Prognosis of uterine and extrauterine low-grade endometrial stromal sarcoma：an observational cohort study

OBJECTIVE

Little is known about the survival differences between uterine and extrauterine low-grade endometrial stromal sarcoma (LGESS). Survival outcomes, consisting of disease-free survivals and overall survivals, were compared in these two entities.

METHODS

From February 2012 to June 2019, all primary LGESS cases and LGESS cases with first recurrence in the study center were reviewed. The clinicopathological characteristics and survival outcomes of extrauterine and uterine LGESS patients were compared for both primary and recurrent diseases.

RESULTS

During the study period, 143 patients with primary LGESS and 56 patients with recurrent LGESS were included and followed up to June 1, 2020, among whom 8 (5.6%) and 10 (17.8%) patients were identified as having extrauterine LGESS. Patients with primary and recurrent extrauterine LGESS had similar clinicopathological characteristics to those of patients with uterine LGESS. In primary or in recurrent LGESS cases, in univariate analysis, patients with uterine and extrauterine LGESS had similar disease-free intervals after the last treatment, and they also had similar overall survivals after the diagnosis. Ovarian preservation led to significantly increased recurrence for primary LGESS (hazard ratio [HR] 4.9, 95% confidence interval [95% CI] 2.3-10.1, P<0.001) and repeated recurrence for recurrent LGESS (HR 3.1, 95% CI 1.3-7.3, P=0.009). Surgical treatment for recurrent LGESS decreased repeated recurrence after the first recurrence (HR 0.2, 95% CI 0.1-0.7, P=0.006). No factors were found to be associated with the overall survival of primary or recurrent LGESS.

CONCLUSION

The clinical characteristics and survival outcomes of extrauterine LGESS are similar to those of uterine LGESS. Surgery is the treatment of choice for recurrent LGESS. Ovarian preservation is detrimental to disease-free survival but not to overall survival in both uterine and extrauterine LGESS.

Fertility preserving management of ovarian torsion

OBJECTIVE

To analyze characteristics of acute and chronic ovarian torsion, review treatment recommendations, and present possible surgical techniques for fertility preservation in young women.

DESIGN

Literature review and demonstration of perioperative management of ovarian torsion using radiologic images and intraoperative video footage. Ovarian torsion is mostly mentioned in context of gynecologic emergencies, where acute ovarian torsion with arterial obstruction leads to ovarian ischemia and necrosis. However, ovarian torsion can also occur as a partial or intermittent torsion with venous and lymphatic obstruction, followed by ovarian swelling. In both cases, surgical management of ovarian torsion commonly includes oophorectomy, although leading guidelines recommend preservation of the ovary. We here aimed to raise awareness for the clinical features of ovarian torsion and demonstrate adequate perioperative management, thereby avoiding surgical overtreatment in young women.

SETTING

Medical University of Vienna, Department of Obstetrics and Gynecology.

PATIENT(S)

We present a case of acute ovarian torsion with a consequently ischemic ovary as well as a case of chronic ovarian torsion with related massive ovarian edema. The patients included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites.

INTERVENTION(S)

Laparoscopic management with detorsion of the torquated ovaries, cystectomy on an ischemic ovary and oophoropexy to the pelvic side wall and utero-ovarian ligament to prevent recurrence.

MAIN OUTCOME MEASURES

Postoperative relief of pain and normalization of ovarian size and morphology on ultrasound imaging.

RESULTS

The current cases show successful conservative surgical management of ovarian torsion, hence preserving hormonal function and fertility in young women.

CONCLUSION

Although it is recommended to preserve fertility in young women affected by ovarian torsion, surgical overtreatment by means of oophorectomy is still common in clinical routine. Increasing awareness for the clinical characteristics of acute and chronic ovarian torsion, as well as for the importance of preservation of the ovary, is crucial. We therefore believe that ovarian torsion and its surgical management deserve increased attention in the future.

