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Ronsini C, Romeo P, Andreoli G, Palmara V, Palumbo M, Caruso G, De Franciscis P, Vizzielli G, Restaino S, Chiantera V, Cianci S. Fertility-Sparing Treatments in Endometrial Cancer: A Comprehensive Review on Efficacy, Oncological Outcomes, and Reproductive Potential. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:471. [PMID: 40142282 PMCID: PMC11944013 DOI: 10.3390/medicina61030471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2025] [Revised: 03/03/2025] [Accepted: 03/05/2025] [Indexed: 03/28/2025]
Abstract
Endometrial cancer (EC) affects 3-14% of women under 40 who wish to preserve their fertility. The standard treatment for EC is a hysterectomy with salpingo-oophorectomy. However, for those desiring fertility preservation, oral progestogens such as medroxy-progesterone acetate (MPA) or megestrol acetate (MA) are the most common therapies in Fertility-Sparing Treatment (FST). Other treatments include gonadotropin-releasing hormone agonist (GnRHa), levonorgestrel-releasing intrauterine system (LNG-IUS), and metformin plus progestin. This comprehensive review evaluates the best FST options for women with reproductive potential. PubMed, EMBASE, and Scopus were searched in June 2023 using specific keywords. Studies included in the review focused on patients with EC undergoing FST, with outcomes such as complete response rate (CRR), recurrence rate (RR), pregnancy rate (PR), and live birth rate. Eighteen studies met the inclusion criteria, involving 23,976 patients. In only-oral progestin trials, CRR ranged from 18% to 100%; RR ranged from 0% to 81.8%; Death Rate ranged from 0% to 3.6%. In studies combining oral progestin with LNG-IUS, CRR ranged from 55% to 87.5%; RR ranged from 0% to 41.7%; Death Rate was 0%. Most patients with Stage IA EC received MPA or MA. Fertility-related outcomes were reported in 15 studies. PR ranged from 4 to 44 patients in trials involving only oral progestins. When combining oral progestin with LNG-IUS, PR ranged from 1 to 46 patients. Progestin therapy, including oral MPA and MA, is considered safe and effective, with limited evidence supporting the use of LNG-IUS.
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Affiliation(s)
- Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.R.); (G.A.); (P.D.F.); (V.C.)
| | - Paola Romeo
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98121 Mesina, Italy; (P.R.); (V.P.)
| | - Giada Andreoli
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.R.); (G.A.); (P.D.F.); (V.C.)
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98121 Mesina, Italy; (P.R.); (V.P.)
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (M.P.); (G.C.)
| | - Giuseppe Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (M.P.); (G.C.)
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.R.); (G.A.); (P.D.F.); (V.C.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (G.V.); (S.R.)
- Department of Medicine (DMED), University of Udine, 33100 Udine, Italy
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (G.V.); (S.R.)
| | - Vito Chiantera
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.R.); (G.A.); (P.D.F.); (V.C.)
| | - Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98121 Mesina, Italy; (P.R.); (V.P.)
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Etrusco A, Laganà AS, Chiantera V, Mikuš M, Arsalan HM, d’Amati A, Vitagliano A, Cicinelli E, Favilli A, D’Amato A. Reproductive and Oncologic Outcomes in Young Women with Stage IA and Grade 2 Endometrial Carcinoma Undergoing Fertility-Sparing Treatment: A Systematic Review. Biomolecules 2024; 14:306. [PMID: 38540726 PMCID: PMC10968417 DOI: 10.3390/biom14030306] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Endometrial cancer (EC) is the most common gynecological malignancy in both Europe and the USA. Approximately 3-5% of cases occur in women of reproductive age. Fertility-sparing treatment (FST) options are available, but very limited evidence regarding grade 2 (G2) ECs exists in the current literature. This systematic review aimed to comprehensively evaluate reproductive and oncologic outcomes among young women diagnosed with stage IA or G2EC disease who underwent FST. METHODS A comprehensive search of the literature was carried out on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), the Health Technology Assessment Database, and Web of Science. Only original studies that reported the oncologic and reproductive outcomes of patients with stage IA and G2EC tumors who underwent FST were considered eligible for inclusion in this systematic review (CRD42023484892). Studies describing only the FST for endometrial hyperplasia or G1 EC were excluded. RESULTS Twenty-two papers that met the abovementioned inclusion criteria were included in the present systematic review. Preliminary analysis suggested encouraging oncologic and reproductive outcomes after FST. CONCLUSIONS The FST approach may represent a feasible and safe option for women of childbearing age diagnosed with G2EC. Despite these promising findings, cautious interpretation is warranted due to inherent limitations, including heterogeneity in study designs and potential biases. Further research with standardized methodologies and larger sample sizes is imperative for obtaining more robust conclusions.
