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Choi CH, Lee YY, Lai YL, Chang K, Kim HS, Chen J, Chen YL. Outcomes of extended progestin therapy in atypical endometrial hyperplasia patients without an initial response to progestin: a retrospective study from two tertiary centers in Korea and Taiwan. J Gynecol Oncol 2024; 36:36.e18. [PMID: 39028151 DOI: 10.3802/jgo.2025.36.e18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVE In this study, we evaluated the role of prolonged progestin treatment on atypical endometrial hyperplasia (AEH) patients who did not achieve complete regression (CR) after at least 3 months of progestin treatment. Possible prognostic factors predicting disease regression and recurrence were also assessed. METHODS We retrospectively identified patients who had histologically confirmed persistent disease after at least 3 months of progestin treatment at two tertiary centers in Korea and Taiwan. Clinicopathologic factors and clinical outcomes were obtained from medical records. Logistic regression was used to analyze the relationship between covariates and the probability of CR and relapse. RESULTS Fifty-two patients were included. Thirty-seven of 52 patients (71.2%) achieved CR after prolonged progestin treatment. Median time from starting progestin treatment to CR was 12.0 months. Daily administration of medroxyprogesterone acetate ≥200 mg or megestrol acetate ≥80 mg was associated with higher probability of regression. Nineteen of 37 patients (51.4%) experienced recurrence, with median time from CR to relapse of 15.0 months. Body mass index ≥27 was associated with higher relapse probability. Twelve of 16 patients with disease progression to endometrial carcinoma underwent surgery. The 12 cases had stage I tumors and lived without disease. CONCLUSION Extension of progestin treatment course is feasible for AEH patients without an initial response to progestin. Higher daily progestin dosage was associated with higher probability of CR, and obesity was associated with higher risk of relapse. The patients without an initial response to progestins and whose AEH progressed to endometrial carcinoma had good prognoses.
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Affiliation(s)
- Chel-Hun Choi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo-Young Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yen-Ling Lai
- Department of Obstetrics and Gynecology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Koping Chang
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hyun-Soo Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Yu-Li Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Chen J, Cao D. Fertility-sparing re-treatment for endometrial cancer and atypical endometrial hyperplasia patients with progestin-resistance: a retrospective analysis of 61 cases. World J Surg Oncol 2024; 22:169. [PMID: 38918837 PMCID: PMC11202344 DOI: 10.1186/s12957-024-03439-w] [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: 04/20/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the oncological and reproductive outcomes of fertility-preserving re-treatment in progestin-resistant endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) women who desire to maintain their fertility. METHODS Our study included 61 progestin-resistant EC/AEH patients. These patients underwent treatment with gonadotropin-releasing hormone agonist (GnRHa) solely or a combination of GnRHa with levonorgestrel-releasing intrauterine system (LNG-IUD) or aromatase inhibitor (AI). Histological evaluations were performed every 3-4 months. Upon achieving complete remission (CR), we recommended maintenance treatments including LNG-IUD, cyclical oral contraceptives, or low-dose cyclic progestin until they began attempting conception. Regular follow-up was conducted for all patients. The chi-square method was utilized to compare oncological and fertility outcomes, while the Cox proportional hazards regression analysis helped identify risk factors for CR, recurrence, and pregnancy. RESULTS Overall, 55 (90.2%) patients achieved CR, including 90.9% of AEH patients and 89.7% of EC patients. The median re-treatment time was 6 months (ranging from 3 to 12 months). The CR rate for GnRHa alone, GnRHa + LNG-IUD and GnRHa + AI were 80.0%, 91.7% and 93.3%, respectively. After a median follow-up period of 36 months (ranging from 3 to 96 months), 19 women (34.5%) experienced recurrence, 40.0% in AEH and 31.4% in EC patients, with the median recurrence time of 23 months (ranging from 6 to 77 months). Among the patients who achieved CR, 39 expressed a desire to conceive, 20 (51.3%) became pregnant, 11 (28.2%) had successfully deliveries, 1 (5.1%) was still pregnant, while 8 (20.5%) suffered miscarriages. CONCLUSION GnRHa-based fertility-sparing treatment exhibited promising oncological and reproductive outcomes for progestin-resistant patients. Future larger multi-institutional studies are necessary to confirm these findings.
