A systematic review and meta‐analysis of prognostic factors for remission in fertility‐sparing management of endometrial atypical hyperplasia and adenocarcinoma

Abstract

Background: Endometrial cancer and atypical hyperplasia are rare in young women but create a dilemma between desire for pregnancy and oncologic outcomes.Objective: To identify remission rates and associated prognostic factors in patients undergoing fertility-sparing management for endometrial cancer and atypical hyperplasia. Search strategy: MEDLINE was searched for studies published between January 1, 1950 and July 31, 2017 using various search terms. Selection criteria: Studies evaluating fertility-sparing management in patients aged between 19 and 44 years with atypical hyperplasia or stage I endometrial cancer. Data collection and analysis: Use of PRISMA guidelines to conduct a meta-analysis of the proportion of patients in remission and meta-regression analysis to test the effect of possible prognostic factors for remission.Main results: A total of 3673 studies were screened; 65 studies including 1604 patients met the inclusion criteria. The remission rate was 0.75 (95% CI, 0.73-0.77).Operative hysteroscopy for endometrial sampling was associated with higher remission rates (OR 2.31; 95% CI, 1.10-4.84; P=0.03). Studies with higher ratios of infertile women were associated with higher remission rates (OR 4.21; 95% CI, 1.44-12.33; P<0.01). Conclusion:Operative hysteroscopy is the preferred endometrial sampling method for patients with atypical hyperplasia or endometrial cancer undergoing fertilitysparing management.

Management of Recurrent Endometrial Cancer or Atypical Endometrial Hyperplasia Patients After Primary Fertility-Sparing Therapy

“…Of 80 patients who received repeated conservative treatment after relapse, 71 (88.6%) patients achieved CR with the 6 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) months' median CR time. Seven (8.8%) patients failed to achieve CR, one PR, four SD, and two PD and then underwent hysterectomy with or without lymphadenectomy (Figure 1).…”

“…Endometrial cancer (EC) is one of the most common gynecologic cancer whose incidence is increasing rapidly in recent years (1). Conservative management for EC or atypical endometrial hyperplasia (AEH) patients who wish to preserve their fertility has been applied and showed encouraging treatment and reproductive outcomes (2)(3)(4). However, a significant portion of patients experience recurrence after achieving complete remission (CR) (5)(6)(7).…”

Gonadotropin-Releasing Hormone Agonist Based Fertility-Sparing Treatment in Women with Endometrial Carcinoma or Atypical Endometrial Hyperplasia

“…With increasing incidence of EC in younger women, increasingly women are likely to seek conservative management options. Progestin therapy is widely accepted as the main fertility-sparing treatment for young women with AEH and well-differentiated EC and acquire satisfactory results (5)(6)(7) . However, there are still about 20% of these patients who failed to achieve CR, and lost fertility after hysterectomy (11) .…”

“…High-dose progestins including medroxyprogesterone acetate (MPA) and megestrol acetate (MA) have been the mainstay of conservative treatment of AEH and early-stage EC (5)(6)(7) . But adverse effects such as weight gain, liver dysfunction and resistance to oral progestins lead to seeking alternative treatments is mandatory.…”

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

“…In fact, the low number of patients included led to a broad 95% CI for our results, requiring a confirmation on larger cohorts. However, given the intention to assess a homogenous study population and the rarity of the condition (only 20%−25% of endometrial cancer and AEH occur in premenopausal women, and only 3%−5% of the women with endometrial cancer are of reproductive age [25]), it seems difficult to perform a prospective study on a greater study population.…”