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Tao M, Wu T, Zhou X, Du X, Ling K, Liang Z. Comparative effects of different treatments based on the levonorgestrel intrauterine system in endometrial carcinoma and endometrial hyperplasia patients: a network meta-analysis. Arch Gynecol Obstet 2024:10.1007/s00404-024-07608-w. [PMID: 38980346 DOI: 10.1007/s00404-024-07608-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 06/18/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE Levonorgestrel intrauterine system (LNG-IUS) has been widely used in patients with endometrial carcinoma (EC), endometrial hyperplasia without atypical (EH), and atypical endometrial hyperplasia (AEH). The purpose of our Network meta-analysis (NMA) is to evaluate the efficacy of the treatments based on the LNG-IUS in patients with EC and EH with or without atypical. METHODS We examined PubMed, EMBASE, Web of Science and the Cochrane Library up to 22 April 2024 to determine studies reporting treatment outcomes in EC and EH patients receiving LNG-IUS therapy, LNG-IUS + metformin (MET), oral progestins (OP), etc. We used EndNote 9 to select studies, Jadad scale and NOS scale to assess quality, stata(16.0) and R (4.3.1) to analysis the data. RESULTS Overall, 28 studies involving 3752 patients were included in our NMA. As for EH patients, LNG-IUS (RR 1.21; 95% CrI [1.11, 1.34]) and LNG-IUS + MET (RR 323.57; 95% CrI [1.61, 214,223,188.1])] significantly increased CR rate in comparison with OP. Based on SUCRA, LNG-IUS + OP was the best treatment to improve CR(SUCRA = 67.2%) in patients with EC, whereas LNG-IUS + MET was superior in increasing CR (SUCRA = 99.8%) than any other treatments for EH patients. Besides, the ranking based on SUCRA illustrated that LNG-IUS alone was the best choice to raise CR rates (SUCRA = 76.7%) for AEH patients. In head-to-head meta-analysis, OP has a higher progression rate (RR 4, 95% CI 1.89-8.46, p = 0.062; I2 = 71.3%), a higher nausea rate (RR 1.93, 95% CI 1.24-3.01, p = 0.187; I2 = 40.4%) than LNG-IUS in patients with EH. In contrast, LNG-IUS had a irregular vaginal bleeding rates (RR 0.76, 95% CI 0.64-0.90, p = 0.034; I2 = 77.7%) than OP in EH patients. In addition, as for AEH patients, OP has a higher persistence rate (RR 4.31, 95% CI 1.43-13.00, p = 0.93; I2 = 0.0%) than LNG-IUS. CONCLUSION According to the NMA, LNG-IUS related studies are feasible for conservative therapy in patients with EC and EH with or without atypical. Therefore, concerning the curative effect, we recommend LNG-IUS-based treatments as the best conservative therapy for EC and EH patients. However, future studies require large sample sizes and more outcomes to further evaluate the differences of treatment selections based on LNG-IUS.
