Fertility-sparing surgery in epithelial ovarian cancer

Fertility potential and safety assessment of residual ovarian cortex in young women diagnosed with epithelial borderline and early-stage malignant ovarian tumors

OBJECTIVE

To establish the safety and quality of ovarian cortex surrounding epithelial ovarian tumors in women eligible for fertility-sparing surgery by identifying occult malignant lesions and characterizing the ovarian follicle pool.

METHODS

Multicentric retrospective study of 48 subjects (15-45 years), diagnosed with borderline ovarian tumors (BOTs) or early-stage epithelial ovarian cancers (EOCs) and eligible for fertility-sparing surgery. Histological samples of ovarian cortex surrounding tumors were analyzed to characterize the follicle pool, find any occult malignant lesion using tumor-specific markers (cytokeratin 7 and mucin 1), and quantify tumor-infiltrating lymphocytes (TILs) by CD3 and tumor associated macrophages (TAMs) by CD68.

RESULTS

Occult ovarian lesions were observed in 6 out of 45 cases investigated (14.6%), including one mucinous stage-I BOT (1/14), one serous stage-I BOT (1/13), 3 advanced-stage serous BOTs (3/11) and one early-stage serous EOC (1/7). Notably, follicle density was significantly lower in subjects diagnosed with ovarian tumors compared to controls (p < 0.001) and at a younger age. Significantly higher follicle atresia was encountered in the ovarian tumor group then in controls (20.1 ± 8.8% vs 9.2 ± 9.4%, p < 0.001) at all ages. Both TILs and TAMs were found in ovarian tumors irrespective of histotype, but no link was established with the status of the ovarian reserve.

CONCLUSIONS

Personalized counseling for fertility preservation is required in the event of BOTs and early-stage EOCs. Fertility-sparing surgery and adjuvant gamete preservation should be considered, balancing the oncological risks according to tumor stage and histotype and fertility potential, especially at a younger age.

Fertility-sparing surgery: a hopeful strategy for young women with cancer

Fertility preservation in cancer patients is currently based on either assisted reproductive technology or fertility-sparing surgery. Loss of fertility may be caused by excisional surgery associated with an adnexal or uterine pathology or secondary to gonadal insufficiency caused by chemotherapy or radiation. The counseling of these patients is very important, being carried out jointly by the oncologist, gynecologist, and reproductive medicine specialist. Reproductive surgery usually requires avoiding laparotomy to significantly reduce the formation of adhesions and trauma or tissue damage. This is done using standard laparoscopic surgery or robotic surgery (computer-assisted laparoscopy), a method increasingly used and accessible to all specialists who want to maintain the fertility of their patients with various oncological diseases.

Detection of ovarian cancer using plasma cell-free DNA methylomes

BACKGROUND

Ovarian cancer (OC) is a highly lethal gynecologic cancer, and it is hard to diagnose at an early stage. Clinically, there are no ovarian cancer-specific markers for early detection. Here, we demonstrate the use of cell-free DNA (cfDNA) methylomes to detect ovarian cancer, especially the early-stage OC.

EXPERIMENTAL DESIGN

Plasma from 74 epithelial ovarian cancer patients, 86 healthy volunteers, and 20 patients with benign pelvic masses was collected. The cfDNA methylomes of these samples were generated by cell-free methylated DNA immunoprecipitation and high-throughput sequencing (cfMeDIP-seq). The differentially methylated regions (DMRs) were identified by the contrasts between tumor and non-tumor groups, and the discrimination performance was evaluated with the iterative training and testing method.

RESULTS

The DMRs identified for cfDNA methylomes can well discriminate tumor groups and non-tumor groups (ROC values from 0.86 to 0.98). The late-stage top 300 DMRs are more late-stage-specific and failed to detect early-stage OC. However, the early-stage markers have the potential to discriminate all-stage OCs from non-tumor samples.

CONCLUSIONS

This study demonstrates that cfDNA methylomes generated with cfMeDIP-seq could be used to identify OC-specific biomarkers for OC, especially early OC detection. To detect early-stage OC, the biomarkers should be directly identified from early OC plasma samples rather than mix-stage ones. Further exploration of DMRs from a k larger early-stage OC cohort is warranted.

