Fertility-preserving Management of Endometrial Carcinoma

European Oncology & Haematology, 2011;7(3):191-5

Abstract:

Endometrial cancer is the most common gynaecological malignancy, usually diagnosed in post-menopausal women. However, an incidence of 2–14 % of cases occurring in women <45 years of age has been reported. In this group of younger patients, because of the childbearing challenges, there is an increased percentage of nulliparity. Due to the early disease stage and the low grade of differentiation at the time of diagnosis, an improved prognosis has been reported in this group of patients. Many reports have described conservative treatment of this tumour in selected patients with the aim of preserving fertility. In this article, we review the literature for a better assessment of selection criteria, risk of concomitant neoplasias, hormonal treatment and clinical and reproductive outcome. We have concluded that fertility-preserving management of endometrial cancer is feasible in selected patients with an acceptable clinical and reproductive outcome.
Keywords: Endometrial carcinoma, conservative treatment, fertility sparing, young patients
Disclosure: The authors have no conflicts of interest to declare.
Received: October 08, 2010 Accepted January 14, 2011 Citation European Oncology & Haematology, 2011;7(3):191-5
Correspondence: Sonsoles Alonso, MD Anderson International Spain, C/ Arturo Soria 270, 28033 Madrid, Spain. E: salonso@mdanderson.es

Endometrial cancer is the most common gynaecological malignancy. The five-year survival rate is excellent: 84.3 % in Spain for all stages with complete treatment.1 The International Federation of Gynecology and Obstetrics (FIGO) stage is the independent criterion that best indicates the prognosis of this tumour. In the last FIGO Annual Report the five-year survival rate for surgical stage I was 90 %.2

In this article, we examine whether preserving fertility is a safe therapeutic option in selected cases of young women with endometrial cancer. We evaluate the characteristics of these young patients, selection of criteria and related problems, diverse treatment regimens, follow-up and reproductive outcome, using the evidence present in the literature. We consider young patients as those <45 years of age. Usually, diagnosis of endometrial cancer occurs in post-menopausal women after their sixth decade, with an average age of 61 to 64 years of age, depending on the series. The hormonal status of patients shows that only 11 % are pre-menopausal when diagnosed.1
Although it is uncommon in young patients, this malignancy is diagnosed in about 2–14 % of women ≥45 years of age. This broad age range is the reason for the variance in cut-off points for young patients in the different series. We diagnose this malignancy in women who have not borne children, and due to the challenge of childbirth, conservative treatment has been discussed in recent years as a safe therapeutic option for these patients. The current evidence is insufficient, but increasingly becoming more available via recent prospective studies and meta-analyses.

Characteristics of Young Patients

For a better assessment of selection criteria for conservative treatment, we consider different population characteristics. This is an initial point in recognising the behaviour of endometrial cancer in young women. The median age at diagnosis in this group of young women is 40 (range 31–45 years of age).
33,4 causing delay and making diagnosis a more difficult task, which sometimes accounts for the confusion with dysfunctional uterine bleeding.

We reported an increased percentage of sterility and nulliparity (61 % of patients <45 years of age were nulliparous versus 24 % in the older group).5 These results are even lower than those reported by other physicians, such as Navarria et al., who found a 79 % incidence of nulliparous patients.6 Other authors have accounted for an increased incidence of endometrial cancer in patients with other hormonal disorders related to an excessive oestrogen exposure, such as anovulation, polycystic ovary syndrome and obesity, all considered risk factors for endometrial cancer in young women.4,7,8

Some physicians emphasise the importance of a family history of malignancies, with 10–13 % of first-degree relatives affected with breast, colon, gastric, ovarian or endometrial cancer, or relatives affected with hereditary non-polyposis colorectal cancer (HNPCC).3,8 Previously, we described a higher rate of associated atypical hyperplasia in the young group (12.5 versus 2.4 %) and the histological type was more frequently grade 1 (62.5 versus 43 %) (see Table 1).1,5 The distribution of stages is nearly the same in both age groups, with a similar prevalence of stage I disease in both, although, in stage I, younger patients are more likely to present with disease confined to the uterus (Stage IA).5,9
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Keywords: Endometrial carcinoma, conservative treatment, fertility sparing, young patients
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