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Affiliation(s)
- Muheng Tao
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Tingting Wu
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xin Zhou
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiurong Du
- Affiliated Rehabilitation Hospital of Chongqing Medical University, Chongqing, China
| | - Kaijian Ling
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zhiqing Liang
- Department of Gynecology and Obstetrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Vasileva R, Wohrer H, Gaultier V, Bucau M, Courcier H, Ben Miled S, Gonthier C, Koskas M. Pregnancy and obstetric outcomes after fertility-sparing management of endometrial cancer and atypical hyperplasia: a multicentre cohort study. Hum Reprod 2024; 39:1231-1238. [PMID: 38719783 DOI: 10.1093/humrep/deae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/08/2024] [Indexed: 06/04/2024] Open
Abstract
STUDY QUESTION What are the pregnancy and obstetric outcomes in women with atypical hyperplasia (AH) or early-stage endometrial cancer (EC) managed conservatively for fertility preservation? SUMMARY ANSWER The study found a live birth rate of 62% in patients with AH or EC after conservative treatment, with higher level of labour induction, caesarean section, and post-partum haemorrhage. WHAT IS KNOWN ALREADY Fertility-sparing treatment is a viable option for women with AH or EC during childbearing years, but the outcomes of such treatments, especially regarding pregnancy and obstetrics, need further exploration. STUDY DESIGN, SIZE, DURATION This retrospective cohort study analysed data from January 2010 to October 2022, involving 269 patients from the French national register of patients with fertility-sparing management of AH/EC. PARTICIPANTS/MATERIALS, SETTING, METHODS Women above 18 years of age, previously diagnosed with AH/EC, and approved for fertility preservation were included. Patients were excluded if they were registered before 2010, if their treatment began <6 months before the study, or if no medical record on the pregnancy was available. MAIN RESULTS AND THE ROLE OF CHANCE In total, 95 pregnancies in 67 women were observed. Pregnancy was achieved using ART in 63 cases (66%) and the live birth rate was 62%, with early and late pregnancy loss at 26% and 5%, respectively. In the 59 cases resulting in a live birth, a full-term delivery occurred in 90% of cases; 36% of cases required labour induction and 39% of cases required a caesarean section. The most common maternal complications included gestational diabetes (17%) and post-partum haemorrhaging (20%). The average (±SD) birthweight was 3110 ± 736 g; there were no significant foetal malformations in the sample. No significant difference was found in pregnancy or obstetric outcomes between ART-obtained and spontaneous pregnancies. However, the incidence of induction of labour, caesarean section, and post-partum haemorrhage appears higher than in the general population. LIMITATIONS, REASONS FOR CAUTION The retrospective nature of the study may introduce bias, and the sample size might be insufficient for assessing rare obstetric complications. WIDER IMPLICATIONS OF THE FINDINGS This study offers valuable insights for healthcare providers to guide patients who received fertility-sparing treatments for AH/EC. These pregnancies can be successful and with an acceptable live birth rate, but they seem to be managed with caution, leading to possible tendency for more caesarean sections and labour inductions. No increase in adverse obstetric outcomes was observed, with the exception of suspicion of a higher risk of post-partum haemorrhaging, to be confirmed. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for this study. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Radostina Vasileva
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
- Faculty of Medicine, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Henri Wohrer
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Victor Gaultier
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Margot Bucau
- Department of Anatomic Pathology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Hélène Courcier
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Selima Ben Miled
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Clementine Gonthier
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Martin Koskas
- Department of Obstetrics & Gynecology and Reproductive Medecine, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
- Faculty of Medicine, Paris Cité University, Paris, France
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Suzuki Y, Ferris JS, Chen L, Dioun S, Usseglio J, Matsuo K, Xu X, Hershman DL, Wright JD. Levonorgestrel-releasing intrauterine device therapy vs oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia: a systematic review and meta-analysis. J Natl Cancer Inst 2024; 116:653-664. [PMID: 38305500 DOI: 10.1093/jnci/djae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/14/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis to examine outcomes of patients with endometrial intraepithelial neoplasia treated with oral progestins or a levonorgestrel-releasing intrauterine device (IUD). METHODS We conducted a systematic review across 5 databases to examine outcomes of progestational treatment (oral progestins or levonorgestrel-releasing IUD) for patients with endometrial intraepithelial neoplasia. The primary outcome was the best complete response rate within 12 months of primary progestational treatment. Sensitivity analyses were performed by removing studies with extreme effect sizes. Secondary outcomes included the pooled pregnancy rate. RESULTS We identified 21 eligible studies, including 824 premenopausal patients with endometrial intraepithelial neoplasia, for our meta-analysis. Among these, 459 patients received oral progestin, and 365 patients received levonorgestrel-releasing IUD as a primary progestational treatment. The pooled best complete response proportion within 12 months was 82% (95% confidence interval [CI] = 69% to 91%) following oral progestin treatment and 95% (95% CI = 81% to 99%) following levonorgestrel-releasing IUD treatment. After removing outlier studies, the pooled proportion was 86% (95% CI = 75% to 92%) for the oral progestin group and 96% (95% CI = 91% to 99%) for the levonorgestrel-releasing IUD group, with reduced heterogeneity. The pooled pregnancy rate was 50% (95% CI = 35% to 65%) after oral progestin and 35% (95% CI = 23% to 49%) after levonorgestrel-releasing IUD treatment. CONCLUSIONS This meta-analysis provides data on the effectiveness of oral progestins and levonorgestrel-releasing IUD treatment within 12 months of treatment among premenopausal patients with endometrial intraepithelial neoplasia. Although based on small numbers, the rate of pregnancy after treatment is modest. These data may be beneficial for selecting progestational therapies that allow fertility preservation for patients with endometrial intraepithelial neoplasia.
