Follow-up of women with cervical adenocarcinoma in situ treated by conization: A single centre clinical experience

OBJECTIVE

Hysterectomy has been the historical gold standard final step in the treatment algorithm of adenocarcinoma in situ (AIS) recommended by most North American colposcopy guidelines. AIS disproportionately affects young childbearing age women, therefore a fertility sparing treatment option is desirable. Our study examines the impact of conservative treatment of AIS with conization followed by serial surveillance.

METHODS

A retrospective chart review was completed of patients treated for AIS from 2006 to 2020. Charts were identified by pathologic diagnosis of AIS on cervical and uterine specimens. Charts were excluded if AIS was not treated with conization, if AIS was not confirmed on initial conization specimen, or if invasive disease was found at initial conization.

RESULTS

121 patient charts were analyzed. Median age of patients at first conization and hysterectomy was 34.8 and 40.9, respectively. First conization was by Cold Knife Cone in 58% of patients, and by Loop Electrosurgical Excisional Procedure in 42% of patients. Median follow-up period in our study was 609 days. 5% of patients had recurrence, with only one patient who recurred as cancer. One case of recurrence had a positive initial conization margin. Median time to recurrence was 700 days. 47% of patients underwent eventual hysterectomy. Residual AIS was found in 23% of hysterectomy specimens. Adenocarcinoma was diagnosed on hysterectomy specimen in four patients.

CONCLUSION

Our study demonstrates the oncologic safety of treating AIS with conization and serial surveillance. Routine hysterectomy completed as a part of the AIS treatment algorithm, as in current clinical guidelines, is unnecessary.

DEAR model in overweight endometrial cancer patients undergoing fertility-sparing treatment: A randomized controlled trial

OBJECTIVE

To evaluate the effects of DEAR weight management in overweight patients undergoing fertility-sparing treatment for endometrial cancer or atypical hyperplasia.

METHODS

Women with endometrial cancer or atypical hyperplasia who received fertility-sparing treatment and had a body mass index of >25 kg/m2 were randomly allocated to the DEAR (DEAR weight management) and control (self weight management) groups. Body morphology and composition, glycolipid metabolism, and tumor outcomes were assessed in both groups before and at 3 and 6 months after intervention.

RESULTS

Overall, 72 subjects were included (36 in each group). Following intervention, the DEAR group showed significantly lower median body weight (69.45 vs. 78.05), body mass index (26.19 vs. 29.15), lipid accumulation index (29.21 vs. 57.86), body fat mass (24.00 vs. 29.30), visceral fat area (112.5 vs. 133.3), and glycolipid metabolic indices (except high density lipoprotein) than the control group (P < 0.05) and showed a decreasing trend. The test group achieved significantly higher complete remission (88.46% vs. 57.14%; P < 0.05); the time to complete remission did not differ significantly (P > 0.05).

CONCLUSIONS

DEAR weight management can improve the studied parameters and complete remission rates in this population.

REGISTRATION

NCT06169449.

Potential of molecular classification to guide fertility-sparing management among young patients with endometrial cancer

The traditional histological classification system for endometrial carcinoma falls short in addressing the disease's molecular heterogeneity, prompting the need for alternative stratification methods. Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) has emerged as a clinically efficient tool to categorize endometrial cancers according to mismatch repair deficiency, POLE exonuclease domain mutations, and p53 expression. However, the application of this classification to fertility-sparing treatments remains unexplored, and current guidelines lack specificity in how it should be used. In this review, we summarize the available literature and establish the framework for future investigations focused on molecular profiling-based risk assessment of endometrial cancer, with the goal of utilizing precision medicine to optimally counsel patients seeking fertility-sparing treatment. While the available evidence is limited and of low quality, it does provide insights and frames future perspectives for managing fertility-sparing approaches on the basis of molecular subtypes. Evidence suggests that mismatch repair-deficient tumors are likely to recur despite progestin therapy, emphasizing the need for alternative treatments, with targeted therapies being a new landscape that still needs to be explored. Tumors with POLE mutations exhibit a favorable prognosis, but the safety of hysteroscopic resection alone requires further investigation. p53 abnormal tumors have an unfavorable prognosis, raising questions about their suitability for fertility-sparing treatment. Lastly, the no specific molecular profile (or p53 wild-type) tumors, while having a relatively good prognosis, are heterogeneous and require more precise biomarkers to effectively guide therapy for those with poorer prognoses. Addressing these research gaps will lead to more precise guidelines to ensure optimal selection for fertility-sparing treatment.

Successful pregnancy with in vitro fertilization after vaginal radical trachelectomy and pelvic lymphadenectomy in stage IB1 cervical cancer

OBJECTIVE

To present a case of successful pregnancy after undergoing vaginal radical trachelectomy (VRT) and pelvic lymph node dissection (PLND) for early-stage cervical cancer.

CASE REPORT

A 37-year-old female patient has been diagnosed with stage IB1 cervical cancer and underwent VRT and PLND. Two years after the surgery, the patient successfully conceived and delivered a healthy baby through a cesarean section.

