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Li X, Wang Y, Wang J, Fan Y, Wang J. Prediction of complete regression in fertility-sparing patients with endometrial cancer and apical hyperplasia: the GLOBAL model in a large Chinese cohort. J Transl Med 2024; 22:127. [PMID: 38308352 PMCID: PMC10837883 DOI: 10.1186/s12967-023-04671-w] [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: 06/01/2023] [Accepted: 10/28/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Fertility preservation treatment is increasingly essential for patients with apical endometrial hyperplasia (AEH) and early endometrial cancer (EEC) worldwide. Complete regression (CR) is the main endpoint of this treatment. Accurately predicting CR and implementing appropriate interventions during treatment are crucial for these patients. METHODS We conducted a retrospective study involving 193 patients diagnosed with atypical AEH or EEC, enrolled from January 2012 to March 2022 at our center. We evaluated 24 clinical parameters as candidate predictors and employed LASSO regression to develop a prediction model for CR. Subsequently, a nomogram was constructed to predict CR after the treatment. We evaluated the performance of the nomogram using receiver operator characteristic (ROC) curve and decision curve analysis (DCA) to assess its predictive accuracy. Additionally, we employed cumulative curves to determine the CR rate among patients. RESULTS Out of the 193 patients, 173 achieved CR after undergoing fertility preservation treatment. We categorized features with similar properties and provided a list of formulas based on their coefficients. The final model, named GLOBAL (including basic information, characteristics, blood pressure, glucose metabolism, lipid metabolism, immunohistochemistry, histological type, and medication), comprised eight variables identified using LASSO regression. A nomogram incorporating these eight risk factors was developed to predict CR. The GLOBAL model exhibited an AUC of 0.907 (95% CI 0.828-0.969). Calibration plots demonstrated a favorable agreement between the predicted probability by the GLOBAL model and actual observations in the cohort. The cumulative curve analysis revealed varying cumulative CR rates among patients in the eight subgroups. Categorized analysis demonstrated significant diversity in the effects of the GLOBAL model on CR among patients with different total points (p < 0.05). CONCLUSION We have developed and validated a model that significantly enhances the predictive accuracy of CR in AEH and EEC patients seeking fertility preservation treatment.
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Affiliation(s)
- Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jiaqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yuan Fan
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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Efficacy and pregnancy outcomes of hysteroscopic surgery combined with progestin as fertility-sparing therapy in patients with early stage endometrial cancer and atypical hyperplasia. Arch Gynecol Obstet 2023; 307:583-590. [PMID: 35674831 DOI: 10.1007/s00404-022-06626-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 05/10/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE This study aims to evaluate the efficacy of hysteroscopic curettage combined with progestin therapy in young patients with early-stage endometrial cancer (EC) and endometrial atypical hyperplasia (EAH) who wished to preserve their fertility. METHODS This prospective cohort study included 16 patients with early-stage EC and 25 patients with EAH in Dalian Maternal and Child Health Hospital from August 2014 to October 2018. All patients received fertility-sparing therapy with hysteroscopic evaluation every 3 months until achieving complete response (CR). Demographic, clinical, and pathological data follow-up information as well as fertility outcomes was analyzed. RESULTS There were 92.6% (37/41) patients who achieved CR. The mean treatment duration to CR was 7.47 ± 2.91 months. BMI ≤ 30 kg/m2 was associated with shorter treatment duration to achieve CR (P = 0.003). Among the patients who attempted to conceive, 30.3% (10/33) had successful pregnancy, and 18.2% (6/33) delivered live births. The implementation of assisted reproductive technology (ART) is closely associated with pregnancy (P = 0.001). CONCLUSION The fertility-sparing therapy, hysteroscopic curettage combined with progestin therapy, of early young EC and EAH patients is safe and effective. BMI is the main factor affecting the duration of CR. After achieving CR, ART can significantly improve the pregnancy rate of these patients.
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Guo Y, Zong X, Li H, Qiao J. Analysis of Factors Associated With Recurrence of Early-Stage Endometrial Carcinoma and Atypical Endometrial Hyperplasia in Infertile Women After In Vitro Fertilization Treatment. Front Oncol 2022; 12:892995. [PMID: 35832548 PMCID: PMC9272564 DOI: 10.3389/fonc.2022.892995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To explore the relationship between different artificial reproductive treatment (ART) strategies and tumor outcomes, by analyzing clinical data of patients with endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH). Methods This retrospective study was performed in a tertiary hospital. Patients (n=131) with EC or AEH, who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment between June 2010 and June 2021, were divided into a recurrence group and a non-recurrence group. Clinical characteristics and tumor outcomes were assessed. Results 131 patients were followed up for 4-132 months; 33 patients had recurrence, the recurrence rate was 25.2%, 3-year recurrence-free survival (RFS) rate was 83.2 ± 3.4%, and the 5-year RFS rate was 72.9 ± 4.4%. Factors including the frequency of controlled ovarian stimulation (COS) and the total days of ovarian stimulation had no significant effect on the recurrence of tumor lesions (p=0.368 and 0.969, respectively). Histology type (HR: 4.94, 95%CI: 2.41-10.15, p <0.001) and successful/un successful live birth (HR: 0.30, 95%CI: 0.14-0.65, p=0.003) were independent factors of recurrence. Twenty-two of the 82 patients who received a single COS had recurrence. Different COS protocols, the total dose of gonadotropin (Gn), and the serum E2 level on the trigger day had no significant effect on recurrence (p=0.326, 0.889 and 0.468, respectively). Conclusions The degree at which an endometrial lesion progresses into carcinoma is a key factor affecting the recurrence of EC/AEH in patients after IVF/ICSI treatment, and successful live birth is a protective factor for the recurrence of endometrial lesions. Different COS protocols and COS frequencies, as well as the dosage and duration of Gn used during IVF did not affect the recurrence of endometrial lesions.
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Affiliation(s)
- Yaxing Guo
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xuan Zong
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Hongzhen Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
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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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Leone Roberti Maggiore U, Khamisy-Farah R, Bragazzi NL, Bogani G, Martinelli F, Lopez S, Chiappa V, Signorelli M, Ditto A, Raspagliesi F. Fertility-Sparing Treatment of Patients with Endometrial Cancer: A Review of the Literature. J Clin Med 2021; 10:jcm10204784. [PMID: 34682906 PMCID: PMC8539778 DOI: 10.3390/jcm10204784] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/10/2021] [Accepted: 10/14/2021] [Indexed: 12/31/2022] Open
Abstract
Endometrial cancer (EC) is currently the most common malignancy of the female genital tract in developed countries. Although it is more common in postmenopausal women, it may affect up to 25% in the premenopausal age and 3–5% under the age of 40 years. Furthermore, in the last decades a significant shift to pregnancy at older maternal ages, particularly in resource-rich countries, has been observed. Therefore, in this scenario fertility-sparing alternatives should be discussed with patients affected by EC. This study summarizes available literature on fertility-sparing management of patients affected by EC, focusing on the oncologic and reproductive outcomes. A systematic computerized search of the literature was performed in two electronic databases (PubMed and MEDLINE) in order to identify relevant articles to be included for the purpose of this systematic review. On the basis of available evidence, fertility-sparing alternatives are oral progestins alone or in combination with other drugs, levonorgestrel intrauterine system and hysteroscopic resection in association with progestin therapies. These strategies seem feasible and safe for young patients with G1 endometrioid EC limited to the endometrium. However, there is a lack of high-quality evidence on the efficacy and safety of fertility-sparing treatments and future well-designed studies are required.
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Affiliation(s)
- Umberto Leone Roberti Maggiore
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
- Correspondence:
| | - Rola Khamisy-Farah
- Clalit Health Service, Akko, Azrieli Faculty of Medicine, Bar-Ilan University, Safed 13100, Israel;
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada;
| | - Giorgio Bogani
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Fabio Martinelli
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Salvatore Lopez
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Valentina Chiappa
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Mauro Signorelli
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Antonino Ditto
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
| | - Francesco Raspagliesi
- Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (G.B.); (F.M.); (S.L.); (V.C.); (M.S.); (A.D.); (F.R.)