Diminished Ovarian Reserve in Endometriosis: Insights from In Vitro, In Vivo, and Human Studies-A Systematic Review

Endometriosis, a prevalent disorder in women of reproductive age, is often associated with undesired infertility. Ovarian reserve, an essential measure of ovarian function that is crucial for maintaining fecundity, is frequently diminished in women with endometriosis. Though the causative relationship between endometriosis and reduced ovarian reserve is not fully understood due to the lack of standardized and precise measurements of ovarian reserve, there is ongoing discussion regarding the impact of interventions for endometriosis on ovarian reserve. Therefore, in this review, we investigate articles that have related keywords and which were also published in recent years. Thereafter, we provide a comprehensive summary of evidence from in vitro, in vivo, and human studies, thereby shedding light on the decreased ovarian reserve in endometriosis. This research consolidates evidence from in vitro, in vivo, and human studies on the diminished ovarian reserve associated with endometriosis, as well as enhances our understanding of whether and how endometriosis, as well as its interventions, contribute to reductions in ovarian reserve. Furthermore, we explore potential strategies to modify existing therapy options that could help prevent diminished ovarian reserve in patients with endometriosis.

Incidence and characteristics of ovarian cancer following endometrial cancer in the emerging era of conservative management of endometrial cancer-Implications for counseling-A SEER analysis

OBJECTIVE

To assess the ovarian cancer (OC) risk following endometrial cancer (EC) in patients who underwent ovarian preservation as part of the EC staging.

STUDY DESIGN

With permission of the Surveillance, Epidemiology and End Results (SEER) program of the United States National Cancer Institute, clinicopathological information of women diagnosed with EC and following OC were analyzed. Incidence of OC and survival according to the surgical approach were studied. Primary analysis was conducted in women up to and including the age of 49 years.

RESULTS

A total of 116 patients up to the age of 49 years were diagnosed with EC and following OC. In this group of patients, no differences in incidence (IRR 0.9, CI 0.56-1.49, p = 0.66) or survival rates (p = 0.71) were found comparing ovarian preservation and bilateral salpingo-oophorectomy (BSO) performance. In an overall analysis of women diagnosed with EC and following OC at any age, incidence of OC did not differ between groups (IRR 1.07, CI 0.83-1.39, p = 0.59) yet when including patients older than 49 years old survival rates were shorter in ovarian preservation patients compared to patients with BSO performed as part of their EC treatment.

CONCLUSION

Ovarian preservation in EC patients under the age of 49 years may be considered safe, with no impact on OC incidence or survival, benefiting longer natural hormonal status.

Treatment and Outcomes of Congenital Ovarian Cysts A Study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS)

OBJECTIVE

We conducted a multicenter study to assess treatments and outcomes in a national cohort of infants with congenital ovarian cysts.

SUMMARY BACKGROUND DATA

Wide variability exists in the treatment of congenital ovarian cysts. The effects of various treatment strategies on outcomes, specifically ovarian preservation, are not known.

METHODS

Female infants diagnosed with congenital intra-abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centers were retrospectively evaluated. Sonographic characteristics, median time to cyst resolution, incidence of ovarian preservation, and predictors of surgery were evaluated. Subgroup analyses were performed in patients with complex cysts and cysts ≥40 mm in diameter.

RESULTS

The study population included 189 neonates. Median gestational age at diagnosis and median maximal prenatal cyst diameter were 33 weeks and 40 mm, respectively. Cysts resolved spontaneously in 117 patients (62%), 14 (7%) prenatally, and the remainder at a median age of 124 days. Intervention occurred in 61 patients (32%), including prenatal aspiration (2, 3%), ovary sparing resection (14, 23%), or oophorectomy (45, 74%). Surgery occurred at a median age of 7.4weeks. Independent predictors of surgery included postnatal cyst diameter ≥40 mm [odds ratio (OR) 6.19, 95% confidence interval (CI) 1.66-35.9] and sonographic complex cyst character (OR 63.6, 95% CI 10.9-1232). There was no significant difference in the odds of ovarian preservation (OR 3.06, 95% CI 0.86 -13.2) between patients who underwent early surgery (n = 22) and those initially observed for at least 3 months (n = 131).

CONCLUSIONS

Most congenital ovarian cysts are asymptomatic and spontaneously resolve. Early surgical intervention does not increase ovarian preservation.