CONCLUSION

This case report demonstrates that pregnancy after VRT and PLND for stage IB1 cervical cancer is possible and can result in a successful outcome. This report provides valuable information for patients and physicians who are considering these surgical options.

Fertility sparing treatment of vaginal clear cell adenocarcinoma in a DES-Naïve young woman

Background

Primary vaginal cancer is rare and comprises 1-2% of female genital tract cancers. Among the types of vaginal cancer, adenocarcinoma accounts for only 10% with the peak incidence in women less than 20 years old. Clear cell type vaginal adenocarcinoma is most associated with exposure to diethylstilbestrol (DES) in-utero.

Case

We present a case of an 18-year-old nulliparous woman, DES-exposure naive, who was diagnosed with stage I clear cell vaginal adenocarcinoma during a routine pelvic exam for abnormal vaginal bleeding. She underwent a fertility-preserving radical vaginectomy and pelvic lymphadenectomy with neovagina creation and uterovaginal cervical reconstruction. She has been without disease for 28 months.

Conclusion

Although rare, vaginal cancer can be diagnosed on routine women's health exams. Early screening and diagnosis allow for innovative fertility-preserving surgical approaches without compromising oncologic outcomes. To our knowledge, this is the first case of a fertility-preserving radical vaginectomy, neovagina creation using a vertical rectus abdominis myocutaneous (VRAM) flap, and uterocervicovaginal reconstruction to successfully treat early stage clear cell vaginal adenocarcinoma with surgery alone, sparing the patient from adjuvant chemotherapy or radiation.

Safety of fertility sparing management in invasive mucinous ovarian carcinoma

BACKGROUND

The aim of the study was to evaluate the safety of fertility-sparing surgery in invasive mucinous ovarian carcinomas (MOC).

METHODS

Retrospective review was performed of MOCs diagnosed between 1999 and 2019 at two tertiary cancer centers. Pathology was reviewed to rule out metastasis from gastrointestinal tract. The demographics and survival outcomes were compared between women who underwent fertility-sparing surgery and those who underwent radical surgery (at least hysterectomy, bilateral salpingo-oophorectomy +/- staging). Cox proportional hazard models were constructed to evaluate the effect of fertility sparing surgery on survival.

RESULTS

Of 134 with stage I disease, 42 (31%) underwent fertility-sparing surgery with unilateral salpingo-oophorectomy. Compared to women who underwent radical surgery, these women were younger with low grade, early-stage disease. Two patients (5%) in the fertility-sparing cohort experienced a recurrence and 1 of these 2 patients died due to disease progression. There was no difference in either OS or RFS between those that underwent fertility-sparing surgery and radical surgery. In a multivariable analysis adjusting for age and use of adjuvant chemotherapy, fertility-sparing surgery was not significantly associated with OS (HR 0.18; 95% CI 0.01-2.78) or RFS (HR 0.19; 95% CI 0.03-1.45). There were 4 patients (9%) with documented full-term delivery with median interval to conception of 11 months.

CONCLUSIONS

Fertility-sparing surgery in stage I MOC is not associated with worse outcomes compared to radical surgery and is reasonable to offer to those with early stage disease who wish to retain fertility.

Survival analysis and obstetric outcomes in patients with early stage ovarian cancer undergoing fertility-sparing surgery

OBJECTIVE

The aim of the present study is to evaluate the long-term outcomes in patients with early stage ovarian cancer undergoing fertility-sparing surgery.

METHODS

The present study performed a retrospective analysis of recurrence, pregnancy and survival of a total of 66 patients who were diagnosed with early stage ovarian cancer (stage I) in XXX Faculty of Medicine Hospital between 2004 and 2019. Of these patients, 16 had undergone fertility-sparing surgery, and the remaining 50 patients had undergone radical surgery.

RESULTS

Of 66 eligible patients, 16 had undergone fertility-sparing surgery, and the remaining 50 patients had undergone radical complete surgery. When demographic and descriptive data are taken into consideration, the mean age was 32.6 ± 6.76 years in patients undergoing fertility-sparing surgery and 54.05 ± 10.8 years in patients undergoing complete surgery, and the difference between the groups was statistically significant (p = 0.001). Of patients undergoing fertility-sparing surgery, 11 (16.7%) had stage Ia disease (most common), 5 (7.5%) had stage Ic disease, whereas no patient with stage Ib disease was detected. Of patients undergoing complete radical surgery, 32 (48.5%) had stage Ia disease (most common), 1 (1.5%) had stage Ib disease with bilateral ovarian involvement, and stage Ic was the second most common disease stage. Also, stage Ic3 was the most common disease stage (8 patients, 12.1%) among those with stage Ic disease. The rate of recurrence was 4.5% (3 patients) in patients undergoing fertility-sparing surgery, and recurrences occurred at 37 months, 69 months, and 76 months, respectively. A patient with stage Ic3 disease and endometrioid type tumor who developed recurrence at 37 months died at 130 months. Of patients undergoing complete surgery, ten patients (15.2%) developed recurrence, and there was no significant difference between the two groups in terms of recurrence (p = 1.00). At the end of 15-year follow-up period, there was no significant difference between patients undergoing fertility-preserving surgery and those undergoing complete surgery in terms of mortality (p = 0.668).