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Affiliation(s)
- Andrea Etrusco
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, 90127 Palermo, Italy; (A.E.); (A.S.L.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, 90127 Palermo, Italy; (A.E.); (A.S.L.)
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
- Unit of Gynecologic Oncology, National Cancer Institute—IRCCS—Fondazione “G. Pascale”, 80131 Naples, Italy
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia;
| | - Hafiz Muhammad Arsalan
- Faculty of General Medicine, Altamimi Bachelor Clinical University, Bishkek 720000, Kyrgyzstan;
| | - Antonio d’Amati
- Gynaecological Pathology Unit, Anatomical Pathology Division, Department of Woman and Child’s Health and Public Health Sciences, “Agostino Gemelli” Foundation IRCCS University Hospital, 00168 Rome, Italy;
- Unit of Human Anatomy and Histology, Department of Translational Biomedicine and Neuroscience (DiBraiN), University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (E.C.)
| | - Ettore Cicinelli
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (E.C.)
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy;
| | - Antonio D’Amato
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (E.C.)
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Wei H, Pan N, Wang Y, Ma C. Analysis of risk factors for recurrence in infertile endometrial cancer patients after in vitro fertilization treatment. Front Endocrinol (Lausanne) 2023; 14:1224622. [PMID: 38075071 PMCID: PMC10702941 DOI: 10.3389/fendo.2023.1224622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/24/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose To investigate the oncologic outcomes of patients with early-stage endometrioid endometrial cancer (EEC) treated with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) following fertility-sparing treatment (FST). Methods A total of 62 patients who underwent IVF/ICSI treatment in a single fertility center between June 2010 and December 2021 after conservative treatment for early-stage EEC were assigned to a recurrence group and a non-recurrence group. Their clinical characteristics and disease outcomes were retrospectively evaluated. Results The 62 women with complete remission (CR) after FST for EEC underwent 103 IVF cycles, resulting in 41 fresh embryo transfers (ETs) and 70 frozen-thawed transfers; 27 (43.55%) achieved clinical pregnancies, and 20 (32.26%) gave birth to a total of 23 live neonates. Additionally, nine patients had live births from natural pregnancies after IVF failure, bringing the cumulative live birth rate to 46.77% (29/62). After a median follow-up period of 53.88 months (range 20.2-127.5 months), 17 patients (27.42%) experienced recurrence within 2.8 to 57.9 months after the first controlled ovarian stimulation (COS). The probability of relapse at 1, 2, and 3 years after the initiation of COS was 14.52% (9/62), 21% (13/62), and 25.81% (16/62), respectively. Factors such as the time to CR, the time to IVF, the frequency of COS, maintenance treatment before IVF, and histology type were not found to significantly affect recurrence (p = 0.079, 0.182, 0.093, 0.267, and 0.41, respectively). Live births (hazard ratio (HR): 0.28, 95% CI: 0.082-0.962, p = 0.043) and the protocol of letrozole plus gonadotropin-releasing hormone (GnRH) antagonist/agonist used during IVF (HR: 0.1, 95% CI: 0.011-0.882, p = 0.038) were identified as independent favorable factors for recurrence. Conclusions Live birth was associated with decreased recurrence of EEC. Reducing estrogen levels during COS may serve to mitigate the risk of endometrial cancer recurrence.