Impacts of endometrioma on ovarian aging from basic science to clinical management

Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.

Characteristics and clinicopathological features of patients with ovarian metastasis of endometrial cancer: a retrospective study

There are no criteria for patient selection for ovarian-preserving surgery for endometrial cancer (EC). In this study, intraoperative findings of ovarian swelling (OvS) and the clinicopathological features of patients with EC with or without ovarian metastasis were analysed to identify risk factors for ovarian metastasis. Patients who underwent surgery for EC between 2012 and 2019 at our hospital were enrolled. In univariate analysis, all features were significantly higher in metastasis(+) cases. In multivariate analysis, lymphatic space invasion (LSI), cervical stromal involvement (CSI), peritoneal dissemination, and OvS were significant risk factors. In univariate analysis in stage I and II cases classified without adnexal pathological factors, type 2 histologic type, LSI, CSI, and OvS were significantly higher in metastasis(+) cases. LSI, CSI, and OvS were significant risk factors in multivariate analysis. Patients with type 1 histologic type EC without myometrial invasion ≥1/2, CSI and extrauterine lesions are appropriate for ovarian preservation. IMPACT STATEMENTWhat is already known on this subject? The number of premenopausal patients with endometrial cancer (EC) is increasing. Bilateral oophorectomy for EC results in surgical primary ovarian insufficiency, and thus, surgery with ovarian preservation has been examined. However, there are few reports on risk factors for ovarian metastasis of EC and no established criteria for patient background or pathological factors to determine suitability for ovarian preservation surgery.What do the results of this study add? In univariate analysis, all pathological findings suggestive of disease progression were more frequent in cases with ovarian metastases. In multivariate analysis, lymphatic space invasion (LSI), cervical stromal involvement (CSI), peritoneal dissemination, and ovarian swelling (OvS) were identified as significant risk factors for ovarian metastasis. In an analysis of stage I and II cases classified without adnexal pathological factors, type 2 histologic type, LSI, CSI, and OvS were significantly more common in cases with ovarian metastasis, and LSI, CSI, and OvS emerged as significant risk factors for ovarian metastasis in multivariate analysis.What are the implications of these findings for clinical practice and/or further research? Patients with type 1 histologic type EC without depth of myometrial invasion ≥1/2, CSI, or extrauterine lesions may be appropriate cases for ovarian preservation.

OPEC study: An international multicenter study of ovarian preservation in endometrial cancers

OBJECTIVE

To evaluate the feasibility and oncological safety of ovarian preservation in early stage endometrial adenocarcinoma (EC) patients aged 40 and below.

METHODS

A total of 11 institutions from eight countries participated in the study. 169 of 5898 patients aged ≤40 years were eligible for the study. Patients with EC treated between March 2007 and January 2019 were retrospectively assessed.

RESULTS

The median duration of follow-up after EC diagnosis was 59 months (4-187). Among 169 participants, ovarian preservation surgery (OPS) was performed in 54 (31.9%), and BSO was performed in 115 (68.1%) patients. Although patients younger than 30 years of age were more likely to have OPS than patients aged 30 to 40 years (20.4% vs. 9.6%, P = 0.021), there was no significant difference by the mean age. There were no other relevant baseline differences between OPS and BSO groups. The Kaplan-Meier analysis revealed no difference in either the overall survival (P = 0.955) or recurrence-free survival (P = 0.068) among patients who underwent OPS, and BSO.

CONCLUSION

OPS appears to be safe without having any adverse impact on survival in women aged ≤40 years with FIGO Stage I EC.

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

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

MRI-Based Radiomics Nomogram for Selecting Ovarian Preservation Treatment in Patients With Early-Stage Endometrial Cancer

Background

Ovarian preservation treatment (OPT) was recommended in young women with early-stage endometrial cancer [superficial myometrial invasion (MI) and grades (G) 1/2-endometrioid adenocarcinoma (EEC)]. A radiomics nomogram was developed to assist radiologists in assessing the depth of MI and in selecting eligible patients for OPT.