Fertility after Cancer: Risks and Successes

The incidence of cancer in reproductive-aged women is 7%, but, despite the increased number of cancer cases, advances in early diagnosis and treatment have raised the survival rate. Furthermore, in the last four decades, there has been a rising trend of delaying childbearing. There has been an increasing number of couples referred to Reproductive Medicine Centers for infertility problems after one partner has been treated for cancer. In these cases, the main cause of reduced fertility derives from treatments. In this review, we describe the effects and the risks of chemotherapy, radiotherapy, and surgery in women with cancer, and we will focus on available fertility preservation techniques and their efficacy in terms of success in pregnancy and live birth rates.

Nomogram for predicting postoperative cancer-specific early death in patients with epithelial ovarian cancer based on the SEER database: a large cohort study

Purpose

Ovarian cancer is a common gynecological malignant tumor. Poor prognosis is strongly associated with early death, but there is no effective tool to predict this. This study aimed to construct a nomogram for predicting cancer-specific early death in patients with ovarian cancer.

Methods

We used data from the Surveillance, Epidemiology, and End Results database of patients with ovarian cancer registered from 1988 to 2016. Important independent prognostic factors were determined by univariate and multivariate logistic regression and LASSO Cox regression. Several risk factors were considered in constructing the nomogram. Nomogram discrimination and calibration were evaluated using C-index, internal validation, and receiver operating characteristic (ROC) curves.

Results

A total of 4769 patients were included. Patients were assigned to the training set (n = 3340; 70%) and validation set (n = 1429; 30%). Based on the training set, eight variables were shown to be significant factors for early death and were incorporated in the nomogram: American Joint Committee on Cancer (AJCC) stage, residual lesion size, chemotherapy, serum CA125 level, tumor size, number of lymph nodes examined, surgery of primary site, and age. The concordance indices and ROC curves showed that the nomogram had better predictive ability than the AJCC staging system and good clinical practicability. Internal validation based on validation set showed good consistency between predicted and observed values for early death.

Conclusion

Compared with predictions made based on AJCC stage or residual lesion size, the nomogram could provide more robust predictions for early death in patients with ovarian cancer.

The complex relationship between infertility and female genital tract cancer: A review

INTRODUCTION

The link between female infertility and gynecological cancer has always been a debated and challenging topic. Although cervical cancer has the worst impact on female fertility, as it is usually diagnosed in patients of reproductive age, endometrial and ovarian cancer are also diagnosed and treated often in relatively younger patients in which fertility preservation is a relevant issue. The aim of this review is to highlight the correlation between therapy for female infertility and the developing cancer's risk and to describe the fertility sparing treatments in gynecological oncology.

MATERIAL AND METHODS

A systematic review of the literature through the main scientific search engines (PubMed and Google Scholar) was performed. We selected the most relevant articles based on the largest case series and the latest updates. All selected documents have been listed in the references.

RESULTS

Fifty-six relevant articles published between 1996 and 2019 were identified.Results from the available evidence report no significant increased risk of endometrial, cervical, and ovarian cancer in patients having infertility treatments.In young patients diagnosed with gynecological cancer, preservation of fertility is a personalized choice depending on several factors (type, stage, age and desire to conceive, safety of the treatment, and feasibility of fertility sparing surgery). For ovarian cancer FIGO stage IA G1, IA G2 (grade), and IC G1; for endometrial adenocarcinoma grade 1 with no lymphovascular space invasion (LVSI) or myometrial invasion and for early-stage cervical cancer (FIGO stage 2018: IA1-IB1), fertility sparing treatment is possible. The role of fertility sparing treatment with the increase of personalization of therapies therapy is always a theme of discussion and research.

CONCLUSION

At present data regarding the risk of gynecological cancers after infertility treatments are reassuring. Careful evaluation of female fertility-sparing options in young women interested by ovarian, endometrial, or cervical tumors should be carried out involving a multidisciplinary team and ensuring safety and efficacy.

A Swedish Nationwide prospective study of oncological and reproductive outcome following fertility-sparing surgery for treatment of early stage epithelial ovarian cancer in young women

Background

Epithelial ovarian cancer (EOC) is rare in women of reproductive age and fertility-sparing surgery (FSS) may be applied in early stages. The purpose of this study was to investigate the safety and efficacy of FSS for treatment of EOC.