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Affiliation(s)
- Hongyi Wei
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Ningning Pan
- 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, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
| | - Yang Wang
- 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, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
| | - Caihong Ma
- 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, Ministry of Education, Peking University, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Peking University Third Hospital, Beijing, China
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Murakami I, Machida H, Morisada T, Terao Y, Tabata T, Mikami M, Hirashima Y, Kobayashi Y, Baba T, Nagase S. Effects of a fertility-sparing re-treatment for recurrent atypical endometrial hyperplasia and endometrial cancer: a systematic literature review. J Gynecol Oncol 2023; 34:e49. [PMID: 36929578 PMCID: PMC10323306 DOI: 10.3802/jgo.2023.34.e49] [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: 08/10/2022] [Revised: 01/02/2023] [Accepted: 01/18/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To examine the effectiveness of progestin re-treatment for recurrent endometrial intraepithelial neoplasia (EIN), atypical endometrial hyperplasia (AH) and endometrial cancer (EC) following initial fertility-sparing treatment. METHODS A comprehensive systematic review and meta-analysis were conducted by an Expert Panel of the Japan Society of Gynecologic Oncology Endometrial Cancer Committee. Multiple search engines, including PubMed/MEDLINE and the Cochrane Database, were searched in December 2021 using the keywords "Endometrial neoplasms," "Endometrial hyperplasia," "Endometrial intraepithelial neoplasia," "Fertility preservation," "Progestins," AND "Recurrence." Cases describing progestin re-treatment for recurrent EIN, AH and EC were compared with cases that underwent conventional hysterectomy. The primary outcomes were survival and disease recurrence, and the secondary outcome was pregnancy. RESULTS After screening 238 studies, 32 with results for recurrent treatment were identified. These studies included 365 patients (270 received progestin re-treatment and 95 underwent hysterectomy). Most progestin re-treatment involved medroxyprogesterone acetate or megestrol acetate (94.5%). Complete remission (CR) following progestin re-treatment was achieved in 219 (81.1%) cases, with 3-, 6- and 9-month cumulative CR rates of 22.8%, 51.7% and 82.6%, respectively. Progestin re-treatment was associated with higher risk of disease recurrence than conventional hysterectomy was (odds ratio [OR]=6.78; 95% confidence interval [CI]=1.99-23.10), and one patient (0.4%) died of disease. Fifty-one (14.0%) women became pregnant after recurrence, and progestin re-treatment demonstrated a possibility of pregnancy (OR=2.48; 95% CI=0.94-6.58). CONCLUSION This meta-analysis suggests that repeat progestin therapy is an effective option for women with recurrent EIN, AH and EC, who wish to retain their fertility.
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Affiliation(s)
- Isao Murakami
- Department of Obstetrics and Gynecology, Toho University Ohashi Medical Center, Tokyo, Japan.
