Conservative Surgery in Endometrial Cancer

Abstract

Endometrial cancer (EC) is the sixth most common female cancer worldwide. The median age of diagnosis is 65 years. However, 4% of women diagnosed with EC are younger than 40 years old, and 70% of these women are nulliparous. These data highlight the importance of preserving fertility in these patients, at a time when the average age of the first pregnancy is significantly delayed and is now firmly established at over 30 years of age. National Comprehensive Cancer Network (NCCN guidelines state that the primary treatment of endometrial endometrioid carcinoma, limited to the uterus, is a total hysterectomy, bilateral salpingo-oophorectomy and surgical staging. Fertility-sparing treatment is not the standard of care, and patients eligible for this treatment always have to undergo strict counselling. Nowadays, a combined approach consisting of hysteroscopic resection, followed by oral or intrauterine-released progestins, has been reported to be an effective fertility-sparing option. Hysteroscopic resection followed by progestins achieved a complete response rate of 95.3% with a recurrence rate of 14.1%. The pregnancy rate in women undergoing fertility-sparing treatment is 47.8%, but rises to 93.3% when only considering women who tried to conceive during the study period. The aim of the present review is to provide a literature overview reflecting the current state of fertility-sparing options for the management of EC, specific criteria for considering such options, their limits, the implications for reproductive outcomes and the latest research trends in this direction.

Fertility-sparing treatment for endometrial cancer and atypical endometrial hyperplasia in patients with Lynch Syndrome: Molecular diagnosis after immunohistochemistry of MMR proteins

“…Furthermore, MMR status is starting to acquire prognostic value, as studies are beginning to demonstrate differences in characteristics and outcomes between MMR-proficient and MMR-deficient EC ( 35 ). In presence of young women with Stage IA G1 EEC or AEH, strongly persuaded to preserve their fertility and candidates for conservative treatment ( 36 – 38 ), identifying MMR-deficient patients and, possibly, patients with LS could also be essential in guiding adequate counseling: indeed, our data show how these patients tend to have a worse outcome than MMR-proficient patients ( 39 , 40 ). In detail, all patients with confirmed LS responded to conservative treatment in our series.…”

Comparison of prognosis of patients with endometrial cancer after hysteroscopy versus dilatation and curettage: A multicenter retrospective study

“…Peritoneal dissemination is most likely to be influenced by HSC ( 7 , 8 , 15 , 19 ). However, in our study, there was no significant difference between the two groups.…”

“…Recently, hysteroscopy is considered to be a standard procedure for diagnosing endometrial cancer ( 4 , 6 – 8 ). Especially, for young women who wants to preserve fertility, hysteroscopy can preserve the integrity of the endometrium to the greatest extent, offering the possibility of fertility for patients with early stage endometrial cancer and reducing the incidence of adverse pregnancies and deliveries ( 9 , 10 ) and for postmenopausal women, the hysteroscopic visual appearance could detect morphological differences in endometrial cancer ( 11 , 12 ).…”

Oncological outcomes in fertility-sparing treatment in stage IA-G2 endometrial cancer

“…Although there is no standardization of the best imaging method to evaluate myometrial infiltration, enhanced MRI proved to be the most accurate technique to diagnose myometrial invasion (37), but TVS is also an appropriate method compared to MRI (37). In addition, pelvic MRI assesses endometrium-limited disease, myometrial invasion, and local dissemination, showing more validity compared to ultrasound (US) in detecting lymph node infiltration and metastases (38,39). In case of persistence or recurrence of disease, the standard of care consists of total abdominal hysterectomy and bilateral salpingo-oophorectomy.…”

“…Clinical evidence has noticed from 70% to 85% of complete responses after second-round therapy prolongation up to 12 months. However, those conservative measures must be considered temporary to allow pregnancy and subsequently perform specific counseling to adopt surgery (39)(40)(41)(42)(43)(44)(45)(46) (53). Although myometrial infiltration has often been considered an exclusion criterion for conservative techniques, recent findings suggest that women with minimally infiltrating G1 EC could be administered with FST (54).…”