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Affiliation(s)
- Junyu Chen
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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Wei H, Pan N, Zhang W, Xiong G, Guo W, Dong Z, Ma C. Levonorgestrel-releasing intrauterine system-based therapies for early-stage endometrial cancer: a systematic review and meta-analysis. J Gynecol Oncol 2023; 34:e36. [PMID: 36731895 PMCID: PMC9995869 DOI: 10.3802/jgo.2023.34.e36] [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: 10/24/2022] [Revised: 11/23/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of studies evaluating the oncological and fertility outcomes of early-stage endometrial cancer (EC) treated with the levonorgestrel-releasing intrauterine system (LIUS)-based regimens. METHODS The Meta-analyses Of Observational Studies in Epidemiology statement for meta-analyses was followed. Searches were conducted on MEDLINE, Embase, PubMed, Preprints, and the Cochrane Central Register of Controlled Trials from January 1990 to August 4, 2022. The Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment. The primary endpoint was the complete response (CR) rate and the secondary endpoints were relapse, pregnancy, and live birth rate. RESULTS A total of 25 studies (821 women) were included. The CR rate of LIUS-based regimens was 63.4% (95% confidence interval [CI]=52.3%-73.2%), with 29.6% (95% CI=23.3%-36.8%) of cases experiencing recurrence during follow-up. In sensitivity analyses, patients younger than 45 years of age with a body mass index <30 kg/m² who were treated with LIUS-based regimens achieved a high CR rate of 84.6% (95% CI=80.3%-88.1%) over a median follow-up of more than 24 months. Overall pregnancy and live birth rates were 37.9% (95% CI=24.1%-53.9%) and 39.3% (95% CI=24.0%-57.0%), respectively. No statistical differences were apparent in CR or relapse rates among the LIUS+GnRH agonist, LIUS+oral progesterone, or hysteroscopic resection followed by LIUS subgroups. CONCLUSION LIUS-based therapies are viable for the conservative management of early-stage endometrioid EC on CR and fertility outcome. TRIAL REGISTRATION PROSPERO Identifier: CRD42022352890.
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Affiliation(s)
- Hongyi Wei
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Ningning Pan
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Wen Zhang
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Guangwu Xiong
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Wenping Guo
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Zhe Dong
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, China
| | - Caihong Ma
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.
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Zhang X, Chen D, Zhao X, Wang C, He Y, Chen Y, Wang J, Shen D. Application of molecular classification to guiding fertility-sparing therapy for patients with endometrial cancer or endometrial intraepithelial neoplasia. Pathol Res Pract 2023; 241:154278. [PMID: 36580798 DOI: 10.1016/j.prp.2022.154278] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/27/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether molecular classification was associated with treatment response in women with endometrial endometrioid carcinoma (EEC) or Endometrial atypical hyperplasia/endometrial intraepithelial neoplasia (EAH/EIN) treated with progestin. METHODS A retrospective analysis of 59 patients with EEC or EAH/EIN who received fertility-sparing therapy between 2013 and 2021 was performed. For each patient, medical records and pathological reports were reviewed. The treatment efficacy and tumor prognosis were evaluated. Immunohistochemistry analysis for p53 and MSH2, MSH6, PSM2, MLH1 were performed. Molecular classification was analyzed using a 11-gene panel based on next generation sequencing technology. RESULTS 23 of 39 patients with EEC received complete response (CR) after fertility-sparing treatment which was significantly lower than the EAH/EIN group (58.97 % vs 80.0 %, P < 0.05). Molecular classification via the Cancer Genome Atlas (TCGA) algorithm was successfully applied to 59 cases. The distribution of specimens into the four molecular classes was as follows: 83.05 % (49/59) CNL(copy number-low),6.78 % (4/59) MSI-H (microsatellite instability -high), 5.08 %(3/59) POLE-mutated and 5.08 % (3/59) CNH(copy number-high). MSI and TP53 sequencing results were concordant with immunohistochemistry analyses of MMR and p53 protein. The patients with CNH and MSI-H subtypes showed worse prognosis than those with POLE-mutated and CNL subtypes. CONCLUSIONS Molecular classification of EAH/EIN prior to management with progestin treatment was feasible and may predict patients at risk of progression.