Methods

From February 2014 to May 2021, 209 G 1/2-EEC patients younger than 45 years (mean 39 ± 4.3 years) were included. Of them, 104 retrospective patients were enrolled in the primary group, and 105 prospective patients were enrolled in the validation group. The radiomics features were extracted based on multi-parametric magnetic resonance imaging, and the least absolute shrinkage and selection operator algorithm was applied to reduce the dimensionality of the data and select the radiomics features that correlated with the depth of MI in G 1/2-EEC patients. A radiomics nomogram for evaluating the depth of MI was developed by combing the selected radiomics features with the cancer antigen 125 and tumor size. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of the radiomics nomogram and of radiologists without and with the aid of the radiomics nomogram. The net reclassification index (NRI) and total integrated discrimination index (IDI) based on the total included patients to assess the clinical benefit of radiologists with the radiomics nomogram were calculated.

Results

In the primary group, for evaluating the depth of MI, the AUCs were 0.96 for the radiomics nomogram; 0.80 and 0.86 for radiologists 1 and 2 without the aid of the nomogram, respectively; and 0.98 and 0.98 for radiologists 1 and 2 with the aid of the nomogram, respectively. In the validation group, the AUCs were 0.88 for the radiomics nomogram; 0.82 and 0.83 for radiologists 1 and 2 without the aid of the nomogram, respectively; and 0.94 and 0.94 for radiologists 1 and 2 with the aid of the nomogram, respectively. The yielded NRI and IDI values were 0.29 and 0.43 for radiologist 1 and 0.23 and 0.37 for radiologist 2, respectively.

Conclusions

The radiomics nomogram outperformed radiologists and could help radiologists in assessing the depth of MI and selecting eligible OPTs in G 1/2-EEC patients.

Does ovarian preservation have an effect on recurrence of early stage low-grade endometrial stromal sarcoma?

Surgical treatment of low-grade endometrial stromal sarcoma consists of hysterectomy. The role of oophorectomy is yet to be established. We aimed to examine the effect of preserving the ovaries on the pattern of recurrences in patients with stage I disease. Thirty-four patients with stage I low-grade endometrial stromal sarcoma were retrospectively analysed. Based on ovarian preservation the whole cohort was divided into two groups. Recurrence (liver, lung, groin and bone) was detected in 4 (11.8%) cases. No significant differences in overall survival or disease-free survival (DFS) were observed between the ovarian preservation and bilateral salpingo-oophorectomy (BSO) groups. Subset analysis revealed no significant difference in DFS between the ovarian preservation and BSO groups in the premenopausal arm. And also, the performance of pelvic (n = 2) or para-aortic lymphadenectomy (n = 6) or adjuvant hormonal therapy did not alter DFS significantly. The 5-year DFS rate for the group which received adjuvant radiotherapy was 62.5 and 94.4% for those which did not (p = .014). Preserving the ovaries had no adverse effect on the recurrence of stage I disease.IMPACT STATEMENTWhat is already known on this subject? Due to the rarity of the disease and the common postoperative diagnosis, only retrospective studies have been reported on low-grade endometrial stromal sarcoma. This disease is commonly diagnosed in premenopausal patients during the early stage. There is no consensus on preserving the ovaries, particularly in young patients, due to the tumour's hormonal characteristics and the risk of late recurrences.What do the results of this study add? Ovarian preservation had no effect on the recurrence of stage I low-grade endometrial stromal sarcoma. Lymphadenectomy and adjuvant hormonal treatment had no effect on DFS, and adjuvant radiotherapy decreased DFS in the current study.What are the implications of these findings for clinical practice and/or further research? Ovarian preservation should be considered, to prevent the negative effects of surgical menopause, particularly in young patients.

Ovarian preservation and prognosis in adnexal torsion surgery - a retrospective analysis

OBJECTIVES

This study aims to analyze the conditions of ovarian preservation during adnexal torsion surgery, and safety of ovarian preservation.

MATERIAL AND METHODS

A retrospective analysis of 130 patients, who underwent surgery for ovarian benign tumor pedicle torsion in Fujian Provincial Maternal and Child Health Hospital from June 2013 to June 2018, was conducted. This study analyses the possible risk factors affecting the operation method using multiple logistic regression and analyses the complications and the recovery of ovarian function after the treatment of the ovarian preservation.