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6
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Ouasti S, Bucau M, Larouzee E, Clement De Givry S, Chabbert-Buffet N, Koskas M. Prospective study of fertility-sparing treatment with chlormadinone acetate for endometrial carcinoma and atypical hyperplasia in young women. Int J Gynaecol Obstet 2021; 157:452-457. [PMID: 34558063 DOI: 10.1002/ijgo.13941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/30/2021] [Accepted: 08/11/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To confirm that the efficiency of the use of chlormadinone acetate for 6 months to obtain remission of atypical hyperplasia or endometrial carcinoma is comparable to that of the use of other fertility-sparing treatments. METHOD The present study is based on the PREFERE prospective registry. All the patients received 3 or 6 months of chlormadinone acetate and were evaluated by hysteroscopic resection and pipelle sampling every 3 months. RESULTS Ninety-four patients were included. Seventy-nine patients achieved complete remission at 6 months (84%). No patients stopped treatment because of a lack of tolerance. Twenty-four per cent of the patients achieved a live birth. CONCLUSION Chlormadinone acetate is an effective and well-tolerated fertility-sparing treatment. Its benefits over other progestins are its tolerability, and its absence of contraindications, which make it a good choice for patients with thromboembolism and high vascular risk.
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Affiliation(s)
- Samia Ouasti
- Department of Obstetrics and Gynecologic Surgery, Hôpital Bichat Claude Bernard, Paris, France
| | - Margot Bucau
- Department of Anatomopathology, Hôpital Bichat Claude Bernard, Paris, France
| | - Elise Larouzee
- Department of Obstetrics and Gynecologic Surgery, Hôpital Bichat Claude Bernard, Paris, France
| | | | - Nathalie Chabbert-Buffet
- Department Obstetrics, Gynecology and Reproductive Medicine, APHP Sorbonne University Hôpital Tenon, Paris, France
| | - Martin Koskas
- Department of Obstetrics and Gynecologic Surgery, Hôpital Bichat Claude Bernard, Paris, France
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7
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Fan Y, Li X, Wang J, Wang Y, Tian L, Wang J. Analysis of pregnancy-associated factors after fertility-sparing therapy in young women with early stage endometrial cancer or atypical endometrial hyperplasia. Reprod Biol Endocrinol 2021; 19:118. [PMID: 34344384 PMCID: PMC8330111 DOI: 10.1186/s12958-021-00808-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fertility-sparing therapy is an alternative conservative treatment for patients with early stage endometrioid cancer or atypical endometrial hyperplasia. In this study, we investigated pregnancy outcomes and pregnancy-associated factors in young patients receiving hormonal therapy. METHODS We retrospectively analyzed 68 patients who attempted to conceive after fertility-sparing therapy and achieving complete remission (CR). They were divided into a pregnancy group and a non-pregnancy group. A Cox proportional hazard regression model was applied for univariate and multivariate analysis to determine factors associated with pregnancy. Kaplan-Meier analysis, combined with the log-rank test, was used to calculate a patient's pregnancy probability and the distribution of recurrence-free survival (RFS). RESULTS A total of 36 patients became pregnant with 47 pregnancies. Univariate and multivariate Cox analysis revealed that several factors were associated with pregnancy, including BMI at the time of pregnancy permission, the time to CR, prolonged treatment time, the number of hysteroscopy procedures, the endometrium thickness after CR, and relapse before pregnancy. The mean RFS of patients who achieved pregnancy, and those who did not, was 27.6 months and 14.8 months, respectively (P = 0.002). No significant difference was detected in terms of cumulative RFS when compared between assisted reproductive technology (ART) cases and those involving natural conception (NC) (P = 0.707). CONCLUSIONS Normal BMI, a shorter time to CR, a prolonged three-month treatment, fewer hysteroscopy procedures, and a thicker endometrium may be positive indicators for successful pregnancies, while relapse before pregnancy may have a negative effect on conception. Moreover, a successful pregnancy protects the endometrium while ART does not increase the risk of recurrence.
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Affiliation(s)
- Yuan Fan
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Jiaqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Li Tian
- Reproductive Medical Center, Peking University People's Hospital, Beijing, 100044, China.
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
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8
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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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Zheng WP, Meng FL, Wang LY. miR-544a Stimulates endometrial carcinoma growth via targeted inhibition of reversion-inducing cysteine-rich protein with Kazal motifs. Mol Cell Probes 2020; 53:101572. [PMID: 32525042 DOI: 10.1016/j.mcp.2020.101572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
Endometrial carcinoma (EC) is a female-specific malignant tumor. Although current treatments can achieve good outcomes and improve patient survival, there remains a high incidence of treatment-induced infertility, a serious side effect that is unacceptable to those of childbearing age. Studies have demonstrated that micro ribonucleic acids (microRNAs or miRNAs) such as miR-544a regulate tumor-related gene expression. However, whether miR-544a is involved in the progression of EC is unknown. This study aimed to investigate the biological functions and underlying mechanisms of miR-544a in EC in vivo and in vitro. Quantitative real-time polymerase chain reaction (qRT-PCR) revealed miR-544a overexpression in EC tissue and cell lines, which was associated with a decreased in overall survival as revealed by Kaplan-Meier analysis. Functionally, the miR-544a inhibitor restricted the proliferation [detected by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay], invasion, and migration (detected by transwell assay) of human endometrial adenocarcinoma cells (HEC-1B and Ishikawa) and facilitated cell apoptosis (detected by flow cytometry assay). Western blotting analysis revealed that the miR-544a inhibitor decreased the expressions of matrix metalloproteinase (MMP)-2 and MMP-9 and elevated the levels of cleaved caspase3 and cleaved poly (ADP-ribose) polymerase. Furthermore, animal experiments indicated that the miR-544a antagonist (antagomir-544a) suppressed tumor growth significantly in a mouse xenograft model. The mechanistic, qRT-PCR, and immunohistochemical indications were that a reversion-inducing cysteine-rich protein with Kazal motifs (RECK) and miR-544a had inverse expression changes in EC. Bioinformatics analysis revealed RECK as a potential target for miR-544a, and this was verified by the dual-luciferase reporter assay. Subsequently, in vitro experiments, including transwell assay, MTT assay, flow cytometry assay, and Western blotting analysis, demonstrated that RECK exerted antitumor effects on EC, which were negatively regulated by miR-544a. Taken together, our study findings suggested miR-544a as a valuable target in EC therapy.
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Affiliation(s)
- Wei-Ping Zheng
- Department of Gynecology, Shaoxing People's Hospital, Shaoxing Hospital, Zhejiang University School of Medicine, Shaoxing, PR China
| | - Fan-Long Meng
- Department of Obstetrics and Gynecology, Changxing County Hospital, Changxing, PR China
| | - Lian-Yun Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China.
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10
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Terzic M, Norton M, Terzic S, Bapayeva G, Aimagambetova G. Fertility preservation in endometrial cancer patients: options, challenges and perspectives. Ecancermedicalscience 2020; 14:1030. [PMID: 32419842 PMCID: PMC7221125 DOI: 10.3332/ecancer.2020.1030] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Indexed: 12/12/2022] Open
Abstract
Several different approaches have been designed by physicians in order to preserve fertility in younger patients with endometrial carcinoma. There are various options offering different advantages, but hysteroscopic resection of pathologic endometrial tissue with placement of a Levonorgestrel Intrauterine Device has proven to be the most successful in allowing patients to conceive and give birth afterwards. However, conservative treatments should only be considered in patients with low-grade and low-stage endometrial tumours. There are many published studies which have sought out a preferable approach to treating endometrial cancer whilst preserving fertility. However, more research on this matter is needed to allow a better understanding as to which techniques/approaches are optimal. In this review, we will summarise the current available treatment options for endometrial cancer in patients of reproductive age.
