Successful in vitro fertilization pregnancy after conservative management of endometrial cancer

OBJECTIVE: To report a successful IVF pregnancy in an infertile couple after conservative treatment of endometrial cancer. DESIGN: Case report and literature review. SETTING: University teaching hospital. PATIENT(S): A 29-year-old infertile white woman. MAIN OUTCOME MEASURE(S): Successful pregnancy after conservative management of endometrial cancer. INTERVENTION(S): Grade 1 endometrial adenocarcinoma diagnosed at hysteroscopy, followed by dilatation and curettage (D&C). On follow-up D&C, pathologic examination was normal after high-dose progesterone therapy. The patient subsequently underwent an IVF cycle with transfer of three blastocysts. RESULT(S): The patient delivered triplets by cesarean section. Laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy was then done. No residual endometrial cancer was evident in the hysterectomy specimen, but a 1.1-cm cystic mixed endometrioid and clear cell-type adenocarcinoma was discovered in the left ovary. The patient is doing well after 3 cycles of chemotherapy; her CA-125 level is normal. The triplets are also doing well. CONCLUSION(S): In carefully chosen situations, deferring surgery in infertile patients with endometrial cancer may be a viable option permitting subsequent successful pregnancy.     

Ovarian metastasis in a nulliparous woman with endometrial adenocarcinoma failing conservative hormonal treatment

BACKGROUND: There have been several reports about successful fertility-preserving treatment of endometrial carcinoma with subsequent pregnancy. However, conservative hormonal treatment for early-stage endometrial cancer still entails some risk. CASE: We present a 36-year-old nulliparous woman, initially diagnosed as clinical stage IA, grade 1 endometrial adenocarcinoma, receiving 6-month conservative treatment with remission achieved at 4 months from diagnosis. Recurrence at the endometrium was documented at the end of treatment. She underwent a definitive surgery including total hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. The final pathology revealed well-differentiated endometrioid adenocarcinoma with inner one-third myometrial invasion and right ovarian metastasis. CONCLUSION: This case report signals a warning that negative preoperative imaging studies are not reassuring for a relapsing low-grade, early-stage endometrial carcinoma failing conservative treatment.     

Endometrial carcinoma remaining after term pregnancy following conservative treatment with medroxyprogesterone acetate

BACKGROUND: Successful pregnancies after conservative progestin treatment to young women with endometrial carcinoma have recently been reported. However, it is not known for certain whether the lesion is completely eradicated in such patients. We present a case of residual endometrial carcinoma after term pregnancy which had been treated conservatively before the pregnancy began. CASE: A 28-year-old woman with endometrial carcinoma received conservative treatment with high-dose medroxyprogesterone acetate (MPA) and then conceived. After delivery at term, atypical cells were found in the endometrial curettage specimen. A hysterectomy was performed 6 months after delivery and revealed the presence of a small focus of intramucosal, grade 1, endometrioid-type adenocarcinoma. Immunohistochemically, the tumor cells were positive for estrogen and progesterone receptors. CONCLUSION: We concluded that while MPA treatment had been effective, it had not completely eradicated the carcinomatous lesion, which remained during and after the term pregnancy.     

Tratamiento conservador del adenocarcinoma de endometrio. Obtención de dos gestaciones con recién nacidos sanos

We present the case of a 30-year-old childless woman who was diagnosed with a well-differentiated endometrial adenocarcinoma. The patient chose conservative treatment consisting of megestrol and hysteroscopic resection. After this treatment, a normal pregnancy ensued, followed by contraception with an intrauterine device (IUD) delivering levonorgestrel for 18 months. After removal of the IUD, a second normal pregnancy occurred. After the second pregnancy, the patient had no desire for more children and a total hysterectomy with bilateral salpingo-oophorectomy was performed. We discuss the ethical, diagnostic and therapeutic dilemmas posed by this case, including the possibility of progression and patient death.     

