ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background: The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. Objectives: To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. Materials and Methods: ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. Results: The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. Conclusions: These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma

Background

The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment.

Objectives

To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma.

Materials and Methods

ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

Results

The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues.

Conclusions

These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

The INTERNATIONAL MISSION study: minimally invasive surgery in ovarian neoplasms after neoadjuvant chemotherapy

OBJECTIVES

The aim of this retrospective multicenter study was to investigate the extent, feasibility, and outcomes of minimally invasive surgery at the time of interval debulking surgery in different gynecological cancer centers.

METHODS/MATERIALS

In December 2016, 20 gynecological cancer centers were contacted by e-mail, to participate in the INTERNATIONAL MISSION study. Seven centers confirmed and five were included, with a total of 127 patients diagnosed with advanced epithelial ovarian cancer after neoadjuvant chemotherapy and minimally invasive interval surgery. Only women with a minimum follow-up time of 6 months from interval surgery or any cancer-related event before 6 months were included in the survival analysis. Baseline characteristics, chemotherapy, and operative data were evaluated. Survival analysis was evaluated using the Kaplan-Meier method. RESULTS : All patients had optimal cytoreduction at the time of interval surgery: among them, 122 (96.1%) patients had no residual tumor. Median operative time was 225 min (range 60 - 600) and median estimated blood loss was 100 mL (range 70 - 1320). Median time to discharge was 2 days (1-33) and estimated median time to start chemotherapy was 20 days (range 15 - 60). Six (4.7%) patients experienced intraoperative complications, with one patient experiencing two serious complications (bowel and bladder injury at the same time). There were six (4.7%) patients with postoperative short-term complications: among them, three patients had severe complications. The conversion rate to laparotomy was 3.9 %. Median follow-up time was 37 months (range 7 - 86): 74 of 127 patients recurred (58.3%) and 31 (24.4%) patients died from disease. Median progression-free survival was 23 months and survival at 5 years was 52 % (95% CI: 35 to 67).

CONCLUSIONS

Minimally invasive surgery may be considered for the management of patients with advanced ovarian cancer who have undergone neoadjuvant chemotherapy, when surgery is limited to low-complexity standard cytoreductive procedures.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

[Meigs' syndrome caused by bilateral ovarian fibroma mimicking ovarian cancer]

We report the case of a 55-year-old patient who pre- sented a pelvic mass, ascites and elevated serum CA125. Suspecting a malignant process she underwent surgery and a total hysterectomy with bilateral salpigo-oforectomy was performed. Pathologic report revealed a bilateral ovarian fibroma and non-tumoral ascites. The presence of elevated serum CA125 levels in a postmenopausal woman with a pelvic mass and ascites suggest an ovarian malignant disease. However, in case of Meigs'syndrome, all symptoms will diappear after removal of the pelvic tumor, so a fast surgical management of the patients is mandatory.

Intravascular leiomyomatosis: an exceptional entity

Intravenous leiomyomatosis (IVL) is a rare benign condition characterized by the proliferation of smooth muscle cells originating from either the uterine venous wall or a uterine myoma. This leiomyomatosis extends most frequently to pelvic vessels, but also occasionally into the inferior vena cava and right cardiac chambers. Preoperative diagnosis is difficult and it should be suspected in the presence of cardiac or pelvic masses in women who have undergone hysterectomy or myomectomy previously. The treatment is hysterectomy, normally associated with a bilateral oophorectomy and removing the mass or metastasis if any. The post-surgical follow-up should be performed at long-term and include exploration and imaging, either ultrasound or MRI. The association of antiestrogenic drugs can be useful for disease control, especially in cases where oophorectomy is not performed and the tumor cannot be removed completely.