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Affiliation(s)
- Xiaobo Zhang
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China
| | - Deyi Chen
- Xiamen Spacegen Co., Ltd, Xiamen 361000, China
| | - Xiaoya Zhao
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China
| | - Chen Wang
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China
| | - Yijiao He
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Yan Chen
- Xiamen Spacegen Co., Ltd, Xiamen 361000, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China.
| | - Danhua Shen
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China.
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Mutlu L, Manavella DD, Gullo G, McNamara B, Santin AD, Patrizio P. Endometrial Cancer in Reproductive Age: Fertility-Sparing Approach and Reproductive Outcomes. Cancers (Basel) 2022; 14:cancers14215187. [PMID: 36358604 PMCID: PMC9656291 DOI: 10.3390/cancers14215187] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
Endometrial cancer is the most common gynecologic malignancy in developed countries and approximately 7% of the women with endometrial cancer are below the age of 45. Management of endometrial cancer in young women who desire to maintain fertility presents a unique set of challenges since the standard surgical treatment based on hysterectomy and salpingo-oophorectomy is often not compatible with the patient's goals. A fertility-preserving approach can be considered in selected patients with early stage and low-grade endometrial cancer. An increasing amount of data suggest that oncologic outcomes are not compromised if a conservative approach is utilized with close monitoring until childbearing is completed. If a fertility-preserving approach is not possible, assisted reproductive technologies can assist patients in achieving their fertility goals.
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Affiliation(s)
- Levent Mutlu
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Diego D. Manavella
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Giuseppe Gullo
- IVF Unit AOOR Villa Sofia Cervello, 90146 Palermo, Italy
| | - Blair McNamara
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Alessandro D. Santin
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Pasquale Patrizio
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Correspondence: ; Tel.: +1-305-689-8003
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Analysis of IVF/ICSI outcomes in infertile women with early-stage endometrial cancer and atypical endometrial hyperplasia after conservative treatment. J Assist Reprod Genet 2022; 39:1643-1651. [PMID: 35648323 DOI: 10.1007/s10815-022-02475-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/19/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To investigate the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes and identify factors that might affect live births in patients with early-stage endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH). METHODS This retrospective study was performed in a tertiary hospital. Patients (n = 123) with EEC or AEH, who underwent IVF/ICSI treatment between January 2010 and December 2019, were divided into a live birth group and a non-live birth group. Clinical characteristics and IVF/ICSI outcomes were assessed. RESULTS A total of 123 patients (28 with EEC and 95 with AEH) underwent 215 ovarian stimulation cycles, resulting in 121 fresh embryo transfer (ET) and 108 frozen-thawed ET. Among 229 ET cycles, 91 (23.7%) of 384 embryos were implanted and 86 pregnancies were achieved, including five ectopic pregnancies (5.8%), 28 miscarriages (32.6%), and 53 live births (61.6%). The clinical pregnancy and live birth rates in each ET cycle were 37.6% and 23.1%, respectively. Fifty-one patients gave birth to 57 live neonates, and the cumulative live birth rate was 41.46%. Multiple logistic regression analysis showed that maternal age, histological type, thin endometrium, and time after complete remission (CR) to IVF cycle started were significantly associated with live births. CONCLUSIONS The live birth rate after IVF/ICSI is promising in infertile patients with EEC and AEH. A shorter interval between CR and IVF/ICSI treatment might be a positive factor, while age > 35 years, endometrial thickness < 8 mm on the day of ET, and degree of endometrial lesion progressing into carcinoma can negatively influence IVF/ICSI outcomes.
