Fertility Sparing in Endometrial Cancer: Where Are We Now?

Abstract

Endometrial cancer is the most common gynecological neoplasm with an increased incidence in the premenopausal population in recent decades. This raises the problem of managing endometrial cancer in fertile women who have not yet achieved pregnancy. In these women, after careful selection, hysterectomy may be postponed in favor of conservative management if specific requirements are met. The latest evidence is focused on early endometrial carcinoma, endometrioid histotype, Grading 1, with no evidence of myometrial infiltration. Few clinical trials have opened this possibility also for women with an endometrial cancer Grading 2 diagnosis. There are still questions about the best medical therapy, dosage, route, and duration of treatment. Oral progestins or levonorgestrel-releasing intrauterine devices appear to be the options associated with the best outcome in terms of complete response and lower recurrence rates. Other options include the use of GnRH analogues, surgical hysteroscopy, or metformin, in a therapeutic approach that takes into account the characteristics of the patient. The pursuit of pregnancy should start as soon as two consecutive endometrial biopsies are obtained 3 months apart from each other; it is recommended to refer the patients to ART centers to maximize the success rate. After having reached the fulfillment of the reproductive desire, surgical radical treatment is still recommended.

Keywords: endometrial cancer; fertility sparing; uterine neoplasms.

Figure 1

Literature search diagram, PRISMA [18] 2020 flow diagram, which includes searches of PubMed. A total of 351 papers filled the search string. Of these, 4 articles were excluded because the full text was not available. In addition, 341 were excluded because they were meta-analyses, reviews, or systematic reviews; only clinical trials and controlled trials were included. A total of 6 papers were eligible for review. After evaluating the titles and abstracts, 1 article was excluded because it was not relevant to the topic of the review, and 1 article was excluded because it was not written in English.

Figure 2

3D scan of the uterus of a patient with endometrial cancer treated with LNG-IUD. The correct positioning of the intrauterine device is monitored by ultrasound, which also allows the identification of any changes in the endometrial pattern during treatment.

Figure 3

Hysteroscopic view of endometrial cancer with exophytic growth within the uterine cavity, treated with a tissue removal device.

Figure 4

Two-dimensional longitudinal scan of the uterus of a patient treated with a levorgestrel-releasing IUD as part of a fertility-sparing regimen. The intrauterine device allows the thickness of the endometrium to remain reduced.