CONCLUSION

The observation of significant findings in terms of the rate of recurrence and disease-free survival following fertility-sparing surgery in patients with low-risk early stage ovarian cancer suggests that survival is positively affected in early stage ovarian cancer.

Fertility sparing treatment in patients with endometrial cancer (FERT-ENC): a multicentric retrospective study from the Spanish Investigational Network Gynecologic Oncology Group (SPAIN-GOG)

OBJECTIVE

The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment.

MATERIAL AND METHODS

This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study.

RESULTS

The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion > 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases.

CONCLUSIONS

Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.

Fertility-Sparing and Less Radical Surgery for Cervical Cancer

PURPOSE OF REVIEW

Patients with early-stage cervical cancer who desire future fertility may be candidates for less radical surgery. We review the literature supporting this approach in early-stage disease.

RECENT FINDINGS

Retrospective data have shown that in carefully selected patients, the risk of parametrial involvement is less than 1%. This has led to interest in moving away from radical surgery towards more conservative approaches. Data from the newly published ConCerv trial, a prospective study evaluating the feasibility of conservative surgery in women with early-stage, low-risk cervical carcinoma, suggest that conservative surgery is feasible and safe in this patient population. Furthermore, neoadjuvant chemotherapy is being assessed as an option to extend fertility-sparing treatment to a larger group of women. Less radical surgery may be appropriate for carefully selected women with early-stage, low-risk cervical cancer, including those desiring future fertility.

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse

STUDY OBJECTIVE

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH).

DESIGN

Stepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board-approved study.

SETTING

Academic tertiary referral center.

INTERVENTIONS

This video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture.

CONCLUSION

vNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.

Significance of serum and pathological biomarkers in fertility-sparing treatment for endometrial cancer or atypical hyperplasia: a retrospective cohort study

Background

This study analyzed the changes of serum and pathological biomarkers during fertility-sparing therapy of endometrial cancer (EC) or endometrial atypical hyperplasia (EAH), to investigate their implications for early prediction of treatment efficacy.

Methods

A retrospective analysis of EC or EAH patients who received fertility-sparing therapy between 2012 and 2016 was performed. Serum and endometrium sampling were obtained for each patient at three time points: at baseline, at 3–6 months' treatment and at the end of conservative treatment. Serum biomarkers including insulin resistance (HbA1c, HOMA-IR), sex hormones and thyroid hormones were measured. Meanwhile expression of endometrial pathological biomarkers including ER, PR, PRB and Ki-67 was also assessed by immunohistochemistry.

Results

For the 53 recruited patients, overall complete response, recurrence and pregnancy rates were 94%, 26% and 36.4%. During the treatment, the serum biomarkers of HOMA-IR remained stable, while pathological markers including PR, PRB and Ki67 diminished significantly. Patients who achieved remission faster had significant lower HOMA-IR level and higher PRB expression at baseline. We also found a more remarkable down-regulation of PRB related with faster remission. Further multivariate analysis confirmed that baseline HOMA-IR ≥ 2.5 negatively affected treatment time to remission (OR 0.206; p = 0.017). While marked reduction of PRB (≥ 30%) at 3–6 months' treatment correlated with faster remission (OR 5.788; p = 0.010).

Conclusion

For EC and EAH patients who received fertility-sparing therapy, baseline status of insulin resistance predicted poor response to progestin, while marked reduction of PRB following the initial 3–6 months' treatment predicted fast remission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01383-5.

Mismatch repair-deficiency specifically predicts recurrence of atypical endometrial hyperplasia and early endometrial carcinoma after conservative treatment: A multi-center study

OBJECTIVE

Deficient expression of mismatch repair proteins (MMR) has been suggested to be a predictor of resistance of atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EEC) to conservative treatment.

AIMS

To assess the predictive value of MMR immunohistochemistry in patients conservatively treated for AEH and EEC, and to calculate its predictive accuracy.

MATERIALS AND METHODS

All patients with AEH or EEC conservatively treated with hysteroscopic resection plus progestins in two referral centers from January 2004 to July 2019 were retrospectively assessed. Immunohistochemistry for MMR was ad hoc performed. Study outcomes were: (i) the association of a deficient immunohistochemical expression of MMR with resistance and recurrence of AEH and EEC after conservative treatment, and (ii) the accuracy of MMR immunohistochemistry in predicting the outcome of conservative treatment. Relative risk (RR) for the associations, and sensitivity, specificity and area under the curve (AUC) on receiver operating characteristic curve for the predictive accuracy were calculated.

