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Fernández-González MJ, Borgmann-Staudt A, Llagostera CG, Ceballos-Garcia E, Gebauer J, Jantke A, Barnbrock A, Kentenich H, Klco-Brosius S, Lotz L, Balcerek M. Oocyte collection and outcome following oncologic treatment: a retrospective multicentre study. Support Care Cancer 2024; 32:390. [PMID: 38806697 PMCID: PMC11133171 DOI: 10.1007/s00520-024-08586-0] [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: 01/23/2024] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE This study assesses fertility treatment outcomes in female patients who had undergone successful oocyte retrieval following cancer therapy. METHODS Between January 2020 and December 2022, we collected fertility treatment data from six participating centres in Spain and Germany. All patients associated with this data had undergone successful oocyte retrieval following cancer treatment. RESULTS Women had most frequently been diagnosed with a haematological (41.9%), breast (22.6%) or gynaecological malignancy (12.9%); two thirds (67.7%) had previously received a chemotherapy, half a radiotherapy (53.3%) and 45.2% had undergone surgery. On average, 7 years (range 0-28) had passed between cancer treatment and first ovarian stimulation cycle. Forty-nine ovarian stimulation cycles had been conducted on these 31 women between 2004 and 2021 (mean age at first oocyte collection following treatment: 34.8 ± 5.7 years). On average, 7 oocytes were collected per cycle (range 0-26) and 11 were collected per patient (range 0-51). Out of the 190 oocytes collected for immediate use of artificial reproductive technique, 139 were fertilised at a rate of 73%. Live birth rate per fresh transfer was 45% (9/20); no births were reported following cryotransfer (0/10). Mean values of anti-Mullerian hormone (AMH) before stimulation declined with time since treatment; however, oocytes were successfully collected from four women with an AMH of <0.5 ng/ml, although no pregnancies were reported. Ten pregnancies were documented; 3 ended in miscarriage. Two twin and 5 single pregnancies resulted in nine live births. On average, children were carried to term. CONCLUSION In this small cohort, oocytes were successfully collected after chemotherapy and radiotherapy, despite-in individual cases-low AMH values. Further studies are needed to enrich the database and ultimately provide appropriate counselling to female cancer patients regarding expectations and ART outcome following cancer therapy.
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Affiliation(s)
- Marta J Fernández-González
- Department of Paediatric Oncology and Haematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anja Borgmann-Staudt
- Department of Paediatric Oncology and Haematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | | | | | - Judith Gebauer
- University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Andreas Jantke
- Kinderwunschärzte Berlin, Zentrum für Kinderwunschbehandlung und Fertilitätsprotektion, Berlin, Germany
| | | | | | - Stephanie Klco-Brosius
- Department of Paediatric Oncology and Haematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Laura Lotz
- University Women's Hospital Erlangen, Erlangen, Germany
| | - Magdalena Balcerek
- Department of Paediatric Oncology and Haematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
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Friedlander H, Blakemore JK, McCulloh DH, Fino ME. Fertility-Sparing Treatment and Assisted Reproductive Technology in Patients with Endometrial Carcinoma and Endometrial Hyperplasia: Pregnancy Outcomes after Embryo Transfer. Cancers (Basel) 2023; 15:cancers15072123. [PMID: 37046784 PMCID: PMC10093683 DOI: 10.3390/cancers15072123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
The goal of fertility-sparing treatment (FST) for patients desiring future fertility with EMCA, and its precursor EH, is to clear the affected tissue and revert to normal endometrial function. Approximately 15% of patients treated with FST will have a live birth without the need for assisted reproductive technology (ART). Despite this low number, little information exists on the pregnancy outcomes of patients who utilize ART. The purpose of this study was to evaluate pregnancy outcomes following embryo transfer in patients with EMCA or EH who elected for FST. This retrospective cohort study at a large urban university-affiliated fertility center included all patients who underwent embryo transfer after fertility-sparing treatment for EMCA or EH between January 2003 and December 2018. Primary outcomes included embryo transfer results and a live birth rate (defined as the number of live births per number of transfers). There were 14 patients, three with EMCA and 11 with EH, who met the criteria for inclusion with a combined total of 40 embryo transfers. An analysis of observed outcomes by sub-group, compared to the expected outcomes at our center (patients without EMCA/EH matched for age, embryo transfer type and number, and utilization of PGT-A) showed that patients with EMCA/EH after FST had a significantly lower live birth rate than expected (Z = −5.04, df = 39, p < 0.01). A sub-group analysis of the 14 euploid embryo transfers resulted in a live birth rate of 21.4% compared to an expected rate of 62.8% (Z = −3.32, df = 13, p < 0.001). Among patients with EMCA/EH who required assisted reproductive technology, live birth rates were lower than expected following embryo transfer when compared to patients without EMCA/EH at our center. Further evaluation of the impact of the diagnosis, treatment, and repeated cavity instrumentation for FST is necessary to create an individualized and optimized approach for this unique patient population.
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Affiliation(s)
- Hilary Friedlander
- Division of Reproductive Endocrinology and Infertility, Duke University School of Medicine, 5601 Arringdon Park Drive, Suite 210, Morrisville, NC 27560, USA
| | - Jennifer K. Blakemore
- Division of Reproductive Endocrinology and Infertility, New York University Langone Prelude Fertility Center, New York, NY 10022, USA
| | - David H. McCulloh
- Division of Reproductive Endocrinology and Infertility, New York University Langone Prelude Fertility Center, New York, NY 10022, USA
| | - M. Elizabeth Fino
- Division of Reproductive Endocrinology and Infertility, New York University Langone Prelude Fertility Center, New York, NY 10022, USA
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Outcomes of in vitro fertilization cycles following fertility-sparing treatment in stage IA endometrial cancer. Arch Gynecol Obstet 2019; 300:975-980. [PMID: 31440822 DOI: 10.1007/s00404-019-05237-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/28/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aimed to present cases involving in vitro fertilization (IVF) cycles in patients with stage IA endometrial adenocarcinoma (EC) who underwent fertility-sparing conservative treatment. METHODS Twenty-two patients who underwent IVF cycles in a single fertility center between May 2005 and February 2017 after progestin treatment for stage IA EC were chosen for this study. Outcomes of IVF cycles were analyzed retrospectively. RESULTS Women of a median age of 34 years (range 26-41 years) underwent a total of 49 embryo transfers within an average of 2 months after their last progestin treatment. The clinical pregnancy rate per transfer was 26.5%, implantation rate was 16.7%, and live birth rate was 14.3%. The cumulative clinical pregnancy rate was 50% (11/22), resulting in 6 live births (27.3%) within 3 cycles of embryo transfer. The median endometrial thickness on the day of human chorionic gonadotropin injection in 34 fresh cycles was 9.0 mm (range 4-10 mm) in live births, 7.5 mm (range 6-9 mm) in miscarriages, and 6.0 mm (range 4-15 mm) in no pregnancy cases. During a median post-cancer treatment follow-up period of 41 months (range 9-150 months), 6 (27.3%) women underwent definitive hysterectomy for EC relapse. CONCLUSIONS This study showed an acceptable cumulative pregnancy rate after the IVF procedure in patients with early-stage EC who were treated conservatively. Considering the high relapse rate, it is of great importance that these patients are closely monitored after the IVF cycles.
