fertility sparing in gynecological cancers
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Fertility SparingFertility Sparing in in
Gynecological Cancers Gynecological Cancers
Fertility SparingFertility Sparing in in
Gynecological Cancers Gynecological Cancers
Melkeet singhMelkeet singh Department of ODepartment of O & & G G
Fertility SparingFertility Sparing Surgery Surgery in in Gynecological Cancers Gynecological Cancers Fertility SparingFertility Sparing Surgery Surgery in in Gynecological Cancers Gynecological Cancers
Most common gynaecological cancers in
reproductive age group includes
- Cervical Cancer - Endometrial Cancer - Ovarian Cancer
Incidence of Gynaecological cancer in Incidence of Gynaecological cancer in Reproductive age group.Reproductive age group.Incidence of Gynaecological cancer in Incidence of Gynaecological cancer in Reproductive age group.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 Mean age of First Time MothersMothersMean age of First Time Mean age of First Time MothersMothersAge 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 TreatmentCancer Treatment
ObjectiveObjective
CureCure
Adverse EffectsAdverse Effects Psychological effectsPsychological effects Cosmetic problemsCosmetic problems Loss of organ functionLoss of organ function Sexual and reproductive Sexual and reproductive
dysfunctiondysfunction
Fertility Fertility ImpairedImpaired
GoalsGoals / Objectives / Objectives of of FSS FSSGoalsGoals / Objectives / Objectives of of FSS FSS
Preservation of reproductive potential Preservation of hormonal function Similiar outcomes to standard therapy Favorable obstetric outcome Benefits > risk
FSSFSS - - CounselingCounselingFSSFSS - - CounselingCounseling
Patient & family aware of the problem.Patient & family aware of the problem.
Aware that they are assuming an undefined risk.Aware that they are assuming an undefined risk.
Aware of limited data on the options.Aware of limited data on the options.
Options are not standard Therapeutic approaches.Options are not standard Therapeutic approaches.
Patient must be extremely compliant with follow up.Patient must be extremely compliant with follow up.
Once fertility Once fertility completed, definitive procedure consideredcompleted, definitive procedure considered
FSSFSS – – PrerequisitesPrerequisitesFSSFSS – – PrerequisitesPrerequisites
Realistic probabilities of achieving conception based on Realistic probabilities of achieving conception based on age, history and infertility evaluationage, history and infertility evaluation
Desire to preserve Desire to preserve fertilityfertility
Tumor factors-Tumor factors-hhistologic type, grade.istologic type, grade.
Availability of ARTAvailability of ART
Abnormal smear → Colposcopy + Biopsy → Cone Biopsy
•No lesion
CIN Microscopic CaCx
Horizontal ≤7mm + Invasion < 3 mm
1A1
1A1- LN mets 0.5% Recurrence 2% LVSI 8-29%
LVSI - LVSI +
TAHBSOIntracavitary RT
Fertility desiredCONE Enough.
≤ 7mm + Invasion 3-5 mm
1A2
1A2 LN mets 6-14% Recurrence 4% LVSI 53%
Modified RH +PLND
Fertility desiredCONE + PLNDTrachelectomy + PLND
•RT
>7mm > 5 mm
1B1-11A
RH + PLND
In selected cases if fertility desired - Trachelectomy + PLND
Nodes positive → Radiotherapy
•Stage 1A1 – Squamous CarcinomaStage 1A1 – Squamous Carcinoma
•A loop cone excision of the cervix is sufficient treatment
.
AdenocarcinomaAdenocarcinoma
•Skip lesions can occur
? Just Pre-invasive
Cone – Fertility & Pregnancy Outcome
< 15 mm
NO EFFECT
> 15 mm
25% PRETERM LABOR 18% PROM
Sadler L. Et al., Am J Med Ass, 2004
Frencezy A, 1995Haffenden DK, 1993Tan L, 2004
(Clin. Exp.(Clin. Exp. Obstet. Gynecol, 1992: 19(1):40-2)Obstet. Gynecol, 1992: 19(1):40-2)
TrachelectomyTrachelectomyTrachelectomyTrachelectomy
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 - CriteriaTrachelectomy - CriteriaTrachelectomy - CriteriaTrachelectomy - 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 Limited endo cervical involvement - Upper endocervical
margins free of tumour (Frozen section) margins free of tumour (Frozen section) && MRIMRI
Trachelectomy Trachelectomy -Results-ResultsTrachelectomy Trachelectomy -Results-ResultsMeta-analysisMeta-analysis
Dargent (Lyon)Dargent (Lyon) 8282 Plante and Roy (Quebec)Plante and Roy (Quebec) 4444 Covens (Toronto) Covens (Toronto) 5858 Shepherd (London, UK) Shepherd (London, UK) 4040 TotalTotal 224224
RecurrencesRecurrences 9(5.8%)9(5.8%) Recurrences in Radical hysterectomy 4.4%Recurrences in Radical hysterectomy 4.4% 5 years survival in both group 97%5 years survival in both group 97%
Pregnancy OutcomePregnancy OutcomeProcedure 315Procedure 315Documented 114 pregnancies in 97 patients Documented 114 pregnancies in 97 patients Live births 93Live births 93
Fertil Steril 2005;84:156
Preserving Fertility in Endometrial Preserving Fertility in Endometrial Cancer Cancer
Preserving Fertility in Endometrial Preserving Fertility in Endometrial Cancer Cancer
2% -14 % of endometrial 2% -14 % of endometrial cancercancer
40 years40 years
Up to 25% Up to 25% PCOSPCOS
GG11 Early stageEarly stage
Respond to Respond to progestin progestin treatment treatment
Early Early StageStage Ca Endo ( Ca Endo (Ia, Ia, G1)G1)
StandarStandardd treatment treatment
TAH + BSOTAH + BSO +/- +/- PLNDPLND
Preserving Fertility in Endometrial Preserving Fertility in Endometrial CancerCancer
Preserving Fertility in Endometrial Preserving Fertility in Endometrial CancerCancer
Is there a fertility sparing surgery for cancer endometrium ?.Is there a fertility sparing surgery for cancer endometrium ?.