RESULTS

Sixty-nine women, (47 AEH and 22 EEC) were included; deficient MMR expression was observed in 8.7% of cases. Resistance to conservative treatment was more common in MMR-deficient than MMR-proficient cases (33.3% vs 15.9%; RR = 2.1), but with no statistical significance (p = 0.2508). On the other hand, recurrence was significantly more common in MMR-deficient than MMR-proficient cases (100% vs 26.4%; RR = 3.8; p < 0.0001). In predicting recurrence, a deficient immunohistochemical expression of MMR showed sensitivity = 22.2%, specificity = 100%, and AUC = 0.61.

CONCLUSION

Deficient MMR immunohistochemical expression does not imply resistance of AEH/EEC to conservative treatment. On the other hand, MMR-deficiency appears as a highly specific predictor of recurrence of AEH/EEC after initial regression.

Minimally invasive radical trachelectomy: Considerations on surgical approach

Current evidence supports that radical trachelectomy is a safe and feasible alternative to patients with early-stage cervical cancer who wish to preserve fertility. In addition, published retrospective literature supports that oncologic outcomes are equivalent to those of radical hysterectomy. First published as a vaginal approach, a number of other approaches have been reported including laparotomic, laparoscopic, and robotic. In 2018, the first ever prospective randomized trial (LACC) comparing open vs. minimally invasive radical hysterectomy showed worse disease-free and overall survival for the minimally invasive (both laparoscopic and robotic) approach than the open approach. This landmark publication raised concerns regarding the oncologic safety of minimally invasive radical trachelectomy. In the United States, minimally invasive became the dominant approach by 2011 for radical trachelectomy. Given that radical trachelectomy is an infrequent performed procedure, only small retrospective studies, systematic reviews, and large database studies have been published. These studies are limited by their retrospective nature, small sample size, patient selection bias, unbalanced groups, and sequential surgical approach comparisons. However, the available evidence thus far shows that oncologic outcomes for both open and minimally invasive radical trachelectomy are equivalent. Given the rarity of the procedure and the low recurrence and death rates of patients with early-stage cervical cancer undergoing radical trachelectomy, a prospective randomized trial seems unlikely. A multi-institutional international registry study (International Radical Trachelectomy Assessment - IRTA - study) has been recently completed evaluating open vs. minimally invasive radical trachelectomy. There are three ongoing prospective studies evaluating the possibility of less radical surgery in a low-risk early-stage cervical cancer population, ConCerv, SHAPE, and GOG 278. We look forward to the final results of these studies that will hopefully shed light on the optimal treatment option for patients with early-stage cervical cancer wishing to preserve fertility. This article will review the most impacting publications comparing open vs. minimally invasive radical trachelectomy and analyze the limitations of the current available literature.

Fertility-sparing surgeries without adjuvant therapy through term pregnancies in a patient with low-grade endometrial stromal sarcoma: A case report

BACKGROUND

Low-grade endometrial stromal sarcoma (LGESS) is a rare indolent tumor with a favorable prognosis. With the importance of improving quality of life recognized, fertility-sparing surgery may be an option for those young women. However, most of the reports suggested that stage IA patients might be candidates for fertility-sparing surgery, and adjuvant hormonal treatment was considered a feasible adjuvant therapy for reducing the recurrence risk of patients with LGESS and hysterectomy was recommended after the completion of pregnancy and delivery.

CASE SUMMARY

A 28-year-old pregnant woman diagnosed with stage IB LGESS was treated by fertility-sparing surgery when term cesarean section delivery was performed. Without any adjuvant treatment, she had the other successful term pregnancy and cesarean section 45 mo after first fertility-sparing surgery. Moreover, only hysteroscopic resection was performed to retain fertility again even when the tumor recurred after 6 years. So far the patient’s fertility and disease-free status have remained for more than 8 years without any adjuvant therapy despite local resection of the sarcoma. And the two babies were in good health.

CONCLUSION

For young patients with stage I LGESS, it seems that repeated fertility-sparing surgeries could be performed even after two term deliveries and the tumor recurrence, and it might be attempted without adjuvant therapy but the counseling should be considered as mandatory.

Continued medical treatment for persistent early endometrial cancer in young women

OBJECTIVE

We aimed to investigate the effectiveness of continuing medical therapy in patients who did not achieve complete response (CR) despite 9 months of progestin treatment. We also sought to determine the prognostic factors associated with achieving CR among these patients.

METHODS

We retrospectively analyzed 51 patients with presumed stage IA, grade 1 or 2 endometrioid adenocarcinoma who had persistent disease on biopsy performed at 9-12 months after at least 9 months of progestin-based therapy. Data on clinicopathological factors and oncological and obstetrical outcomes following continuous hormonal treatment were extracted from the patients' medical records and analyzed. Univariate and multivariate analyses for predicting CR were performed.