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Affiliation(s)
- Yukio Suzuki
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jennifer S Ferris
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ling Chen
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shayan Dioun
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - John Usseglio
- Augustus C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Matsuo
- University of Southern California, Los Angeles, CA, USA
| | - Xiao Xu
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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Gallo A, Di Spiezio Sardo A, Conforti A, Iorio GG, Zizolfi B, Buonfantino C, De Angelis MC, Strina I, Marrone V, Bifulco G, Alviggi C. Assessing ovarian stimulation with letrozole and levonorgestrel intrauterine system after combined fertility-sparing approach for atypical endometrial lesions: a retrospective case-control study. Reprod Biomed Online 2024; 48:103750. [PMID: 38430660 DOI: 10.1016/j.rbmo.2023.103750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 03/05/2024]
Abstract
RESEARCH QUESTION Is ovarian stimulation with levonorgestrel intrauterine system (LNG-IUS) in situ and co-treatment with letrozole safe and effective in patients undergoing fertility-sparing combined treatment for atypical endometrial hyperplasia (AEH) or early endometrial cancer limited to the endometrium? DESIGN Retrospective case-control study recruiting women who had undergone fertility-sparing 'combined' treatment and ovarian stimulation with letrozole and LNG-IUS in situ. The 'three steps' hysteroscopic technique was used. Once complete response was achieved, the ovaries were stimulated, and mature oocytes cryopreserved. The LNG-IUS was removed, and embryos transferred. A comparative analysis was conducted between the two control groups of the initial outcomes of ART (number of oocytes and MII oocytes retrieved): healthy infertile women undergoing ovarian stimulation for IVF/ICSI (control group A); and patients diagnosed with breast cancer who underwent ovarian stimulation with letrozole (control group B). RESULTS Of the 75 patients analysed, 15 underwent oocyte cryopreservation after achieving a complete response to fertility-sparing treatment (study group); 30 patients in control group A and B, respectively. No statistically significant differences were observed in retrieved oocytes and mature oocytes between the study and control groups. In the nine patients who underwent embryo transfer, clinical pregnancy (55.6%), cumulative live birth (44.4%) and miscarriage (20%) rates were reported. In three patients with AEH, recurrence occurred (12%) at 3, 6 and 16 months after removing the LNG-IUS to attempt embryo transfer, respectively. CONCLUSION Fertility-sparing hysteroscopic combined treatment and subsequent ovarian stimulation with letrozole and LNG-IUS in situ could be suggested to women with AEH or early endometrial cancer who ask for future fertility preservation.
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Affiliation(s)
- Alessandra Gallo
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Attilio Di Spiezio Sardo
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Alessandro Conforti
- University of Naples "Federico II". Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine. Naples, Italy.