Carcinoma of the recto-vaginal septum. Comprehensive literature review

Carcinoma of the recto-vaginal septum is an extremely rare entity. We performed a MEDLINE-based search on recto-vaginal septum carcinoma, focussing on its management, in order to clarify which are the best treatment options for this disease. In addition an unpublished case report has been added to the review. 34 case reports were included in our review. Surgery and adjuvant chemoradiation therapy seem to be the most common treatment option. However, since primary surgical treatment leads to mutilation by removing a large portion of the vagina and the anal sphincter with a permanent terminal colostomy, primary platinum-based chemoradiation therapy could be considered. In case of extragastrointestinal stromal tumours primary surgical treatment seems to be the best option. Due to the rarity of this entity only limited data is available. Therefore further investigation is necessary.

Granular cells tumor of the vulva: an exceptional entity

INTRODUCTION

Granular cells tumor (GCT) is a rare tumor that develops on skin and soft tissues. Only 1-2% of these tumors present malignant behavior.

MATERIAL AND METHODS

The authors report three cases of GCT and review the management of these tumors.

CASE REPORT

The first case is a 73-year-old woman who was diagnosed with an atypical GCT. She was treated with local excision and then presented a local recurrence 21 months after the surgery. The other two cases are 60- and 58-year-old women diagnosed with a benign GCT. They were treated with single excision; both patients underwent second surgery due to margin affectation.

CONCLUSION

Management of GCT is not clear nowadays. The careful selection of patients with poor prognostic factors is very important. Follow-up for early diagnosis of local recurrence and metastases of these tumors is of utmost importance.

Experience and results of office hysteroscopy at a primary hospital

Our aim was to analyse, retrospectively, the perioperative outcomes of 3,488 office hysteroscopies. Age, menopausal status, parity, medical indications, use or not of anaesthesia, incidents, presence of pathology in the cavity, endometrial pathology, type of surgery and pain assessment details were collected. The mean age of patients was 52.1 years. The most common medical indication was suspicious ultrasound for endometrial disease, and the most frequent symptom was metrorrhagia. We did not use any type of anaesthesia in 89.5% of patients and we could access the uterine cavity in 99.4% of cases. The complication rate was very low though 12% of patients reported severe pain while performing the test. Although office hysteroscopy in outpatients is fully established and is usually well tolerated, there is a group of patients who could benefit from analgesic treatment prior to the test, to improve their tolerance.

Conservative treatment of early stage ovarian cancer: oncological and fertility outcomes

BACKGROUND

Ovarian cancer may appear in young women during their reproductive age. As a result of late childbearing nowadays, fertility preservation has become a major issue in young women with gynecological cancer. The aim of this review is to update the current knowledge on conservative treatment and fertility preservation of women affected of early stage epithelial ovarian cancer.

MATERIAL AND METHODS

A web-based search in Medline and CancerLit databases on conservative treatment for early stage ovarian cancer has been carried out. All relevant information has been collected and analyzed.

RESULTS

Less than 40% of ovarian cancers are diagnosed at early stages. Conservative treatment may be considered in young patients with a relapse rate that ranges from 9% to 29%, and a 5-year survival ranging from 83% to 100%. Recurrences in the controlateral ovary has been reported to be less than 5%, with most of these patients being alive after savage treatments. Moreover, it has been reported good fertility outcomes after conservative treatment with a successful conception rate that ranges from 60% to 100%, with an abortion rate under 30% in all series reported.

CONCLUSIONS

Conservative treatment for early epithelial ovarian cancers could be a safe option for women younger than 40 years who wish to preserve their childbearing potential. We need a strict case selection such as FIGO stage I grade 1 and 2, although grade 3 cases could be considered.

Nodal involvement evaluation in advanced cervical cancer: a single institutional experience

PURPOSE

To assess the usefulness of different imaging techniques in the detection of nodal involvement in patients with advanced cervical carcinoma. Moreover, to analyze the correlation between the presurgical (FIGO) and postsurgical (pTNM) staging classifications.