RESULTS

Thirty-seven (72.5%) of 51 patients achieved CR after prolonged fertility-sparing treatment. Median time to CR from starting initial progestin was 17.3 months (range, 12.1-91.7 months). On univariate analysis, history of polycystic ovarian syndrome, histologic grade 2, and not achieving partial response (PR) until 12 months were significantly associated with failure to CR (odds ratio [OR], 6.188, 95% confidence interval [CI], 1.405-27.244, p = 0.018; OR, 9.722, 95% CI, 1.614-58.581, p = 0.013; and OR, 21.750, 95% CI, 4.016-117.783, p < 0.001, respectively). Multivariate analysis revealed that not achieving PR until 12 months was an independent prognostic factor predicting failure to CR after prolonged progestin therapy (OR, 21.803, 95% CI, 3.601-132.025, p = 0.001).

CONCLUSIONS

Continued medical treatment is effective for persistent early endometrial carcinoma after at least 9 months of progestin therapy in young women who want to preserve their fertility.

Predictive Accuracy of Progesterone Receptor B in Young Women with Atypical Endometrial Hyperplasia and Early Endometrial Cancer Treated with Hysteroscopic Resection plus LNG-IUD Insertion

STUDY OBJECTIVE

The immunohistochemical expression of isoform B of the progesterone receptor (PRB) has shown promising results in predicting the response of atypical endometrial hyperplasia (AEH) and early endometrial cancer (EEC) to conservative treatment. We aimed to calculate the accuracy of PRB as a predictive marker of conservative treatment outcome in AEH or EEC.

DESIGN

Retrospective cohort study.

SETTING

University of Naples Federico II, Naples, Italy.

PATIENTS

Thirty-six consecutive premenopausal women <45 years of age with AEH (n = 29) or EEC (n = 7) conservatively treated from January 2007 to June 2018 were retrospectively assessed.

INTERVENTIONS

All patients had been treated with hysteroscopic resection plus levonorgestrel-releasing intrauterine device insertion and followed for at least 1 year. The immunohistochemical expression of PRB was separately assessed in the glands and stroma of the lesion and dichotomized as "weak" or "normal."

MEASUREMENT AND MAIN RESULTS

The treatment outcomes considered were (1) treatment failure (i.e., a combined outcome including no regression or recurrence); (2) no regression; and (3) recurrence. The predictive accuracy of PRB immunohistochemistry was assessed by calculating sensitivity (SE), specificity (SP), and area under the receiver operating characteristic curve (AUC). A weak glandular PRB expression showed SE = 70%, SP = 77%, and AUC = 0.74 for treatment failure; SE = 66.7%, SP = 70%, and AUC = 0.68 for no regression; and SE = 75%, SP = 68.8%, and AUC = 0.72 for recurrence. A weak stromal PRB expression showed SE = 100%, SP = 53.8%, and AUC = 0.77 for treatment failure; SE = 100%, SP = 46.7%, and AUC = 0.73 for no regression; and SE = 100%, SP = 43.8%, and AUC = 0.72 for recurrence.

CONCLUSION

A weak stromal PRB expression is a highly sensitive predictive marker of both no response and recurrence of AEH and EEC conservatively treated.

Simple conization and pelvic lymphadenectomy in early-stage cervical cancer: A retrospective analysis and review of the literature

OBJECTIVES

To evaluate the feasibility of cervical conization and laparoscopic pelvic lymphadenectomy as a fertility-sparing surgery to treat early-stage cervical cancer.

METHODS

We conducted a retrospective analysis from a prospectively maintained database of patients with stage IA1-IB1 grossly invisible cervical cancers undergoing conization plus laparoscopic lymphadenectomy between January 2014 and July 2019.

RESULTS

Forty patients were identified. Five patients (12.5%) had stage IA1 with lymphovascular space invasion, 21 (52.5%) had stage IA2, and 14 (35.0%) had stage IB1. All of the patients had tumors <2 cm. Histology included 35 (87.5%) squamous-cell carcinomas, three (7.5%) adenocarcinomas, and two (5.0%) adenosquamous carcinomas. Median duration of the procedure was 105 min (range, 31-219), and the median estimated blood loss was 50 ml (range, 30-200). One patient received abdominal radical trachelectomy due to the presence of positive margin after conization. Three patients developed postoperative cervical stenosis. After a median follow-up of 35 months (range, 8-74), only one patient (2.5%) developed a recurrence in the remaining cervix, and no patients died. Four of 17 patients attempting to conceive had a spontaneous pregnancy: three delivered at term and one was currently pregnant.

CONCLUSION

Cervical conization and pelvic lymphadenectomy seems to be an acceptable treatment for well-selected patients with low-risk, early-stage cervical cancer who wish to preserve fertility. It offers excellent oncologic outcomes, low perioperative morbidities, and good reproductive results. Further large prospective studies are warranted to prove the effectiveness of this surgery.

