|Year : 2019 | Volume
| Issue : 1 | Page : 16-19
Fertility preservation surgeries in gynecological malignancies at a tertiary care institute in South India
Paapa Dasari, Sonal Garg
Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
|Date of Web Publication||25-Jun-2019|
Prof. Paapa Dasari
Department of Obstetrics and Gynaecology, WCH, JIPMER, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Background: Fertility preservation surgery is a method to preserve the fertility potential of women without affecting the management of Gynecological cancer. It is important to know the type of malignancies and age group at which these are diagnosed and managed as this differs from centre to centre.
Aims and Objectives: The aim was to find out the spectrum of Gynaecological malignancies in young women and to find out the type of malignancies in which Fertility sparing surgery was feasible.
Materials and Methods: This is a retrospective analysis of young women (≤ 40 years of age) with Gynaecological malignancies who underwent fertility sparing surgeries from January 2017 to December 2018 in the department of Obstetrics and Gynaecology, JIPMER, Puducherry, South India
Results: Out of 558 women with Gynecological malignancies admitted for management, 127 were ≤ 40 years of age. The most common malignancy was Ovarian (58%) followed by Cervix (24%) and Endometrium (14%). In Ovarian carcinoma, surface epithelial tumors were the commonest (62%) followed by Germ cell tumors (31%). Fertility sparing surgery was feasible in all germ cell tumors and only 30 % of surface epithelial tumors as the mean age at presentation was 25 years. In women with carcinoma cervix and carcinoma endometrium the mean age was 37 and 35 years respectively and all of them completed their family.
Conclusion: In this retrospective cohort, fertility sparing surgery was needed only in Ovarian malignancies.
Keywords: Fertility preservation surgery, gynecological malignancies, ovarian malignancy
|How to cite this article:|
Dasari P, Garg S. Fertility preservation surgeries in gynecological malignancies at a tertiary care institute in South India. Onco Fertil J 2019;2:16-9
|How to cite this URL:|
Dasari P, Garg S. Fertility preservation surgeries in gynecological malignancies at a tertiary care institute in South India. Onco Fertil J [serial online] 2019 [cited 2019 Sep 22];2:16-9. Available from: http://www.tofjonline.org/text.asp?2019/2/1/16/261252
| Introduction|| |
Fertility preservation surgery is a method to preserve the fertility potential of women. This procedure is done for gynecological cancer patients without affecting the management of gynecological cancer. Preservation of fertility is important especially so for a nulliparous woman. The cure of malignancy cannot be ascertained prior to surgery, and hence adequate counseling involving fertility specialists, gynecological oncologists, and medical oncologists is essential. In tertiary care setups, these specialists are available, and hence it is desirable to know the type of malignancies and the stage of the disease so as to counsel women for fertility options and offer them the techniques essential to preserve the fertility. It is also essential to explain the prognosis and necessity of chemotherapy and long-term follow-up.
The purpose of this study was (1) to find out the percentage of women with gynecological malignancies requiring fertility preservation surgery and to know the type or spectrum of malignancies and (2) to know the type of fertility preservation surgery and management undertaken.
| Materials and Methods|| |
This is a retrospective analysis of data from case records of 558 women with gynecological malignancies managed in the Department of Obstetrics and Gynaecology, Women and Children Hospital, JIPMER, Puducherry, over a period of 2 years (January 2016 to December 2017). Details of the data collection included age, parity, type and stage of malignancy, and the surgical procedure performed. Results were analyzed for women with ≤40 years of age with respect to age group, stage of the malignancy, and type of malignancies and expressed in percentages or frequencies.
| Results|| |
Out of the 558 women who were admitted to our hospital for the treatment of gynecological tumors, 127 (22.75%) were ≤40 years of age and out of these, 50 (39.3%) had histopathologically proven gynecological malignancy. The most common malignancy was ovarian carcinoma (58%) followed by cervical carcinoma (24%) and endometrial carcinoma (14%) [Figure 1].