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Affiliation(s)
- Milan Terzic
- Clinical Academic Department of Women's Health, National Research Center for Mother and Child Health, University Medical Center, Astana, Kazakhstan.,Department of Medicine, Nazarbayev University, School of Medicine, Astana, Kazakhstan.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA.,http://orcid.org/0000-0003-3914-5154
| | - Melanie Norton
- Whittington Hospital, Department of Urogynaecology, Magdala Ave, London N19 5NF, UK
| | - Sanja Terzic
- Department of Medicine, Nazarbayev University, School of Medicine, Astana, Kazakhstan
| | - Gauri Bapayeva
- Clinical Academic Department of Women's Health, National Research Center for Mother and Child Health, University Medical Center, Astana, Kazakhstan
| | - Gulzhanat Aimagambetova
- Department of Biomedical Sciences, Nazarbayev University, School of Medicine, Astana, Kazakhstan.,http://orcid.org/0000-0002-2868-4497
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Liao S, Yang Y, Chen S, Bi Y, Huang Q, Wei Z, Qin A, Liu B. IL-24 inhibits endometrial cancer cell proliferation by promoting apoptosis through the mitochondrial intrinsic signaling pathway. Biomed Pharmacother 2020; 124:109831. [PMID: 31972354 DOI: 10.1016/j.biopha.2020.109831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Endometrial cancer is a type of malignant tumor of the female reproductive system. Preserving fertility in endometrial cancer patients is currently a formidable challenge. Interleukin-24 (IL-24) is a unique cytokine tumor suppressor gene belonging to the IL-10 cytokine family. IL-24 has broad-spectrum antitumor activity through different signaling pathways but does not affect normal cells. IL-24 gene therapy may provide a new method for the treatment of endometrial cancer. METHODS Transfection was used for gene transfer. The expression of IL-24 and related pathway proteins in endometrial cancer tissue and the Ishikawa cell line was detected by immunohistochemistry and Western blotting, respectively. The antitumor function of IL-24 was examined in vitro and in vivo. Cell proliferation was determined by CCK-8 assay, cell migration was shown by wound-healing assay, and cell invasion was detected by Transwell assay. Apoptosis was analyzed by TUNEL assay, and HE staining was performed to observe the morphology of the samples. RESULTS Immunohistochemical analysis showed different expression levels of IL-24 in human endometrial cancer tissues and normal endometrial tissues. IL-24 increased protein expression of BAX and Cytochrome C, while BCL-2, MMP-3, VEGF, Caspase-9 and Caspase-3 expression was decreased. Overexpression of IL-24 inhibited cell proliferation, migration and invasion, but increased cell apoptosis in endometrial cancer. Mechanistically, we demonstrated that IL-24 inhibited endometrial cancer cell growth by inducing cell apoptosis through the mitochondrial intrinsic signaling pathway. In addition, IL-24 inhibited tumor development by inducing cell apoptosis and inhibiting angiogenesis, as shown in xenograft tumor experiments. CONCLUSIONS Our study demonstrates the antitumor effect of IL-24 on endometrial cancer and shows that IL-24 may be a promising therapeutic gene for endometrial cancer gene therapy.
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Affiliation(s)
- Shengbin Liao
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Yihua Yang
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Saiqiong Chen
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Yin Bi
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Qiuyan Huang
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Zhiyao Wei
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China
| | - Aiping Qin
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China.
| | - Bo Liu
- Center of Reproductive Medicine, Guangxi Medical University First Affiliated Hospital, Nanning, Guangxi, China.
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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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Wang Y, Yu M, Yang JX, Cao DY, Yuan Z, Zhou HM, Zhang Y, Li L, Shen K, Wu H. Prolonged conservative treatment in patients with recurrent endometrial cancer after primary fertility-sparing therapy: 15-year experience. Int J Clin Oncol 2019; 24:712-720. [PMID: 30746595 DOI: 10.1007/s10147-019-01404-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/20/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the efficacy and prognosis of repeated treatment on patients with recurrent endometrial cancer (EC) after complete remission for primary fertility-preserving therapy. MATERIALS AND METHODS We performed a retrospective study of patients with presumed stage IA endometrial cancer who had recurrence after achieving complete remission by fertility-preserving management at the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, from January 2003 to April 2018. For each patient, medical records and pathology reports were reviewed. The demographic features, treatment efficacy, tumor prognosis, and reproductive outcome were analyzed. RESULTS Of the 41 recurrent patients with a median disease-free interval period of 16 months (range, 5-55 months), 23 were diagnosed at recurrence as EC, and 18 were diagnosed as atypical hyperplasia (AH) or endometrial intraepithelial neoplasia (EIN). 26 patients received repeated fertility-preserving treatment, and 23 patients were evaluable for efficacy. The complete response (CR) rate of repeated treatment (19/23, 82.6%) was lower than that of primary fertility-preserving treatment (161/170, 94.7%) with borderline significance (P = 0.053). The CR rate of AH/EIN patients was higher than that of EC patients with no statistical difference (92.9% vs 66.7%, P = 0.260). Among 19 patients achieved CR, 3 got pregnant and delivered successfully, while 3 had a second relapse. Four cases failed to response to the repeated treatment and underwent definitive surgery. 15 patients referred to definitive surgery directly after recurrence and one of them had a pelvic recurrence after 120 months. All patients are alive without evidence of disease at last follow-up. CONCLUSIONS For patients with recurrent EC after primary fertility-preserving treatment, repeated fertility-preserving treatment can still achieve a promising response and patients have possibilities of completing childbirth.
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Affiliation(s)
- Yao Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mei Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Jia-Xin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Dong-Yan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Zhen Yuan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Hui-Mei Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
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Fertility Preserved Hysteroscopic Approach for the Treatment of Stage Ia Endometrioid Carcinoma. Int J Gynecol Cancer 2018; 27:1919-1925. [PMID: 28885274 PMCID: PMC5671800 DOI: 10.1097/igc.0000000000001109] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE This study aims to explore the feasibility of a hysteroscopic procedure combined with progestin therapy in young patients with stage Ia endometrioid carcinoma (EC) to avoid sterilization. MATERIALS AND METHODS Eleven young women with stage Ia EC (International Federation of Gynecology and Obstetrics grade 1) who were treated with a hysteroscopic approach combined with progestin from July 2004 to June 2016 were retrospectively analyzed and followed up to monitor their general recovery and pregnancy outcome. RESULTS The patients' median age was 27.3 years (range, 25-39 years). Comorbidities consisted of primary infertility in 8 patients, polycystic ovary syndrome in 4, uterine fibroids in 2, and diabetes in 1. The results of immunohistochemical analysis were positive for all estrogen and progestin receptors. After treatment, 9 patients attained complete remission, and 2 patients achieved partial remission. The results of peritoneal cytology in 4 patients were negative. As of this writing, 6 of the 11 patients have given birth to 7 infants, and 1 patient had an ectopic pregnancy. Two patients ultimately underwent radical resection. The average follow-up time was 82.3 months (range, 15 to 152 months), and all patients remain disease-free. CONCLUSIONS Hysteroscopic surgery combined with progestin treatment for stage Ia EC in young patients to avoid sterilization was practical and may represent a new option for patients with stage Ia EC who wish to preserve their fertility.
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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: 77] [Impact Index Per Article: 11.0] [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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Zhang Q, Qi G, Kanis MJ, Dong R, Cui B, Yang X, Kong B. Comparison among fertility-sparing therapies for well differentiated early-stage endometrial carcinoma and complex atypical hyperplasia. Oncotarget 2017; 8:57642-57653. [PMID: 28915701 PMCID: PMC5593673 DOI: 10.18632/oncotarget.17588] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/05/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To compare fertility-sparing therapies including oral progestogens, hysteroscopic resection (HR), and the levonorgestrel- releasing intrauterine system (LNG-IUS) in achieving disease regression, recurrence and live birth rate in well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia(CAH). STUDY DESIGN This was a meta-analysis of previous studies focus on the fertility-sparing therapy for well differentiate early-stage endometrial carcinoma (eEC) and complex atypical hyperplasia (CAH). DATE SOURCES Medline, the Cochrane Library and Embase was searched with the terms and Synonyms: words similar to eEC and CAH with therapies associated with fertility-sparing. MAIN OUTCOME MEASURES The number of all patients accepted fertility sparing therapies, patients got regressed, relapsed and delivered were extracted from each study, and the regression, recurrence, and live birth rate of each study were calculated. The regression, recurrence and live birth rates between each two interventions were compared with the aid of meta-regression in packages of "meta" and "meta for" written in R. RESULTS Fifty-four studies reported fertility sparing therapies in young women with eEC and CAH were included. Meta-analysis showed that HR followed by progestogens achieved a higher pooled regression (98.06% vs 77.20% P < 0.0001) and live birth rate (52.57% vs 33.38%, P = 0.0944) and a lower recurrence rate compared with oral progestogens alone (4.79% vs 32.17% P = 0.0004). At the same time, the pooled live birth rate (52.57% vs 18.09% P =0.0399) of HR followed by progestogens are significantly higher than the LNG-IUS alone. Which no statistical difference in regression (98.06% vs 94.24%; P = 0.4098) and recurrence rates (4.79% vs 3.90% P = 0.8561) was seen. CONCLUSIONS Of the available fertility-sparing therapeutic options, HR followed by progestogens may be a more effective one.
