Download Fertility-Sparing Surgery in Gynaecological Oncology

Fertility Sparing
in
Gynecological Cancers
Melkeet singh
Department of O & G
Fertility Sparing Surgery in
Gynecological Cancers
Most common gynaecological cancers in
reproductive age group includes
- Cervical Cancer
- Endometrial Cancer
- Ovarian Cancer
Incidence of Gynaecological cancer in
Reproductive age group.
Incidence for (age < 49 year) /100000
 Cervical Cancer 1.5-14.9/100000
 Endometrial cancer 1.2-24 /100000
 Ovarian Cancer 1.6-16.6 /100000
Mean age of First Time
Mothers
Age 30-34 → 28.4%
Age 35-39 → 10.4%
Age 40-44 → 2%
 40% of first time births occurs beyond age of 30.
 Among the reproductive age group, those beyond age of 30
are at greater risk of malignancy - which can jeopardize
fertility.
 Need for fertility Sparing Surgery.
Cancer Treatment
Objective
Cure
Adverse Effects




Psychological effects
Cosmetic problems
Loss of organ function
Sexual and reproductive
dysfunction
Fertility Impaired
Goals / Objectives of FSS





Preservation of reproductive potential
Preservation of hormonal function
Similiar outcomes to standard therapy
Favorable obstetric outcome
Benefits > risk
FSS - Counseling
 Patient & family aware of the problem.
 Aware that they are assuming an undefined risk.
 Aware of limited data on the options.
 Options are not standard Therapeutic approaches.
 Patient must be extremely compliant with follow up.
 Once fertility completed, definitive procedure considered
FSS – Prerequisites
 Realistic probabilities of achieving conception based on
age, history and infertility evaluation
 Desire to preserve fertility
 Tumor factors-histologic type, grade.
 Availability of ART
Abnormal smear → Colposcopy + Biopsy → Cone Biopsy
•No
lesion
CIN
Microscopic CaCx
Horizontal ≤7mm + Invasion < 3 mm
≤ 7mm + Invasion 3-5 mm
1A1
>7mm
> 5 mm
1A2
1B1-11A
LVSI TAHBSO
Intracavitary RT
Fertility desired
CONE Enough.
1A1- LN mets 0.5%
Recurrence 2%
LVSI 8-29%
LVSI +
RH + PLND
Modified RH +PLND
•RT
Fertility desired
CONE + PLND
Trachelectomy + PLND
1A2 LN mets 6-14%
Recurrence 4%
LVSI 53%
In selected cases if
fertility
desired
Trachelectomy + PLND
Nodes positive → Radiotherapy
•Stage 1A1 – Squamous Carcinoma
•A loop cone excision of the cervix is sufficient treatment
.
Adenocarcinoma
•Skip lesions can occur
? Just Pre-invasive
Cone – Fertility & Pregnancy Outcome
(Clin. Exp. Obstet. Gynecol, 1992: 19(1):40-2)
NO EFFECT
< 15 mm
Frencezy A, 1995
Haffenden DK, 1993
Tan L, 2004
25% PRETERM LABOR
18% PROM
> 15 mm
Sadler L. Et al., Am J Med Ass, 2004
Trachelectomy
 Abdominal / Vaginal
 Nodes must be assessed prior to
procedure via frozen section
 Includes resection of the cervix + upper
2-cm of vagina + parametrium, with
preservation of the uterine corpus.
 The uterine corpus is then sutured to the
upper vagina.
 Cervical Circulage
Trachelectomy - Criteria








A desire for fertility.
No documentation of infertility.
A proven diagnosis of cervical cancer
Stage IA2 disease to stage IB1 disease
Tumor limited to cervix.
Tumor less than 2 cm
No evidence of nodal metastases.
Limited endo cervical involvement - Upper endocervical
margins free of tumour (Frozen section) & MRI
Trachelectomy -Results
Meta-analysis





Dargent (Lyon)
Plante and Roy (Quebec)
Covens (Toronto)
Shepherd (London, UK)
Total
Recurrences
Recurrences in Radical hysterectomy
5 years survival in both group
82
44
58
40
224
9(5.8%)
4.4%
97%
Pregnancy Outcome
Procedure 315
Documented 114 pregnancies in 97 patients
Live births 93
Fertil Steril 2005;84:156
Preserving Fertility in Endometrial
Cancer
2% -14 % of endometrial
cancer
 40 years
Up to 25%
PCOS
G1
Early stage
Respond to
progestin
treatment
Preserving Fertility in Endometrial
Cancer
Early Stage Ca Endo (Ia, G1)
Standard treatment
TAH + BSO +/PLND
Is there a fertility sparing surgery for cancer endometrium ?.
FSS in Endometrial Cancer
I. Mazzon, et al (2010) described a three-step Technique , each
characterized by a pathologic analysis.
(1) removal of the tumor,
(2) removal of endometrium adjacent to tumor
(3) removal of the myometrium underlying the tumor.
Followed by megestrol acetate 160 mg/day x 6 /12
Biopsies at 3, 6, 9, and 12 months were negative
4/6 (66%) achieved childbearing.
I. Mazzon, G. Corrado, V. Masciullo, D. Morricone, G. Ferrandina, and G.Scambia “Conservative surgical
management of stage IA endometrial carcinoma for fertility preservation,” Fertility and Sterility, vol. 93,
no. 4, pp. 1286–1289, 2010.
Conservative Management Endometrial Cancer
Criteria

Patient and family aware of the possible risk

Nulliparous Status.