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Fertility Preserved Hysteroscopic Approach for the Treatment of Stage Ia Endometrioid Carcinoma. Int J Gynecol Cancer 2018; 27:1919-1925. [PMID: 28885274 PMCID: PMC5671800 DOI: 10.1097/igc.0000000000001109] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE This study aims to explore the feasibility of a hysteroscopic procedure combined with progestin therapy in young patients with stage Ia endometrioid carcinoma (EC) to avoid sterilization. MATERIALS AND METHODS Eleven young women with stage Ia EC (International Federation of Gynecology and Obstetrics grade 1) who were treated with a hysteroscopic approach combined with progestin from July 2004 to June 2016 were retrospectively analyzed and followed up to monitor their general recovery and pregnancy outcome. RESULTS The patients' median age was 27.3 years (range, 25-39 years). Comorbidities consisted of primary infertility in 8 patients, polycystic ovary syndrome in 4, uterine fibroids in 2, and diabetes in 1. The results of immunohistochemical analysis were positive for all estrogen and progestin receptors. After treatment, 9 patients attained complete remission, and 2 patients achieved partial remission. The results of peritoneal cytology in 4 patients were negative. As of this writing, 6 of the 11 patients have given birth to 7 infants, and 1 patient had an ectopic pregnancy. Two patients ultimately underwent radical resection. The average follow-up time was 82.3 months (range, 15 to 152 months), and all patients remain disease-free. CONCLUSIONS Hysteroscopic surgery combined with progestin treatment for stage Ia EC in young patients to avoid sterilization was practical and may represent a new option for patients with stage Ia EC who wish to preserve their fertility.
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Kim SW, Kim H, Ku SY, Suh CS, Kim SH, Choi YM. A successful live birth with in vitro fertilization and thawed embryo transfer after conservative treatment of recurrent endometrial cancer. Gynecol Endocrinol 2018. [PMID: 28650773 DOI: 10.1080/09513590.2017.1342239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Estrogen-dependent early stage endometrial cancer is relatively common in young women of reproductive age. The standard treatment is hysterectomy and bilateral salpingo-oophorectomy (BSO), even in early stage well-differentiated endometrial cancer patients. This surgical option results in permanent loss of fertility. There have been some reports of live births using in vitro fertilization after conservative management of endometrial cancer with high-dose progestin for the purpose of fertility preservation. However, most were not recurrent cases and pregnancy was achieved through conventional in vitro fertilization, which usually raises serum estradiol levels and may lead to the recurrence of endometrial cancer. To date, it is hard to find a case that can be referred for any possible different approach needed for the patients who experience recurrence. Here we report a successful live birth with in vitro fertilization using letrozole to maintain physiological levels of estradiol, and subsequent thawed embryo transfer after elective cryopreservation of embryos in a patient with recurrent endometrial cancer. There has been no evidence of disease recurrence at one year after delivery.
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Affiliation(s)
- Sung Woo Kim
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
| | - Hoon Kim
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
| | - Seung-Yup Ku
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
| | - Chang Suk Suh
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
| | - Seok Hyun Kim
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
| | - Young Min Choi
- a Department of Obstetrics and Gynecology , Seoul National University Hospital , Seoul , South Korea
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Feichtinger M, Rodriguez-Wallberg KA. Fertility preservation in women with cervical, endometrial or ovarian cancers. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2016; 3:8. [PMID: 27468354 PMCID: PMC4962474 DOI: 10.1186/s40661-016-0029-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/06/2016] [Indexed: 12/19/2022]
Abstract
Background Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance. Outcomes Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery. Conclusions Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.
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Affiliation(s)
- Michael Feichtinger
- Department of Obstetrics and Gynecology, Division of Gynecological Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria ; Wunschbaby Institut Feichtinger, Vienna, Austria ; Department of Obstetrics and Gynecology, Section of Reproductive Medicine, Karolinska University Hospital, Novumhuset Plan 4, SE-141 86 Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology - Pathology, Karolinska Institutet, Stockholm, Sweden ; Department of Obstetrics and Gynecology, Section of Reproductive Medicine, Karolinska University Hospital, Novumhuset Plan 4, SE-141 86 Stockholm, Sweden
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Kalogera E, Dowdy SC, Bakkum-Gamez JN. Preserving fertility in young patients with endometrial cancer: current perspectives. Int J Womens Health 2014; 6:691-701. [PMID: 25114594 PMCID: PMC4122529 DOI: 10.2147/ijwh.s47232] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries and affects predominantly postmenopausal women. It is estimated, however, that 15%–25% of women will be diagnosed before menopause. As more women choose to defer childbearing until later in life, the feasibility and safety of fertility-sparing EC management have been increasingly studied. Definitive treatment of total hysterectomy and bilateral salpingo-oophorectomy precludes future fertility and may thus be undesirable by women who wish to maintain their reproductive potential. However, the consideration of conservative management carries the oncologic risks of unstaged EC and the risk of missing a synchronous ovarian cancer. It is further complicated by the lack of consensus regarding the initial assessment, treatment, and surveillance. Conservative treatment with progestins has been shown to be a feasible and safe fertility-sparing approach for women with low grade, early stage EC with no myometrial invasion. The two most commonly adopted regimens are medroxyprogesterone acetate at 500–600 mg daily and megestrol acetate at 160 mg daily for a minimum of 6–9 months, with initial response rates commonly reported between 60% and 80% and recurrence rates between 25% and 40%. Photodynamic therapy and hysteroscopic EC excision have recently been reported as alternative approaches to progestin therapy alone. However, limited efficacy and safety data exist. Live birth rates after progestin therapy have typically been reported around 30%; however, when focusing only on those who do pursue fertility after successful treatment, the live birth rates were found to be higher than 60%. Assisted reproductive technology has been associated with a higher live birth rate compared with spontaneous conception, most likely reflecting the presence of infertility at baseline. Close follow-up is of paramount importance, and definitive treatment after completion of childbearing is advised.