Clinical experiences with treatment of granulosa cell tumors]

Symptoms, tumor morphology and clinical course were reviewed in 15 cases of granulosa cell tumors of the ovaries. The main symptoms were irregular menstrual bleedings. In 2 cases were found signs of glandular cystic hyperplasia additionally and in one case an adenocarcinoma of the endometrium. The appropriate treatment was the hysterectomy with bilateral salpingo-oophorectomy performed in most of the cases, followed by additional irradiation and polychemotherapy in 4 cases each.     

Young women with atypical endometrial hyperplasia or endometrial adenocarcinoma stage I: will conservative treatment allow pregnancy? Results of a French multicentric survey

OBJECTIVES: To analyse the carcinological and obstetrical results of young women with atypical endometrial hyperplasia or endometrial adenocarcinoma, treated in a conservative way to allow pregnancy. PATIENTS AND METHODS: A retrospective analysis of 13 cases (5 adenocarcinomas and 8 atypical hyperplasias) followed in 8 French centers between 1997 and 2004. RESULTS: After 4.6 months of conservative treatment, there were no residual lesions in 61.5% of the cases. Progestatives seem to be the most effective treatment. Tumoral regression makes it possible to plan a pregnancy, with childbirth in 25% of the cases. In these frequently infertile patients, all the techniques of assisted reproduction can be used. Recurrences are not rare after hormonal treatment (37.5%), so, total hysterectomy is justified after delivery. DISCUSSION AND CONCLUSION: Conservative treatment for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma stage I can be considered in some cases to enable pregnancy.     

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.     

A successful live birth with in vitro fertilization and thawed embryo transfer after conservative treatment of recurrent endometrial cancer

Estrogen-dependent early stage endometrial cancer is relatively common in young women of reproductive age. The standard treatment is hysterectomy and bilateral salpingo-oophorectomy (BSO), even in early stage well-differentiated endometrial cancer patients. This surgical option results in permanent loss of fertility. There have been some reports of live births using in vitro fertilization after conservative management of endometrial cancer with high-dose progestin for the purpose of fertility preservation. However, most were not recurrent cases and pregnancy was achieved through conventional in vitro fertilization, which usually raises serum estradiol levels and may lead to the recurrence of endometrial cancer. To date, it is hard to find a case that can be referred for any possible different approach needed for the patients who experience recurrence. Here we report a successful live birth with in vitro fertilization using letrozole to maintain physiological levels of estradiol, and subsequent thawed embryo transfer after elective cryopreservation of embryos in a patient with recurrent endometrial cancer. There has been no evidence of disease recurrence at one year after delivery.     

Conservative treatment may be beneficial for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma

OBJECTIVE: To evaluate whether an alternative treatment to radical hysterectomy exists for young women with endometrial adenocarcinoma. DESIGN: A review of the literature (70 articles) plus personal results. SETTING: University hospital. PATIENT(S): Women with atypical endometrial hyperplasia or adenocarcinoma. MAIN OUTCOME MEASURE(S): The recurrence rate and the pregnancy rate after conservative therapy. CONCLUSION(S): Conservative treatment of well-differentiated stage I endometrial adenocarcinoma can be considered in young patients, with close surveillance to diagnose any possible recurrence.     

Controversies in the management of atypical hyperplasia: Conservative management vs. simple hysterectomy

Objective:   Review the status of diagnosis of atypical hyperplasia. Discuss therapeutic options based on recently prospective pathologic studies.
Research:   Review recent prospective histopathology studies of atypical endometrial hyperplasia. Discuss recent advances in treatment of atypical endometrial hyperplasia. Review pretreatment imaging studies and their impact on treatment decision-making.
Results:   The diagnosis of atypical endometrial hyperplasia by endometrial biopsy is associated with a higher-than-expected incidence of invasive adenocarcinoma in hysterectomy specimens. This calls into question the safety of conservative therapy. Newer imaging studies and improved pathologic diagnosis may help to identify patients eligible for conservative therapy.
Conclusions:   Atypical endometrial hyperplasia is typically associated with invasive endometrial adenocarcinoma. Adequate sampling and expert pathological review may be helpful. Further research and clinical trials will answer the question of optimal treatment of atypical endometrial hyperplasia for those patients who desire preservation of fertility.     