Cryoablation used in fertility-sparing treatment for early endometrial cancer: A pig model experiment using a new designed balloon cryoprobe

Young patients with early endometrial cancer have a strong desire to retain reproductive function, which require us to develop a therapeutic method that can not only assure the complete resection of tumor but also retain the uterine integrity. In the present study, we proposed a fertility-sparing surgery option that combined hysteroscopic resection with cryoablation to achieve this goal. To verify the safety and effectiveness of cryoablation for local uterine wall, we designed the experiment in pig model using a novel cryoablation balloon probe. In the process of freezing and thawing, the temperature of different parts of the uterus was measured in real time. The uterus was harvested immediately, three weeks after cryotherapy for histological evaluation. The results demonstrated cryoablation using the new cryoprobe is safe and effective. The effective freezing range can cover a range of 2 cm in diameter at least. This study provided us evidence before cryoablation could be applied in clinical practice of fertility-sparing treatment for young women with early endometrial cancer.

Management of acute haemorrhage following chemotherapy for invasive molar pregnancy by embolization and conservative fertility-sparing surgery

•

Surgery for perforating invasive molar pregnancy usually results in hysterectomy.

•

Uterine artery embolization and conservative uterine surgery should be an option.

•

Successful term pregnancy outcome is possible after fertility preserving surgery.

Management of perforated invasive molar pregnancy, especially, in those women desirous of future fertility can be difficult. We report one of the very few instances, to our knowledge, where a combination of preoperative uterine artery embolization and conservative surgical techniques was used. This was successful in terms of minimising intraoperative blood loss and long term in attaining control of disease when combined with multiagent chemotherapy. Subsequent term pregnancy was achieved with no maternal of fetal complications.

Endometrial carcinoma in a 14-year-old: A case report

•

We present a case of endometrial carcinoma (EC) in a 14-year-old girl with no risk factors for EC.

•

The patient received MPA therapy and endometrial curettage.

•

At 47 weeks after her last MPA treatment, she has had no recurrence.

•

EC should be considered in diagnosing juveniles with sustained abnormal uterine bleeding, even those without risk factors.

Oncological and obstetric outcomes after fertility-sparing radical abdominal trachelectomy for early stage cervical cancer: a tertiary centre's 10 years' experience

The aim of this study is to present our clinical experience about fertility-sparing procedures in early stage cervical cancer and its obstetrical and oncological outcomes. Between the years 2006 and 2016, a total of 22 early stage cervical cancer patients who underwent a fertility-sparing radical abdominal trachelectomy in our clinic were retrospectively analysed. The median age was 33 (range: 28-39) years. The median follow-up was 47 (range: 22-125) months. Five patients (22.7%) had Stage IA1, three patients had (13.6%) Stage IA2, and 14 patients (63.6%) had Stage IB1 disease. Only one patient had a recurrence. A pregnancy was obtained in five patients (22.7%) and one of them (20%) had a live birth. A pregnancy was obtained spontaneously in two patients (40%), whereas assisted reproductive techniques were used in three of the patients (60%). A miscarriage occurred in two patients (40%), and one of them was within the first trimester and the other was within the second trimester. Impact statement What is already known on the subject? Currently, the first-line treatment of early stage cervical cancer is surgery. However, a fertility-sparing trachelectomy is the most widely adopted approach in the reproductive aged patients who have a desire to be pregnant later. What does this study add? In the literature, there is a growing number of studies on this subject. However, it would take time to obtain adequate knowledge. We believe that our study would contribute to the existing data. What are the implication of these findings for clinical practice? This study is important as it indicates that a multidisciplinary approach is required to preserve fertility among gynaecologic oncologists and the outcomes would be reflected into the clinical practice. In addition, we believe that our study would pave the way for further studies regarding this subject among oncologists.

Case report: term birth after fertility-sparing treatments for stage IB1 small cell neuroendocrine carcinoma of the cervix

Background

Advances in cervical cancer management for childbearing women have led to less radical approaches. Use of fertility-sparing treatment to treat small cell neuroendocrine carcinoma (SCNEC) is challenging owing to the aggressive nature of the disease, even in early stage disease.

Case presentation

A 25-year-old nulligravida woman presented with malodorous vaginal discharge and was diagnosed to have an exophytic cervical SCNEC. A magnetic resonance image scan showed no evidence of parametrial invasion or distant metastasis. Clinical staging allocated her to stage IB1 disease. She underwent radical abdominal trachelectomy for reproductive purpose. Preoperative and postoperative chemotherapy with ifosfamide/etoposide/cisplatin combining gonadotropin-releasing hormone agonist were administered. She had a spontaneous, uneventful pregnancy and successfully delivered a term baby via cesarean section 7 years after treatment.

Conclusion

To our knowledge, we describe the first success in offering a fertility-preserving multimodality strategy to present favorable oncologic, reproductive, and obstetric outcomes in a fertile woman of stage I SCNEC. Individualized multimodality therapy may be utilized in specific patients with early-stage cervical cancer to preserve their fertility.

Significance of body weight change during fertility-sparing progestin therapy in young women with early endometrial cancer

OBJECTIVE

To evaluate the influence of body weight change during fertility-sparing progestin therapy on oncologic and reproductive outcomes in young women with early-stage endometrial cancer who did not complete child bearing.

