4 kg/m2. CR rate was 100%, and time to CR was 3–6 months. None of the patients had recurrence after a median follow-up of 4.0 years (range, 1.3–7.0 years). The most common side effects were menopause-like symptoms. Among these patients, no weight gain was observed during treatment. The pregnancy rate and live birth rate was 50.0% and 75.0%, respectively, with a median time to pregnancy of 2.4 years (range, 1.0–5.5 years). Conclusion The combination of GnRH agonist and AI demonstrated promising long-term effect in young obese EC patients who wished to preserve their fertility. No weight gain side effects were observed. Further studies with a larger sample size are needed to fully evaluate this novel treatment regimen.
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Affiliation(s)
- Zhibo Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Huifang Huang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jinhui Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Ninghai Cheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
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Peiretti M, Congiu F, Ricciardi E, Maniglio P, Mais V, Angioni S. Conservative treatment for well-differentiated endometrial cancer: when and why it should be considered in young women. Ecancermedicalscience 2019; 13:892. [PMID: 30792809 PMCID: PMC6369973 DOI: 10.3332/ecancer.2019.892] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 12/25/2022] Open
Abstract
The aim of this review was to update current knowledge on the conservative treatment of endometrial cancer (EC) based on a literature review. A web-based search in the MEDLINE database was carried out on EC management and treatment. All relevant information has been collected and analysed. Case series were mainly found in the literature search. Conservative treatments were offered to young patients with stage I low-grade endometrioid carcinomas of the endometrium. Different options included high/low dose progestin treatments, hysteroscopic resection of the disease, a levonorgestrel intrauterine device or a combination of various strategies. The overall complete response rate was near 76.5% with a recurrence rate of up to 33.8%. Pregnancy outcomes reached rates of 64.8% for live births. The current clinical outcomes show that conservative treatment aimed at preserving fertility is feasible for stage I endometrial well-differentiated adenocarcinomas in motivated patients under close monitoring.
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Affiliation(s)
- Michele Peiretti
- Department of Surgical Sciences, Division of Gynecology and Obstetrics, University of Cagliari, 09124 Cagliari, Italy
| | - Francesca Congiu
- Department of Surgical Sciences, Division of Gynecology and Obstetrics, University of Cagliari, 09124 Cagliari, Italy
| | - Enzo Ricciardi
- Department of Gynäkologie and Gynäkologische Onkologie, Kliniken Essen-Mitte, 45136 Essen, Germany
| | - Paolo Maniglio
- Department of Scienze Medico-Chirurgiche e di Medicina Traslazionale, Sapienza University of Rome, 00185 Rome, Italy
| | - Valerio Mais
- Department of Surgical Sciences, Division of Gynecology and Obstetrics, University of Cagliari, 09124 Cagliari, Italy
| | - Stefano Angioni
- Department of Surgical Sciences, Division of Gynecology and Obstetrics, University of Cagliari, 09124 Cagliari, Italy
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Kim MK, Seong SJ, Kang SB, Bae DS, Kim JW, Nam JH, Lim MC, Lee TS, Kim S, Paek J. Six months response rate of combined oral medroxyprogesterone/levonorgestrel-intrauterine system for early-stage endometrial cancer in young women: a Korean Gynecologic-Oncology Group Study. J Gynecol Oncol 2019; 30:e47. [PMID: 30740964 PMCID: PMC6393640 DOI: 10.3802/jgo.2019.30.e47] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/20/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of combined oral medroxyprogesterone acetate (MPA)/levonorgestrel-intrauterine system (LNG-IUS) treatment and to compare the diagnostic accuracy of endometrial aspiration biopsy with dilatation & curettage (D&C) in young women with early-stage endometrial cancer (EC) who wished to preserve their fertility. METHODS A prospective phase II multicenter study was conducted from January 2012 to January 2017. Patients with grade 1 endometrioid adenocarcinoma confined to the endometrium were treated with combined oral MPA (500 mg/day)/LNG-IUS. At 3 and 6 months of treatment, the histologic change of the endometrial tissue was assessed. The regression rate at 6 months treatment and the consistency of the histologic results between the aspiration biopsy and the D&C were evaluated. RESULTS Forty-four patients were enrolled. Nine voluntarily withdrew and 35 patients completed the protocol treatment. The complete regression (CR) rate at 6 months was 37.1% (13/35). Partial response was shown in 25.7% of cases (9/35). There were no cases of progressive disease and no treatment-related complications. A comparison of the pathologic results from aspiration biopsy and D&C was carried out for 33 cases. Fifteen cases were diagnosed as "EC" by D&C. Among these, only 8 were diagnosed with EC from aspiration biopsy, yielding a diagnostic concordance of 53.3% (κ=0.55). CONCLUSION Combined oral MPA/LNG-IUS treatment for EC showed 37.1% of CR rate at 6 months. Considering the short treatment periods, CR rate may be much higher if the treatment continued to 9 or 12 months. So, this treatment is still a viable treatment option for young women of early-stage EC. Endometrial aspiration biopsy with the LNG-IUS in place is less accurate than D&C for follow-up evaluation of patients undergoing this treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01594879.
