A review of the fertility sparing approach to endometrial cancer: Current recommendations

Abstract

© 2013, Oncology Institute of Vojvodina, Sremska Kamenica Endometrial cancer is the most common cancer of the female genital tract; with 20%-25% diagnosed pre-menopausally, the median age in this group of patients is 40 yrs (range 31-45 yrs) (1). However future fertility is an issue for these young patients as many as 61%-79% are nulliparous compared to 24% in the older group (1). In women with early stage endometrial cancer the standard surgical treatment of total hysterectomy, bilateral salpingo-oophorectomy (TAHBSO) and possible lymph node assessment is often not acceptable. The conservative fertility retaining option is often only possible in a select group of early stage cases, and in these cases the risks are something that needs to be carefully weighed. The low risk group of grade 1 endometrioid adenocarcinoma confined to the endometrium without lymphovascular space invasion (LVSI) or disease outside the uterus are those who may be candidates for conservative treatment. Since these patients do not undergo the usual surgical staging procedure they need to be carefully evaluated. Indeed as survival in these group approaches 95% and above it can be difficult to contemplate the risk associated option of conservative management. However it is not uncommon for women to come to clinic and request this line of management. It is important that several factors are assessed before contemplating the conservative option. Pre-treatment investigation must include a hysteroscopy and biopsy and contrast MRI. The biopsy will give information regarding cell type i.e. endometrioid adenocarcinoma, grade 1 and may exclude the presence of LVSI and may also detect myometrial invasion. The contrast-enhanced MRI is used to assess the primary tumour and exclude myometrial invasion. In addition it can be used to exclude cervical or extra uterine disease including lymph nodal involvement. This group of patients with grade 1 cancer and no myometrial invasion (i.e. presumed IA) will have a risk of lymph nodal disease of approximately 3%-5% (2). Some clinicians have advocated a laparoscopy with concurrent peritoneal washings and a preoperative CA125. Others recommend a PET scan for evaluation at distant sites but microscopic disease will not be detected. The continual evaluation of the sentinel node procedure may be relevant in these early cases to evaluate and exclude lymph node involvement. Finally, the case should be evaluated in a multi-disciplinary team setting, the options discussed and a treatment plan reached (see Table 1 for prerequisites). All other cases other than grade 1, endometrioid adenocarcinoma without apparent LVSI, myometrial, cervical or extrauterine disease should be offered standard treatment involving surgery including TAH BSO, pertioneal washes and possibly lymph nodal harvest (pelvic with/without para-aortic nodes). Table 1. Pre-treatment factors that need to be met prior to conservative management • Age less than 45 years and wishes fertility, understands consent implications • Grade 1 endometrioid carcinoma • No LVSI • MRI: no myometrial invasion • No evidence of – Cervical involvement, – Ovarian involvement, – Lymph nodal involvement, or – Other extra-uterine disease • MDM confirmed G1 (2 gynoncology pathologists review) • stage IA confined to endometrium