The clinical profile is shown in [Table 1]. The mean age of women with carcinoma cervix and carcinoma endometrium was 37 and 35 years, respectively. All women with carcinoma cervix and carcinoma endometrium were multiparous with live children. In ovarian cancer, 52% were nulliparous and 58% presented as Stage I disease. All women with endometrial cancer were diagnosed in Stage I. Majority of women with carcinoma cervix were Stage II and 33% were Stage I. Other malignancies included carcinoma vulva in one case and choriocarcinoma in another case.
|Table 1: Clinical profile of young women with gynecological malignancies|
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[Table 2] shows the stage of disease with respect to age. The mean age of women with ovarian carcinoma was found to be 25 years. In 29 women with carcinoma ovary, 11 (37.9%) were nulliparous/uniparous. Fertility preservation surgeries were done in 15/29 (51.7%) women with ovarian malignancies. Forty percent (6/15) of women who underwent fertility preservation surgeries in Stages I and II received chemotherapy.
The type of fertility preservation surgeries performed and further management is shown in [Table 3].
Majority (86.6%) underwent cystectomy/ovariotomy as the surgical staging was Stage I.
Forty percent of the women received chemotherapy.
The most common malignancy was surface epithelial tumors followed by germ cell tumors. Germ cell tumors presented at very young age (<25 years). Surface epithelial tumors presented most commonly between 26 and 35 years of age [Table 4].
Among the surface epithelial tumors and germ cell tumors, serous cystadenocarcinoma (70.5%) and dysgerminoma (60%) were the most common, respectively [Table 5].
| Discussion|| |
Fertility preservation surgeries in gynecological malignancies include conization radical trachelectomy for carcinoma cervix, unilateral salpingo-ovariotomy for ovarian tumors, and endometrial resection with hormone therapy for endometrial cancer.
In this series of women of ≤40 years of age, we did not find any woman with carcinoma cervix and endometrial cancer who underwent fertility-preserving surgery. This is because the mean age at presentation in carcinoma cervix and carcinoma endometrium was 37 and 35 years, respectively, and in India, family bearing most often gets completed earlier because of early age at marriage. The age-adjusted incidence of cervical cancer in India is reported to be 1.3% among women of 20–29 years of age and 10.2% in women of 30–39 years, and the peak age is reported to be between 55 and 59 years of age. In the USA, among women <40 years of age, cervical cancer incidence of 1% occurred below 20 years of age, 21% between 20 and 29 years of age, and 78% between 30 and 39 years of age, and the overall incidence reported was 4.3/100,000 women. Hence, fertility preservation surgeries in the form of radical trachelectomy are reported more often. In India, 85% of cervical cancers are diagnosed in late stages compared to the USA and the UK where 22% and 25% were in late stages, respectively.
Fertility preservation surgeries for cervical cancer (abdominal radical trachelectomy) were reported to be successful in 82.7% for tumors larger than 2 cm, 85.1% for all sizes, and 89% for neoadjuvant chemotherapy followed by surgery in Stage B1 cancers. Pregnancy outcomes were reported to result in a live birth rate of 70% and prematurity of 38%.
Endometrial carcinoma was diagnosed in this series in Stage I in all women <40 years of age. A retrospective review reported 80% in Stage I disease. Only 2%–14% of endometrial cancers were reported to occur below 40 years of age, and fertility preservation surgeries in endometrial cancer are possible in Stage I and Grade I tumors.
In ovarian cancer, the mean age of young women of ≤40 years with gynecological malignancies was 25 years at presentation, which was less as compared to other malignancies, i.e., cervix and endometrium. This is similar to a retrospective study which analyzed reproductive outcomes after fertility-sparing surgery in Fudan University, China, from October 2003 to October 2013. The most common tumor in the present study was surface epithelial tumor (58%) followed by germ cell tumors (34%). In the study of Ratanasrithong and Benjapibal, majority (35%) belonged to borderline tumors.
Out of 29 women with carcinoma ovary, fertility preservation surgeries were done in 15 (51.7%) women. This was done in 30% of surface epithelial tumors and 100% of germ cell tumors. According to a review article published in 2017 by Di Tucci et al. on fertility management for malignant ovarian germ cell tumors, fertility-sparing surgery was feasible in >70% of patients. Germ cell ovarian tumors commonly occur at an younger age. A 5-year survival rate of up to 90% can be expected for those suffering from a germ cell tumor; hence, the option of considering fertility preservation is of utmost importance. Women who undergo fertility-sparing surgery for an early cancer of the ovary have a 10.3% chance of recurrence and 5.5% chance of death from disease, which needs to be kept in mind in order to address the need for long-term follow-up. In the present study, 40% (6/15) of women ≤40 years of age who underwent fertility preservation surgeries received chemotherapy.