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Affiliation(s)
- Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea.
| | - Soon Beom Kang
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Korea
| | - Duk Soo Bae
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myong Cheol Lim
- Cancer Healthcare Research Branch, Center for Uterine Cancer and Center for Clinical Trials, Research Institute and Hospital, and Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Taek Sang Lee
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Jiheum Paek
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
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Wang Y, Yang JX. Fertility-preserving treatment in women with early endometrial cancer: the Chinese experience. Cancer Manag Res 2018; 10:6803-6813. [PMID: 30584372 PMCID: PMC6289121 DOI: 10.2147/cmar.s188087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Endometrial cancer (EC) is the most common malignant tumor of the female reproductive tract in developed countries and the second most common gynecologic malignancy in China. Although EC is most often diagnosed in postmenopausal women, the increase in obesity rates and other lifestyle changes has been accompanied by an increase in the prevalence of EC among younger women. Approximately 4% of patients are diagnosed before the age of 40 years and before having given birth. Such patients may have a strong desire to preserve their fertility despite oncologic risks and thus may be reluctant to undergo standard treatment for EC, which includes hysterectomy, bilateral salpingo-oophorectomy, and surgical staging. Therefore, more conservative treatment approaches may need to be discussed, along with their associated oncologic and reproductive outcomes. In fact, various studies have confirmed the effectiveness and safety of conservative treatment in EC. This review aimed to provide a concise yet informative overview of the current status of fertility-preserving treatment for EC in China, as well as to summarize the latest and ongoing research efforts in this area.
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Affiliation(s)
- Yao Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China,
| | - Jia-Xin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China,
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Pragout D, Laurence V, Baffet H, Raccah-Tebeka B, Rousset-Jablonski C. [Contraception and cancer: CNGOF Contraception Guidelines]. ACTA ACUST UNITED AC 2018; 46:834-844. [PMID: 30385358 DOI: 10.1016/j.gofs.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To synthesize knowledge on cancer risks related to hormonal contraception and to propose recommendations on contraception during treatment and after cancer. METHODS A systematic review of the literature about hormonal contraception and cancer was conducted on PubMed/Medline and the Cochrane Library. RESULTS Overall, there is no increase in cancer (all types together) incidence or mortality among hormonal contraceptive users. Estroprogestin combined contraceptive use is associated with an increased risk of breast cancer (during use), and with a reduced risk of endometrial, ovarian, lymphatic or hematopoietic cancers that persist after discontinuation, and a decreased risk of colorectal cancer. Information on cancer risk is part of the systematic information given to patients wishing contraception. However, these data will not influence its prescription, considering the positive risk/benefit balance in women without specific cancer risk factor. Contraception is required during and after cancer treatment in every non-menopausal woman at cancer diagnosis. Specific thromboembolic, immunologic or vomiting risks due to the oncological context should be taken into account before the contraceptive choice. All hormonal contraceptives are contra-indicated after breast cancer, regardless of the delay since treatment, hormone receptor status and histological subtype. There is no data in the literature to limit hormonal or non-hormonal contraceptive use after colorectal or thyroid cancer. There was insufficient data in the literature to propose recommendations on contraceptive choice after cervical cancer, melanoma, lung cancer, tumor of the central nervous system, or after thoracic irradiation. If an emergency contraception is needed in a woman previously treated for a hormone-sensitive cancer, a non-hormonal copper intrauterine device should be preferred. CONCLUSIONS Information on cancer risk is part of the patient's information but does not influence the prescription of contraception in the absence of any specific risk factor. Contraception should be proposed in every woman treated or previously treated for cancer. The whole context should be taken into account to choose a tailored contraception.