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Affiliation(s)
- Qing Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
- Gynecology Oncology Key Laboratory, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
| | - Gonghua Qi
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
- School of Medicine, Shandong University, Ji’nan, Shandong, 250012, P.R. China
| | - Margaux J. Kanis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Ruifen Dong
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
| | - Xingsheng Yang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
| | - Beihua Kong
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
- Gynecology Oncology Key Laboratory, Qilu Hospital, Shandong University, Ji’nan, Shandong, 250012, P.R. China
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Carneiro MM, Lamaita RM, Ferreira MCF, Silva-Filho AL. Fertility-preservation in endometrial cancer: is it safe? Review of the literature. JBRA Assist Reprod 2016; 20:232-239. [PMID: 28050959 PMCID: PMC5265623 DOI: 10.5935/1518-0557.20160045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/01/2016] [Indexed: 12/02/2022] Open
Abstract
Almost 5% of women with endometrial cancer are under age 40, and they often have well-differentiated endometrioid estrogen-dependent tumors. Cancer survival rates have improved over the last decades so strategies to avoid or reduce the reproductive damage caused by oncologic treatment are needed. We reviewed the published literature to find evidence to answer the following questions: How should we manage women in reproductive age with endometrial cancer? How safe is fertility preservation in endometrial cancer? Can pregnancy influence endometrial cancer recurrence? What are the fertility sparing options available? Progestins may be prescribed after careful evaluation and counseling. Suitable patients should be selected using imaging methods and endometrial sampling since surgical staging will not be performed. Conservative treatment should only be offered to patients with grade 1 well-differentiated tumors, absence of lymph vascular space invasion, no evidence of myometrial invasion, metastatic disease or suspicious adnexal masses, and expression of progesterone receptors in the endometrium. The presence of co-existing ovarian metastatic of synchronous cancer should be investigated and ruled out before the decision to preserve the ovaries. The availability of Assisted Reproductive Technology (ART) has made it possible for women with endometrial cancer to give birth to a child without compromising their prognoses. Gamete, embryo or ovarian tissue cryopreservation techniques can be employed, although the latter remains experimental. Unfortunately, fertility preservation is rarely considered. Current recommendations for conservative management are based on the overall favorable prognosis of grade 1 minimally invasive tumors. Selected patients with endometrial cancer may be candidates to a safe fertility-preserving management.
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Affiliation(s)
- Márcia Mendonça Carneiro
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais/MG - Brazil
- Center for Human Reproduction, Mater Dei Hospital, Belo Horizonte/MG - Brazil
| | - Rívia Mara Lamaita
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais/MG - Brazil
- Center for Human Reproduction, Mater Dei Hospital, Belo Horizonte/MG - Brazil
| | - Márcia Cristina França Ferreira
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais/MG - Brazil
- Center for Human Reproduction, Mater Dei Hospital, Belo Horizonte/MG - Brazil
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Tomao F, Peccatori F, Del Pup L, Franchi D, Zanagnolo V, Panici PB, Colombo N. Special issues in fertility preservation for gynecologic malignancies. Crit Rev Oncol Hematol 2015; 97:206-19. [PMID: 26358422 DOI: 10.1016/j.critrevonc.2015.08.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/25/2015] [Accepted: 08/26/2015] [Indexed: 11/27/2022] Open
Abstract
Gynecologic malignancies account for 1,09 million new cancer cases worldwide consisting of about 12% of tumors affecting female population. About 10% of all female cancer survivors are younger than 40 years of age. Since cancers affecting female genital organs are usually treated by radical surgery, chemotherapy or chemoradiation approaches that induce permanent damage of reproductive functions, the development of strategies for fertility preservation represent one of the most important goals for gynecologic oncology. In this scenario, the newly defined oncofertility discipline acquires increasing interest, offering patients maximal chances to make an adequate decision about future fertility, based on their oncologic diagnosis and prognosis. However, the majority of physicians do not pay particular attention to these issues, even if impressive progresses have been made in this field in the last decades. Possibly, it is due to the lack of strong evidences from clinical trials without an adequate number of cases to establish safety and efficacy of these procedures. In this review we will discuss the most recently debated options for fertility preservation in gynecologic oncology, highlighting issues and controversies related to oncofertility.
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Affiliation(s)
- Federica Tomao
- European Institute of Oncology "IEO", Via Giuseppe Ripamonti 435, 20141 Milan, Italy; University of Rome "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy.
| | - Fedro Peccatori
- European Institute of Oncology "IEO", Via Giuseppe Ripamonti 435, 20141 Milan, Italy
| | - Lino Del Pup
- National Cancer Institute "CRO", Via Franco Gallini 2, 33081 Aviano PD, Italy
| | - Dorella Franchi
- European Institute of Oncology "IEO", Via Giuseppe Ripamonti 435, 20141 Milan, Italy
| | - Vanna Zanagnolo
- European Institute of Oncology "IEO", Via Giuseppe Ripamonti 435, 20141 Milan, Italy
| | | | - Nicoletta Colombo
- European Institute of Oncology "IEO", Via Giuseppe Ripamonti 435, 20141 Milan, Italy
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European Society of Gynecological Oncology Task Force for Fertility Preservation: Clinical Recommendations for Fertility-Sparing Management in Young Endometrial Cancer Patients. Int J Gynecol Cancer 2015; 25:1258-65. [DOI: 10.1097/igc.0000000000000493] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
AbstractEndometrial cancer (EC) in young women of reproductive age is a relatively rare diagnosis. However, since in the modern era women delay their childbearing for a variety of social reasons, more and more women in the near future will be nulliparous and have a diagnosis of EC at the same time. Hence, a more conservative approach of EC is desirable to preserve fertility of these women, without compromising their survival. Recently, the number of studies reporting encouraging results on fertility-sparing management of EC with high dose of progestins is increasing. It seems that preserving the uterus and the ovaries in a carefully selected patient with EC confers only a very small risk combined with an enormous benefit. Selection of women suitable for such a conservative approach, as well as method of treatment, follow-up, recurrence, obstetric outcomes, and survival rates are very important parameters when consulting women with EC wishing to preserve their fertility. In this article, we try to elucidate all the previously mentioned aspects and formulate clinical recommendations, based on published data, about the most proper approach and consultation of these patients.
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Zhang H, Yan L, Bai Y, Li C, Guo Q, Wang C, Zhao X, Li M. Dual-specificity phosphatase 6 predicts the sensitivity of progestin therapy for atypical endometrial hyperplasia. Gynecol Oncol 2015; 136:549-53. [DOI: 10.1016/j.ygyno.2014.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/02/2014] [Accepted: 11/07/2014] [Indexed: 12/20/2022]
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Park JY, Nam JH. Progestins in the fertility-sparing treatment and retreatment of patients with primary and recurrent endometrial cancer. Oncologist 2015; 20:270-8. [PMID: 25673106 DOI: 10.1634/theoncologist.2013-0445] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Endometrial cancer is the most common gynecologic cancer in developed countries. Approximately 3%-14% of endometrial cancers are diagnosed in young women under 40 who want to preserve their fertility. The incidence of endometrial cancer in this age group is increasing, for which fertility-sparing therapy is increasingly used because it is one of the most important quality of life issues in these women. Progestin therapy is the most common type of fertility-sparing therapy. In this review, the most up-to-date findings regarding fertility-sparing progestin therapy for young women with primary and recurrent endometrial cancer is addressed in terms of diagnosis, treatment, follow-up, and oncologic and reproductive outcomes. Fertility-sparing progestin therapy is highly effective in selected young women with primary and recurrent endometrial cancer. The selection of appropriate patients through comprehensive pretreatment evaluation is of paramount importance to achieve the best outcomes without compromising survival. Because of the high rate of recurrence after successful fertility-sparing therapy, close surveillance is mandatory, and prophylactic hysterectomy is the best option for patients who have completed family planning. Pregnancy outcomes are very promising with the aid of assisted reproductive technologies. Continuous daily oral medroxyprogesterone acetate and megestrol acetate are the preferred progestins for fertility-sparing therapy, but future studies should be performed to determine the optimal dose and treatment duration of these agents.