FSS in Endometrial CancerFSS in Endometrial CancerFSS in Endometrial CancerFSS 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.
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
Conservative ManagementConservative Management Endometrial Cancer Endometrial Cancer CriteriaCriteria
Conservative ManagementConservative Management Endometrial Cancer Endometrial Cancer CriteriaCriteria
Complex Atypical Complex Atypical HyperplasiaHyperplasiaComplex Atypical Complex Atypical HyperplasiaHyperplasia
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 Hormonal therapy Hormonal therapy Hormonal therapy
Hormonal Therapy Endometrial Hyperplasia Endometrial Cancer
With out Atypia With Atypia
Medroxyprogestrone Acetate
10-30 mg PO
100 mg PO 400-800 mg in divided
dose daily
Megestrol Acetate 40 mg PO
160 mg PO 160 mg PO
Depo-ProveraMirena coil
Various dosages used in trials
No consensus on type, dosage, duration, frequency, route and maintainance therapy
Endometrial CancerEndometrial CancerEndometrial CancerEndometrial 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.
Standart treatmentStandart treatment
TAH BSOTAH BSO + Omentec + append + PLND + PAND + washings + peritoneal biopsies + Omentec + append + PLND + PAND + washings + peritoneal biopsies
Preserving Fertility in Preserving Fertility in Epithelial OvarianEpithelial Ovarian Cancer CancerPreserving Fertility in Preserving Fertility in Epithelial OvarianEpithelial Ovarian Cancer Cancer
Fertility Sparing SurgeryFertility Sparing Surgery
Preserve Uterus and contra-lateral OvaryPreserve 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 CancerFSS-Epithelial Ovarian CancerFSS-Epithelial Ovarian CancerFSS-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
Stage IA G1Stage IA G1
No further treatment
Stage IAStage IAG2, G3G2, G3
Chemotherapy
Stage IC-IIIStage IC-IIISelected casesrequested by patients
HistologyHistology
Invasive Epithelial Ovarian CancerInvasive Epithelial Ovarian Cancer
Modified Staging
Chemotherapy
Chemotherapy and FertilityChemotherapy and FertilityChemotherapy and FertilityChemotherapy 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 Epithelial Ovarian Cancer Treatment with Ovarian Cancer Treatment with Fertility-Sparing Therapy Fertility-Sparing Therapy Epithelial Epithelial Ovarian Cancer Treatment with Ovarian Cancer Treatment with Fertility-Sparing Therapy Fertility-Sparing Therapy
Stage IA and IC epithelial ovarian cancerStage IA and IC epithelial ovarian cancer 1965 to 2000, n=521965 to 2000, n=52 20 (%38) received chemotherapy20 (%38) received chemotherapy 9 (17%) eventual TAH9 (17%) eventual TAH 5(10%) recurred, 2 died5(10%) recurred, 2 died 24 (46%) attempted, 17 (33%) conceived 24 (46%) attempted, 17 (33%) conceived
26 ter26 termm
Schilder et al., Gynecol Oncol, 2002Schilder et al., Gynecol Oncol, 2002
Germ Cell TumorGerm Cell Tumorss of the Ovary of the OvaryGerm Cell TumorGerm Cell Tumorss of the Ovary of the Ovary
Age - first and second decadeAge - first and second decade
Usually unilateralUsually unilateral
Highly chemo sensitive to BEPHighly chemo sensitive to BEP
Even advance stage responds wellEven advance stage responds well
Fertility preserving surgery is the normFertility preserving surgery is the norm
A Report of 28 germ cell / Cancer 42, 1152-1160 A Report of 28 germ cell / Cancer 42, 1152-1160 - 26 received chemotherapy except two with stage I immature teratoma.- 26 received chemotherapy except two with stage I immature teratoma.- 7 of 12 married patients, became pregnant, all had term delivery.- 7 of 12 married patients, became pregnant, all had term delivery.
Borderline ovarian tumourBorderline ovarian tumourBorderline ovarian tumourBorderline 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.
Retrospective reviewRetrospective review 82 patients82 patients 39 patients conservative management39 patients conservative management Three patients contralateral recurrence (7%)Three patients contralateral recurrence (7%) 22 pregnancies were achieved.22 pregnancies were achieved.
Border-line Tumors of the Ovary Border-line Tumors of the Ovary Conservative Management and Conservative Management and
Pregnancy OutcomePregnancy Outcome
Border-line Tumors of the Ovary Border-line Tumors of the Ovary Conservative Management and Conservative Management and
Pregnancy OutcomePregnancy OutcomeCancer 1998 Jan, 1;82(1):141-6Cancer 1998 Jan, 1;82(1):141-6
Thank you…Thank you…Thank you…Thank you…
Cancer TreatmentCancer Treatment
ObjectiveObjective
CureCure
Adverse EffectsAdverse Effects Psychological effectsPsychological effects Cosmetic problemsCosmetic problems Loss of organ functionLoss of organ function Sexual and reproductive Sexual and reproductive
dysfunctiondysfunction
Fertility Fertility ImpairedImpaired