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Affiliation(s)
- D Pragout
- Service de gynécologie obstétrique, unité d'orthogénie, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - V Laurence
- Département d'oncologie médicale, Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - H Baffet
- Service de gynécologie médicale, orthogénie et médecine du couple, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - B Raccah-Tebeka
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, 75019 Paris, France
| | - C Rousset-Jablonski
- Département de chirurgie, centre de lutte contre le cancer Léon Bérard, 28, rue Laënnec, 69008 Lyon, France; Service de chirurgie gynécologique et oncologique - obstétrique, centre hospitalier Lyon Sud, 165, chemin du grand Revoyet, 69310 Pierre Bénite, France.
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Janda M, McGrath S, Obermair A. Challenges and controversies in the conservative management of uterine and ovarian cancer. Best Pract Res Clin Obstet Gynaecol 2018; 55:93-108. [PMID: 30243603 DOI: 10.1016/j.bpobgyn.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022]
Abstract
Uterine cancer is the fifth most common cancer in women worldwide with an estimated 320,000 annual diagnoses. Its most common form, endometrioid adenocarcinoma of the endometrium (endometrial adenocarcinoma [EAC]), is thought to develop through excessive proliferation of endometrial glands, and then increasing steadily in incidence. The current standard treatment for EAC is hysterectomy, which is often curative. However, it may be unacceptably expensive for women with severe medical comorbidities, those who are at risk of intra- and postoperative adverse events and those who desire fertility. Ovarian cancer is the most malignant of all gynaecological cancers, but patients with disease limited to one ovary and patients with non-epithelial tumours may expect a good prognosis. A selected group of young patients who desire fertility may be well treated with conservative surgery. This chapter reviews patient selection, diagnosis, pre-treatment evaluation, treatment options, surveillance and risk of relapse.
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Affiliation(s)
- M Janda
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Level 2, Building 33, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Brisbane, Australia
| | - S McGrath
- Queensland Centre for Gynaecological Cancer, Royal Brisbane & Women's Hospital, 6th Floor Ned Hanlon Building, Herston QLD 4029, Brisbane, Australia
| | - A Obermair
- Queensland Centre for Gynaecological Cancer, Royal Brisbane & Women's Hospital, 6th Floor Ned Hanlon Building, Herston QLD 4029, Brisbane, Australia; Clinical School, Faculty of Medicine, The University of Queensland, Herston QLD 4029, Brisbane, Australia.
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Tock S, Jadoul P, Squifflet JL, Marbaix E, Baurain JF, Luyckx M. Fertility Sparing Treatment in Patients With Early Stage Endometrial Cancer, Using a Combination of Surgery and GnRH Agonist: A Monocentric Retrospective Study and Review of the Literature. Front Med (Lausanne) 2018; 5:240. [PMID: 30211167 PMCID: PMC6119688 DOI: 10.3389/fmed.2018.00240] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/06/2018] [Indexed: 12/12/2022] Open
Abstract
Objectives: To evaluate the efficacy and safety of gonadotropin-releasing hormone (GnRH) agonist after endometrial resection in women suffering early stage endometrial carcinoma (EC) and/or endometrial intra-epithelial neoplasia (EIN). Design: A retrospective review of clinical files between January 1999 and December 2016. Setting: University hospital. Patients: Eighteen women younger than 41 years with grade 1 endometrial carcinoma (G1EC) and/or Endometrial intra-epithelial neoplasia (EIN). INTERVENTIONS All patients received GnRH agonist for 3 months after an endometrial resection combined with a laparoscopy to exclude concomitant ovarian tumor and/or other extra-uterine disease. The patient underwent a follow-up of 3 months interval with endometrial sampling by hysteroscopy. Main Outcome Measure(s): The recurrence rate and the pregnancy rate after fertility sparing treatment. Results: We identified 9 patients with EIN (50%), 7 patients with G1EC (38.9%), 1 with combined histology (5.5%), and 1 with G2EC (5.5%). After a median follow-up of 40.7 months, 12 patients conserved their uterus (66.7%), and 8 (53.3%) patients were pregnant with a total of 14 pregnancies among those who tried to become pregnant. We observed a complete response rate in 12 patients (66.7%) but 3 of these patients relapsed (25%). We also found a stable disease in 6 patients (33.3%). Conclusions: Compared with other fertility sparing treatments, GnRH agonist after surgery is an effective fertility-sparing strategy for women with EIN and/or G1EC. We recommend hysterectomy once a family has been completed even if the literature does not clearly lead to radical surgery.