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Affiliation(s)
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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8
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Frumovitz M, Gershenson DM. Fertility-sparing therapy for young women with endometrial cancer. Expert Rev Anticancer Ther 2014; 6:27-32. [PMID: 16375641 DOI: 10.1586/14737140.6.1.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Approximately 1600 women under the age of 40 will be diagnosed with endometrial cancer this year. For these women, preservation of fertility may be one of the most important factors when seeking treatment options. The objective of this article is to review the available literature on fertility-sparing therapy for young women with endometrial cancer. Patient selection, pretreatment testing, treatment regimens, response rates and pregnancy outcomes will be explored. Recommendations regarding this approach for the treatment of endometrial cancer in young women will also be made.
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Affiliation(s)
- Michael Frumovitz
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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van Gent MD, Kagie MJ, Trimbos BJ. No Surgery for Low-Grade Endometrial Cancer in Women with a Desire to Preserve Fertility. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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10
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Bakkum-Gamez JN, Kalogera E, Keeney GL, Mariani A, Podratz KC, Dowdy SC. Conservative Management of Atypical Hyperplasia and Grade I Endometrial Carcinoma: Review of the Literature and Presentation of a Series. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2012.0011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Gary L. Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Andrea Mariani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karl C. Podratz
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sean C. Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
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Traitement conservateur du cancer et des hyperplasies atypiques de l’endomètre en vue de préserver la fertilité : revue de la littérature. Bull Cancer 2012; 99:51-60. [DOI: 10.1684/bdc.2011.1516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Eskander RN, Randall LM, Berman ML, Tewari KS, Disaia PJ, Bristow RE. Fertility preserving options in patients with gynecologic malignancies. Am J Obstet Gynecol 2011; 205:103-10. [PMID: 21411052 DOI: 10.1016/j.ajog.2011.01.025] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 12/26/2010] [Accepted: 01/14/2011] [Indexed: 12/23/2022]
Abstract
A proportion of reproductive age women are affected by gynecologic malignancies. This patient population is faced with difficult decisions, related to their cancer care and treatment, as well as future childbearing potential. Therefore, it is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer. In addition to understanding the surgical approaches available, providers should be able to counsel patients regarding their eligibility for and the indications and limitations of fertility sparing therapy for gynecologic cancer, allowing for appropriate referrals. A comprehensive PUBMED literature search was conducted using the key words "fertility preservation," "cervical cancer," "endometrial cancer," "ovarian cancer," "borderline tumor of the ovary," "germ cell tumor," "obstetrical outcomes," "chemotherapy," and "radiation." The following review summarizes fertility sparing options for patients with cervical, ovarian and endometrial cancer, with an emphasis on appropriate patient selection, oncologic, and obstetric outcomes.
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14
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Obstetric outcomes of pregnancy after conservative treatment of endometrial cancer: Case series and literature review. Taiwan J Obstet Gynecol 2011; 50:62-6. [DOI: 10.1016/j.tjog.2009.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2009] [Indexed: 11/23/2022] Open
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Erkanli S, Ayhan A. Fertility-Sparing Therapy in Young Women With Endometrial Cancer. Int J Gynecol Cancer 2010; 20:1170-87. [DOI: 10.1111/igc.0b013e3181e94f5a] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fadhlaoui A, Ben Hassouna J, Khrouf M, Zhioua F, Chaker A. Endometrial adenocarcinoma in a 27-year-old woman. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2010; 3:31-9. [PMID: 21769252 PMCID: PMC3046005 DOI: 10.4137/ccrep.s5346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Endometrial adenocarcinoma usually occurs after menopause, but in 2%-14% of cases, it occurs in young patients (less than 40 years of age) who are eager to preserve their fertility. Its treatment includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy, and, in some cases, radiation therapy. AIM To describe a case of endometrial adenocarcinoma occurring in a young woman and to undertake a literature review of risk factors and therapeutic options proposed for young women wishing to preserve their fertility. CASE We report a case of endometrial cancer in a 27-year-old woman treated for resistant menorrhagia and cared for in our department as well as in the Salah Azaiez Institute. CONCLUSION Endometrial adenocarcinoma rarely occurs in young women. In such cases, other therapeutic options can be proposed: progesterone therapy and LH-RH (Luteinzing-Hormone-Releasing-Hormone) agonists therapy in order to preserve fertility in younger patients.
