The Perspectives of Fertility Preservation in Women with Endometrial Cancer

Abstract

Endometrial cancer is the most common gynecological cancer in developed countries. The disease is diagnosed with increasing frequency in younger women, commonly also in their reproductive age. The standard treatment of endometrial cancer is surgical in the form of hysterectomy and bilateral salpingo-oophorectomy, and this precludes future fertility in younger women. The current challenge is to identify the group of women with endometrial cancer and low-risk features that would benefit from more conservative treatment options. More focus in management needs to be aimed towards the preservation of quality of life, without jeopardizing oncological outcomes. In this review, we analyze the current approaches to identification of women for conservative management and evaluate the success of different medical options for treatment and surgical techniques that are fertility sparing. We also elaborate on the future perspectives, focusing on the incorporation of molecular characterization of endometrial cancer to fertility preservation algorithms. Future studies should focus specifically on identifying reliable clinical and molecular predictive markers in this group of young women. With improved knowledge and better risk assessment, the precision medicine is the path towards improved understanding of the disease and possibly widening the group of women that could benefit from treatment methods preserving their fertility.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma,

“…Synchronous or metastatic ovarian cancer occurs in 5–29% of patients with endometrial carcinoma, and younger women <45 years of age are five times more likely to have synchronous ovarian cancer than women aged >45 years ( Obermair et al , 2020 ). However, in women with low-risk disease (no myometrial invasion, Grade 1 endometrioid histology, normal looking ovaries) no cases of ovarian cancer were detected ( Knez et al , 2021 ). Adnexal involvement can be identified using pelvic MRI or transvaginal US ( Guillon et al , 2019 ; Obermair et al , 2020 ).…”

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

“…With an increasing incidence of EC in younger women, increasingly more women are likely to seek conservative management options to preserve their uterus. Fertility-sparing management is well known and has been used for young women with EC and AEH who wish to preserve their fertility (12). Previous studies revealed a high remission rate of conservative treatment, as well as an association with a high rate of relapse, ranging from 10% to 88%, which is the most problematic feature of this therapy (13)(14)(15)(16)(17)(18).…”

“…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).…”

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

“…Side-effects or contraindications of progestins, such as weight gain or liver dysfunction call for alternative regimes other than oral high dose progestins. (12) .…”