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Affiliation(s)
- Stéphanie Tock
- Department of Gynecology, Université catholique de Louvain, Cliniques Universitaires St Luc, Brussels, Belgium
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Giampaolino P, Di Spiezio Sardo A, Mollo A, Raffone A, Travaglino A, Boccellino A, Zizolfi B, Insabato L, Zullo F, De Placido G, Bifulco G. Hysteroscopic Endometrial Focal Resection followed by Levonorgestrel Intrauterine Device Insertion as a Fertility-Sparing Treatment of Atypical Endometrial Hyperplasia and Early Endometrial Cancer: A Retrospective Study. J Minim Invasive Gynecol 2018; 26:648-656. [PMID: 30017893 DOI: 10.1016/j.jmig.2018.07.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 01/05/2023]
Abstract
STUDY OBJECTIVE To evaluate safety and effectiveness of the combination of hysteroscopic endometrial focal resection with levonorgestrel-releasing intrauterine device (LNG-IUD) for International Federation of Gynecology and Obstetrics stage IA G1 early endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH) in young women to preserve their fertility. DESIGN Retrospective case series (Canadian Task Force classification II-3). SETTING University Federico II, Naples, Italy. PATIENTS The medical records of 69 consecutive patients treated from 2007 to 2017 with diagnosis of EEC (n = 14) or AEH (n = 55) meeting inclusion criteria were reviewed. INTERVENTIONS Patients with focal EEC were treated by hysteroscopic resection of the lesion according to Mazzon's technique; patients with AEH were treated by superficial endometrial resection, preserving the basal layer of the endometrium. An LNG-IUD was inserted in all patients after surgery. Patients were followed for 24 months with serial hysteroscopic biopsies. MEASUREMENTS AND MAIN RESULTS Rates of response, live birth, and recurrence were assessed. Of the 14 patients with EEC, 11 (78.6%) achieved a complete response, 2 (18.2%) of whom had subsequent relapse, 1 (7.1%) showed partial response, whereas 2 (14.3%) were nonresponders (1 stable disease and 1 progression). Of the 55 patients with AEH, 51 (92.7%) achieved a complete response, 2 (3.9%) of whom had subsequent relapse, 3 (5.5%) showed partial response, whereas only 1 (1.8%) was nonresponder with stable disease. Among 25 patients who had removed the LNG-IUD, 10 (40%) gave birth after natural conception in the last 12 months of follow-up. CONCLUSION The combination of hysteroscopic resection with an LNG-IUD as fertility-sparing treatment of EEC and AEH showed similar response and live birth rates compared with those reported in literature for progestins alone, but with considerably lower relapse rate. We advocate the use of this combined approach as an alternative fertility-sparing option in patients with ECC and AEH.