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Affiliation(s)
- Anis Fadhlaoui
- Department of Obstetrics and Gynecology, Aziza Othmana University Hospital. Place du Gouvernement, La Kasba 1008 Tunis, Tunisia
- Medical University of Tunis, 15 Rue Djebel Lakhdhar, Bab Saadoun 1007, Tunis, Tunisia
| | - Jamel Ben Hassouna
- Department of Oncological Surgery, Salah Azaeiz Institute, Boulevard du 9 Avril, Bab Saadoun 1007 Tunis, Tunisia
- Medical University of Tunis, 15 Rue Djebel Lakhdhar, Bab Saadoun 1007, Tunis, Tunisia
| | - Mohamed Khrouf
- Department of Obstetrics and Gynecology, Aziza Othmana University Hospital. Place du Gouvernement, La Kasba 1008 Tunis, Tunisia
- Medical University of Tunis, 15 Rue Djebel Lakhdhar, Bab Saadoun 1007, Tunis, Tunisia
| | - Fethi Zhioua
- Department of Obstetrics and Gynecology, Aziza Othmana University Hospital. Place du Gouvernement, La Kasba 1008 Tunis, Tunisia
- Medical University of Tunis, 15 Rue Djebel Lakhdhar, Bab Saadoun 1007, Tunis, Tunisia
| | - Anis Chaker
- Department of Obstetrics and Gynecology, Aziza Othmana University Hospital. Place du Gouvernement, La Kasba 1008 Tunis, Tunisia
- Medical University of Tunis, 15 Rue Djebel Lakhdhar, Bab Saadoun 1007, Tunis, Tunisia
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Mazzon I, Corrado G, Masciullo V, Morricone D, Ferrandina G, Scambia G. Conservative surgical management of stage IA endometrial carcinoma for fertility preservation. Fertil Steril 2010; 93:1286-9. [DOI: 10.1016/j.fertnstert.2008.12.009] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 11/13/2008] [Accepted: 12/08/2008] [Indexed: 11/16/2022]
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Ercan CM, Duru NK, Sakinci M, Alanbay I, Karasahin KE, Baser I. Successful twin pregnancy achieved by assisted reproductive technology in a patient with polycystic ovary syndrome with complex atypical endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system. Gynecol Endocrinol 2010; 26:125-8. [PMID: 20074021 DOI: 10.3109/09513590903015569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrinopathy and a major cause of infertility. PCOS may be associated with chronic anovulation and endometrial hyperplasia. Conservative treatment should be considered in young women wishing to preserve their fertility. Standard treatment for complex endometrial hyperplasia is the use of high-dose progesterone, whereas we preferred levonorgestrel-releasing intrauterine system (LNG-IUS) as a last resort in our patient who was resistant to oral gestagens. We present a case with complex atypical endometrial hyperplasia treated conservatively in a long-term period first by oral gestagens, then by LNG-IUS. In our case, LNG-IUS was more effective than oral systemic progestins, not only for reducing the menstrual blood loss but also for improving the pathological findings. After extraction of LNG-IUS rapid achievement of pregnancy was carried out by intracytoplasmic sperm injection and embryo transfer and she took home twin babies. To the best of our knowledge, this is the first successful twin pregnancy case with ICSI and ET in a patient with oral gestagen resistant endometrial complex/atypical hyperplasia achieved after application of LNG-IUS. In complex atypical hyperplasia, LNG-IUS should be kept in mind as an effective alternative treatment modality before assisted reproductive technology (ART).
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Affiliation(s)
- Cihangir Mutlu Ercan
- Gulhane Military Medical Faculty, Obstetrics and Gynecology Department, 06018 Etlik, Ankara, Turkey.
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Hahn HS, Yoon SG, Hong JS, Hong SR, Park SJ, Lim JY, Kwon YS, Lee IH, Lim KT, Lee KH, Shim JU, Mok JE, Kim TJ. Conservative treatment with progestin and pregnancy outcomes in endometrial cancer. Int J Gynecol Cancer 2009; 19:1068-73. [PMID: 19820370 DOI: 10.1111/igc.0b013e3181aae1fb] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The purpose of this study was to evaluate the efficacy of conservative treatment with progestin and pregnancy outcomes in women with early-stage endometrial cancer. METHODS We retrospectively analyzed the medical records of 35 patients with endometrial adenocarcinoma, who were treated with progestin from January 1996 to December 2006. Women with early-stage grade 1 endometrioid endometrial adenocarcinoma, who wanted to receive conservative treatment or preserve fertility, were included. All women were treated with medroxyprogesterone acetate or megestrol acetate, with regular dilation and curettage performed. Complete remission (CR) was defined as no evidence of endometrial adenocarcinoma or hyperplasia. Partial remission was diagnosed when the patient developed endometrial hyperplasia, and persistent disease was defined as residual endometrial adenocarcinoma by pathologic confirmation. RESULTS The median age was 31 years (range, 21-43 years), and the median follow-up period was 39 months (range, 5-108 months). Complete remission was achieved in 22 patients (62.9%), partial remission was achieved in 1 patient (2.9%), and 12 patients (34.3%) had persistent disease. The median time to CR was 9 months (range, 2-12 months). Of the 22 patients with CR, 9 (40.9%) had recurrent disease, and the median time to recurrence was 12 months (range, 8-48 months). Ten (83.3%) of the 12 patients with CR who tried to conceive were successful, and 8 of the 10 pregnancies resulted in live births. There were no congenital anomalies in babies associated with progestin treatment. CONCLUSIONS Conservative treatment with progestin can be considered a good therapeutic option in patients with well-differentiated early-stage endometrioid endometrial adenocarcinoma who wish to preserve their uteri or become pregnant.
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Affiliation(s)
- Ho-Suap Hahn
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
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Gadducci A, Spirito N, Baroni E, Tana R, Genazzani AR. The fertility-sparing treatment in patients with endometrial atypical hyperplasia and early endometrial cancer: a debated therapeutic option. Gynecol Endocrinol 2009; 25:683-91. [PMID: 19562604 DOI: 10.1080/09513590902733733] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Fertility-sparing treatment may represent a realist option for accurately selected young patients with endometrial atypical hyperplasia or well differentiated, early endometrial cancer. Oral progestins, and especially medroxyprogesterone acetate (MPA) and megestrol acetate with different doses and schedules, represent the most commonly used hormone agents in this clinical setting. Approximately three fourths of the women achieve a histologically documented complete response, with an mean response time of 12 weeks, but about one third of these subsequently developed a recurrence after a mean time of 20 months. The expression of receptor for progesterone receptor (PR), PTEN gene, DNA mismatch repair gene MLH1 and phospho-AKT on tissue specimens may be useful for selecting patients fit for a conservative management. Several successful pregnancies have occurred after a fertility-sparing treatment of endometrial atypical hyperplasia or endometrial cancer, more frequently with assisted reproductive technologies. The implementation of in vitro fertilisation techniques not only increases the chance of conception, but it may also decrease the interval to conception. The opportunity of a demolitive surgery after delivery or after childbearing being no longer required is a still debated issue. Large multicenter trials are strongly warranted to better define the selection criteria for a conservative treatment, endocrine regimen of choice, the optimal dosing, the duration of treatment and follow-up protocols. In any case, the patient should be accurately informed about the relatively high recurrence rates after complete response to hormone treatment and expectations for pregnancy.
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Affiliation(s)
- Angiolo Gadducci
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, via Roma 56, Pisa 56127, Italy.