A study on pregnancy outcomes after conservative surgery for early-stage ovarian cancer reported that 40.5% required chemotherapy and received the same. The pregnancy rate was reported to be 52%, and the rates were not affected by surgical staging or chemotherapy. Pregnancy did not affect the progression-free survival. If ovarian cancer is detected during Stage I, it is associated with a 5-year survival rate of 62%–85%.
| Conclusion|| |
In this retrospective cohort of young women of ≤ 40 years of age with gynecological malignancies, carcinoma endometrium constituted 14%, followed by carcinoma cervix 24% and ovarian malignancies 58%.
None of the women with carcinoma cervix and carcinoma endometrium underwent fertility-preserving surgery as their mean age at presentation was 37 and 35 years, respectively, and had completed their family.
Of the ovarian malignancies, surface epithelial tumors were the most common (62%) followed by germ cell tumors (31%).
Fertility preservation surgery was feasible only in 51% of women with ovarian malignancies. This was done in 30% of surface epithelial tumors and 100% of germ cell tumors. Ovariotomy was done in 86.6% of women and unilateral salpingo-ovariotomy was done in 13.3% of women.
In Stage I and II ovarian malignancies, fertility-preserving surgery was performed in all women, and the most common age group was 10–19 years.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Loren AW, Mangu PB, Beck LN, Brennan L, Magdalinski AJ, Partridge AH, et al.
Fertility preservation for patients with cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2013;31:2500-10.
Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical cancer and role of screening in India. Indian J Med Paediatr Oncol 2016;37:278-85.
] [Full text]
Sreedevi A, Javed R, Dinesh A. Epidemiology of cervical cancer with special focus on India. Int J Women's Health 2015;7:405-14.
Benard VB, Watson M, Castle PE, Saraiya M. Cervical carcinoma rates among young females in the United States. Obstet Gynecol 2012;120:1117-23.
Pareja R, Rendón GJ, Vasquez M, Echeverri L, Sanz-Lomana CM, Ramirez PT. Immediate radical trachelectomy versus neoadjuvant chemotherapy followed by conservative surgery for patients with stage IB1 cervical cancer with tumors 2cm or larger: A literature review and analysis of oncological and obstetrical outcomes. Gynecol Oncol 2015;137:574-80.
Bentivegna E, Maulard A, Pautier P, Chargari C, Gouy S, Morice P. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: A systematic review of the literature. Fertil Steril 2016;106:1195-1211.e5.
Duska LR, Garrett A, Rueda BR, Haas J, Chang Y, Fuller AF. Endometrial cancer in women 40 years old or younger. Gynecol Oncol 2001;83:388-93.
Ota T, Yoshida M, Kimura M, Kinoshita K. Clinicopathologic study of uterine endometrial carcinoma in young women aged 40 years and younger. Int J Gynecol Cancer 2005;15:657-62.
Carneiro MM, Lamaita RM, Ferreira MC, Silva-Filho AL. Fertility-preservation in endometrial cancer: Is it safe? Review of the literature. JBRA Assist Reprod 2016;20:232-9.
Zhang N, Chen R, Hua K, Zhang Y. A retrospective study of reproductive outcomes after fertility-sparing surgery and postoperative adjuvant chemotherapy in malignant ovarian germ cell tumors and sex cord-stromal tumors. J Ovarian Res 2017;10:52.
Ratanasrithong P, Benjapibal M. Pregnancy outcomes after conservative surgery for early-stage ovarian neoplasms Asian Pac J Cancer Prev 2017;18:2083-7.
Di Tucci C, Casorelli A, Morrocchi E, Palaia I, Muzii L, Panici PB, et al.
Fertility management for malignant ovarian germ cell tumors patients. Crit Rev Oncol Hematol 2017;120:34-42.
Henes M, Neis F, Krämer B, Walter C, Brucker S, Von Wolff M, et al.
Possibilities of fertility preservation in young patients with ovarian cancer. Anticancer Res 2014;34:3851-4.
Fertility Sparing Treatments in Gynaecological Cancers. RCOG Scientific Paper No. 353; February, 2013.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]