| | - Hiroko Machida
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | - Tohru Morisada
- Department of Obstetrics and Gynecology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Isehara, Japan
| | | | - Yoichi Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Tsukasa Baba
- Department of Obstetrics and Gynecology, Iwate Medical University, Iwate, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
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Darin MC, Di Guilmi J, Toscano M, Bambaci F, Chae-Kim J. Multiple attempts at fertility preservation in atypical endometrial hyperplasia and early endometrial cancer. Int J Gynecol Cancer 2022; 32:1332-1335. [PMID: 35459710 DOI: 10.1136/ijgc-2021-003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Maria Cecilia Darin
- Department of Gynecology Oncology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Julian Di Guilmi
- Department of Gynecology Oncology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Maria Toscano
- Department of Pathology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Florencia Bambaci
- Department of Radiology, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Jennifer Chae-Kim
- Obstetrics and Gynecology, Texas A&M University College of Medicine, Temple, Texas, USA
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Ronsini C, Mosca L, Iavarone I, Nicoletti R, Vinci D, Carotenuto RM, Pasanisi F, Solazzo MC, De Franciscis P, Torella M, La Verde M, Colacurci N, Cobellis L, Vizzielli G, Restaino S. Oncological outcomes in fertility-sparing treatment in stage IA-G2 endometrial cancer. Front Oncol 2022; 12:965029. [PMID: 36185260 PMCID: PMC9524219 DOI: 10.3389/fonc.2022.965029] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background The gold standard treatment for early-stage endometrial cancer (EC) is hysterectomy with bilateral salpingo-oophorectomy (BSO) with lymphadenectomy. In selected patients desiring pregnancy, fertility-sparing treatment (FST) can be adopted. Our review aims to collect the most incisive studies about the possibility of conservative management for patients with grade 2, stage IA EC. Different approaches can be considered beyond demolition surgery, such as local treatment with levonorgestrel-releasing intra-uterine device (LNG-IUD) plus systemic therapy with progestins. Study design Our systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, EMBASE, and Scopus databases were consulted, and five studies were chosen based on the following criteria: patients with a histological diagnosis of EC stage IA G2 in reproductive age desiring pregnancy and at least one oncological outcome evaluated. Search imputes were “endometrial cancer” AND “fertility sparing” AND “oncologic outcomes” AND “G2 or stage IA”. Results A total of 103 patients were included and treated with a combination of LNG-IUD plus megestrol acetate (MA) or medroxyprogesterone acetate (MPA), gonadotrophin-releasing hormone (GnRH) plus MPA/MA, hysteroscopic resectoscope (HR), and dilation and curettage (D&C). There is evidence of 70% to 85% complete response after second-round therapy prolongation to 12 months. Conclusions Conservative measures must be considered temporary to allow pregnancy and subsequently perform specific counseling to adopt surgery. Fertility-sparing management is not the current standard of care for young women with EC. It can be employed for patients with early-stage diseases motivated to maintain reproductive function. Indeed, the results are encouraging, but the sample size must be increased.
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Affiliation(s)
- Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
- *Correspondence: Carlo Ronsini,
| | - Lavinia Mosca
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Irene Iavarone
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Roberta Nicoletti
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Davide Vinci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Raffaela Maria Carotenuto
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Francesca Pasanisi
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Maria Cristina Solazzo
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco Torella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Luigi Cobellis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giuseppe Vizzielli
- Department of Obstetrics, Gynecology, and Pediatrics, Obstetrics and Gynecology Unit, Udine University Hospital, Udine, Italy
- Dipartimento di Area Medica (DAME), Udine University Hospital, Udine, Italy
| | - Stefano Restaino
- Department of Obstetrics, Gynecology, and Pediatrics, Obstetrics and Gynecology Unit, Udine University Hospital, Udine, Italy
- Dipartimento di Area Medica (DAME), Udine University Hospital, Udine, Italy
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Uccella S, Zorzato PC, Dababou S, Bosco M, Torella M, Braga A, Frigerio M, Gardella B, Cianci S, Laganà AS, Franchi MP, Garzon S. Conservative Management of Atypical Endometrial Hyperplasia and Early Endometrial Cancer in Childbearing Age Women. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1256. [PMID: 36143933 PMCID: PMC9504942 DOI: 10.3390/medicina58091256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