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Sodano M, Bogliatto F, Morero S, Mosso L, Torchio B, Leidi L. Successful IVF programme after conservatively treated endometrial cancer. Reprod Biomed Online 2009; 18:578-81. [DOI: 10.1016/s1472-6483(10)60137-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Han AR, Kwon YS, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Pregnancy Outcomes Using Assisted Reproductive Technology After Fertility-Preserving Therapy in Patients With Endometrial Adenocarcinoma or Atypical Complex Hyperplasia. Int J Gynecol Cancer 2009; 19:147-51. [DOI: 10.1111/igc.0b013e31819960ba] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives:To evaluate the outcomes of pregnancy in young women (<40 years old) with early endometrial cancer or atypical complex hyperplasia who were treated by conservative management followed by assisted reproductive technology (ART).Materials and Methods:Medical charts of 11 patients treated from January 1997 to October 2007 at Asan Medical Center were retrospectively reviewed. These patients had all been treated with progestin and serial dilatation and curettage as primary fertility-preserving therapies.Results:After pathological remission of disease, 10 patients tried to become pregnant by ART, 4 by in vitro fertilization and embryo transfer, and 6 by controlled ovarian hyperstimulation, with or without intrauterine insemination. Eight women had intrauterine pregnancies, and 6 patients had live births. Patients have been followed up for 9 to 51 months (mean, 21 months) after delivery, with no evidence of tumor recurrence.Conclusions:Fertility-preserving therapy followed by ART can be a good option in well-selected patients with early endometrial cancer who want to become pregnant.
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ICSI outcome following conservative fertility sparing management of endometrial cancer. Reprod Biomed Online 2009; 18:416-20. [DOI: 10.1016/s1472-6483(10)60102-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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24
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Sparing fertility in young patients with endometrial cancer. Gynecol Oncol 2008; 111:S101-4. [DOI: 10.1016/j.ygyno.2008.07.056] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 07/09/2008] [Indexed: 11/17/2022]
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25
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Conservative management of patients with early endometrial carcinoma: a systematic review. Clin Transl Oncol 2008; 10:155-62. [DOI: 10.1007/s12094-008-0173-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Elizur SE, Beiner ME, Korach J, Weiser A, Ben-Baruch G, Dor J. Outcome of in vitro fertilization treatment in infertile women conservatively treated for endometrial adenocarcinoma. Fertil Steril 2007; 88:1562-7. [PMID: 17412340 DOI: 10.1016/j.fertnstert.2007.01.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Revised: 01/16/2007] [Accepted: 01/16/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate IVF characteristics and outcome of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma. DESIGN Observational case series study. SETTING The Department of Gynecology Oncology and IVF unit of Chaim Sheba Medical center, Tel-Hashomer, Israel. PATIENT(S) Eight women referred to IVF treatment because of failure of other fertility treatments after conservative treatment of endometrial adenocarcinoma. All women were selected carefully for conservative treatment at the Department of Gynecology Oncology of the Chaim Sheba Medical Center after a thorough metastatic workup. INTERVENTION(S) In vitro fertilization/intracytoplasmic sperm injection treatment. MAIN OUTCOME MEASURE(S) Serum E(2) levels at hCG administration, endometrial thickness, number of oocytes retrieved, fertilization rate, pregnancy and delivery rate. RESULT(S) All women were nulliparous before IVF treatment, and only one woman was older than 35 years. In four of them, endometrial adenocarcinoma was diagnosed during infertility workup or treatment. A total of 31 IVF cycles were performed. The mean number of oocytes retrieved was 9.4 (95% confidence interval, 5.1-13.6), and fertilization rate was 58.6%. Six women (75%) conceived, and four (50%) delivered six healthy offspring. CONCLUSION(S) In vitro fertilization treatment of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma is highly successful and offers the opportunity to cryopreserve embryos for future use.
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Azim A, Oktay K. Letrozole for ovulation induction and fertility preservation by embryo cryopreservation in young women with endometrial carcinoma. Fertil Steril 2007; 88:657-64. [PMID: 17428480 DOI: 10.1016/j.fertnstert.2006.12.068] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 12/28/2006] [Accepted: 12/28/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To reduce estrogen exposure in women with endometrial cancer undergoing in vitro fertilization using an aromatase inhibitor. DESIGN Prospective case series. SETTING Academic center for reproductive medicine. PATIENT(S) Endometrial carcinoma patients presenting for fertility preservation or fresh embryo transfer to gestational carrier. INTERVENTION(S) Four patients with endometroid carcinoma underwent five IVF cycles for immediate or delayed embryo transfer to gestational carriers before or after staging and definitive surgery. To prevent surge in E(2) levels, letrozole was started 2 days before gonadotropin administration and then given concomitantly. Embryos were either cryopreserved for fertility preservation or transferred freshly to a surrogate. MAIN OUTCOME MEASURE(S) Peak E(2) level during stimulation, pregnancy in a gestational carrier. RESULT(S) Peak E(2) level during stimulation was 386.67 +/- 102.93 pg/mL. A mean of 7 +/- 2.85 oocytes were retrieved, resulting in 4.8 +/- 1.76 embryos per cycle. In one patient, two embryos were transferred to a surrogate, resulting in a triplet pregnancy. The delivery occurred at 31 weeks and the infants did not show any congenital or developmental abnormalities. Three patients had their embryos cryopreserved for future use. CONCLUSION(S) The use of letrozole and gonadotropins is associated with lower E(2) levels compared with standard stimulation cycles in endometrial carcinoma patients. Combination of this approach with surrogacy may enable these young women to preserve their fertility.
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Affiliation(s)
- Amr Azim
- Fertility Preservation Program, Center for Reproductive Medicine and Infertility, Weill Medical College of Cornell University, New York, New York 10021, USA
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Silva-Filho AL, Carmo GAL, Athayde GRS, Assis ME, Almeida RC, Leal RHS, Lamaita RM, Santos-Júnior JL, Castro e Silva JG. Safe fertility-preserving management in gynecological malignancies. Arch Gynecol Obstet 2007; 275:321-30. [PMID: 17219164 DOI: 10.1007/s00404-006-0271-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 10/17/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To provide a review in the available literature about the safe fertility-preserving management in gynecological malignancies, focusing on the selection criteria of the patients, treatment options and follow-up. DESIGN Literature survey. RESULTS The incidence of cancer in women who still want to get pregnant is increasing significantly. An early detection in gynecological malignancies allows less aggressive approaches to cure such disorders. A more conservative management, which preserves fertility, is considered safe and an option for those who have not completed their child-bearing. CONCLUSIONS Selected patients with cervical, endometrial and ovarian cancer may be candidates to a safe fertility-preserving management. A careful stage and follow-up of the patients is essential to achieve success with this practice.