| | - Giuseppe Gabriele Iorio
- University of Naples "Federico II". Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine. Naples, Italy
| | - Brunella Zizolfi
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Cira Buonfantino
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Maria Chiara De Angelis
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Ida Strina
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Vincenzo Marrone
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Giuseppe Bifulco
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Carlo Alviggi
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
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Barral Y, Borrás A, Carrillo P, Agustí I, Peralta S, Casals G, Fàbregues F, Guimerà M, Corral JM, Calafell JM, Redondo M, Glickman A, Rovira M, Adamo B, Ricart E, Trullàs DM. Current status of fertility preservation in a Spanish tertiary public hospital: multidisciplinary approach and experience in over 1500 patients. Clin Transl Oncol 2024; 26:1129-1138. [PMID: 37872422 DOI: 10.1007/s12094-023-03330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE Currently, 15% of gynaecological and 9% of haematological malignancies are diagnosed before the age of 40. The increased survival rates of cancer patients who are candidates for gonadotoxic treatments, the delay in childbearing to older ages, and the optimization of in vitro fertilisation techniques have all contributed to an increased interest in fertility preservation (FP) treatments. This study reviews the experience of the Fertility Preservation Programme (FPP) of a tertiary public hospital with a multidisciplinary approach. METHODS This retrospective study included all the available (FP) treatments, performed in patients of childbearing age between 2006 and 2022. RESULTS 1556 patients were referred to the FPP: 332 oocyte vitrification cycles, 115 ovarian cortex cryopreservation with 11 orthotopic autotransplantations, 175 gonadotropin-releasing hormone (GnRH) agonist treatments, 109 fertility-sparing treatments for gynaecological cancer, and 576 sperm cryopreservation were performed. Malignancy was the main indication for FP (the main indications being breast cancer in women and haematological malignancies in men), although non-oncological pathologies, such as endometriosis and autoimmune diseases, have increased in recent years. Currently, the most widely used FP technique is oocyte vitrification, the increase of which has been associated with a decrease in the use of cortex CP and GnRH agonists. CONCLUSIONS The increase in FP treatment reflects the implementation of reproductive counselling in oncology programmes. A multidisciplinary approach in a tertiary public hospital allows individualised FP treatment for each patient. In recent years, there has been a change in trend with the introduction of new indications for FP and a change in techniques due to their optimisation.
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Affiliation(s)
- Yasmina Barral
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Aina Borrás
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Pilar Carrillo
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Inés Agustí
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Sara Peralta
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Gemma Casals
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesc Fàbregues
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Marta Guimerà
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Juan Manuel Corral
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Josep Maria Calafell
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Miriam Redondo
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Ariel Glickman
- Gynecologic Oncology Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Department of Hematology, Clinical Institute of Hematological and Oncological Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Bárbara Adamo
- Department of Medical Oncology, Hospital Clínic, Clinical Institute of Hematological and Oncological Diseases, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Elena Ricart
- Gastroenterology Department, Clinical Institute of Digestive and Metabolic Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Dolors Manau Trullàs
- Assisted Reproduction Unit, Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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Kashihara Y, Sekiyama K, Abe A, Yamamura A, Kozono Y, Okuda A, Yoshioka Y, Higuchi T. Successful fertility preservation in stage II endometrial carcinoma with long-term progestin therapy: A case report. Gynecol Oncol Rep 2024; 52:101357. [PMID: 38469132 PMCID: PMC10925927 DOI: 10.1016/j.gore.2024.101357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/24/2024] [Accepted: 02/28/2024] [Indexed: 03/13/2024] Open
Abstract
Progestin therapy is a fertility-sparing treatment option for well-differentiated stage IA endometrioid carcinomas without myometrial invasion. Here, we present a case of successful pregnancy and live birth following long-term progestin therapy in a patient with stage II well-differentiated endometrioid carcinoma. A 30-year-old nulliparous woman with an unremarkable medical history presented with abnormal uterine bleeding. A 45 mm mass was identified in the lower uterine segment. An endometrial biopsy revealed grade 1 endometrioid carcinoma, leading to a diagnosis of stage II uterine corpus cancer based on hysteroscopic findings. The patient refused surgical treatment and underwent oocyte retrieval and cryopreservation at another hospital. A subsequent endometrial biopsy revealed a marked reduction in the Ki-67 index from approximately 60 % to less than 10 %, suggesting the possibility of a hormone-sensitive tumor. The patient persistently refused surgery. Therefore, progestin therapy with medroxyprogesterone acetate (MPA) at a dose of 400 mg/day was initiated as a temporary measure until the patient would accept surgery. The tumor gradually reduced in size and eventually disappeared after 9 months. The MPA therapy was discontinued uneventfully after 20 months. Sixteen months after the discontinuation of MPA therapy, atypical endometrial hyperplasia was detected, and a second round of MPA therapy was initiated. Progestin retreatment was successful and was discontinued at 6 months. Four years after the initial treatment, the patient achieved pregnancy through timed intercourse and delivered a healthy baby at 38 weeks of gestation.