Methods

The Swedish nationwide population-based Quality Register for Gynecological Cancer was used to identify all women 18–40 years of age diagnosed with stage I EOC between 2008 and 2015. Detailed data on surgery, staging, histopathology, and follow-up were extracted and reviewed. Cross-linking of individuals to population-based registries allowed retrieval of data on obstetrical and reproductive outcomes after FSS. Disease-free survival (DFS) and overall survival (OS) rates were compared (Kaplan-Meier method) between women who underwent FSS vs. radical surgery (RS).

Results

In total 83 women were identified; 36 who had FSS performed and 47 RS. The 5-year OS rate was 92% and no statistical differences between DFS or OS were found between women treated by FSS or RS. The recurrence rate after RS was 13% compared to 6% after FSS. Recurrences were more frequently found in women with stage IC tumor or with histologic subtypes with more aggressive behavior. In the FSS cohort, nine women gave birth to 12 healthy children, all delivered at fullterm. Only one women had received assisted reproductive technology treatment.

Conclusion

In this nationwide population-based cohort study natural fertility was maintained after FSS. Specific histologic subtypes showed greater prognostic impact on the oncological outcome than the use of FSS. Recurrences occurred after FSS, but none in the uterus, which questions the need of hysterectomy in young women with EOC.

Trial registration

This article reports the results of a healthcare intervention using the data prospectively registered in the Swedish population-based registries including the Quality Register for Gynecological Cancer, the National Death Register, the Swedish Medical Birth Register, and the National Quality Register for Assisted Reproduction.

Oncological and Reproductive Outcomes of Fertility-sparing Surgery in Women with Early-stage Epithelial Ovarian Carcinoma: A Multicenter Retrospective Study

With delayed childbearing in women, preservation of fertility is an important issue for reproductive-age patients with epithelial ovarian carcinoma (EOC). Fertility-sparing surgery (FSS) can be considered in patients with early-stage disease in order to preserve fertility and improve quality of life. In order to evaluate oncological safety, attitudes toward childbearing and reproductive outcomes in women with EOC who underwent FSS, this multicenter retrospective study was conducted. Between January 2005 and December 2014, total of 87 young women with FIGO stage I EOC were included, with their clinicopathologic parameters in relation to disease-free survival (DFS) and overall survival (OS) assessed. Attitudes toward childbearing, ovarian function and fertility were studied in women undergoing FSS (n=36). As a result, in contrast to radical surgery, FSS did not affect prognosis by Kaplan-Meier curves (log-rank test; DFS: P=0.484; OS: P=0.125). However, two of the three recurrence cases and both death cases were in FSS group stage IC. All women undergoing FSS resumed regular menstrual periods after chemotherapy. Only 16 (44.44%) had tried to conceive, and 17 pregnancies occurred in 15 (93.75%) women. Among 20 women who did not attempt conception, the most common reason was not being married (70%), followed by already having children (15%). In summary, FSS is considered safe in young women with stage IA EOC. Regular menstruation and good obstetric outcomes can be achieved. This study also provides some insight into the attitudes and social factors regarding fertility in EOC patients.

Fertility preservation in women with early-stage gynecologic cancer: optimizing oncologic and reproductive outcomes

Almost all standard therapies for gynecologic cancer, including surgical intervention, gonadotoxic chemotherapy, and radiation therapy, threaten a woman's childbearing potential. Preservation of fertility should be discussed with premenopausal women with early-stage gynecologic cancer shortly after diagnosis and, for women who desire to preserve fertility, during treatment planning. Many authors have investigated both oncologic and reproductive outcomes following fertility-sparing therapy, and there is ongoing development of assisted reproduction techniques available to cancer patients and survivors. Women with early-stage (IA1-IB1) cervical cancer may be candidates for fertility-sparing cervical conization, simple trachelectomy, or radical trachelectomy. In women with stage I epithelial ovarian cancer, fertility-sparing surgery appears safe overall, although controversy remains in patients with high-risk features (eg, high pathologic grade, clear cell histology, or stage IC disease). In women with low-grade, early-stage endometrial cancer, hormonal therapy has emerged as a viable option. Criteria for patient selection for fertility-sparing therapy are not well defined, thus patients and providers must carefully discuss potential risks and benefits. In general, in carefully selected patients, survival outcomes do not appear to differ significantly between radical and fertility-sparing approaches. Women who undergo fertility-sparing therapies may experience a number of fertility and obstetric complications. Preconception counseling with high-risk obstetric specialists is important to optimize health before a woman attempts to conceive. Identifying appropriate candidates for fertility-sparing treatments, assessing fertility potential, and helping women conceive after cancer treatment is best accomplished through multidisciplinary collaboration between gynecologic oncologists and fertility specialists.