RESULTS

Among these patients, 58 received ovarian cystectomy, while 72 received ovariectomy. There was no significant difference in terms of age, preoperative blood, operation time and surgical bleeding volume between the two groups (p > 0.05). However, there was a significant difference in preoperative adnexal blood flow, abdominal pain to the surgical interval, and a collection of torsion cycles (p < 0.05). There was an increased risk of ovarian resection in patients whose blood flow of the annex disappeared, whose time of abdominal pain was long, and whose number of twists were significant. For the preservation group, there were no increases in postoperative complications.

CONCLUSIONS

According to clinical indicators, such as preoperative adnexal blood flow, abdominal pain to the interval of surgery and the number of torsion cycles, it was determined whether it was feasible to keep the ovary. Retaining the ovary is safe, effective and feasible in adnexal torsion.

Laparoscopic Detorsion and Fertility Preservation in Twisted Ischemic Adnexa - A Single-Center Prospective Study

Objective:

This study aimed to analyze our experience about the salvageability of ovary in cases of adnexal torsion by laparoscopy, irrespective of the grade of necrosis and number of twists, and to assess the subsequent ovarian viability.

Materials and Methods:

This is a prospective study conducted in a tertiary care laparoscopic institute. All the cohorts of intraoperative diagnosis of adnexal torsion were included irrespective of the age group from January 2015 to January 2018 over the period of 3 years after obtaining approval from the institute's human ethics committee. Their demographic details and clinical and operative findings were entered after obtaining an informed written consent. All patients underwent laparoscopy except those with a suspicious diagnosis of malignancy. Postoperatively, ovarian viability was assessed by ultrasound Doppler in terms of vascularity and follicular development at 1, 6, and 12 months.

Results:

A total of 84 patients were included in the study. Acute abdominal pain (71.4%) was the main presenting symptom in all age groups. The total number of cases of adnexal torsion was 69. Adnexal torsion was mainly diagnosed in young and adolescent girls. Out of 46 attempted detorsion, 45 ovaries were preserved (97.8%). Most of the pathologies were benign. All the preserved ovaries were showing follicles and vascularity during ultrasound follow-up.

Conclusion:

Laparoscopic detorsion of the ovary is the best treatment modality irrespective of the grade of ischemia. Ovarian structure and follicles were preserved following detorsion in all the cases, even in gravely ischemic ovaries.

Ovarian preservation for low-grade endometrial stromal sarcoma: a systematic review of the literature and meta-analysis

OBJECTIVE

To evaluate the effect of ovarian preservation on oncologic outcomes for women with low-grade endometrial stromal sarcoma of the uterus.

METHODS

A systematic search of the Medline, Embase, Cohrane, and Web of Science databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies including patients with low-grade endometrial stromal sarcoma who had hysterectomy were identified. Data on tumor recurrence and death rate were pooled using a random effects model.

RESULTS

A total of 17 studies met the inclusion criteria and reported on 786 patients. Based on available information, ovarian preservation was noted in 190 patients while 501 had bilateral salpingo-oophorectomy. A significantly increased tumor recurrence rate was observed in the ovarian preservation group (89/190, 46.8%) compared with the bilateral salpingo-oophorectomy group (121/501, 24.2%) (OR 2.70, 95% CI 1.39 to 5.28). Based on data from 162 patients, no difference in death rate was noted between the ovarian preservation (2/34, 5.9%) and bilateral salpingo-oophorectomy (9/128, 7%) groups (OR 0.80, 95% CI 0.18 to 3.47).

CONCLUSIONS

Approximately one-quarter of patients with low-grade endometrial stromal sarcoma were managed with ovarian preservation. These women experienced a higher recurrence rate. Hormone exposure may be responsible for this elevated risk. Given the apparent high salvage rate, however, ovarian preservation may be an option only in a well-informed patient population.

Oncological Outcomes and Safety of Ovarian Preservation for Early Stage Adenocarcinoma of Cervix: A Systematic Review and Meta-Analysis

Objectives: To evaluate the oncological outcomes and safety of ovarian preservation, and to review the prognostic factors for ovarian metastases in early stage cervical adenocarcinoma.