METHODS

This multicenter, retrospective study included 154 young patients with well-differentiated, endometrium-confined endometrioid endometrial adenocarcinoma on magnetic resonance imaging who received fertility-sparing progestin therapy.

RESULTS

The mean body weight and body mass index (BMI) at baseline and progestin therapy completion was 65.3±16.2 and 66.5±15.9kg (P=0.044), respectively, and 25.51±5.99 and 25.99±5.94kg/m² (P=0.034), respectively. During progestin therapy, 51 (33.1%), 29 (18.8%), and 74 patients (48.1%) had weight loss, no weight change, and weight gain, respectively, of which 11 (7.1%) had 10% weight loss and 30 (19.5%) had 10% weight gain. A pretreatment BMI of ≥25kg/m² was significantly associated with a lower complete response rate to progestin therapy (P=0.003) and a high recurrence rate (P=0.033). A posttreatment BMI of ≥25kg/m² was also a significant factor for high recurrence rate (P=0.049). However, weight change during therapy was not significantly associated with complete response or recurrence rate. Pre and posttreatment BMIs and weight change were not associated with pregnancy and live birth rates.

CONCLUSION

Weight change during progestin therapy has little influence on complete response, recurrence, pregnancy, and live birth rates. However, pre and posttreatment BMIs of ≥25kg/m² were significant predictors for poor treatment response and high recurrence. Therefore, it is important to maintain patients' normal BMIs during progestin therapy.

Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease.

FINDINGS

Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation.

CONCLUSION

Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

Utility of indocyanine green (ICG) intra-operative angiography to determine uterine vascular perfusion at the time of radical trachelectomy

OBJECTIVES

The aim of our study was to measure and analyze uterine perfusion utilizing laser angiography with ICG during uterine artery sparing and non-sparing radical trachelectomy.

METHODS

Data were collected from all patients diagnosed with early-stage cervical cancer that underwent laser angiography with ICG during open or laparoscopic radical trachelectomy from June 2012 to December 2015. Regression analysis was use to determine the p values and R-squares on fluorescence, surgical time, hospital stay, age and BMI; a p-value<0.05 was considered statistically significant.

RESULTS

A total of 20 patients met the inclusion criteria and were included in this study. Ten patients underwent uterine artery-sparing surgery, and ten patients underwent uterine artery non-sparing surgery. The most frequent stage for the entire cohort was IA2 (55%), and the most common histologic subtype was squamous cell carcinoma (49%). Lymph-vascular invasion was noted in 30% of the patients. There was no statistical significance difference in the mean ICG fundal fluorescence intensity between the uterine artery-sparing group 162.5 (range, 137-188) and the uterine artery non-sparing group 160.5 (range, 135-186), p=0.22. In both groups, 100% of the patients regained their menstrual function by postoperative week 8. A total of 4 (40%) pregnancies have occurred in the uterine artery-sparing group and 3 (30%) in the non-uterine artery-sparing group.

CONCLUSIONS

Based on our real-time intraoperative angiography observations, there is no need to preserve the uterine artery during radical trachelectomy to maintain uterine viability.

Hysteroscopic Methotrexate Injection Under Ultrasonographic Guidance for Interstitial Pregnancy

A 36-year-old woman presented with pelvic pain and vaginal blood loss and interstitial pregnancy (a single gestational sac located in the proximity of the right uterine horn, without visualization of an embryo and/or attachments inside) on 2- and 3-dimensional ultrasonographic examination. The patient was clinically stable. Her abdomen was soft with normal peristalsis; superficial and deep palpation were painless, as was decompression. With the patient under general anesthesia, an operative hysteroscopy was performed visually via ultrasound. A slow injection of methotrexate solution was pushed through the right cornual region inside the gestational sac and into the myometrial tissue tangentially at the 4 cardinal points. Twelve weeks later, the patient exhibited normal tubal patency via sonohysterography, as well as a viable pregnancy of 7 weeks' gestation. This minimally invasive approach is well tolerated and shows promise for the management of interstitial pregnancy, with no adverse effect on potential subsequent fertility.

Breast cancer in the setting of fertility-sparing treatment for endometrial cancer

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Progesterone therapy is a commonly used alternative to surgical management for women with endometrial cancer who desire fertility preservation.

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Prior research suggests that progestins may contribute to breast tumorigenesis.

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We report a patient diagnosed with progesterone receptor positive breast cancer during hormonal treatment of endometrial cancer.

Long-term safety of fertility sparing surgery in early stage ovarian cancer: comparison to standard radical surgical procedures

OBJECTIVE

Fertility-sparing surgery (FSS) is a strategy often considered in young patients with low-grade (G1-2) early-stage epithelial ovarian cancer (eEOC), while is still controversial in high-risk patients. We investigated the role of FSS in low and high-risk eEOC patients undergoing comprehensive surgical staging.