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Affiliation(s)
- Agnaldo L Silva-Filho
- Department of Gynecology and Obstetrics, Federal University of Minas Gerais, School of Medicine, Avenida Professor Alfredo Balena 190, Santa Efigênia, 30130-100 Belo Horizonte, MG, Brazil.
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Preserving fertility before assisted reproduction in women with endometrial carcinoma: case report and literature review. Reprod Biomed Online 2007; 15:561-5. [DOI: 10.1016/s1472-6483(10)60389-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Park JC, Cho CH, Rhee JH. A successful live birth through in vitro fertilization program after conservative treatment of FIGO grade I endometrial cancer. J Korean Med Sci 2006; 21:567-71. [PMID: 16778408 PMCID: PMC2729970 DOI: 10.3346/jkms.2006.21.3.567] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infertile women with chronic anovulation are prone to be exposed to unopposed estrogen stimulation and have the high risk of being suffering from endometrial hyperplasia or even endometrial carcinoma. A few reports have suggested that nulliparous young women (under 40 yr of age) with endometrial carcinoma could be treated conservatively to preserve fertility and succeed the live birth. We report on a 36-yr-old woman who received conservative treatment of endometrial carcinoma (stage I, grade 1) by curettage and progestin. After megestrol medication of total 71,680 mg during 24 weeks, we found the regression of endometrial lesion by curettage and hysteroscopic examination. Then we decided to perform in vitro fertilization program. Two embryos were transferred and heterotypic pregnancy was diagnosed 27 days after embryo transfer. After right salpingectomy, she received routine obstetrical care and delivered by cesarean section at 38 weeks in gestational periods. Two years after delivery, she is healthy without any evidence of recurrent disease. The fertility preserving treatment is an option in endometrial cancer patients if carefully selected, and assisted reproductive technologies would be helpful.
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Affiliation(s)
- Joon-Cheol Park
- Department of Obstetrics and Gynecology, Keimyung University, School of Medicine, Daegu, Korea
| | - Chi-Hum Cho
- Department of Obstetrics and Gynecology, Keimyung University, School of Medicine, Daegu, Korea
| | - Jeong-Ho Rhee
- Department of Obstetrics and Gynecology, Keimyung University, School of Medicine, Daegu, Korea
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Abstract
PURPOSE OF REVIEW Endometrial cancer can affect reproductive-age women who may desire fertility preservation. This article discusses the current, available data about conservative management of endometrial cancer in young women. RECENT FINDINGS Reproductive-age women with well differentiated endometrial carcinoma have an overall favorable prognosis provided that the tumor is identified at an early, noninvasive stage; however, advanced disease can be present. This article discusses current modalities to evaluate and clinically stage endometrial cancer including hysteroscopy, dilation and curettage, pelvic ultrasound, abdominopelvic computed tomography scan, pelvic magnetic resonance imaging, tumor marker CA125 level, and surgical exploration with laparoscopy or laparotomy. Thorough evaluation is critical as 10 to 29% of young women with endometrial cancer have a synchronous ovarian malignancy. Detailed counseling about the risks and benefits of conservative management, and expectations for fertility after treatment, surveillance, and definitive surgical management is essential. Multiple effective protocols exist for conservative treatment of endometrial cancer, and the initial response rates are as high as 57 to 75%. Successful pregnancies have occurred after conservative management, spontaneously, and with assisted reproductive technologies. SUMMARY There are no standard recommendations for selection of appropriate women, treatment protocols, or long-term surveillance for conservative management of clinical stage I endometrial adenocarcinoma, and larger prospective clinical studies are warranted.
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Affiliation(s)
- Beth W Rackow
- Division of Reproductive Endocrinology and Infertility, Yale University School of Medicine, New Haven, Connecticut 06520-8063, USA.
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Böing C, Kimmig R. Fertility-Preserving Treatment in Young Women with Endometrial Cancer. ACTA ACUST UNITED AC 2006; 46:25-33. [PMID: 16452817 DOI: 10.1159/000089974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Nonsurgical fertility-preserving treatment of well-differentiated endometrial cancer with systemic progestins has been described for young women who desire to preserve their fertility. The overall response to progestin treatment in 9 retrospective studies is 79% with 79 subsequent live births. Recurrence can be expected in approximately 36-40% of conservatively treated patients who initially responded. Synchronous ovarian cancer has been reported in approximately 9%. However, amongst 162 receiving systemic, continuous treatment with progestins no death caused by cancer has been reported. We review guidelines for diagnosis, treatment and follow-up in young women undergoing conservative treatment for endometrial cancer.
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Affiliation(s)
- Carsten Böing
- Department of Gynecology and Obstetrics, University of Essen, Essen, Germany.
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Yahata T, Fujita K, Aoki Y, Tanaka K. Long-term conservative therapy for endometrial adenocarcinoma in young women. Hum Reprod 2005; 21:1070-5. [PMID: 16361282 DOI: 10.1093/humrep/dei434] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of long-term conservative therapy with medroxyprogesterone acetate (MPA) for endometrial carcinoma in young patients who had experienced failure after initial therapy or relapse, we reviewed the clinical and pathologic records of eight patients diagnosed with well-differentiated endometrial adenocarcinoma without myometrial invasion who were treated with MPA for over 6 months because of treatment failure or relapse. RESULTS The average duration of MPA treatment was 22 months. All patients were followed-up for a mean of 76.5 months. Seven patients responded to initial MPA treatment within a period of 14 months (mean, 7.9 months). All these patients experienced relapse and the mean time to relapse was 11.6 months (range, 4-33 months). All six patients with relapse were treated with additional treatments of MPA, and all but one responded to this treatment within a period of 16 months (mean, 8.0 months). Six patients ultimately underwent hysterectomy. All presented well-differentiated endometrioid adenocarcinomas without extrauterine disease. Three became pregnant and two delivered full-term normal infants. No patient died of the disease. CONCLUSION Although lesions are expected to disappear with prolonged MPA treatment, this form of progestin therapy is hazardous because recurrence occurs frequently. Only strictly selected patients should therefore be indicated for long-term MPA treatment and careful evaluation before and after treatment should be performed.