Methods: PubMed, Embase, and Cochrane databases were searched for publications up to January 2019. Two investigators independently screened the studies for eligibility and extracted specific data. The primary outcomes were overall survival (OS) and progression-free survival (PFS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using STATA statistical software version 19.0.

Results: A total of 68 unique manuscripts were identified through the search strategy, and 10 studies were included in the meta-analysis of the safety of ovarian preservation. Fixed-effects model was used because of moderate heterogeneity. Pooled results of the included studies showed that ovarian preservation is not associated with a statistically significant OS (OR 1.00, 95% CI 0.64–1.56, I² = 25.7%) or PFS (OR 0.98, 95% CI 0.57–1.66, I² = 0%) in early stage cervical adenocarcinoma. In addition, 19 studies were included in the review of prognostic factors for cervical adenocarcinoma and risk factors for ovarian metastases. The incidence of ovarian metastases was 0% in stage IA, 2.8% in stage IB, 3.4% in stage IIA, and 11.8% in stage IIB cervical adenocarcinoma. International Federation of Gynecology and Obstetrics (FIGO) stage, tumor size, deep stromal invasion (DSI), lymph node metastasis (LNM), and vaginal invasion were significantly related to poor prognosis. Risk factors associated with ovarian metastases included age, FIGO stage, tumor size, DSI, parametrial invasion, corpus uteri invasion, LNM, vaginal invasion, and blood vessel invasion.

Conclusions: Ovarian preservation in young patients with early stage cervical adenocarcinoma is safe and has no significant effect on OS or PFS. Preserving ovaries in patients with FIGO stage IIB seems not reasonable because of the high rate of ovarian metastasis.

Independent risk factors for ovarian metastases in stage IA-IIB cervical carcinoma

INTRODUCTION

Cervical cancer is a common malignant tumor in women; most cervical cancer patients are premenopausal. Ovarian resection or preservation remains controversial. The purpose of this study was to discover the risk factors for ovarian metastasis in women with stage I-II cervical cancer.

MATERIAL AND METHODS

A total of 3292 women with cervical carcinoma who had undergone radical hysterectomy, with pelvic lymphadenectomy and bilateral oophorectomy or wedge resection of ovaries, were included in this multicenter retrospective study. We analyzed patients' demographics, International Federation of Obstetrics and Gynecology stage, and histopathologic records to determine clinicopathologic risk factors of ovarian metastasis.

RESULTS

Of the patients, 115 (3.49%) were confirmed to have ovarian metastasis. The ovarian metastasis rate was 2% (56/2794) for squamous cell carcinoma and 11.8% (59/498) for nonsquamous cell carcinoma. The risk factors independently associated with ovarian metastasis were histologic type (odds ratio [OR] 8.76, 95% CI 2.09-19.24), lymph node metastasis (OR 2.57, 95% CI 1.76-4.89), lymphovascular space invasion (OR 2.82, 95% CI 1.98-4.24), and corpus invasion (OR 6.34, 95% CI 2.37-11.42).

CONCLUSIONS

The histologic type, lymph node metastasis, lymphovascular space invasion, and corpus invasion were independently associated with ovarian metastasis. Histologic type and corpus invasion were the most important risk factors. Therefore, we suggest that corpus invasion might be a strong contraindication for preservation of the ovaries.

Strategies for overcoming oncological treatment-related ovarian dysfunction - literature review

In the majority of developed countries, it is observed that the time for maternity is being postponed to over the 30th and even 40th year of life. A significant number of cancers are diagnosed during reproductive age, often before the first pregnancy. A fertility preservation is an important issue in oncological treatment, where there is a need for balancing between radicality and the preservation of function of reproductive organs. The authors discuss the problem of ovarian dysfunction after oncological treatment and present the possible strategies for saving the reproductive function of ovaries, including both invasive and pharmacological approaches.