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Affiliation(s)
- Jeong-Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joo-Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Kalogera E, Dowdy SC, Bakkum-Gamez JN. Preserving fertility in young patients with endometrial cancer: current perspectives. Int J Womens Health 2014; 6:691-701. [PMID: 25114594 PMCID: PMC4122529 DOI: 10.2147/ijwh.s47232] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries and affects predominantly postmenopausal women. It is estimated, however, that 15%–25% of women will be diagnosed before menopause. As more women choose to defer childbearing until later in life, the feasibility and safety of fertility-sparing EC management have been increasingly studied. Definitive treatment of total hysterectomy and bilateral salpingo-oophorectomy precludes future fertility and may thus be undesirable by women who wish to maintain their reproductive potential. However, the consideration of conservative management carries the oncologic risks of unstaged EC and the risk of missing a synchronous ovarian cancer. It is further complicated by the lack of consensus regarding the initial assessment, treatment, and surveillance. Conservative treatment with progestins has been shown to be a feasible and safe fertility-sparing approach for women with low grade, early stage EC with no myometrial invasion. The two most commonly adopted regimens are medroxyprogesterone acetate at 500–600 mg daily and megestrol acetate at 160 mg daily for a minimum of 6–9 months, with initial response rates commonly reported between 60% and 80% and recurrence rates between 25% and 40%. Photodynamic therapy and hysteroscopic EC excision have recently been reported as alternative approaches to progestin therapy alone. However, limited efficacy and safety data exist. Live birth rates after progestin therapy have typically been reported around 30%; however, when focusing only on those who do pursue fertility after successful treatment, the live birth rates were found to be higher than 60%. Assisted reproductive technology has been associated with a higher live birth rate compared with spontaneous conception, most likely reflecting the presence of infertility at baseline. Close follow-up is of paramount importance, and definitive treatment after completion of childbearing is advised.
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Affiliation(s)
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Liu G, Wang Y, Zhang X, Yuan B, Han C, Xue F. Endometrial carcinoma in a 15-year-old obese patient with persistent uterine bleeding. Gynecol Endocrinol 2014; 30:277-9. [PMID: 24456540 DOI: 10.3109/09513590.2013.875156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Endometrial carcinoma is the most common malignancy of the upper female genital tract but is rare in teenagers. Here, we report the case of a 15-year-old, nulliparous, morbidly obese female with complaints of asthenia and menometrorrhagia lasting for six months. On examination, the patient had an enlarged uterus approximately 14 gestational weeks in size, and ultrasound revealed an intrauterine mass and polycystic ovaries. An endometrial biopsy performed during hysteroscopy revealed endometrioid adenocarcinoma, and magnetic resonance imaging showed myometrial invasion. The patient underwent a laparotomy involving total abdominal hysterectomy, right salpingo-oophorectomy, wedge-shape dissection of the left ovary, and pelvic and para-aortic lymphadenectomy. We analyze the pathogenesis of endometrial carcinoma in this case and discuss the risk factors for endometrial carcinoma, especially in young women. Gynecologists should be vigilant for persistent abnormal uterine bleeding and other signs of endometrial carcinoma in young women, especially those who have risk factors for the disease.
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Affiliation(s)
- Guoyan Liu
- Department of Gynecology and Obstetrics, Tianjin Medical University General Hospital , Tianjin , China
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Koskas M, Uzan J, Luton D, Rouzier R, Daraï E. Prognostic factors of oncologic and reproductive outcomes in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma: systematic review and meta-analysis. Fertil Steril 2014; 101:785-94. [DOI: 10.1016/j.fertnstert.2013.11.028] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 11/15/2013] [Accepted: 11/19/2013] [Indexed: 01/10/2023]
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Kudesia R, Singer T, Caputo TA, Holcomb KM, Kligman I, Rosenwaks Z, Gupta D. Reproductive and oncologic outcomes after progestin therapy for endometrial complex atypical hyperplasia or carcinoma. Am J Obstet Gynecol 2014; 210:255.e1-4. [PMID: 24211482 DOI: 10.1016/j.ajog.2013.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/17/2013] [Accepted: 11/04/2013] [Indexed: 01/02/2023]
Abstract
OBJECTIVES This study evaluated fertility and oncological outcomes in women with complex atypical hyperplasia (CAH) or nonmyoinvasive grade 1 endometrioid endometrial carcinoma (EM) who desired fertility-sparing therapy. STUDY DESIGN The retrospective cohort study included women younger than 45 years with CAH or EM who desired fertility-sparing treatment at our institution. Only patients for whom both oncological treatment and pregnancy outcomes were available were included. Statistical analyses were performed using a Fisher exact test, Pearson χ(2) test, and Spearman rank correlation test, as appropriate. RESULTS Seventy-five patients were identified, and 23 (13 CAH, 10 EM) met the inclusion criteria. All 23 patients had at least 1 prior pregnancy. Treatment was split between oral progesterone only (38.5% CAH, 40% EM), levonorgestrel intrauterine device only (30.8% CAH, 20% EM), and both (30.8% CAH, 40% EM). After a median follow-up of 13 months (range, 3-74 months), 9 patients (46.2% CAH, 30% EM, P = .39) had persistent/progressive disease. Eight patients (30.8% CAH, 40% EM, P = .69) ultimately had a hysterectomy, and 3 of these (13.0%) were found to have persistent/progressive disease. Median time from diagnosis to hysterectomy was 13 months (range, 4-56 months). Fourteen of the 23 patients utilized assisted reproductive techniques (60.9%); 12 underwent IVF and 2 chose a gestation carrier. Seven clinical intrauterine pregnancies (30.4%) resulting in 6 live births (26.1%) were found in the entire cohort. CONCLUSION Fertility-sparing treatment for CAH and grade 1 endometrial cancer is feasible with progestin therapy and leads to clinically meaningful rates of pregnancy in young women who desire fertility.
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Holland C. Unresolved issues in the management of endometrial cancer. Expert Rev Anticancer Ther 2014; 11:57-69. [DOI: 10.1586/era.10.207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Marton I, Vranes HS, Sparac V, Maricic I, Kuna K, Kopjar M. Two cases of successful pregnancies after hysteroscopic removal of endometrioid adenocarcinoma grade I, stage IA, in young women with Lynch syndrome. J Turk Ger Gynecol Assoc 2014; 15:63-6. [PMID: 24790520 PMCID: PMC4004308 DOI: 10.5152/jtgga.2013.69379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 08/17/2013] [Indexed: 11/22/2022] Open
Abstract
We present two cases of endometrioid adenocarcinoma grade I, FIGO IA (staging according to the International Federation of Gynecology and Obstetrics) in young women, diagnosed within endometrial polyps. Both patients underwent repeated hysteroscopies and multiple biopsies after initial treatment to medroxyprogesterone one 400 mg daily or the insertion of IUD-LND (intrauterine device-levonorgestrel) for three months. In both of them, all histological samples were negative. Both of them decided that they would try to conceive. The first patient conceived spontaneously and the second patient after IVF (in vitro fertilisation) treatment. They both gave birth to full-term infants. Hysterectomy was recommended to both of our patients, and was carried out. Both of the patients fulfilled both Amsterdam II and revised Bethesda criteria for hereditary non-polyposis colorectal cancer (HNPCC).