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Affiliation(s)
- T Yahata
- Department of Obstetrics & Gynecology, School of Medicine, Niigata University, Niigata city, Niigata, Japan.
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Yang YC, Wu CC, Chen CP, Chang CL, Wang KL. Reevaluating the safety of fertility-sparing hormonal therapy for early endometrial cancer. Gynecol Oncol 2005; 99:287-93. [PMID: 16051341 DOI: 10.1016/j.ygyno.2005.06.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Revised: 05/17/2005] [Accepted: 06/06/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the safety of fertility-sparing hormonal therapy for endometrial cancer in young patients. METHODS Six patients diagnosed with endometrial adenocarcinoma grade I and had undergone progestin treatment were reviewed. Four patients failed progestin treatment and were then found at surgery to have both endometrial and ovarian cancers. A clonality assay using the human androgen receptor gene as the X-linked polymorphic marker and immunohistochemistry for steroid hormone receptor expression were used to delineate the relation between the endometrial and ovarian lesions and to explore possible causes of treatment failure. RESULTS The patients were followed for a mean of 48.8 months. Four of the six responded to the treatment at a mean of 3.5 months. Two of these patients had a recurrence within a mean of 4.5 months after their initial response. Two patients did not respond to progestin treatment. At surgery in those 4, both endometrial and ovarian tumors were found. All 6 are still alive, and 2 successfully delivered healthy infants. The clonality assay revealed an independent cell origin for the endometrial and ovarian lesions in 2 of the 4 women who failed progestin treatment. Progesterone receptors were absent in both endometrial and ovarian tumors in 2 of these 4 patients. CONCLUSION The absence of progesterone receptors may relate to the failure of progestin treatment. The use of progestin treatment for well-differentiated early endometrial carcinoma should be cautious and requires very careful clinical evaluation before and after treatment.
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MESH Headings
- Adult
- Antineoplastic Agents, Hormonal/therapeutic use
- Carcinoma, Endometrioid/drug therapy
- Carcinoma, Endometrioid/genetics
- Carcinoma, Endometrioid/metabolism
- Carcinoma, Endometrioid/surgery
- Chromosomes, Human, X/genetics
- Endometrial Neoplasms/drug therapy
- Endometrial Neoplasms/genetics
- Endometrial Neoplasms/metabolism
- Endometrial Neoplasms/surgery
- Estrogen Receptor alpha/biosynthesis
- Female
- Fertility
- Humans
- Immunohistochemistry
- Megestrol Acetate/therapeutic use
- Neoplasm Recurrence, Local
- Ovarian Neoplasms/genetics
- Ovarian Neoplasms/metabolism
- Ovarian Neoplasms/surgery
- Prospective Studies
- Receptors, Androgen/genetics
- Receptors, Progesterone/biosynthesis
- Treatment Failure
- X Chromosome Inactivation
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Affiliation(s)
- Yuh-Cheng Yang
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, 92 Sec. 2 Chung-San North Road, Taipei 104, Taiwan.
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Piura B. Two successful pregnancies after in vitro fertilization and embryo transfer in a patient with endometrial atypical hyperplasia bordering on adenocarcinoma treated conservatively with high-dose progesterone. Gynecol Obstet Invest 2005; 61:21-3. [PMID: 16131806 DOI: 10.1159/000087916] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 06/24/2005] [Indexed: 11/19/2022]
Abstract
Women suffering from anovulatory infertility may develop endometrial hyperplasia and adenocarcinoma due to the unopposed estrogen effect. We present the case of a young infertile woman with endometrial atypical hyperplasia bordering on adenocarcinoma who refused hysterectomy and bilateral salpingo-oophorectomy and achieved two successful pregnancies after conservative treatment with high-dose progesterone followed by in vitro fertilization and embryo transfer. It is concluded that conservative treatment with high-dose progesterone for endometrial hyperplasia and well-differentiated early-stage adenocarcinoma followed by assisted reproductive technologies is an appropriate means for achieving pregnancy. However, the issue of hysterectomy and bilateral salpingo-oophorectomy after delivery or after fertility being no longer required is controversial. If surgery is not performed, close observation with endometrial sampling every 6 months is advisable.
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Affiliation(s)
- Benjamin Piura
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Soroka Medical Center and Faculty of Health Sciences, Cancer Research Center, Ben Gurion University of the Negev, Beer-Sheva, Israel.
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Juretzka MM, O'Hanlan KA, Katz SL, El-Danasouri I, Westphal LM. Embryo cryopreservation after diagnosis of stage IIB endometrial cancer and subsequent pregnancy in a gestational carrier. Fertil Steril 2005; 83:1041. [PMID: 15820822 DOI: 10.1016/j.fertnstert.2004.09.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 09/30/2004] [Accepted: 09/30/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe a case of embryo cryopreservation before hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. DESIGN Case report. SETTING University and community service. PATIENT(S) An infertile woman with endometrial biopsy demonstrating grade II/III moderately differentiated endometrial adenocarcinoma. INTERVENTION(S) A Progestasert intrauterine device (IUD) was inserted into the uterine cavity to potentially reduce tumor proliferation during the stimulation cycle followed by oocyte retrieval and cryopreservation of 14 embryos. MAIN OUTCOME MEASURE(S) Pregnancy. RESULT(S) Successful pregnancy in a gestational carrier. CONCLUSION(S) Embryo cryopreservation and use of a gestational carrier may offer a fertility option for patients with endometrial malignancies without substantially delaying treatment.
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Affiliation(s)
- Margrit M Juretzka
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynecology, Stanford University Hospital and Clinics, Stanford, California
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Benshushan A. Endometrial adenocarcinoma in young patients: evaluation and fertility-preserving treatment. Eur J Obstet Gynecol Reprod Biol 2005; 117:132-7. [PMID: 15541846 DOI: 10.1016/j.ejogrb.2004.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2004] [Indexed: 12/20/2022]
Abstract
Carcinoma of the endometrium is the most common female pelvic malignancy in the US. Although it is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physicians. Medical treatment for young patients with grade 1 endometrial carcinoma who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include. A complete history and physical examination. A formal D&C with review of histology with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade 1 tumor and who want to preserve fertility, thorough counseling including risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. For patients willing to conceive at this stage, treatment options should be discussed. In women who do not want pregnancy at this stage, a maintenance treatment with oral contraceptive agent or Depo-provera (medroxyprogesterone acetate 150 mg i.m. q 12 weeks) should be recommended, with periodic ultrasound evaluation of the endometrium. When the patient finishes her fertility plans, the option of hysterectomy should be considered. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy.
