Review ArticleUpdates on Conservative Management of Endometrial Cancer
Section snippets
Candidates for Conservative Management
The most recent National Comprehensive Cancer Network (NCCN) guidelines provide specific details regarding ideal candidates and options to be considered in young women interested in future fertility [16]. The patient must be diagnosed with well-differentiated (grade 1) endometrioid adenocarcinoma on dilation and curettage (D&C) that is confirmed by expert pathology review. Disease must be limited to the endometrium on magnetic resonance imaging (MRI) (preferred) or transvaginal ultrasound.
Diagnosis
An endometrial biopsy has been the hallmark study when diagnosing endometrial cancer. However, some have proposed that a pipelle biopsy may be inferior to a D&C when making this diagnosis. In a study by Leitao et al [18], the authors showed that by performing a D&C only 8.7% of patients were upgraded in the final specimen compared with 17.4% of those patients who had a pipelle biopsy (p < .007) [18]. One may also consider that a D&C may not only be diagnostic but also therapeutic because it may
Role of Imaging Studies
Myometrial invasion is another important prognostic factor in patients with endometrial cancer. According to the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) 26th Annual Report, the 5-year overall survival rate in patients with tumors limited to the endometrium is as high as 90.8%; however, this rate drops to 85.4% when deep myometrial invasion is identified [20]. The imaging study of choice for preoperative assessment of myometrial invasion is not specified; however,
Hormonal Therapy
When considering the pathophysiology of endometrial hyperplasia and cancer, it is well-known that endometrioid precancerous lesions arise from the prolonged exposure of the endometrium to estrogen without the opposing effect of progestins, which are associated with the inhibition of endometrial proliferation. Despite having shown efficacy, many studies have tested the presence of estrogen and progesterone receptors in an attempt to predict the response of treatment. However, recent guidelines
Hysteroscopic Tumor Resection and Progestational Therapy
As a more directed and targeted approach, hysteroscopic tumor resection of localized endometrial hyperplasia or carcinoma has been considered by a number of authors. This is with the intent to remove the primary site of disease and follow this intervention with further progestational therapy. The first of the cases reported was of a 30-year old woman with Lynch syndrome who underwent a hysteroscopic polypectomy that demonstrated endometrial cancer. She was managed conservatively for 3 months
Surveillance
When discussing a conservative approach with patients diagnosed with endometrial cancer, it is imperative that the patient understand that frequent follow-up visits and periodic endometrial resampling are mandatory. The frequency of the sampling remains a topic of debate, but current guidelines recommend uterine reevaluation every 3 to 6 months 16, 17. Another area of controversy is the method of reevaluation; however, a D&C offers the most accurate tool to obtain adequate amounts of tissue,
Ongoing Prospective Clinical Trials
Currently, there are a number of prospective trials evaluating several strategies in the conservative management of patients with endometrial cancer. The feMMe trial [44] is a 3-arm, randomized multicenter study with the objective of testing the efficacy of conservative treatment in women (body mass index >30 kg/m2) with early endometrial cancer. Patients are randomized to 1 of 3 treatment arms: levonorgestrel IUD, levonorgestrel IUD + weight loss intervention, or levonorgestrel
Summary
Uterine preservation is a safe and feasible option in select young women interested in future fertility. It is important to note that only those patients with complex atypical hyperplasia or grade 1 endometrial endometrioid adenocarcinoma are candidates for such conservative approach. Adequate pretreatment evaluation is key, and all patients should undergo pelvic MRI and a D&C to confirm no evidence of myometrial invasion and the appropriate diagnosis. Although there is no established standard
References (44)
- et al.
Impact of weight change and weight cycling on risk of different subtypes of endometrial cancer
Eur J Cancer
(2013) - et al.
Insulin resistance and endometrial cancer risk: a systematic review and meta-analysis
Eur J Cancer
(2015) - et al.
Management options and fertility-preserving therapy for premenopausal endometrial hyperplasia and early-stage endometrial cancer
Int J Gynaecol Obstet
(2015) - et al.
Young patients with endometrial cancer: how many could be eligible for fertility-sparing treatment?
Gynecol Oncol
(2009) - et al.
Comparison of D&C and office endometrial biopsy accuracy in patients with FIGO grade 1 endometrial adenocarcinoma
Gynecol Oncol
(2009) - et al.
Endometrial cancer
Lancet
(2016) - et al.
Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review
Gynecol Oncol
(2004) - et al.
Oncologic and reproductive outcomes with progestin therapy in women with endometrial hyperplasia and grade 1 adenocarcinoma: a systematic review
Gynecol Oncol
(2012) - et al.
Endometrioid adenocarcinoma treated by hysteroscopic endomyometrial resection
J Minim Invasive Gynecol
(2007) - et al.
Conservative surgical management of stage IA endometrial carcinoma for fertility preservation
Fertil Steril
(2010)
Conservative treatment of early endometrial cancer: preliminary results of a pilot study
Gynecol Oncol
Sparing fertility in young patients with endometrial cancer
Gynecol Oncol
Impact of obesity on the results of fertility-sparing management for atypical hyperplasia and grade 1 endometrial cancer
Gynecol Oncol
Improving treatment for obese women with early stage cancer of the uterus: rationale and design of the levonorgestrel intrauterine device +/- metformin +/- weight loss in endometrial cancer (feMME) trial
Contemp Clin Trials
Cancer of the endometrium-cancer stat facts
Should we be more aware of endometrial cancer in adolescents?
Dev Period Med
Endometrial adenocarcinoma in a 13-year-old girl
Obstet Gynecol Sci
SEER Cancer Statistitcs Review
A systematic review and meta-analysis of physical activity and endometrial cancer risk
Eur J Epidemiol
Evidence of a causal association between insulinemia and endometrial cancer: a Mendelian randomization analysis
J Natl Cancer Inst
Endometrial cancer risk factors among Lynch syndrome women: a retrospective cohort study
Br J Cancer
Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome: a systematic review and meta-analysis
Hum Reprod Update
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Dr. Westin has research funding from Novartis, AstraZeneca, and Critical Outcomes Technologies, Inc., and has received consulting fees from AstraZeneca, Clovis, Roche/Genentech, Casdin Capital, Ovation, Vermilion, and Medivation.