Fertility considerations and the pediatric oncology patient

Ovarian-sparing surgery for ovarian tumors in children: A systematic review and meta-analysis

INTRODUCTION

An increased number of children and adolescents with ovarian tumors have been managed with ovarian-sparing surgery in the last few years. However, comprehensive data on fertility outcomes and local relapse are scarce. In this study, we systematically describe the contemporary outcomes of ovarian-sparing surgery, as reported in the literature.

MATERIALS AND METHODS

Using PRISMA guidelines, we analyzed studies reporting ovarian-sparing techniques for ovarian tumors in children and adolescents. from 1980 to 2022. Reports with fewer than three patients, narrative reviews, and opinion articles were excluded. Statistical analysis was performed for dichotomous and continuous variables.

RESULTS

Of 283 articles screened, 16 papers (3057 patients) met inclusion criteria (15 retrospective/1 prospective) and were analyzed. The vast majority of studies had no long-term fertility follow-up data and direct comparison between ovarian-sparing surgery vs oophorectomy was reported in only a few studies. Ovarian sparing surgery was not associated with worse oncologic outcomes in terms of (i) tumour spillage or (ii) recurrence rates, and of key importance allowed a higher ovarian reserve at long term follow-up.

CONCLUSIONS

Ovarian-sparing surgery is a safe and feasible technique for benign tumors. Long-term outcome studies are needed to show efficacy and fertility preservation.

Fertility preservation in ovarian cancer patients

Ovarian cancer is more frequent in post-menopausal women, however it can also occur in young premenopausal women. After diagnosis and cancer staging, health care providers should address the possibility of infertility and might offer fertility preservation options. Chemotherapy, frequently used when treating ovarian cancer, has proven to cause extensive ovarian damage. Standard surgery may be aggressive and the recurrence risk may not be relevant enough to opt for these approaches. Fertility sparing surgery has been progressively accepted and many alternative surgical approaches have proven to be successful in both cancer treatment, fertility preservation and low recurrence rates. Though there are several techniques available for fertility preservation in cancer patients, when dealing with ovarian cancer patients, oocyte and embryo cryopreservation are the only suitable. Ovarian tissue cryopreservation has been largely studied, but no data on ovarian cancer patients exist, due to the risk of reimplanting cancer cells.

The impact of childhood cancer and its treatment on puberty and subsequent hypothalamic pituitary and gonadal function, in both boys and girls

Childhood cancer survivors (CCS) are at an increased risk of endocrine disorders. Disorders of the hypothalamic-pituitary-gonadal (HPG) axis are a particular concern because of their impact on pubertal development and future fertility and may be of central (hypothalamic or pituitary damage) or primary (gonadal) origin. Hypogonadism may present as pubertal disorders during adolescence and subsequent infertility in adulthood but should be anticipated to ensure appropriate surveillance is in place to address these issues at an appropriate age. Those at risk of HPG axis dysfunction include those with tumours primarily affecting the hypothalamus, pituitary or gonads themselves or due to their treatment with surgery, radiotherapy and chemotherapy. CCS who have had cranial irradiation of more than 30 Gy are at risk of gonadotrophin deficiency. Those who have had gonadotoxic chemotherapy, especially alkylating agents or radiotherapy to the gonads are at risk of primary gonadal failure. HSCT survivors who have had chemotherapy and total body irradiation are at risk of primary gonadal failure but may also have gonadotrophin deficiency. Understanding those at risk is essential to appropriate counselling and long-term follow-up. This chapter gives an overview on the impact of childhood cancer and its treatment on puberty, gonadal function and fertility in childhood cancer survivors.

Sperm DNA Damage in Cancer Patients

Fertility is a growing healthcare issue for a rising number of cancer survivors. In men, cancer itself and its treatment can negatively affect spermatogenesis by targeting the dividing spermatogonia and their cellular environment, ultimately leading to a reduction of testicular germ cells and sperm count. Experimental data and prospective longitudinal studies have shown that sperm production can recover after cancer treatment. But despite this, yet unpredictable, recovery in sperm production, cancer survivors are more at risk to produce sperm with aneuploidy, DNA damage, abnormal chromatin structure, and epigenetic defects even 2 years post-treatment. Sperm DNA alteration is of clinical concern, as these patients may father children or seek assisted reproduction technologies (ART) using gametes with damaged genome that could result in adverse progeny outcomes. Interestingly, large cohort studies revealed lower birth rate but no significant impact on the health of the children born from male cancer survivors (naturally or using ART). Nevertheless, a better understanding of how cocktail of chemotherapy and new anticancer agents affect spermatogenesis and sperm quality is needed to reduce side effects. Moreover, developing new fertility preservation strategies is essential as sperm cryopreservation before treatment is currently the only option but does not apply for prepubertal/young postpubertal patients.

Testicular damage in children and adolescents treated for malignancy: a short review

Significant advances have been made over recent decades in the treatment of childhood malignancies. These advances had an incredible cost, as an increasing number of young survivors suffer subfertility or infertility, because of the high sensitivity of testicular cells, especially the rapidly dividing germ cells, to cytotoxic drugs and irradiation. Therefore, the impact of treatment on future fertility is of significant concern, both to parents and patients. Assessment of fertility damage in childhood remains problematic. For post-pubertal males, semen analysis represents a good indicator of spermatogenesis and testicular function, and allows for sperm cryopreservation. The available method for prepubertal children is only gonadal tissue cryopreservation. This method is still experimental and raises ethical concerns. Ideally, a multidisciplinary team approach needs to be used in addressing the needs of fertility preservation for this population. Precise knowledge of these issues would help pediatric oncologists and endocrinologists to counsel their patients and inform them for factors and resources that may protect or preserve parenthood options in the future. (www.actabiomedica.it)

Engineered endothelium provides angiogenic and paracrine stimulus to grafted human ovarian tissue

Despite major advances in tissue cryopreservation and auto-transplantation, reperfusion ischemia and hypoxia have been reported as major obstacles to successful recovery of the follicular pool within grafted ovarian tissue. We demonstrate a benefit to follicular survival and function in human ovarian tissue that is co-transplanted with exogenous endothelial cells (ExEC). ExECs were capable of forming functionally perfused vessels at the host/graft interface and increased both viability and follicular volume in ExEC-assisted grafts with resumption of antral follicle development in long-term grafts. ExECs that were engineered to constitutively express anti-mullerian hormone (AMH) induced a greater proportion of quiescent primordial follicles than control ExECs, indicating suppression of premature mobilization that has been noted in the context of ovarian tissue transplantation. These findings present a cell-based strategy that combines accelerated perfusion with direct paracrine delivery of a bioactive payload to transplanted ovarian tissue.