Ovarian preservation improves overall survival in young patients with early-stage endometrial cancer

We searched Medline, Embase, Cochrane library, the Chinese Biomedicine Literature Database, the Chinese Scientific Journal Full-text Database, the Chinese Journal Full-text Database, and the Wanfang Database to collect observational studies on the effects of ovary-saving surgery in comparison to bilateral salpingo-oophorectomy (BSO) in young patients with early-stage endometrial cancer (EC). The literature search included studies up to March 2017, and 10 retrospective cohort studies met our selection criteria. Random and fixed effect models revealed that ovarian preservation (OP) was associated with better overall survival (OS) (hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.57–0.99, P = 0.044), and was not associated with reduced recurrence-free survival (RFS) in pre-menopausal patients with early-stage endometrial cancer (HR 1.22, 95% CI 0.32–4.72, P = 0.648; risk ratio [RR] 1.11, 95% CI 0.59–2.10, P = 0.745). Preservation of the ovaries appears to be a safe option with significant benefit for this low risk population after a thorough preoperative evaluation and extensive intraoperative exploration.

Safety of ovarian preservation in women with stage I and II cervical adenocarcinoma: a retrospective study and meta-analysis

BACKGROUND

The safety of ovarian preservation remains uncertain in women with cervical adenocarcinoma and significant risk factors for ovarian metastases vary among different studies.

OBJECTIVE

We sought to evaluate the impact of ovarian preservation on prognosis in women with cervical adenocarcinoma and to assess clinical factors associated with ovarian metastases.

STUDY DESIGN

A retrospective study of 194 women with cervical adenocarcinoma was conducted and 159 women were followed up until the end of the study. To compare the impact of ovarian preservation on prognosis, women with successful follow-up were studied, including 33 women with ovarian preservation and 126 women who underwent bilateral salpingo-oophorectomy. For women who underwent radical hysterectomy, pelvic lymphadenectomy, and bilateral salpingo-oophorectomy, the risk factors for ovarian metastases were identified. A meta-analysis of the literature was carried out to further validate the findings.

RESULTS

There was no significant difference in survival between women with bilateral salpingo-oophorectomy and ovarian preservation (P = .423 for disease-free survival; P = .330 for overall survival). Tumor size (>4 cm), deep cervical stromal invasion, and lymph node metastasis were significant independent prognostic factors related to poor disease-free survival, and lymph node metastasis was significantly associated with overall survival. Of 153 women with cervical adenocarcinoma who underwent bilateral salpingo-oophorectomy, a significant difference was found in the relationship between ovarian metastasis and deep cervical stromal invasion, lymph node metastasis, and parametrial invasion. The meta-analysis showed that clinical stage IIB vs I-IIA (odds ratio, 4.64; 95% confidence interval, 2.11-10.23), deep stromal invasion (odds ratio, 10.63; 95% confidence interval, 3.12-36.02), lymph node metastasis (odds ratio, 8.54; 95% confidence interval, 4.15-17.57), corpus uteri invasion (odds ratio, 7.39; 95% confidence interval, 3.69-14.78), and parametrial invasion (odds ratio, 9.72; 95% confidence interval, 4.67-20.22) were significantly related to ovarian metastasis.

CONCLUSION

Ovarian preservation has no effect on prognosis in women with early-stage cervical adenocarcinoma. Risk factors for ovarian metastases were stage IIB, deep cervical stromal invasion, lymph node metastasis, corpus uteri invasion, and parametrial invasion. In women with early-stage cervical adenocarcinoma without these risk factors, ovarian conservation can be considered.

Controversies over the use of GnRH agonists for reduction of chemotherapy-induced gonadotoxicity

The increase in cancer incidence in younger people and the significant improvement in long and permanent remission have brought concern about their reproductive future and quality of life. Up to two-thirds of adult female patients undergoing chemotherapy for malignancies eventually develop premature ovarian failure. This condition is related to many complaints including vasomotor symptoms, osteoporosis, increased risk of cardiovascular diseases, sexual dysfunction, and infertility. Therefore, protection against iatrogenic infertility and loss of endocrine ovarian function caused by chemotherapy is currently of high priority. Several options have been used for preserving ovarian function. Established methods include cryopreservation of embryos and/or ova, and ovarian transposition, while others such as ovarian tissue preservation are new, yet promising treatments for fertility preservation. The administration of gonadotropin releasing hormone (GnRH) agonistic analogs (GnRH-a) is still considered experimental. However, the recent evidence is strong to recommend the use of GnRH-a co-treatment during chemotherapy in young women with cancer to protect ovarian function, with promising results regarding fertility preservation. As the use of GnRH-a is non-invasive, highly available and without impact on cancer treatment outcomes, it should be offered to all young female cancer patients to preserve their ovarian function.