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Affiliation(s)
- Abraham Benshushan
- Department of Obstetrics and Gynecology, Division of Gynecologic-Oncology, Hadassah Medical Center, The Hebrew University P.O. Box 12000, Jerusalem 91120, Israel.
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Morice P, Fourchotte V, Sideris L, Gariel C, Duvillard P, Castaigne D. A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment. Gynecol Oncol 2005; 96:245-8. [PMID: 15589610 DOI: 10.1016/j.ygyno.2004.09.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this paper was to report two cases of extrauterine disease in patients with early stage endometrial cancer (EC) who desired fertility-sparing management. CASES Two patients presenting an apparent early stage EC and desiring conservative management. The two patients, aged 35 and 36 years old, had a grade 1 and grade 2 EC diagnosed after curettage or hysteroscopic resection of a polyp. Ultrasound (US) imaging was normal (ovary). Once informed about the risk of recurrence, both patients opted for conventional therapy (hysterectomy with bilateral salpingo-oophorectomy). A small ovarian carcinoma was found in one patient and isolated positive peritoneal cytology in the other. CONCLUSIONS These cases seem to suggest that laparoscopic evaluation including adnexal exploration and peritoneal cytology (and possibly pelvic lymphadenectomy) should be performed in patients with early stage EC selected for conservative management to confirm the absence of extrauterine disease.
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Affiliation(s)
- Philippe Morice
- Service de Chirurgie Gynécologique, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France.
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Demirol A, Bahce M, Ayhan A, Gurgan T. Pregnancy following intracytoplasmic sperm injection and preimplantation genetic diagnosis after the conservative management of endometrial cancer. Reprod Biomed Online 2005; 10:770-3. [PMID: 15970008 DOI: 10.1016/s1472-6483(10)61122-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A rare case of a patient with conservatively treated endometrial carcinoma who conceived and delivered a healthy baby after the transfer of embryos with intracytoplasmic sperm injection (ICSI) and preimplantation genetic diagnosis (PGD) is presented. A 41-year-old woman had an office hysteroscopy in the infertility work-up and stage I endometrial adenocarcinoma was diagnosed. After conservative treatment, the patient underwent ICSI and PGD. She achieved pregnancy with two normal embryos. Two gestational sacs were observed but one of them was blighted. The patient subsequently delivered a healthy female infant. Repeated office hysteroscopy and endometrial sampling was performed after delivery. The appearance of the endometrium was normal on hysteroscopy, and the histology report was normal. The principal concern with medical therapy is that the lesion cannot be fully evaluated until the hysterectomy is performed, the nodes palpated, and the uterus is sectioned. The patient was referred to a gynaecological oncologist for definitive surgery.
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Affiliation(s)
- A Demirol
- Women's Health Clinic, Infertility and IVF Centre, Cankaya, Ankara, Turkey.
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Yarali H, Bozdag G, Aksu T, Ayhan A. A successful pregnancy after intracytoplasmic sperm injection and embryo transfer in a patient with endometrial cancer who was treated conservatively. Fertil Steril 2004; 81:214-6. [PMID: 14711571 DOI: 10.1016/j.fertnstert.2003.05.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe a patient with polycystic ovary syndrome (PCOS) conceiving with intracytoplasmic sperm injection (ICSI) and embryo transfer after conservative treatment of early stage endometrial cancer. DESIGN Case report. SETTING Tertiary center for assisted reproductive technologies.A 32-year-old woman with PCOS, primary infertility of 4 years duration, and grade 1 endometrioid endometrial cancer. INTERVENTION(S) Assessment of myometrial invasion and extrauterine spread with magnetic resonance imaging (MRI) and explorative laparotomy. High-dose progestin treatment and ICSI and embryo transfer. MAIN OUTCOME MEASURE(S) Successful take-home baby and no residual endometrial cancer. RESULT(S) A healthy normal female infant with a birth weight of 1740 g was born by cesarean section at 30 weeks' gestation. No residual cancer was detected at the follow-up curettage performed 2 months after the delivery. CONCLUSION(S) Conservative uterus-preserving treatment may be considered in patients with early stage endometrial cancer. Assisted reproductive technologies may be used in such patients for immediate achievement of pregnancy.
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Affiliation(s)
- Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University, School of Medicine, Ankara, Turkey.
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Jadoul P, Donnez J. Conservative treatment may be beneficial for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma. Fertil Steril 2004; 80:1315-24. [PMID: 14667859 DOI: 10.1016/s0015-0282(03)01183-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate whether an alternative treatment to radical hysterectomy exists for young women with endometrial adenocarcinoma. DESIGN A review of the literature (70 articles) plus personal results. SETTING University hospital. PATIENT(S) Women with atypical endometrial hyperplasia or adenocarcinoma. MAIN OUTCOME MEASURE(S) The recurrence rate and the pregnancy rate after conservative therapy. CONCLUSION(S) Conservative treatment of well-differentiated stage I endometrial adenocarcinoma can be considered in young patients, with close surveillance to diagnose any possible recurrence.
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Affiliation(s)
- Pascale Jadoul
- Université Catholique de Louvain, Cliniques Universitaires St Luc, Department of Gynecology, Brussels, Belgium
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Lowe MP, Cooper BC, Sood AK, Davis WA, Syrop CH, Sorosky JI. Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia. Gynecol Oncol 2003; 91:569-72. [PMID: 14675678 DOI: 10.1016/j.ygyno.2003.08.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia. METHODS A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology. RESULTS Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy. CONCLUSION This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.
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Affiliation(s)
- M Patrick Lowe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
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Outcome of Fertility-Sparing Treatment With Progestins in Young Patients With Endometrial Cancer. Obstet Gynecol 2003. [DOI: 10.1097/00006250-200310000-00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Su MT, Su RM, Yue CT, Chou CY, Hsu CC, Chang FM. Three-dimensional transvaginal ultrasound provides clearer delineation of myometrial invasion in a patient with endometrial cancer and uterine leiomyoma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:434-436. [PMID: 14528484 DOI: 10.1002/uog.213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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