|Year : 2021 | Volume
| Issue : 1 | Page : 31-34
Fertility in a woman with bilateral ovarian cancer
Sadhana Patwardhan, Mangala Ketkar, Nitya Agrawal
Nagpur Test Tube Baby Centre and Ketkar Hospital, Nagpur, Maharashtra, India
|Date of Submission||04-Dec-2020|
|Date of Acceptance||23-Apr-2021|
|Date of Web Publication||17-Dec-2021|
Dr. Sadhana Patwardhan
Nagpur Test Tube Baby Centre and Ketkar Hospital, Nagpur, Maharashtra.
Source of Support: None, Conflict of Interest: None
Ovarian cancer is one of the most lethal gynecological malignancies. It is estimated that 10% of ovarian cancer cases will be diagnosed in women of reproductive age and >80% would be in advanced stage. Conservative treatment can be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics) to preserve fertility. Evidence-based data from the descriptive series suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. Here, we present the case report of a patient who underwent bilateral salpingo-oophorectomy for early stage ovarian cancer and borderline tumor, conceived through in vitro fertilization, with successful pregnancy outcome.
Keywords: Fertility, in vitro fertilization, ovarian cancer, pregnancy
|How to cite this article:|
Patwardhan S, Ketkar M, Agrawal N. Fertility in a woman with bilateral ovarian cancer. Onco Fertil J 2021;4:31-4
| Introduction|| |
Ovarian cancer is considered to be one of the most lethal gynecological malignancies. It is estimated that 10% of ovarian cancer cases will be diagnosed in women of reproductive age and >80% would be in advanced stage. Conservative treatment can be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics [FIGO]) to preserve fertility.[1–3] Borderline ovarian tumors (BOTs) comprise 10%–20% of ovarian epithelial tumors and are typically diagnosed during the reproductive years. Survival rates are about 99%, with a 70-month disease-free survival in cases of Stage I tumors, and the survival rate in cases of Stage III tumors is about 89%., While some authors recommend bilateral salpingo-oophorectomy as the initial treatment for early-stage BOT, others have also reported excellent results with more conservative treatments, including cystectomy or unilateral salpingo-oophorectomy. The standard treatment for patients in International FIGO Stage I–II epithelial ovarian cancer is based on total hysterectomy, bilateral salpingo-oophorectomy, peritoneal sampling, omentectomy, both pelvic and para-aortic lymphadenectomy. According to the available guidelines, in women wishing to maintain fertility, conservative surgery can be performed, for all grades at Stage IA or IC while this approach is still debated for high-risk patients (clear cell, stage > or equal IAG3).,,,
| Case report|| |
This case concerns a 27-year-old female patient with a history of pain in the abdomen. In 2015, ultrasonography showed huge adnexal mass. Computed tomography scan revealed huge mass in the left adnexa 12 cm × 11 cm × 8 cm (650 cc) with multiple thick-walled cystic spaces and right ovary measuring 4.8 cm × 2.5 cm × 3.2 cm with peripheral solid areas. Metastasis to adjacent viscera was not seen. The value of cancer antigen 125 was >1000 U/ml and beta-human chorionic gonadotropin (β-HCG) and alpha-fetoprotein were normal. The patient underwent exploratory laparotomy which did not reveal any findings. An omental biopsy revealed low-grade papillary serous carcinoma in the left ovary (completely excised) and serous papillary tumor of borderline malignancy in the right ovary (preserved). Chemotherapy was not indicated due to early stage (IB) and low-grade carcinoma.
Approximately after 1 year, in 2016, the patient again experienced abdominal discomfort. Transvaginal sonography was performed which reported normal uterus, endometrium thickness-1.2 cm, right ovary was enlarged 3.4 cm × 3.9 cm × 5 cm (34cc) showing cysts with irregular isoechoic soft-tissue components, with mild vascularity. Magnetic resonance imaging scan was performed which reported right ovarian complex mass of 7 cmm × 5.5 cmm × 4.4 cmm with enhancing solid components, not involving rectum/uterus, no perifocal disease. Subsequently, laparotomy with right salpingo-oophorectomy was performed. Omental biopsy and peritoneal washings came out to be negative. The histopathology report revealed BOT. In April 2017, the patient desired to have a baby. The patient was referred for infertility treatment as the cancer antigen 125 value was 10.8 IU/ml. In vitro fertilization (IVF) was planned for the patient. Antagonist protocol was chosen and 13 oocytes were retrieved from donor out of which nine embryos formed and frozen using culture media Vitrolife. Meanwhile, patient’s endometrium was prepared by administering hormone replacement therapy since both ovaries of patient were sacrificed. When the endometrium was 8 mm trilaminar with good sub-endometrial flow, embryo transfer was done. In August 2017, two eight celled Grade 1 embryos were transferred. In September 2017, serum β-HCG was 2075.9 mIU/ml. The patient had an uneventful pregnancy and delivered full-term healthy female child by elective cesarean section.