Assessment of transposed ovarian movement: how much of a safety margin should be added during pelvic radiotherapy?

The purpose of this study was to analyze transposed ovarian movement. Data from 27 patients who underwent ovarian transposition after surgical treatment for uterine cancer were retrospectively analyzed. Computed tomography (CT) images including transposed ovaries were superimposed on other CT images acquired at different times, and were matched on bony structures. Differences in ovarian position between the CT images were measured. The planning organ at risk volume (PRV) margins were calculated from the formula of the 90% reference intervals (RIs) and the 95% RI, which were defined as mean ± 1.65 standard deviation (SD) and mean ± 1.96 SD, respectively. The 90% RI in the cranial, caudal, anterior, posterior, left and right directions were 1.5, 1.5, 1.4, 1.0, 1.7 and 0.9 cm, respectively. The 95% RI in the corresponding directions were 1.5, 2.0, 1.7, 1.2, 1.9 and 1.2 cm, respectively. These data suggest that bilateral ovaries need a PRV margin of ∼2 cm in all directions. The present study suggests that a transposed ovary needs the same PRV margin as a normal ovary (∼2 cm). Even after transposition, ovaries should be kept away from the radiation field to take into consideration the degree of ovarian movement.

Impact of ovarian preservation in women with endometrial cancer

BACKGROUND

Bilateral salpingo-oophorectomy (BSO) is standardly performed in the treatment of endometrial cancer. The purpose of this study was to evaluate the impact of ovarian preservation on the outcome of patients with endometrial cancer.

METHODS

A retrospective cohort study was performed using the 2000-2010 database of endometrial cancer patients who were treated at Taipei Veterans General Hospital. Information regarding patient age, pathologic reports, and follow-up results was abstracted from medical records.

RESULTS

Five hundred and twenty-nine patients were reviewed in this study. Mean age and follow-up duration were 55.7 ± 11.4 years and 37.5 ± 30.1 months, respectively. The median disease-free survival was 31.2 months (range 0.2-126.9 months). There were no significant differences in disease-free survival between stage I patients with ovarian preservation versus those with oophorectomy (p = 0.473). In a multivariate Cox model, ovarian preservation had no effect on disease-free survival [hazard ratio (HR) = 2.72; 95% confidence interval (CI), 0.48-15.59]; however, it was not significantly related to stage and para-aortic lymph node involvement.

CONCLUSION

Ovarian preservation may be considered in premenopausal women with early-stage low-risk endometrial cancer.

Acute torsion of uterine remnant leiomyoma with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE

To report a case of acute abdomen secondary to torsion of uterine remnant leiomyoma and ipsilateral adnexa in a woman with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and known history of bilateral uterine remnant leiomyomas.

DESIGN

Case report.

SETTING

Tertiary care center.

PATIENT(S)

A 40-year-old nulligravid woman with MRKH syndrome and a known history of bilateral uterine remnant leiomyomas with a surgical abdomen.

INTERVENTION(S)

SURGERY

right salpingo-oopherectomy, excision of right and left hemiuteri with pedunculated leiomyomas, and left salpingectomy.

MAIN OUTCOME MEASURE(S)

Definitive therapy with preservation of premenopausal state.

RESULT(S)

First known case of acute surgical presentation secondary to torsion of uterine remnant leiomyoma and ipsilateral adnexa in a woman with MRKH syndrome and bilateral voluminous uterine remnant leiomyomas without any plan for elective surgical intervention.

CONCLUSION(S)

Elective surgical removal of uterine remnant leiomyoma for women with MRKH syndrome can prevent the complication of torsion as well as prevent ovarian resection in premenopausal women. Torsion should be considered in the differential diagnosis in a woman with MRKH syndrome and known history of leiomyomas who presents with acute abdomen.