Endometrial cancer is one of the three major malignant tumors of the female reproductive tract, and its incidence is on the rise worldwide. Endometrial cancer mostly occurs in older women, with an average age of onset of 60 years, of which 75% of patients are over 50 years old. However, in recent years, the proportion of younger patients has been increasing, and recent studies have shown that the proportion of women aged <40 years old among endometrial cancer patients has reached 15%, and 70% of them have not given birth. Fertility is a basic need for human reproduction and an important bond for family and social relationships. Although surgery is the standard treatment for endometrial cancer and can achieve good results, removal of the uterus means loss of fertility.
Therefore, when faced with endometrial cancer, most young patients with fertility needs are faced with a dilemma: Is it possible to preserve the uterus with treatment? If the uterus is not removed, will the disease deteriorate? In this article, we will introduce the treatment of endometrial cancer with fertility preservation. Is conservative treatment with preservation of fertility suitable for everyone? The answer is no.
Endometrial cancer is a malignant tumor and the safety of treatment must be ensured before fertility preservation can be considered. Conservative treatment can only be performed if the following conditions are met.
1.Age <40 years old and have fertility requirements.
2. The lesion is confined to the endometrial layer and the imaging (e.g. MRI) does not invade the myometrium and there is no extrauterine metastasis.
3. Pathological diagnosis of highly differentiated endometrioid adenocarcinoma (G1), confirmed by pathologist.
4.positive estrogen and progesterone receptors.
5, Those who are in a position to be closely followed up.
6.Normal serum CA125, no family history of breast cancer or gynecologic tumor, no combination of other risk factors, no contraindication to drug therapy and pregnancy.
7.The patient understands that conservative treatment is not the standard treatment.
8. Patients should consult a fertility specialist before treatment to rule out other infertility factors.
Why is conservative treatment to preserve fertility in young patients of childbearing age?
Young endometrial cancer patients of childbearing age are mostly early stage, highly differentiated, rarely infiltrate the muscular layer, less likely to have ovarian metastasis and fallopian tube metastasis, and most of them are estrogen-dependent, with better prognosis. This makes it possible to preserve fertility.
Options for conservative treatment of endometrial cancer.
1.Pharmaceutical treatment: Progestin has been used to treat endometrial cancer for nearly 50 years, and is the first-line drug for conservative treatment of endometrial cancer. It is the first-line drug for the conservative treatment of endometrial cancer. The commonly used drugs are megestrol acetate and medroxyprogesterone acetate. The duration of progestin administration is at least 12 weeks, after which MRI and hysteroscopy or hysteroscopy are performed. If no cancer foci or hyperplasia are seen on pathological examination, the patient is diagnosed to be in complete clinical remission. In addition, since progestin receptors may be downregulated by prolonged and heavy use of progestin, while tamoxifen may upregulate progestin receptors, progestin has been used in combination with tamoxifen to treat endometrial cancer. The complete remission rate of progestin treatment is about 50%.
2.Conservative surgical treatment: If the lesion is relatively limited, especially if the lesion is polypoid, hysteroscopic resection can be used to remove the cancerous lesion and its surrounding endometrium and part of the muscular layer first, and then oral progestin can be taken for 6 months after the surgery. It should be noted that if more uterine tissues are removed and the morphology of the uterine cavity is severely changed, the postoperative pregnancy will be affected.
3.Other treatment methods: In recent years, some researchers have proposed the use of progestin-containing intrauterine device (IUD) for conservative treatment, which can play a local role in inhibiting tumor cells.
Fertility after conservative treatment of endometrial cancer
Early pregnancy is recommended for patients with fertility intention. Young endometrial cancer patients are often combined with obesity, polycystic ovary syndrome and other diseases that can lead to ovulatory dysfunction, which, together with endometrial factors, can lead to infertility. It is recommended that such patients be treated for related diseases or assisted reproductive technology to help them conceive as soon as possible after complete remission. If no pregnancy occurs after 3 months, assisted reproductive technology is recommended as soon as possible. The highest pregnancy rate reported in existing studies is 35% in young endometrial cancer patients treated conservatively. However, if pregnancy is not achieved during ovulation promotion, the disease may recur and endometrial examination is needed once every 3-6 months.
Management of endometrial cancer after conservative treatment
About 50% of endometrial cancer cannot get complete remission after 6 months of conservative treatment. If pathological examination reveals partial remission, another 3 months of medication is needed, and if complete remission cannot be achieved, surgery is needed to remove the uterus; if there is no change of cancer lesion after 6 months of treatment, or it progresses to intermediate or low differentiated cancer, surgery is needed immediately.
Even if conservative treatment results in complete remission and successful pregnancy (35%), there is still a recurrence rate of 35%-57%, so close follow-up is needed to monitor changes in the disease. Those who have retained the uterus are followed closely for 2 years, with hysteroscopic scraping every 3 months in the first year and every 6 months in the second year. For those who have a need to have another child after normal delivery, a hysteroscopic curettage was performed 6 weeks after delivery. For those who have no need to have another child after normal delivery, they should undergo standard endometrial cancer staging after delivery. Intraoperative exploration, including careful exploration of the ovaries, cytology of abdominal irrigation fluid, sampling of pelvic and para-aortic lymph nodes, and biopsy of any suspicious lesions, is required for those who have a need to have another child after cesarean delivery. Standard endometrial cancer staging procedures can be performed at the same time for those who do not require re-birth after cesarean delivery. Serum CA125 is also a valuable indicator for the follow-up of endometrial cancer.
In conclusion, conservative treatment of endometrial cancer can create a chance for patients to have children. However, it should be re-emphasized that not all patients with endometrial cancer are suitable for conservative treatment and must be carefully evaluated before treatment and closely followed up after treatment to monitor changes.