METHODS

We analyzed data from patients operated for an eEOC from 1975 to 2011, focusing on patients submitted to FSS. Seventy patients out of 307 with eEOC were identified. Patients underwent FSS were compared with 237 patients underwent radical-comprehensive-staging (RCS) in the same period. Disease free (DFS) and overall (OS) survivals were evaluated using Kaplan-Meier and Cox models.

RESULTS

Overall, 307 patients had surgery for eEOC: 70 (22.8%) and 237 (77.2%) women had FSS and RCS, respectively. At univariate analysis, the execution of FSS not influenced DFS (HR:1.06 (95%CI: 0.56,2.02); p=0.84) and OS (HR:1.94 (95%CI: 0.75,4.98); p=0.16). Stage of disease was the only factor correlating with DFS (HR:4.73; 95%CI: 2.01,11.11; p<0.001). Independently, increased age (HR per 1-unit of age:1.06 (95%CI: 1.03,1.11); p<0.001) and high risk disease (HR:3.26; 95%CI: 1.23,8.62; p=0.01) remained associated with worse OS. Focusing on the high risk group (stage IAG3 or more) we observed that type of surgery (FSS v. RCS) did not influence DFS (p=0.77, log-rank test) and OS (p=0.08, log-rank test).

CONCLUSIONS

FSS upholds oncologic effectiveness of RCS, preserving reproductive and endocrine functions. FSS does not increase risk of recurrence among high risk eEOC patients. Further prospective studies on this issue are warranted to improve patients' care.

Progestins in the fertility-sparing treatment and retreatment of patients with primary and recurrent endometrial cancer

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.

Laparoscopic fertility-sparing surgery for early stage ovarian cancer: a single-centre case series and systematic literature review

Background

There is as yet limited evidence about fertility-sparing surgery for early ovarian cancer (EOC) carried out laparoscopically. We sought to analyze recurrence patterns and fertility outcome in a cohort of ovarian cancer patients who underwent fertility-saving laparoscopic surgical staging.

Methods

We conducted a retrospective analysis of prospectively collected data on all patients undergoing fertility-sparing laparoscopic staging procedures for presumed EOC at a single gynecologic oncology service. Oncologic safety and reproductive outcome were the main outcome measures. The pertinent literature is reviewed.

Results

The study cohort consisted of 12 women. Cases included 5 invasive epithelial tumors and 7 nonepithelial tumors. The disease was reclassified to a higher stage in one woman. After a median follow up period of 38 months (range: 14–108), the overall survival was 100% and recurrence-free survival 90.9%. Five (100%) of patients who attempted pregnancy conceived spontaneously. Three of them had uneventful term pregnancy delivering healthy babies. The literature search yielded 62 cases of laparoscopic fertility conserving surgery for ovarian cancer. There were 4 (6.2%) recurrences. Cumulative pregnancy and live birth rate were not estimable as earlier publications lack essential data.

Conclusions

Laparoscopic staging may represent a viable option for premenopausal women seeking fertility preservation in the setting of early ovarian cancer. More research is needed to determine whether laparoscopy may offer reproductive benefits to this particular population.

Preoperative imaging in patients undergoing trachelectomy for cervical cancer: validation of a combined T2- and diffusion-weighted endovaginal MRI technique at 3.0 T

AIM

The aim of this study is to validate high-resolution endovaginal T2- and diffusion-weighted MRI measurements (tumour size, volume and length of uninvolved cervical canal) against histology in patients undergoing trachelectomy.

PATIENTS/INTERVENTIONS

55 consecutive patients 25-44 years with cervical cancer being considered for trachelectomy were prospectively assessed with endovaginal T2-W and diffusion-weighted MRI. Two independent observers blinded to histology recorded maximum tumour dimension, volume and distance from the superior aspect of the tumour to the internal os. Following trachelectomy, pathologist-outlined tumour sections were photographed with a set scale and similar measurements were recorded.

RESULTS

Fifteen of 45 patients subsequently treated with fertility-sparing surgery had residual tumour (median histological volume: 0.28 cm(3), IQR=0.14-1.06 cm(3)). Sensitivity, specificity, positive and negative predictive values for detecting tumour: Observer 1: 86.7%, 80.0%, 68.4%, and 92.3%, respectively; Observer 2: 86.7%, 90.0%, 81.0%, and 93.1%, respectively. Size and volume correlated between observers (r=0.96, 0.84, respectively, p<0.0001). Size correlated between each observer and histology (observer 1 r=0.91, p<0.0001; observer 2 r=0.93, p<0.0001), volume did not (observer 1: r=0.08, p=0.6; observer 2: r=0.21, p=0.16); however, differences between observer measurements and histology were not significant (size p=0.09, volume p=0.15). Differences between MRI and histology estimates of endocervical canal length were not significant (p=0.1 both observers).

CONCLUSION

In subcentimetre cervical cancers, endovaginal MRI correlates with pathology and is invaluable in assessing patients for fertility-sparing surgery.