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Endometrial Cancer Management in Young Women. Cancers (Basel) 2022; 14:cancers14081922. [PMID: 35454829 PMCID: PMC9033146 DOI: 10.3390/cancers14081922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/30/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Endometrial cancer (EC) rarely develops in young women. Most cases are associated with known risk factors: BMI > 30, history of Polycystic Ovary Syndrome (PCOs), and race differentiation. The molecular EC classification based on The Cancer Genome Atlas Research Network divides these heterogeneous cancers into four types: Polymerase Epsilon Mutation (POLE), Microsatellite Instability (MSI), Copy Number Low (CNL), and Copy Number High (CNH). This division was introduced to allow for early assessment of neoplastic changes and clinical management, including targeted therapies. The basic technique for imaging endometrium changes is transvaginal sonography. Hysteroscopy is the standard for obtaining endometrial material for histological evaluation. The MRI result permits assessment of the extent of EC cancer infiltration. In young women who want to preserve fertility, apart from surgery, conservative management is often implemented after strict selection based on clinical and pathological data. This pharmacological treatment involves the administration of progestogens MPA (medroxyprogesterone acetate) and MA (megestrol acetate). The use of metformin may increase the effectiveness of such treatment. An alternative option is to apply progestogens locally—via the levonorgestrel-releasing intrauterine device. In addition to pharmacological treatment, hysteroscopic resection may be used—part of the uterine muscle adjacent to the pathologically changed endometrium may also undergo resection. An alternative is the administration of estrogen receptor modulators (e.g., SERMs) or aromatase inhibitors, or GnRH agonists.
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Contreras NA, Sabadell J, Verdaguer P, Julià C, Fernández-Montolí ME. Fertility-Sparing Approaches in Atypical Endometrial Hyperplasia and Endometrial Cancer Patients: Current Evidence and Future Directions. Int J Mol Sci 2022; 23:ijms23052531. [PMID: 35269674 PMCID: PMC8910633 DOI: 10.3390/ijms23052531] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022] Open
Abstract
Endometrial cancer (EC) is the fourth most common cancer in women in developed countries. Although it is usually diagnosed in postmenopausal women, its incidence has increased in young women, as well in recent decades, with an estimated rate of 4% in those under 40 years of age. Factors involved in this increase, particularly in resource-rich countries, include delayed childbearing and the rise in obesity. The new molecular classification of EC should help to personalize treatment, through appropriate candidate selection. With the currently available evidence, the use of oral progestin either alone or in combination with other drugs such as metformin, levonorgestrel-releasing intrauterine devices and hysteroscopic resection, seems to be feasible and safe in women with early-stage EC limited to the endometrium. However, there is a lack of high-quality evidence of the efficacy and safety of conservative management in EC. Randomized clinical trials in younger women and obese patients are currently underway.
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Affiliation(s)
| | - Jordi Sabadell
- Department of Gynaecology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Paula Verdaguer
- Department of Gynaecology-ASSIR, Ronda General Prim 35, Mataró, 08302 Barcelona, Spain;
| | - Carla Julià
- Department of Gynaecology, Hospital de Viladecans, Avda de Gavà 38, Viladecans, 08840 Barcelona, Spain;
| | - Maria-Eulalia Fernández-Montolí
- Department of Gynaecology, Hospital Universitari de Bellvitge, Universitat de Barcelona-IDIBELL, Feixa Llarga s/n, L´Hospitalet de LLobregat, 08907 Barcelona, Spain
- Correspondence: or
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