[Epithelial ovarian cancer and fertility preservation: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

OBJECTIVES

To study the methods and strategies of fertility preservation in young women with stage I epithelial ovarian cancer (EOC), in order to provide recommendations for clinical practice.

METHODS

The PubMed database was searched for english and french language articles, between 2005 and 2001, according to predefined search equations.

RESULTS

Young patients with stage IA EOC willing to conceive should be informed that conservative treatment (contralateral ovary and salpinx, uterus) is possible (GradeC), associated with a 6 % to 13 % recurrence risk (GradeC) on the remaining ovary. This conservative surgical treatment includes adnexectomy, peritoneal and lymph node staging for all subtypes, and additional endometrial curettage for endometriosis and mucinous subtypes (GradeC). In case of positive staging conservative treatment is not possible. In case of mucinous EOC with an infiltrative pattern, lymph node staging is not necessary. Multidisciplinary analysis (including oncologists and reproductive medicine specialists) of the risk-benefit balance for a conservative surgery is recommended and must rely on a complete final pathology report (GradeC). No recommendation on bilateral adnexectomy and uterine conservation to allow pregnancy using egg donation can be provided in case of low-grade stage IA EOC, in the absence of data. Bilateral adnexectomy and uterine conservation to allow pregnancy using egg donation can be offered in case of serous, mucinous or endometrioid high-grade FIGO stage IA or low-grade FIGO stage IC1 or IC2 EOC (GradeC). Preservation of the uterus and contralateral ovary and Fallopian tube can be discussed with a specialized rare ovarian tumors multidiciplinary staff in case of clear cell stage I EOC.

Fertility sparing surgery for ovarian sex cord stromal tumors: a nine case series

Ovarian Sex Cord Stromal Tumors (SCST) are a rare disease carrying a good prognosis. They generally affect young women; therefore fertility preservation is a critical issue. Fertility Sparing Surgery (FSS) showed promising results in both oncologic safety and fertility preservation. A retrospective case series involving 9 patients diagnosed with SCST and treated with fertility sparing surgery at our institution was conducted between January 2000 and May 2015. The median age was 24 years old (10 to 39). The main clinical manifestation was pelvic pain seen in seven patients. Five patients complained about menstrual cycle disorders. The nine patients went through fertility sparing surgery; seven had conservative staging and the other two had a unilateral salpingo-oophorectomy. Three patients out of nine had a pelvic unilateral lymphadenectomy. Two patients received adjuvant chemotherapy. Only two patients presented locoregional recurrence that occurred respectively after 7 and 192 months. The treatment combined chemotherapy and surgery based on mass resection. One patient achieved a natural pregnancy after the treatment. FSS seems to be a suitable approach for SCST. However, more case series and meta-analysis should be conducted.

Surgical manual of the Korean Gynecologic Oncology Group: ovarian, tubal, and peritoneal cancers

The Surgery Treatment Modality Committee of the Korean Gynecologic Oncology Group has determined to develop a surgical manual to facilitate clinical trials and to improve communication between investigators by standardizing and precisely describing operating procedures. The literature on anatomic terminology, identification of surgical components, and surgical techniques were reviewed and discussed in depth to develop a surgical manual for gynecologic oncology. The surgical procedures provided here represent the minimum requirements for participating in a clinical trial. These procedures should be described in the operation record form, and the pathologic findings obtained from the procedures should be recorded in the pathologic report form. Here, we describe surgical procedure for ovarian, fallopian tubal, and peritoneal cancers.

Fertility Preservation: A Key Survivorship Issue for Young Women with Cancer

Fertility preservation in the young cancer survivor is recognized as a key survivorship issue by the American Society of Clinical Oncology and the American Society of Reproductive Medicine. Thus, health-care providers should inform women about the effects of cancer therapy on fertility and should discuss the different fertility preservation options available. It is also recommended to refer women expeditiously to a fertility specialist in order to improve counseling. Women’s age, diagnosis, presence of male partner, time available, and preferences regarding use of donor sperm influence the selection of the appropriate fertility preservation option. Embryo and oocyte cryopreservation are the standard techniques used while ovarian tissue cryopreservation is new, yet promising. Despite the importance of fertility preservation for cancer survivors’ quality of life, there are still communication and financial barriers faced by women who wish to pursue fertility preservation.