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Affiliation(s)
- Yuki Kashihara
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
- Department of Gynecology and Obstetrics, Kyoto University Hospital, Kyoto, Japan
| | - Kentaro Sekiyama
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
| | - Akiko Abe
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
| | - Akitoshi Yamamura
- Department of Gynecology and Obstetrics, Kyoto University Hospital, Kyoto, Japan
| | - Yuki Kozono
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
| | - Akiko Okuda
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
| | - Yumiko Yoshioka
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
| | - Toshihiro Higuchi
- Department of Obstetrics and Gynecology, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, Osaka, Japan
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7
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Takeda A, Yamamoto Y, Tamura K, Aoki H, Noguchi H, Minato S, Kamada S, Arakaki R, Kaji T, Iwasa T. Oncologic, fertility, and obstetric outcomes with MPA therapy in women with endometrial cancer and atypical endometrial hyperplasia. J Obstet Gynaecol Res 2024; 50:633-638. [PMID: 38154145 DOI: 10.1111/jog.15872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
AIM Medroxyprogesterone acetate (MPA) is one of the treatments of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) to preserve the fertility. Efficacy of MPA therapy and fertility and obstetric outcomes after remission were evaluated in EC or AEH patients. METHODS Among patients diagnosed with EC or AEH at Tokushima University Hospital between January 2002 and October 2020, we retrospectively analyzed patients, ages range from 26 to 40, who underwent conservative management using MPA (400-600 mg/day). RESULTS In total, 19 patients underwent MPA therapy. The 18 (94%) patients achieved complete response (CR), and 1 (5%) patient achieved partial response (PR). Relapse occurred in 6 (32%) patients who had achieved CR. Of the patients who relapsed, 4 patients resumed MPA therapy and were in remission. Among 19 patients, 13 patients attempted pregnancy after CR. All of them underwent ovulation induction or assisted reproductive technology. As a result, 20 pregnancies in 10 (77%) patients and 12 live births in 9 (69%) patients were achieved. Rate of spontaneous abortion was 35% (7/20). CONCLUSIONS MPA therapy can produce a high remission rate, and be considered an effective treatment for patients who wish fertility preservation. Around 70% patients who attempt to pregnancy can have at least one baby by infertility treatments. Because recurrence rate after MPA therapy is high, it may be desirable to aim for early pregnancy by active intervention.
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Affiliation(s)
- Asuka Takeda
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yuri Yamamoto
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Kou Tamura
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Hidenori Aoki
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Hiroki Noguchi
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Saki Minato
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Shuhei Kamada
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Ryosuke Arakaki
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Takashi Kaji
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Takeshi Iwasa
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
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Ronsini C, Napolitano S, Iavarone I, Fumiento P, Vastarella MG, Reino A, Molitierno R, Cobellis L, De Franciscis P, Cianci S. The Role of Adjuvant Therapy for the Treatment of Micrometastases in Endometrial Cancer: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:1496. [PMID: 38592342 PMCID: PMC10932314 DOI: 10.3390/jcm13051496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph nodes are the primary site of extra-uterine dissemination in endometrial cancer (EC), setting the 5-year survival to 44-52%. It is standard practice for radiation therapy (RT) and/or chemotherapy (CTX) to be given as adjuvant treatments to prevent the progression of micrometastases. Also, administration of EC patients with RT and/or CTX regimens before surgery may decrease micrometastases, hence the need for lymphadenectomy. The primary aim of the systematic review and meta-analysis is to assess whether adjuvant RT and/or CTX improve oncological outcomes through the management of micrometastases and nodal recurrence. We performed systematic research using the string "Endometrial Neoplasms" [Mesh] AND "Lymphatic Metastasis/therapy" [Mesh]. The methods for this study were specified a priori based on the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Outcomes were 5-year overall survival, progression-free survival, recurrence rate, and complications rate. We assessed the quality of studies using the Newcastle-Ottawa Scale (NOS). A total of 1682 patients with stage I-to-IV EC were included. Adjuvant treatment protocols involved external-beam RT, brachytherapy, and CTX either alone or in combination. The no-treatment group showed a non-statistically significant higher recurrence risk than any adjuvant treatment group (OR 1.39 [95% CI 0.68-2.85] p = 0.36). The no-treatment group documented a non-statistically significant higher risk of death than those who underwent any adjuvant treatment (RR 1.47 [95% CI 0.44-4.89] p = 0.53; I2 = 55% p = 0.000001). Despite the fact that early-stage EC may show micrometastases, adjuvant treatment is not significantly associated with better survival outcomes, and the combination of EBRT and CTX is the most valid option in the early stages.