Endometrial endometrioid adenocarcinoma in a premenopausal woman presenting with metastasis to bone: a case report and review of the literature.

We describe the clinicopathologic and immunohistochemical features and microsatellite instability analysis of a rare case of endometrial endometrioid adenocarcinoma presenting as a metastasis to the ischium in a 39-year-old premenopausal woman. The patient was treated with a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and para-aortic lymphadenectomy. One month later, she underwent an ischial resection followed by radiotherapy. After a follow-up of 3 years, the patient shows no evidence of disease.     

Complications of pelvic lymphadenectomy in patients with endometrial adenocarcinoma

The complications of surgical treatment in 193 cases of endometrial adenocarcinoma, subdivided into two groups, were analyzed: 58 without lymphadenectomy and 135 with systematic pelvic lymphadenectomy before total abdominal hysterectomy and bilateral salpingo-oophorectomy with vaginal cuff. The only significant differences concern the number of patients requiring transfusions and the length of the postoperative stay. It is suggested that lymphadenectomy should always be performed when an abdominal approach is chosen.     

子宫内膜不典型增生和早期子宫内膜癌保守治疗方案分析

随着癌症发病的年轻化,患有子宫内膜癌的育龄期女性越来越多。为了保留生育能力,大部分患者倾向于保守治疗。故而众多研究者提出了子宫内膜不典型增生和早期子宫内膜癌的保守治疗方案,并在临床上进行了小样本研究。传统治疗以口服大剂量孕激素为主,然而多数口服孕激素治疗的患者复发率高、并发症多。左炔诺孕酮宫内缓释节育系统通过局部作用于子宫内膜,可减少大量孕激素对机体造成的不良反应。宫腔镜能够精准切除病灶,保护正常子宫内膜,相对降低了发生不孕、流产风险。二甲双胍的抗肿瘤作用能增加孕激素的有效率。通过综述子宫内膜不典型增生和早期子宫内膜癌各种保守治疗后的缓解率、复发率和妊娠结局,为临床上在治疗前对每位患者的自身因素及疾病特点进行评估,以采取对患者最有益的治疗方案及管理模式提供依据。     

Malignant pericardial effusion and cardiac tamponade in endometrial adenocarcinoma

BACKGROUND: Malignant pericardial effusion as a complication of gynecological cancers is a rare occurrence. A review of the literature revealed only two cases of pericardial effusion secondary to endometrial adenocarcinoma. We describe another patient with FIGO stage IIIA endometrial cancer who developed malignant pericardial effusion with cardiac tamponade. CASE: A 57-year-old woman with a history of endometrial carcinoma presented with pericardial effusion and cardiac tamponade. The patient had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by three cycles of radiotherapy postoperatively. Chest X ray and echocardiogram confirmed the presence of pericardial effusion with impending cardiac tamponade. Pericardial biopsy revealed adenocarcinoma. The treatment consisted of emergency pericardial window and subsequent therapy with tamoxifen. A follow-up after 6 months revealed the patient to be asymptomatic. CONCLUSION: Patients with cancer may develop a pericardial effusion for different reasons. Early diagnosis of the specific cause is not only useful but also essential in determination of the mode of therapy and estimation of prognosis.     

Prevention of vaginal recurrence of stage I endometrial adenocarcinoma with postoperative vaginal radiation

From 1975 to 1982 a prospective study was conducted at Roswell Park in 68 patients (group 1) for surgical stage I endometrial cancer, grade 1 or 2, and less than 50% myometrial invasion. These patients were treated by total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative vaginal radium. With median follow-up of 4.8 years, there has not been a single vaginal recurrence. This treatment plan was based on a prospective study at the same institute from 1958 to 1967, which compared patients with stage I endometrial cancer treated by hysterectomy alone, preoperative radium followed by hysterectomy, and hysterectomy followed by postoperative radium. In addition, 19 patients (group 2) were evaluated as to their initial treatment after their referral to Roswell Park with vaginal recurrence after surgical treatment for stage I endometrial cancer. None of these patients were treated initially with postoperative vaginal radium after hysterectomy. Based on the zero incidence of vaginal recurrence in 117 patients with FIGO stage I endometrial cancer, the estimated five-year survival rate of 97.2% for the group 1 patients, and the actuarial five-year survival of 95% in the 1958 to 1967 prospective study, it is concluded that primary surgery should be followed by postoperative vaginal radium (cesium) in those patients with stage I endometrial cancer, grade 1 or 2, with less than 50% myometrial invasion.     