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Affiliation(s)
- Ingrid Marton
- Clinic of Gynecology and Obstetrics, University Hospital “Sv. Duh”, Zagreb, Croatia
| | | | - Vladimir Sparac
- Polyclinic of Gynecology and Obstetrics “Cito”, Split, Croatia
| | - Igor Maricic
- Department of Gynecology and Obstetrics, General Hospital Zabok, Zabok, Croatia
| | - Krunoslav Kuna
- Clinic of Gynecology and Obstetrics, Clinical Medical Centre “SM”, Zagreb, Croatia
| | - Miroslav Kopjar
- Clinic of Gynecology and Obstetrics, Clinical Medical Centre “SM”, Zagreb, Croatia
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Parlakgumus HA, Kilicdag EB, Simsek E, Haydardedeoglu B, Cok T, Aytac PC, Bagis T, Erkanlı S. Fertility outcomes of patients with early stage endometrial carcinoma. J Obstet Gynaecol Res 2013; 40:102-8. [DOI: 10.1111/jog.12132] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/12/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Huriye Ayse Parlakgumus
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Esra Bulgan Kilicdag
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Erhan Simsek
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Bulent Haydardedeoglu
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Tayfun Cok
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Pinar Caglar Aytac
- Department of Obstetrics and Gynecology; Baskent University Faculty of Medicine; Ankara Turkey
| | - Tayfun Bagis
- Department of Obstetrics and Gynecology; Acıbadem University Faculty of Medicine; Istanbul Turkey
| | - Serkan Erkanlı
- Department of Obstetrics and Gynecology; Acıbadem University Faculty of Medicine; Istanbul Turkey
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A prospective study of fertility-sparing treatment with megestrol acetate following hysteroscopic curettage for well-differentiated endometrioid carcinoma and atypical hyperplasia in young women. Arch Gynecol Obstet 2013; 288:1115-23. [PMID: 23644919 DOI: 10.1007/s00404-013-2826-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 03/22/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate the feasibility and efficacy of curettage with hysteroscopy followed by megestrol acetate (MA) for well-differentiated endometrioid carcinoma (EC) confined to the endometrium and for atypical hyperplasia (AH) in young women. PATIENTS AND METHODS Fourteen patients with EC and 12 patients with AH were prospectively enrolled in this study. All of the patients received at least 12 weeks of oral MA (160 mg/day) following thorough curettage with hysteroscopy. The response was assessed histologically every 12 weeks. The primary endpoint was the complete response rate. Adverse events, pregnancy rates and recurrence rates were secondary end points. RESULTS Twenty-one (80.8 %) patients responded to treatment. The median time to response was 12 weeks. After a median follow-up of 32 months, 6 patients had recurrences. Significantly, more patients with infertility or PCOS experienced recurrence (P = 0.040, P = 0.015). Eight patients attempted to conceive after complete response; two spontaneous conceptions and one normal delivery were achieved. No disease-related or treatment-related deaths were observed. CONCLUSIONS Fertility-sparing treatment with MA following entirely hysteroscopic curettage is effective, demonstrating the least toxicity for rigorously selected young women with well-differentiated EC confined to the endometrium or with AH; however, close follow-up is required for the potential consequences of improper patient selection and a substantial rate of recurrence.
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Bovicelli A, D'Andrilli G, Giordano A, De Iaco P. Conservative treatment of early endometrial cancer. J Cell Physiol 2013; 228:1154-8. [PMID: 23172641 DOI: 10.1002/jcp.24292] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/14/2012] [Indexed: 11/08/2022]
Abstract
Endometrial cancer is the most common cancer of the female genital tract in Europe and in the United States. Endometrial cancer has increased 21% in incidence since 2008, and the death rate has increased more than 100% over the past two decades. Approximately 15% of patients with endometrial cancer are pre-menopausal. The aim of this review is to discuss the conservative management of endometrial cancer. A number of studies largely support the conservative treatment of endometrial carcinoma (EC) in women desiring future fertility. We focus on the role of progestin hormonal therapy, including the risks associated with non-standard care, appropriate candidate selection, expected outcomes, various progestin agents and recommended follow-up.
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Affiliation(s)
- Alessandro Bovicelli
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, USA
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Minig L, Franchi D, Valero de Bernabé J, Sideri M. Controversies of the hormonal conservative treatment of endometrial cancer. Gynecol Obstet Invest 2013; 75:145-51. [PMID: 23548769 DOI: 10.1159/000349891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/14/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hysterectomy plus salpingo-oophorectomy represents the standard treatment for patients with well-differentiated endometrial cancer (EC) limited to the endometrium. It is estimated that over 5% of EC are diagnosed in nulliparous women aged 35-44 years. In addition, EC can affect obese women with diabetes, hypertension and other comorbidities increasing the surgical risk. METHODS This article reviews the English literature in PubMed regarding hormonal treatment of EC. RESULTS Use of hormonal therapies has resulted in complete remission in 60-70%; many of these women were able to achieve full-term pregnancies, and in case of contraindication to surgery, resection could be avoided. Several topics, however, such as patient selection, interobserver histologic evaluation, the type/duration of hormonal treatment, modality of evaluation before treatment and surveillance after treatment, which are still subject to controversy, are therefore discussed in this paper. CONCLUSION Uterus-sparing treatment of well-differentiated EC limited to the endometrium is feasible and has acceptable efficacy in women with increased surgical risk or those who wish to preserve their fertility. Although the methods applied to determine disease extent beyond the endometrium are still unsatisfactory, patient selection is a crucial factor determining the outcome of treatment. However, women must be fully informed about the possibility of treatment failure and the necessity of a close follow-up after therapy.
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Affiliation(s)
- Lucas Minig
- Gynecology Oncology Program, Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Madrid, Spain. lucasminig @ yahoo.com
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Carneiro MM, Lamaita RM, Ferreira MCF, Silva-Filho AL. Safe Fertility-Preserving Management in Endometrial Cancer: Is It Feasible? Review of the Literature. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2012.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Márcia Mendonça Carneiro
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Brazil
- CAPES Foundation, Ministry of Education of Brazil. Postdoctoral Scholarship BEX3965/11-2
| | - Rívia Mara Lamaita
- Pró-Criar Clinic of Assisted Reproduction, MaterDei Hospital, Belo Horizonte, Minas Gerais, Brazil
| | - Márcia Cristina França Ferreira
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Brazil
- Universidade Federal de Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
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Seyhan A, Ata B, Chen HY, Varghese AC, Mumcu A, Tan SL. Fertility Preservation. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2012. [DOI: 10.1007/s13669-012-0025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lai CH, Wang CJ, Chao A. The Clinical Management of Endometrial Cancer in Young Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2012. [DOI: 10.1007/s13669-012-0032-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Regression, relapse, and live birth rates with fertility-sparing therapy for endometrial cancer and atypical complex endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2012; 207:266.e1-12. [PMID: 23021687 DOI: 10.1016/j.ajog.2012.08.011] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 05/26/2012] [Accepted: 08/07/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the regression, relapse, and live birth rates of early-stage endometrial cancer (EC) and atypical complex hyperplasia (ACH) with fertility-sparing treatment. STUDY DESIGN This was a metaanalysis of the proportions from observational studies with a random-effects model and a meta-regression to explore for heterogeneity. RESULTS Thirty-four observational studies, evaluating the regression, relapse, and live birth rates of early-stage EC (408 women) and ACH (151 women) with fertility-sparing treatment. Fertility-sparing treatment for EC achieved a pooled regression rate of 76.2%, a relapse rate of 40.6%, and a live birth rate of 28%. For ACH the pooled regression rate was 85.6%, a relapse rate of 26%, and a live birth rate of 26.3%. Twenty women were diagnosed with ovarian cancer (concurrent or metastatic) during follow-up (3.6%) and 10 progressed to higher than stage I EC (1.9%) from which 2 women died. CONCLUSION Fertility-sparing treatment of EC and ACH is feasible and selected women can satisfy their reproductive wishes.