Total hysterectomy and bilateral adnexectomy is the standard treatment for atypical endometrial hyperplasia and early-stage endometrial cancer. However, the recommended surgical treatment precludes future pregnancy when these conditions are diagnosed in women in their fertile age. In these patients, fertility-sparing treatment may be feasible if the desire for childbearing is consistent and specific conditions are present. This review summarizes the available evidence on fertility-sparing management for atypical endometrial hyperplasia and early-stage endometrial cancer. Historically, oral progestins have been the mainstay of conservative management for atypical endometrial hyperplasia and stage IA endometrioid endometrial cancer with no myometrial invasion, although there is no consensus on dosage and treatment length. Intrauterine progestin therapy has proved a valid alternative option when oral progestins are not tolerated. GnRH analogs, metformin, and hysteroscopic resection in combination with progestins appear to increase the overall efficacy of the treatment. After a complete response, conception is recommended; alternatively, maintenance therapy with strict follow-up has been proposed to decrease recurrence. The risk of disease progression is not negligible, and clinicians should not overlook the risk of hereditary forms of the disease in young patients, in particular, Lynch syndrome. Hysterectomy is performed once the desire for childbearing desire has been established. The conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer is feasible, provided a strong desire for childbearing and permitting clinical-pathological conditions. However, patients must be aware of the need for a strict follow-up and the risk of progression with a possible consequent worsening of the prognosis. More homogenous and well-designed studies are necessary to standardize and identify the best treatment and follow-up protocols.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Susan Dababou
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Marco Torella
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Andrea Braga
- Department of Obstetrics and Gynecology, EOC—Beata Vergine Hospital, 6850 Mendrisio, Switzerland
| | - Matteo Frigerio
- Gynecology Department, San Gerardo Hospital, Milano Bicocca University, ASST Monza, 20900 Monza, Italy
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98121 Messina, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), ARNAS “Civico-Di Cristina-Benfratelli” Hospital, University of Palermo, 90127 Palermo, Italy
| | | | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
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Lee AJ, Shim SH, Kim NR, Yang EJ, So KA, Lee SJ, Lee JY, Kim TJ, Kang SB. Retreatment with progestin for recurrence after complete response with fertility-sparing treatment in patients with endometrial cancer. Int J Gynecol Cancer 2022; 32:1001-1008. [PMID: 35750352 DOI: 10.1136/ijgc-2022-003546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the outcomes of retreatment using progestin for recurrence after a complete response with fertility-sparing treatment in patients with early endometrial cancer. METHODS We retrospectively reviewed the data of patients with presumed stage IA, grade 1 endometrioid endometrial cancer who developed intra-uterine recurrence after a complete response with fertility-sparing treatment using progestin. Oncological and pregnancy outcomes were analyzed after repeated fertility-sparing treatment. Logistic and Cox regression analyses were performed to analyze the prognostic factors associated with a complete response with secondary fertility-sparing treatment and recurrence-free survival after secondary fertility-sparing treatment, respectively. RESULTS Fifty patients with a median age of 31 years (range 23-40) underwent secondary fertility-sparing treatment. With a median secondary progestin treatment duration of 9 months (range 3-55), the complete response rate was 78% (39/50) and no patients had extra-uterine spread of disease. Among the 26 (67%) patients who attempted to conceive after complete response, 10 became pregnant (3 spontaneous abortions, 7 live births). Eighteen (46.1%) patients had a second recurrence, with a median recurrence-free survival after secondary fertility-sparing treatment of 14 months (range 3-36); 15 patients received tertiary fertility-sparing treatment and nine (60%) achieved a complete response. Polycystic ovary on ultrasound (OR 5.82, 95% CI 1.1 to 30.6, p=0.037) was associated with an increased complete response rate with secondary fertility-sparing treatment. Multivariable analysis revealed that recurrence-free survival after initial hormonal treatment >6 months (HR 0.11, 95% CI 0.02 to 0.51, p=0.005) and pregnancy after secondary fertility-sparing treatment (HR 0.27, 95% CI 0.08 to 0.98; p=0.047) were significantly associated with longer recurrence-free survival after secondary fertility-sparing treatment. CONCLUSIONS Repeated progestin treatment was associated with a 78% response rate and it was safe in patients with intra-uterine recurrent endometrial cancer. Thus, it might help preserve fertility after first and second recurrences.
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Affiliation(s)
- A Jin Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Nae Ry Kim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Eun Jung Yang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Kyeong A So
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ji Young Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Tae Jin Kim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
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