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Affiliation(s)
| | | | - Antonio Mollo
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Antonio Raffone
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Antonio Travaglino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (Drs. Travaglino and Insabato)
| | - Antonio Boccellino
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Brunella Zizolfi
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Luigi Insabato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy (Drs. Travaglino and Insabato)
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences and Dentistry (Drs. Mollo, Raffone, Boccellino, Zizolfi, Zullo, De Placido, and Bifulco)
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Gonadotropin-Releasing Hormone Agonist Combined With a Levonorgestrel-Releasing Intrauterine System or Letrozole for Fertility-Preserving Treatment of Endometrial Carcinoma and Complex Atypical Hyperplasia in Young Women. Int J Gynecol Cancer 2018; 27:1178-1182. [PMID: 28562472 DOI: 10.1097/igc.0000000000001008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the efficacy and safety with gonadotropin-releasing hormone agonist (GnRHa) combined with a levonorgestrel-releasing intrauterine system or an aromatase inhibitor (letrozole) in young women with well-differentiated early endometrial carcinoma (EC) and complex atypical hyperplasia (CAH). METHODS We performed a retrospective analysis including the clinical characteristics of 29 patients younger than 45 years with early well-differentiated endometrioid adenocarcinoma of the uterus (EC) or CAH who were treated at the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, from January 2012 to April 2016. Eighteen patients were treated with the combination of intramuscular injections of GnRHa every 4 weeks with the levonorgestrel intrauterine hormonal system (Mirena® Bayer Health Care Pharmaceutical Inc, Wayne, NY) was inserted. Eleven patients were treated with the combination of intramuscular injections of GnRHa every 4 weeks with oral letrozole 2.5 mg daily. The patients underwent follow-up with endometrial sampling by hysteroscopy and curettage for endometrial response every 3 months. RESULTS After a median follow-up of 18.7 months (range, 5.6-54.9 months), 15 women (88.2%) in the EC group and 12 women (100%) in the CAH group had complete response (CR) after GnRHa combination treatment. Among the women who achieved CR, 1 woman (8.3%) with CAH and 1 woman (5.9%) with EC had recurrence after CR, and they finally underwent a hysterectomy. Time to CR was similar in the 2 groups (4.5 ± 1.9 months in the CAH group vs 5.0 ± 2.9 months in the EC group). Ten women (34.5%) had CR after the first 3 months, 8 women (27.6%) had CR after 6 months, and 9 women (31.0%) had CR after 9 months. CONCLUSIONS Both GnRHa with the levonorgestrel-releasing intrauterine system and GnRHa with letrozole are alternative treatments for women with CAH and EC who desire fertility preservation. A larger multicenter trial of the fertility-preserving treatment is warranted.
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Fertility-Preserving Treatment in Young Women With Grade 1 Presumed Stage IA Endometrial Adenocarcinoma. Int J Gynecol Cancer 2018; 28:385-393. [DOI: 10.1097/igc.0000000000001164] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Pal N, Broaddus RR, Urbauer DL, Balakrishnan N, Milbourne A, Schmeler KM, Meyer LA, Soliman PT, Lu KH, Ramirez PT, Ramondetta L, Bodurka DC, Westin SN. Treatment of Low-Risk Endometrial Cancer and Complex Atypical Hyperplasia With the Levonorgestrel-Releasing Intrauterine Device. Obstet Gynecol 2018; 131:109-116. [PMID: 29215513 PMCID: PMC5739955 DOI: 10.1097/aog.0000000000002390] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess efficacy of the levonorgestrel-releasing intrauterine device (LNG-IUD) for treatment of complex atypical hyperplasia or low-grade endometrial cancer. METHODS This retrospective case series included all patients treated with the LNG-IUD for complex atypical hyperplasia or early-grade endometrial cancer from January 2003 to June 2013. Response rates were calculated and the association of response with clinicopathologic factors, including age, body mass index, and uterine size, was determined. RESULTS Forty-six patients diagnosed with complex atypical hyperplasia or early-grade endometrial cancer were treated with the LNG-IUD. Of 32 evaluable patients at the 6-month time point, 15 had complex atypical hyperplasia (47%), nine had G1 endometrial cancer (28%), and eight had grade 2 endometrial cancer (25%). Overall response rate was 75% (95% CI 57-89) at 6 months; 80% (95% CI 52-96) in complex atypical hyperplasia, 67% (95% CI 30-93) in grade 1 endometrial cancer, and 75% (CI 35-97) in grade 2 endometrial cancer. Of the clinicopathologic features evaluated, there was a trend toward the association of lack of exogenous progesterone effect in the pathology specimen with nonresponse to the IUD (P=.05). Median uterine diameter was 1.3 cm larger in women who did not respond to the IUD (P=.04). CONCLUSION Levonorgestrel-releasing IUD therapy for the conservative treatment of complex atypical hyperplasia or early-grade endometrial cancer resulted in return to normal histology in a majority of patients.