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A Turkish Gynecologic Oncology Group study of fertility-sparing treatment for early-stage endometrial cancer. Int J Gynaecol Obstet 2012; 119:270-3. [DOI: 10.1016/j.ijgo.2012.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/09/2012] [Accepted: 07/26/2012] [Indexed: 11/18/2022]
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Pashov AI, Tskhay VB, Ionouchene SV. The combined GnRH-agonist and intrauterine levonorgestrel-releasing system treatment of complicated atypical hyperplasia and endometrial cancer: a pilot study. Gynecol Endocrinol 2012; 28:559-61. [PMID: 22296608 DOI: 10.3109/09513590.2011.649813] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In this article, we present the results of organ-preserving treatment applied in 24 patients of reproductive age with atypical endometrial hyperplasia or early-stage endometrial cancer. All of them would like to preserve their reproductive potential. Thirteen women with atypical endometrial hyperplasia were treated with the combination of six intramuscular injections of 3.75 mg gonadotropin-releasing hormone agonist (GnRHa)--leuproreline acetate depot every 4 weeks. After the third injection of 3.75 mg of leuproreline acetate, the levonorgestrel intrauterine hormonal system containing 52 mg levonorgestrel (Mirena®, Bayer, Germany) was inserted for at least 6 months. In 11 women with stage IA well-differentiated endometrial adenocarcinoma, hormonal therapy included nine intramuscular injections of 3.75 mg of GnRHa every 4 weeks. After the third injection of 3.75 mg of GnRHa, we also inserted a GnRH-IUS (Mirena®) for at least 12 months. This type of therapy was effective for all these patients and may be offered to be used as an alternative to surgery in women with atypical endometrial hyperplasia or early stage 1A well-differentiated endometrial cancer in women of reproductive age. Three women with endometrial cancer became pregnant and two of them delivered at term and one has an ongoing pregnancy.
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Affiliation(s)
- Alexandr I Pashov
- Department of Obstetrics and Gynecology, State Medical University n.a. V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
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Gunderson CC, Fader AN, Carson KA, Bristow RE. Oncologic and reproductive outcomes with progestin therapy in women with endometrial hyperplasia and grade 1 adenocarcinoma: a systematic review. Gynecol Oncol 2012; 125:477-82. [PMID: 22245711 DOI: 10.1016/j.ygyno.2012.01.003] [Citation(s) in RCA: 262] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 12/31/2011] [Accepted: 01/04/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this review was to analyze published contemporary oncologic and reproductive outcomes in women with endometrial hyperplasia or cancer undergoing medical management with progestin therapy. METHODS A systematic review of oncologic and pregnancy outcomes in women with complex atypical hyperplasia or grade 1 adenocarcinoma was performed using a comprehensive search of the MEDLINE literature. English language studies published from 2004 to 2011 which utilized hormonal therapy were identified using key words endometrial hyperplasia, endometrial cancer, fertility preservation, hormone and progestin therapy. Fisher's exact test was used to calculate statistical differences. RESULTS Forty-five studies with 391 study subjects were identified. The median age was 31.7 years. Therapies included medroxyprogesterone (49%), megestrol acetate (25%), levonorgestrel intrauterine device (19%), hydroxyprogesterone caproate (0.8%), and unspecified/miscellaneous progestins (13.5%). Overall, 344 women (77.7%) demonstrated a response to hormonal therapy. After a median follow up period of 39 months, a durable complete response was noted in 53.2%. The complete response rate was significantly higher for those with hyperplasia than for women with carcinoma (65.8% vs. 48.2%, p=.002). The median time to complete response was 6 months (range, 1-18 months). Recurrence after an initial response was noted in 23.2% with hyperplasia and 35.4% with carcinoma during the study periods (p=.03). Persistent disease was observed in 14.4% of women with hyperplasia and 25.4% of women with carcinoma (p=.02). During the respective study periods, 41.2% of those with hyperplasia and 34.8% with a history of carcinoma became pregnant (p=.39), with 117 live births reported. CONCLUSION Based on this systematic review of the contemporary literature, endometrial hyperplasia has a significantly higher likelihood of response (66%) to hormonal therapy than grade 1 endometrial carcinoma (48%). Disease persistence is more common in women with carcinoma (25%) compared to hyperplasia (14%). Reproductive outcomes do not seem to differ between the cohorts.
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Affiliation(s)
- Camille C Gunderson
- Johns Hopkins Hospital, Department of Gynecology and Obstetrics, 600 North Wolfe Street, Phipps 279, Baltimore, MD 21287, USA.
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Traitement conservateur du cancer et des hyperplasies atypiques de l’endomètre en vue de préserver la fertilité : revue de la littérature. Bull Cancer 2012; 99:51-60. [DOI: 10.1684/bdc.2011.1516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Marnitz S, Köhler C. Current therapy of patients with endometrial carcinoma. A critical review. Strahlenther Onkol 2011; 188:12-20. [PMID: 22189438 DOI: 10.1007/s00066-011-0004-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/28/2011] [Indexed: 10/14/2022]
Abstract
Magnetic resonance imaging (MRI), 18-FDG positron emission tomography ((18)FDG PET-CT), and computed tomography (CT) have demonstrated disappointing detectability of lymph node metastases in endometrial cancer. The treatment of choice in patients with endometrial cancer is hysterectomy and bilateral salpingoophorectomy. Above all, obese patients with comorbidity have benefited the most from laparoscopically assisted approaches. For inoperable patients in FIGO stage I/II, radiation remains an alternative to hysterectomy. The role of pelvic and paraaortic lymphadenectomy is the most controversial issue in endometrial carcinoma treatment. The current spectrum of treatment ranges from no lymphadenectomy, exclusive pelvic or additional inframesentric paraaortic sampling, or complete pelvic to infrarenal paraaortic lymphadenectomy. The sentinel concept in patients with endometrial carcinoma is far from being introduced into routine clinical practice. Without a lymphadenectomy, decision making for adjuvant therapy remains a challenge, because no information is available from lymph node status and the reliability of pathologic grading is poor. For patients after hysterectomy with a low risk of local relapse (stage I/II without additional risk factors), vaginal brachytherapy is sufficient to prevent vaginal relapses. Adjuvant external beam irradiation (EBRT) in stage I/II demonstrated improved local control which impacted overall survival only in patients with high-risk features (higher age, grading myometrial infiltration). Stage IIIC patients seem to benefit from EBRT with regard to overall survival. In patients at high risk of progression (grade 3, MI > 50%, FIGO IIIC, unfavorable histology), multimodal treatment should be considered. The optimal substances and sequences are under investigation.
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Affiliation(s)
- S Marnitz
- Department of Radiooncology, Charité University Medicine, Charité - Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Efficacy of oral or intrauterine device-delivered progestin in patients with complex endometrial hyperplasia with atypia or early endometrial adenocarcinoma: a meta-analysis and systematic review of the literature. Gynecol Oncol 2011; 125:263-70. [PMID: 22196499 DOI: 10.1016/j.ygyno.2011.11.043] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate the efficacy of progestin treatment to achieve pathological complete response (pCR) in patients with complex atypical endometrial hyperplasia (CAH) or early endometrial adenocarcinoma (EC). METHODS A systematic search identified 3245 potentially relevant citations. Studies containing less than ten eligible CAH or EC patients in either oral or intrauterine treatment arm were excluded. Only information from patients receiving six or more months of treatment and not receiving other treatments was included. Weighted proportions of patients achieving pCR were calculated using R software. RESULTS Twelve studies met the selection criteria. Eleven studies reported treatment of patients with oral (219 patients, 117 with CAH, 102 with grade 1 Stage I EC) and one reported treatment of patients with intrauterine progestin (11 patients with grade 1 Stage IEC). Overall, 74% (95% confidence interval [CI] 65-81%) of patients with CAH and 72% (95% CI 62-80%) of patients with grade 1 Stage I EC achieved a pCR to oral progestin. Disease progression whilst on oral treatment was reported for 6/219 (2.7%), and relapse after initial complete response for 32/159 (20.1%) patients. The weighted mean pCR rate of patients with grade 1 Stage I EC treated with intrauterine progestin from one prospective pilot study and an unpublished retrospective case series from the Queensland Centre of Gynaecologic Oncology (QCGC) was 68% (95% CI 45-86%). CONCLUSIONS There is a lack of high quality evidence for the efficacy of progestin in CAH or EC. The available evidence however suggests that treatment with oral or intrauterine progestin is similarly effective. The risk of progression during treatment is small but longer follow-up is required. Evidence from prospective controlled clinical trials is warranted to establish how the efficacy of progestin for the treatment of CAH and EC can be improved further.