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Affiliation(s)
- Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Stefania Napolitano
- Division of Medical Oncology, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Irene Iavarone
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Pietro Fumiento
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Maria Giovanna Vastarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Antonella Reino
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Rossella Molitierno
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Lugi Cobellis
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (I.I.); (P.F.); (M.G.V.); (A.R.); (R.M.); (L.C.); (P.D.F.)
| | - Stefano Cianci
- Gynecologic Oncology Unit, Women Wealth Area, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00136 Rome, Italy
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Shim SH, Noh E, Lee AJ, Jang EB, Kim M, Hwang HS, Cho GJ. Risk of adverse obstetric outcomes in patients with a history of endometrial cancer: A nationwide population-based cohort study. BJOG 2023; 130:1662-1668. [PMID: 37218424 DOI: 10.1111/1471-0528.17553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To evaluate adverse obstetric outcomes in women with a history of endometrial cancer (EC). DESIGN Population-based cohort study. SETTING The Korean National Health Insurance (KNHI) claims database. POPULATION Women who gave birth between 2009 and 2016, with a history of EC prior to pregnancy. METHODS The KNHI database was used to compare obstetric outcomes of women with and without a history of EC, using the ICD-10 codes. Multivariable logistic regression models were used to determine the associations between a history of EC and adverse obstetric outcomes. MAIN OUTCOMES MEASURES Adverse obstetric outcomes. RESULTS Overall, 248 and 3 335 359 women with and without a history of EC, respectively, gave birth. When adjusted for age, primiparity and comorbidities, an increased risk of multiple gestations (odds ratio [OR] 4.925, 95% confidence interval [CI] 3.394-7.147), caesarean delivery (OR 2.005, 95% CI 1.535-2.62) and preterm birth (OR 1.941, 95% CI 1.107-3.404) was observed among women with a history of EC. We were unable to demonstrate significant differences in the risk of pre-eclampsia, gestational diabetes, vacuum delivery, placenta praevia, placenta accreta spectrum, placental abruption and postpartum haemorrhage between the groups. In the sensitivity analyses excluding multiple gestations, an increased risk of preterm birth was not observed among women with a history of EC (OR 1.276, 95% CI 0.565-2.881). CONCLUSIONS There is no convincing evidence of an increased risk of adverse obstetric outcomes among women with a history of EC. Our findings would be useful in counselling of patients with EC who are undergoing fertility-sparing treatment.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynaecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Eunjin Noh
- Smart Healthcare Cancer, Korea University Guro Hospital, Seoul, South Korea
| | - A Jin Lee
- Department of Obstetrics and Gynaecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Eun Bi Jang
- Department of Obstetrics and Gynaecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Minjeong Kim
- Department of Obstetrics and Gynaecology, Korea University College of Medicine, Seoul, South Korea
| | - Han Sung Hwang
- Department of Obstetrics and Gynaecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynaecology, Korea University College of Medicine, Seoul, South Korea
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Wu W, Wang W, Zou J. Recurrent endometrial atypical hyperplasia diagnosed by pathological examination of the placenta from a live birth: a case report. BMC Pregnancy Childbirth 2023; 23:691. [PMID: 37749522 PMCID: PMC10519068 DOI: 10.1186/s12884-023-05972-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/04/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Pregnancy complicated with endometrial atypical hyperplasia, which is often observed during early pregnancy, is extremely rare. CASE PRESENTATION The patient was a 30-year-old woman who had premature delivery at 30+ 1 weeks gestation, and endometrial atypical hyperplasia was discovered by placental examination. CONCLUSIONS For patients who undergo fertility-sparing treatment for endometrial atypical hyperplasia, the evaluation of the decidua via the placental pathological examination is particularly important. These examinations make a great clinical contribution to the early detection and diagnosis of endometrial atypical hyperplasia.