MATERIALS AND METHODS

All patients diagnosed with advanced cervical cancer (FIGO Stages IIB-IV) from 2005 to 2012 were selected. The medical charts of 51 patients that underwent presurgical assessment with posterior surgical staging by means of para-aortic lymphadenectomy, were reviewed. Nodal status assessment by computed tomography scan (CT scan), magnetic resonance imaging (MRI), positron emission tomography (PET), and sonography was compared, as well as the size given in imaging techniques compared to the final pathologic report information.

RESULTS

Presurgical analysis by CT scan, MRI, PET, and sonography showed pelvic nodal involvement in 51.3% of patients, and para-aortic involvement in 30.8% of cases. CT scan showed positive pelvic nodes in 35% of cases, but pathologic confirmation was observed in just 17.6% of cases. However, MRI resulted in higher rates of up to 48.8% of cases. Concerning para-aortic nodal involvement, CT scan showed positive nodes in 25% of cases, MRI in 3.2% of cases, and the pathologic report in 15.6% of cases. The authors found significant differences between staging groups among both classifications (FIGO vs. pTNM; p < 0.001). Eight cases (15.7%) were understaged by FIGO classification.

CONCLUSIONS

Despite all imaging techniques available, none has demonstrated to be efficient enough to avoid the systematic study of para-aortic nodal status by means of surgical evaluation.

Management of recurrent cervical cancer: a review of the literature

OBJECTIVE

The aim of this narrative review is to update the current knowledge on the treatment of recurrent cervical cancer based on a literature review.

MATERIAL AND METHODS

A web based search in Medline and CancerLit databases has been carried out on recurrent cervical cancer management and treatment. All relevant information has been collected and analyzed, prioritizing randomized clinical trials.

RESULTS

Cervical cancer still represents a significant problem for public health with an annual incidence of about half a million new cases worldwide. Percentages of pelvic recurrences fluctuate from 10% to 74% depending on different risk factors. Accordingly to the literature, it is suggested that chemoradiation treatment (containing cisplatin and/or taxanes) could represent the treatment of choice for locoregional recurrences of cervical cancer after radical surgery. Pelvic exenteration is usually indicated for selected cases of central recurrence of cervical cancer after primary or adjuvant radiation and chemotherapy with bladder and/or rectum infiltration neither extended to the pelvic side walls nor showing any signs of extrapelvic spread of disease. Laterally extended endopelvic resection (LEER) for the treatment of those patients with a locally advanced disease or with a recurrence affecting the pelvic wall has been described.

CONCLUSIONS

The treatment of recurrences of cervical carcinoma consists of surgery, and of radiation and chemotherapy, or the combination of different modalities taking into consideration the type of primary therapy, the site of recurrence, the disease-free interval, the patient symptoms, performance status, and the degree to which any given treatment might be beneficial.

Bax expression in untreated breast cancer: an immunocytometric study of 255 cases

BACKGROUND

Bax is one of the main effectors of apoptosis in breast cancer. However, in contrast with the antiapoptotic protein Bcl-2, which has been extensively studied in this tumor, there are relatively few clinical studies on the biological role of Bax in breast cancer.

MATERIALS AND METHODS

The expression of the apoptosis-related Bax gene was studied in a series of 255 previously untreated breast cancers by means of immuno-flow cytometry. Additionally, and by the same method, the expression of the Bcl-2, VEGF and Nup88 genes were also studied. As variables of the study for the final statistical analysis, the histological variety of the tumors, histological and nuclear grade, the expression of hormone receptors, p53, Ki-67 or c-erb-B2, axillary node invasion, tumor size and DNA-ploidy were also included.

RESULTS

The expression of the proapoptotic Bax protein was significantly associated with the expression of Nup88 (p<0.0001), VEGF (p=0.0014) and Bcl-2 (p=0.0063), all measured by the same method. An inverse correlation with c-erb-B2 expression, which almost attained statistical significance (p=0.058) was also registered.

CONCLUSION

This study adds evidence to the little explored link between apoptosis and angiogenesis. Furthermore, it discloses a previously unreported relationship between Bax and Nup88 expression.