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Gynecological fertility-sparing surgery. Placenta 2011; 32 Suppl 3:S224-31. [DOI: 10.1016/j.placenta.2011.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 06/21/2011] [Accepted: 06/23/2011] [Indexed: 01/20/2023]
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Abstract
OBJECTIVE To estimate cancer outcome and outcome predictors of women with endometrial intraepithelial neoplasia (EIN). METHODS Outcomes of women with first diagnosis of EIN ("index biopsy") were determined by follow-up pathology. Patient characteristics were correlated with EIN regression, EIN persistence, and progression to cancer. RESULTS Fifteen percent (95% confidence interval [CI] 9.8-20.8%, 26 of 177) of index EIN biopsy samples had concurrent cancer. Of the women with cancer-free index EIN biopsy samples and follow-up by hysterectomy or more than 18 months of surveillance, 25% (95% CI 18.4-33.3%, 36 of 142) showed regression, 35% (95% CI 27.4-43.7%, 50 of 142) showed persistence, and 39% (95% CI 31.3-48.0%, 56 of 142) showed progression. Nonwhite ethnicity and progestin treatment reduced cancer outcomes (odds ratio [OR] 0.16, 95% CI 0.03-0.84 and OR 0.24, 95% CI 0.08-0.70, respectively), whereas body mass index greater than 25 increased malignant outcomes (body mass index 25 or higher, OR 3.05, 95% CI 1.10-8.45). CONCLUSION Endometrial intraepithelial neoplasia confers a high risk of cancer, but individual patient outcomes cannot be predicted. Management should include exclusion of concurrent carcinoma and consideration of hysterectomy.
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Effectiveness of high-dose progestin and long-term outcomes in young women with early-stage, well-differentiated endometrioid adenocarcinoma of uterine endometrium. Arch Gynecol Obstet 2011; 285:473-8. [PMID: 21706284 DOI: 10.1007/s00404-011-1959-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 06/15/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE We assessed the effectiveness of high-dose progestins as a conservative treatment in young women with endometrial adenocarcinoma. METHODS We retrospectively reviewed the hospital data of patients with endometrial cancer that were managed conservatively. Of those women with grade 1 endometrioid endometrial adenocarcinoma, we included those who were younger than 40 years and in whom the disease was clinically confined to the endometrium. A complete response was defined pathologically as the absence of tissue with adenocarcinoma or hyperplasia. RESULTS Fourteen patients were included. Their mean age was 30.0 ± 4.8 years and the mean follow-up period was 47.3 ± 29.7 months. Twelve patients received 30-500 mg/day medroxyprogesterone acetate and two received 160 or 240 mg/day megestrol acetate. The median duration of treatment was 6 months (range 3-15 months) and 13 (93%) patients showed a complete response. Endometrial pathology reappeared in four patients (4/13, 31%) including two relapses, three of whom developed after the patients gave birth. Six patients used a combined oral contraceptive or a progestin-releasing intrauterine device as a maintenance therapy and experienced no recurrence. Four women (4/7, 57%) conceived successfully seven times with assisted-reproductive technology. No adverse effects of the progestins or tumor-related death were noted. CONCLUSIONS High-dose progestin therapy can be an effective conservative treatment in young patients with well-differentiated early-stage endometrial cancer. If patients wish to preserve their fertility even after they have completed childbearing, maintenance therapy with a cyclic oral contraceptive or a progestin-releasing intrauterine device may be an option to prevent recurrence.
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Abstract
Endometrial intraepithelial neoplasia (EIN) is a monoclonal premalignant endometrial glandular lesion that precedes the development of endometrioid-type endometrial adenocarcinoma. EIN arises through complex interactions involving the sequential accumulation of genetic damage in endometrial glands and the positive selective pressure of unopposed estrogen. Recent data have revealed a preclinical latent precursor lesion composed of mutated but morphologically nondescript glands that may persist for years in normal-appearing premenopausal cycling endometrium. This latent precursor shares many of the molecular features of EIN and endometrial adenocarcinoma, including frequent inactivation of both the tumor suppressor gene PTEN and the paired box-containing gene PAX2. Upon progression to EIN, the distinctive appearance of crowded and cytologically altered glands heralds a 45-fold increased risk of developing endometrial adenocarcinoma. To preserve the high predictability of EIN for concurrent/ subsequent adenocarcinoma, strict adherence to defined diagnostic criteria is essential. These criteria, as well as potential diagnostic pitfalls and their resolution, are discussed herein.
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Affiliation(s)
- Elke A Jarboe
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah 84112, USA.
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Minig L, Franchi D, Boveri S, Casadio C, Bocciolone L, Sideri M. Progestin intrauterine device and GnRH analogue for uterus-sparing treatment of endometrial precancers and well-differentiated early endometrial carcinoma in young women. Ann Oncol 2011; 22:643-649. [DOI: 10.1093/annonc/mdq463] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kalogiannidis I, Agorastos T. Conservative management of young patients with endometrial highly-differentiated adenocarcinoma. J OBSTET GYNAECOL 2011; 31:13-7. [DOI: 10.3109/01443615.2010.532249] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Prolonged Conservative Treatment of Endometrial Cancer Patients: More Than 1 Pregnancy Can Be Achieved. Int J Gynecol Cancer 2011; 21:72-8. [DOI: 10.1097/igc.0b013e31820003de] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background:Preserving reproductive function in young patients with early endometrial cancer is an accepted concept today. The safety and feasibility of long-term conservative treatment, allowing more than 1 pregnancy, remain to be ascertained.Methods:This study was a retrospective chart review of a 27 women with endometrioid adenocarcinoma of the endometrium, who were treated conservatively at 2 tertiary-care institutions. Treatment comprised oral high-dose progestins with or without a levonorgestrel-releasing intrauterine device. Endometrial biopsy was repeated every 2 to 3 months.Results:Over 7.8 to 412 months (median, 57.4 months), tumors regressed completely in 24 (89%) of 27 patients and partially in 2 patients, with 79% responding within 1 to 17 months. Of the complete responders, 15 (62%) of 24 had a recurrence; 4 underwent hysterectomy, and 11 underwent subsequent progestational treatment. All 11 responded, and 3 subsequently conceived. After 2 to 4 years, 5 patients again had a recurrence, of whom 3 underwent hysterectomy. Overall, 2 patients developed ovarian adenocarcinoma. All patients are currently disease-free. Conception occurred in 14 (51.8%) of 27 patients, in 5 more than once. There were 17 live births, and 2 patients are pregnant.Conclusions:According to our data, prolonged progestational therapy for early-stage endometrial adenocarcinoma, allowing women to conceive, is feasible and apparently does not alter clinical outcome. Patients should be advised of the high recurrence rate and possible concomitant ovarian malignancy.
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Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2010; 203:547.e1-10. [PMID: 20934679 DOI: 10.1016/j.ajog.2010.07.037] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 05/22/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To conduct a systematic review and metaanalysis of studies evaluating the regression rate of endometrial hyperplasia with oral progestogens and levonorgestrel-releasing intrauterine system. STUDY DESIGN Searches were conducted on Medline, Embase, Cochrane Library, and Web of Science, and reference lists of relevant articles were examined. The methodologic index for nonrandomized studies was used for quality assessment. Metaanalysis was performed with random effects model. RESULTS There were 24 observational studies (1001 women), of low methodologic quality, evaluating the outcome of regression of endometrial hyperplasia with oral progestogens or levonorgestrel-releasing intrauterine system. Metaanalysis showed that oral progestogens achieved a lower pooled regression rate compared with levonorgestrel-releasing intrauterine system for complex (pooled rate, 66% vs 92%; P < .01) and atypical hyperplasia (pooled rate, 69% vs 90%; P = .03). There was no statistical difference in simple hyperplasia (pooled rate, 89% vs 96%; P = .41). CONCLUSION Oral progestogens appear to induce a lower disease regression rate than Levonorgestrel-releasing intrauterine system in the treatment of endometrial hyperplasia.
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