History (infertility )

Histology type- Endometroid type. Clear cell and UPSC excluded .

Grade 1 malignancy.

Tumour size

Myometrial invasion excluded.

ART facilities available

After single delivery –hysterectomy
Complex Atypical
Hyperplasia
 Precursor to cancer.
 Commonly detected in patients with PCOS.
 30-60 % of hysterectomy performed for CAH are
found to have frank malignancy.
 Standard recommendations is hysterectomy.
 Fertility preservation -hormonal therapy is an option
after formal D&C
Hormonal therapy
No consensus on type, dosage, duration, frequency, route and
maintainance therapy
Hormonal Therapy
Endometrial Hyperplasia
With out Atypia
With Atypia
Medroxyprogestrone
Acetate
10-30 mg PO
100 mg PO
Megestrol Acetate
40 mg PO
160 mg PO
Depo-Provera
Mirena coil
Endometrial Cancer
Various dosages used in trials
400-800 mg in divided
dose daily
160 mg PO
Endometrial Cancer
Literature Overview (1961-2003)

Patients = 81

62 (76%) responded

Median time to response 12/52 (range 4-60/52)

15(24%) recurrence

7 retreated with hormones -5 responded.

20 patients conceived - 12 by ART

31 life births. ( some conceived more than once)
Ramirez PT, Frumovitz M, Bodurka DC et al. Hormonal therapy for the management of
grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol 2004;95:133–
138.
Preserving Fertility in Epithelial Ovarian Cancer
Standart treatment
TAH BSO + Omentec + append + PLND + PAND + washings + peritoneal biopsies
Fertility Sparing Surgery
Preserve Uterus and contra-lateral Ovary
118 early ovarian cancers that appeared to have disease limited to one ovary were however
subjected to full staging. 3/118 (2.5%) of contra-lateral ovary were found to have
microscopic disease. This risk must be conveyed to patients concerned. ( Bejamin et al)
FSS-Epithelial Ovarian Cancer
 Histology type
Endometroid,
Mucinous,
Serous
(Clear cell excluded)
 Stage 1A
 Grade 1 and possibly 2.
 After completion of fertility residual ovary and
uterus should be taken out
Invasive Epithelial Ovarian Cancer
Modified Staging
Histology
Stage IA G1
No further treatment
Stage IA
G2, G3
Stage IC-III
Selected cases
requested by patients
Chemotherapy
Chemotherapy
Chemotherapy and Fertility
 Premature ovarian failure after
chemotherapy is more common with
alkylating agents cyclophosphamide ( upto
68%)
 Ovarian failure less common with taxol and
carboplatin (15-25%)
Epithelial Ovarian Cancer Treatment with
Fertility-Sparing Therapy






Stage IA and IC epithelial ovarian cancer
1965 to 2000, n=52
20 (%38) received chemotherapy
9 (17%) eventual TAH
5(10%) recurred, 2 died
24 (46%) attempted, 17 (33%) conceived
 26 term
Schilder et al., Gynecol Oncol, 2002
Germ Cell Tumors of the Ovary
 Age - first and second decade
 Usually unilateral
 Highly chemo sensitive to BEP
 Even advance stage responds well
 Fertility preserving surgery is the norm
A Report of 28 germ cell / Cancer 42, 1152-1160
- 26 received chemotherapy except two with stage I immature teratoma.
- 7 of 12 married patients, became pregnant, all had term delivery.
Borderline ovarian tumour
 Oophorectomy is not necessary if the initial operation was a
cystectomy
 Surgical staging is not indicated
 Risk of recurrence- 6% for ipsilateral ovary ,3% for contralateral
ovary and 3% for bilateral recurrence
 5 Years survival 95-97%
 Recurrence higher in those with fertility sparing surgery but
survival is similar to those who had a TAHBSO.
Border-line Tumors of the Ovary
Conservative Management and
Pregnancy Outcome
Cancer 1998 Jan, 1;82(1):141-6





Retrospective review
82 patients
39 patients conservative management
Three patients contralateral recurrence (7%)
22 pregnancies were achieved.
Thank you…
Cancer Treatment
Objective
Cure
Adverse Effects




Psychological effects
Cosmetic problems
Loss of organ function
Sexual and reproductive
dysfunction
Fertility Impaired