Uterine sarcoma. Case report

55 years female patient who is sent to the New Hospital Durango management fibroids and anemia, why not start the study protocol for hysterectomy, preoperative presenting within normal parameters, transvaginal ultrasound uterine fibroids and endometrial hyperplasia, biopsy endometrium with endometrial hyperplasia without atypia simple, and is scheduled for total abdominal hysterectomy with bilateral salpingo-oophorectomy. Surgical procedure is performed with the incident of tearing the uterine body on the right side with extension to the neck and externalization of endometrial tissue, the event is completed without complications. Histopathologic endometrial stromal sarcoma of high grade. Management in a row by the oncology department by 25 sessions of radio and brachytherapy.     

Endometrial cancer

Endometrial carcinoma is the most common gynaecological malignancy in the Western world. The standard management of endometrial carcinoma is total hysterectomy and bilateral salpingo-oophorectomy with or without pelvic and para-aortic lymph-node dissection. Increasingly, endometrial cancer is being diagnosed in younger women in whom preserving fertility may be an important consideration when deciding optimal management. Conservative management of endometrial carcinoma may be a therapeutic option in carefully selected women with well-differentiated endometrial cancer in the absence of any myometrial invasion or adnexal disease seen on imaging. The biggest concern with conservative management of endometrial carcinoma is disease progression while on treatment or after initial response to medical treatment. Women opting for conservative management should be aware that hormonal therapy is not the standard form of management. Potential adverse outcomes should be taken into consideration.     

Endometrial Adenocarcinoma Complicated by Malignant Pericardial Effusion

A case of malignant pericardial effusion associated with endometrial adenocarcinoma is presented. A total abdominal hysterectomy with bilateral salpingo-oophorectomy and partial omentectomy was performed 8 months before the occurrence of cardiac tamponade. The treatment of malignant pericardial effusion consisted of emergency pericardiocentesis and systemic chemotherapy and a clinical response for 6 months was achieved.     

Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia

OBJECTIVE: The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia. METHODS: A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology. RESULTS: Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy. CONCLUSION: This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.     

Total laparoscopic hysterectomy versus total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial carcinoma: a randomised controlled trial with 5-year follow-up

This report is on recovery and long-term outcomes in a small-scale randomised controlled trial (RCT) after total laparoscopic hysterectomy versus total abdominal hysterectomy in (potential) endometrial carcinoma patients. An RCT was performed among women with atypical endometrial hyperplasia and endometrial carcinoma scheduled for hysterectomy in a teaching hospital in The Netherlands. Women were randomised to total laparoscopic hysterectomy versus total abdominal hysterectomy both with bilateral salpingo-oophorectomy and were followed until 5 years after the intervention. Patients completed the RAND 36-Item Short Form Health Survey (RAND-36), Quality of Recovery-40 (QoR-40) and Recovery Index-10 (RI-10) until 12 weeks after surgery. Main outcome measure was quality of life and recovery in the first 12 weeks after surgery. A linear mixed model was used for statistical analysis while accounting for baseline values where applicable. Seventeen women were included, of whom 11 allocated to the laparoscopic arm and 6 to the abdominal arm. Laparoscopic hysterectomy performed better on all scales and subscales used in the study. A statistically significant treatment effect, favouring laparoscopic hysterectomy, was found in the total RAND-36 (difference between groups 142 units, 95% confidence interval 46; 236). Clinical follow-up was completed after median 60 months, but this study was too small for conclusions regarding the safety and survival. Laparoscopic hysterectomy results in better postoperative quality of life in the first 12 weeks after surgery when compared with abdominal hysterectomy.