| Background:Endometrial cancer is the most frequent gynecological malignancy. Two broad clinicopathologic subtypes of endometrial cancer have been recognized since1983. Almost from70%to80%of endometrial cancer were the type I EC. The prototype of type I cancer is endometrial adenocarcinoma. Currently the therapeutic approach to EC consists of a staging laparotomy/laparoscopy. Therefore, the current standard of surgical approach is preclusive of fertility. Nevertheless, the desire to preserve fertility is often strong in this patient subset. Over70%of these patients are, in fact, nulliparous at the time of EC diagnosis. So far, conservative management has been experimented in very small series of selected young patients with early EC.Almost from5%to14%of EC are in women up to40years aged with a history of estrogen-or hormone-related disorders, such as ovarian dysfunction, chronic anovulation, infertility, obesity, and polycystic ovary syndrome. This profile corresponds to the type I EC, which correlates with the estrogen/progesterone receptor positive (ER+/PR+) pattern. Primary progestin therapy has been demonstrated to be safe and effective in early well-differentiated tumors. The worldwide experience and data concerning fertility-sparing treatment are, however, still limited due to the small numbers of cases, potential methodological bias, and the use of different therapeutic regimes. We therefore prospectively planned a study to conservatively treat young women up to40years aged with endometrial cancer with progestin. The study aimed to assess the efficacy and safety of fertility-sparing treatment with progestin for endometrial carcinoma (EC) of stage I a and complex atypical hyperplasia(CAH) and to observe the prognosis and pathological change and to evaluate our pathological criteria for determining response to progestin.PurposeTo assess the efficacy and safety of fertility-sparing treatment with progestin for endometrial carcinoma (EC) of stage I a and complex atypical hyperplasia (CAH) and to observe the prognosis and pathological change and to evaluate our pathological criteria for determining response to progestin.Methods:1、Nine EC patients of stage I a and21CAH patients aged under40years who desired childbearing and/or retaining their fertility were enrolled into this study. Patients were enrolled in Women’s Hospital, School of Medicine, Zhejiang University from2004to2011. All patients were given a daily oral high-dose of progestin with duration of treatment ranging from6to9months.2、Dilatation and curettage(D&C) was performed every3months as a modality for seeing the histologic change of endometrial tissue. Pathological criteria:complete response (CR) was defined as the absence of evidence of hyperplasia or carcinoma; partial response (PR) was defined as a regression to complex or simple hyperplasia without atypia; stable disease (SD) as a persistent lesion; and progressive disease (PD) as progression to a lesion of higher grade or clinically progressive disease including myometrial invasion, extrauterine disease, or lymph node metastasis.3、Patients achieved CR stopped progesterone treatment or continued a further3or6months of consolidation therapy. Patients achieved PR often continued the treatment. Patients with SD for3to6months or PD should undergo hysterectomy. A careful and long-term follow-up is necessary.Results1、During the first period of fertility-sparing management, according to histologic change,5EC patients and18CAH patients showed CR with no evidence of endometrial adenocarcinoma or hyperplasia,2EC patients and2CAH patients showed PR with a regression to complex or simple hyperplasia without atypia,2EC patients and1CAH patients showed SD or PD. Accordingly, a total of26patients showed CR(26of30patients). The median time to CR was6months (range,3-21months) of progestin treatment.6EC patients and4CAH patients underwent hysterectomy. According to the pathologic report after the hysterectomy,7patients showed stage I a endometrioid endometrial adenocarcinoma,3patients showed complex atypical hyperplasia The median follow-up time was55.5months (range,24-104months) and all patients were alive. During follow-up, among the26patients with CR,3of6EC patients achieved CR recurred disease after a median time interval of10months (range,6-51months),7of20CAH patients achieved CR had recurrent disease after a median time interval of12months (range,6-55months).4of7CAH with recurrent disease achieved CR to progestin re-treatment. One of them had recurrence three times and achieved CR to progestin re-treatment every time.8of26patients achieved CR continued a further3or6months of consolidation therapy,3of them had recurrent disease, the remaining18stopped progesterone treatment after CR and7patients had recurrent disease. There was no significant statistical difference between the two groups (P=1.000). EC patients succeeded in4pregnancies. CAH patients succeeded in10pregnancies. They gave birth to16healthy babies in all.2、pathological change:a regression to complex or simple hyperplasia without atypia was regarded as PR. The absence of evidence of hyperplasia or carcinoma was regarded as CR. The endometrial tissue showed partial hormonal effect or remarkable hormonal effect with decidual changes in the stroma. A variety of metaplasias especially squamous metaplasia were exited in EC and CAH.ConclusionEC of stage Ⅰ a and CAH had slow progression of symptoms. Progestm treatment in EC of stage Ⅰ a and CAH patients was effective. A careful and long-term follow-up is required because of the substantial high rate of recurrence. Progestin re-treatment in most patients with recurrent endometrial cancer was effective and safe. Pathological assessment of endometrial tissue in fertility-sparing treatment with progestin for endometrial carcinoma of stage I a and complex atypical hyperplasia is the most direct and accurate evaluation method. Conservative treatment with progestin can be considered a good therapeutic option in patients with well-differentiated early-stage endometrioid endometrial adenocarcinoma who wish to preserve their uteri or become pregnant. |
PDF Full Text Request