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Affiliation(s)
- Navdeep Pal
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Russell R. Broaddus
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Diana L. Urbauer
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Nyla Balakrishnan
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Andrea Milbourne
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Larissa A. Meyer
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Pamela T. Soliman
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Karen H. Lu
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Lois Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Diane C. Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Shannon N. Westin
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
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Abstract
The incidence of endometrial cancer is increasing, and the age of onset is younger than in prior years. Although endometrial cancer still occurs more commonly in older women, for whom the mortality rate is increasing, it also is being diagnosed in younger and younger women. The underlying cause of the increase in incidence is the epidemic of obesity and the resulting hyperinsulinemia. Conservative treatment may be indicated for younger women who wish to retain their fertility. Lifestyle modifications such as diet and exercise can modulate the risk of developing endometrial cancer as well as prevent recurrence and other comorbidities associated with obesity.
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Affiliation(s)
- Kathleen Moore
- From the Stephenson Cancer Center, Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center, Farmington, CT
| | - Molly A Brewer
- From the Stephenson Cancer Center, Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center, Farmington, CT
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McEvoy SH, Nougaret S, Abu-Rustum NR, Vargas HA, Sadowski EA, Menias CO, Shitano F, Fujii S, Sosa RE, Escalon JG, Sala E, Lakhman Y. Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management. Abdom Radiol (NY) 2017; 42:2488-2512. [PMID: 28528388 PMCID: PMC5857967 DOI: 10.1007/s00261-017-1179-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.
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Affiliation(s)
- Sinead H McEvoy
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Radiology, The Christie NHS Foundation, 550 Wilmslow Rd, Manchester, M20 4BX, UK.
| | - Stephanie Nougaret
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Institut Régional du Cancer de Montpellier, Montpellier, France
- IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM, U1194, Montpellier, France
| | - Nadeem R Abu-Rustum
- Gynecologic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Fuki Shitano
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Fujii
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Ramon E Sosa
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanna G Escalon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Evis Sala
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yulia Lakhman
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Wei J, Zhang W, Feng L, Gao W. Comparison of fertility-sparing treatments in patients with early endometrial cancer and atypical complex hyperplasia: A meta-analysis and systematic review. Medicine (Baltimore) 2017; 96:e8034. [PMID: 28906392 PMCID: PMC5604661 DOI: 10.1097/md.0000000000008034] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There are some fertility-sparing treatments in patients with early endometrial cancer (EEC) or atypical complex hyperplasia (ACH), and the objective is to compare them by evaluating the oncologic and reproductive outcomes. METHODS We searched the published literature using Medline, Cochrane, EMBASE, and Google Scholar databases up to January 3, 2017, with various combinations of keywords fertility-sparing treatments, progesterone, progestin, intrauterine devices, early endometrial cancer, and atypical complex hyperplasia. The primary endpoint is the complete response (CR) rate, and the secondary endpoints are the partial response (PR) rate, relapse rate (RR), pregnancy rate, and live birth rate. RESULTS Twenty-eight studies containing 1038 women with EEC or ACH were included for review and meta-analysis. The results demonstrated that women with EEC or ACH managed with progestin had a pooled CR rate of 71% (95% confidence interval [CI]: 63-77%). The pooled pregnancy outcomes showed that 34% of women taking progestin treatment for EEC or ACH became pregnant (95% CI: 30-38%); however, only 20% of them delivered live newborns. The pooled CR rate for women using intrauterine device (IUD) was 76% (95% CI: 67-83%), and pooled RR was 9% (95% CI: 5-17%). The pregnancy rate for women whom underwent IUD was 18% (95% CI: 7-37%), and 14% of them delivered live newborns. In patients using progestin plus IUD, the pooled CR rate was 87% (95% CI: 75-93%); among those patients, 40% became pregnant (95% CI: 20-63%), and 35% delivered live newborns. There is no publication bias for the CR rate. CONCLUSION For patients with EEC and ACH, treatments with progestin, with or without IUD, or IUD alone can reach good CR rate; however, the pregnancy outcomes might be worse in patients treated with IUD alone. Further randomized-controlled studies are warranted to find out a better solution.
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Affiliation(s)
- Jing Wei
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University
| | - Weiyuan Zhang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University
| | - Limin Feng
- Department of Obstetrics and Gynecology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Wanli Gao
- Department of Obstetrics and Gynecology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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