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Affiliation(s)
- Weilu Wu
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China
| | - Wei Wang
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China
| | - Juan Zou
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China.
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Schubert M, Mettler L, Deenadayal Tolani A, Alkatout I. Fertility Preservation in Endometrial Cancer-Treatment and Molecular Aspects. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020221. [PMID: 36837423 PMCID: PMC9962641 DOI: 10.3390/medicina59020221] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/10/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
Endometrial cancer is one of the most common gynecological malignancies worldwide; incidences are rising, with 417,367 new cases registered in 2020. Of these, the proportion of women that are of reproductive age is around 4-14% and the number is increasing. Thus, in addition to oncological therapy and safety, the preservation of fertility plays a central role in therapeutic strategies. Molecular genetic patient data provide a robust supplementary benefit that improves primary risk assessment and can help design personalized treatment options to curtail over- and undertreatment and contribute to fertility preserving strategies. The aim of our review is to provide an overview of the latest significant recommendations in the diagnosis and therapy of endometrial cancer during reproductive age. In this paper the most recent groundbreaking molecular discoveries in endometrial cancer are highlighted and discussed as an opportunity to enhance the prognostic and therapy options in this special patient collective.
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Affiliation(s)
- Melanie Schubert
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Kiel, 24105 Postcode Kiel, Germany
| | - Liselotte Mettler
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Kiel, 24105 Postcode Kiel, Germany
| | - Aarti Deenadayal Tolani
- Mamata Fertility Hospital, Infertility Institute and Research Centre, Secunderabad 500026, Telangana, India
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Kiel, 24105 Postcode Kiel, Germany
- Correspondence:
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Metformin in Combination with Progesterone Improves the Pregnancy Rate for Patients with Early Endometrial Cancer. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:1961016. [PMID: 35854762 PMCID: PMC9279044 DOI: 10.1155/2022/1961016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022]
Abstract
Objective. To study the therapeutic effects of metformin in combination with medroxyprogesterone in the early endometrial cancer patients with fertility requirements. A total of 120 patients with early endometrial cancer admitted to and treated in our hospital were enrolled and evenly assigned into two groups according to different therapeutic regimens, namely, metformin group (metformin combined with medroxyprogesterone acetate) and control group (medroxyprogesterone acetate alone). The objective response rate (ORR) and disease control rate (DCR) were 71.7% (43/60) and 90.0% (54/60) in the metformin group and 53.3% (32/60) and 78.3% (47/60) in the control group, respectively. Adverse reactions such as gastrointestinal reaction, headache, and insomnia were mainly observed in patients. The body mass index (BMI) declined from (34.43 ± 4.34) kg/m2 to (24.77 ± 2.39) kg/m2 in the metformin group and from (33.37 ± 4.49) kg/m2 to (31.28 ± 3.55) kg/m2 in the control group after treatment. After treatment, serum levels of vascular endothelial growth factor (VEGF), angiotensin-2 (Ang-2), carbohydrate antigen 125 (CA125), and CA19-9 in the metformin group were significantly lower than those in the control group (P = 0.005, P < 0.001, P = 0.002, and P < 0.001). During follow-up, the pregnancy rate was 81.7% (49/60) in the metformin group and 61.7% (37/60) in the control group, and the former was prominently higher than the latter (P = 0.025). Metformin in combination with progesterone is effective in treating early endometrial cancer patients with fertility requirements, which significantly reduced the BMI of patients and increased the pregnancy rate after treatment.
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