| Background:Endometrial carcinoma(EC),one of the most common malignancy of the female genital tract,and atypical hyperplasia(AH),its precursor lesion,most frequently affects peri-and post-menopausal women.It is reported that the incidence of EC among women 40 years or younger comprised 2.1-14.4%of all patients diagnosed with EC.However,the incidence of young women who are diagnosed with EC and AH is increasing,particularly as the rate of obesity increases and popularity of postpone delivery age.This poses a dilemma for those who wish to retain fertility as a total hysterectomy and bilateral salpingo-oophorectomy(TH/BSO)is the standard treatment.Recent studies have focused on fertility-sparing therapy for eEC and AH.Oral progestogens such as megestrol acetate(MA)and medroxyprogesterone acetate(MPA)are most frequently used,but in recent years,the levonorgestrel-releasing intrauterine system(LNG-IUS),and hysteroscopic resection(HR)of the cancer or hyperplastic area followed by oral or intrauterine progestogens have been demonstrated to be safe and effective alternatives.However,previous reports of these are limited to small sample studies and meta-analysis,and few focuses on the comparison among these therapies.Objective:To discuss the safety and efficiency of fertility-sparing therapy for patients with eEC or AH in Qilu Hospital,Shandong University.To compare fertility-sparing therapies including oral progestogens,the levonorgestrel-releasing intrauterine system(LNG-IUS),and hysteroscopic resection(HR)in achieving disease regression,recurrence and live birth rate in well differentiate early-stage endometrial carcinoma(eEC)and atypical hyperplasia(AH).Methods:The datebase of Qilu Hospital Shandong University was searched for women with well differentiate early-stage endometrial carcinoma(eEC)and atypical hyperplasia(AIH)between Jan 1st 2008 and Dec 31st 2017.The therapies and prognosis of each patient was collected and analysed.Medline,the Cochrane Library and Embase were searched with the terms and Synonyms:words similar to eEC and AH with therapies associated with fertility-sparing to find related studies.The number of all patients accepted fertility sparing therapies,patients got regressed,relapsed and delivered was extracted from each study,and the regression,recurrence,and live birth rate of each study were calculated.The regression,recurrence and live birth rate between each two interventions were compared with the aid of RevMan 5.3 software and meta-regression in packages of "meta" and "meta for" written in R.Results:In the datebase of Qilu Hospital between Jan 1st 2008 and Dec 31st 2017,a total of 47 patients with eEC or AH who wanted to be pregnant were collected,20(42.55%)patients got complete response,4(18.18%)patients relapsed,12(25.53%)patients got pregnancy and 7(14.89%)live babies were born,a radical surgery were performed to 20 patients,12 of which responsed or persisted and eight progressed.Fifty-four studies reported fertility sparing therapies in young women with eEC and AH were included.Meta-analysis showed that women with AH achieved a higher regression(88.74%vs 79.47%,P=0.0417)and lower recurrence rate(9.20%vs 27.34%,P=0.0044)but no difference in live birth rate(28.74%vs 32.28%,P=0.7247)when treated with oral progestogens only compared to women with eEC.Meta-analysis showed that HR followed by progestogens achieved a higher pooled regression(98.06%vs 77.20%,P=<0.0001)and a lower recurrence rate(4.79%vs 32.17%,P=0.0004),but a little difference in live birth rate(52.57%vs 33.38%,P=0.0944)compared with oral progestogens alone.At the same time,the pooled live birth rate(52.57%vs 18.09%P =0.0399)of HR followed by progestogens are significantly higher than the LNG-IUS alone,with no statistical difference in regression(98.06%vs 94.24%,P=0.4098)and recurrence rate(4.79%vs 3.90%,P=0.8561).When comparing LNG-IUS with oral progestogens alone,a higher regression(94.24%vs 77.20%,P=0.0010)and lower recurrence rate(3.90%vs 32.17%,P =0.0001)was achieved,with no difference in live birth rate(18.09%vs 33.68%,P=0.1242).Conclusion:Fertility-sparing therapies are safe and efficient.Of the available fertility-sparing therapeutic options,HR followed by progestogens may be a more effective one.A standard surgery should be performed after delivery or unsatisfying response. |
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