| Discussion|| |
With 21,650 new cases every year, ovarian cancer is currently the fifth leading cause of death from all cancers in women in the USA. Among gynecological cancers, it is the leading cause of death, typically presenting with stage III/IV disease. At present, 12.2% of ovarian cancers occur in women younger than 40 years of age. Most of these cases are tumors of low malignant potential, malignant germ cell tumors, and early-stage invasive epithelial cancer. Among quality-of-life factors in cancer survivors, fertility preservation in premenopausal women is a high priority. A study by Wenzel et al. reported that survivors of lymphoma, gestational trophoblastic tumor, and cervical cancer who were unable to have children after cancer treatment, but who still desired fertility, experienced significant regret. Ovarian cancer is surgically treated by hysterectomy and bilateral salpingo-oophorectomy, but fertility preservation is possible in germ cell cancers, border line tumors, and even early epithelial ovarian cancers.
Germ cell ovarian tumors affect girls in their first or second decade of life. They present usually with early-stage disease and are always candidates for fertility preservation. The surgical staging includes unilateral salpingo-oophorectomy with comprehensive surgical staging. Extraovarian disease is effectively treated by chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Although ovarian failure is a risk of chemotherapy, most of the patients after BEP regain menstrual periods and have good fertility outcome. Nishio et al. published a recent study in Japan involving 35 patients, 30 of whom underwent conservative surgery, as five of them had Stage III and IV disease and, therefore, received radical surgery. Of the 30 patients who underwent conservative therapy, 12 attempted to conceive and eight achieved at least one pregnancy. In an earlier study, one of the largest series, Tangir et al. followed 64 patients fora median of 122 months. Of the 38 patients who attempted to conceive, 29 achieved at least one pregnancy (76%). Of the ten patients with Stage III disease who attempted to conceive, eight were successful. These data suggest that conservative management can be considered for women with malignant ovarian germ cell tumors even when diagnosed at advanced stages.
Borderline cancers also called low malignant potential tumors (LMPTs) affect patients in reproductive age group and are effectively treated by fertility preservation surgery. Unilateral tumors need only unilateral salpingo-oophorectomy. Rarely can they be bilateral and, in such situations, ovarian cystectomy preserving normal ovarian tissue is done. They also have good prognosis and excellent survival. However, recurrences can occur even more than 10 years after the diagnosis. Conservative surgery is complicated by a higher rate of relapse. In a recent large retrospective study, De Iaco et al. compared the outcome of 168 women who had fertility-sparing surgery – cystectomy or unilateral salpingo-oophorectomy with radical surgery, which included BSO with or without total hysterectomy. As in prior studies, the rate of recurrence was highest in the cystectomy group (34%) compared with unilateral salpingo-oophorectomy (20%) or the radical group (6%). Given the risk of recurrence, cystectomy should only be considered in young patients with bilateral tumors or a previous history of unilateral adnexectomy. A recent French study focused on the more challenging group of LMPTs and limited the study to only advanced-stage serous LMPTs. The study looked at 162 women with advanced stage serous LMPTs who received conservative treatment. A total of 18 pregnancies (nine spontaneous) were observed in 14 patients. This study demonstrates that spontaneous pregnancy can be achieved after conservative treatment even in advanced-stage borderline ovarian tumors (with noninvasive implants) but the recurrence rate is high; however, this high rate had no apparent impact on survival.
Unlike the above-mentioned tumors, epithelial ovarian cancers are highly aggressive and are the most common cause of death among gynecological malignances. Although the disease affects elderly females, 3%–17% of tumors affect patients <40 years and 30% patients present with Stage I disease. In these patients, fertility preservation is possible for a limited group of patients with early-stage disease and favorable histology. Therefore, standard treatment for patients with epithelial ovarian cancer consists of total abdominal hysterectomy, BSO, omentectomy, tumor debulking, pelvic and para-aortic lymphadenectomy, multiple biopsies, and peritoneal washings. Most cases are followed by adjuvant platinum-based chemotherapy. A review article revealed six studies with an aggregate of 98 pregnancies in 66 women, with 22 recurrences in 215 patients. Most were Stage I, but these included those up to Stage III. When comparing conservative treatment with radical surgery, the series by Zanetta et al., Schilder et al., Raspagliesi et al., and Anchezar et al. show no significant difference in early-stage patients with well-differentiated tumors.,,
The conservative treatment of bilateral BOTs has advantages through the preservation on a greater amount of ovarian tissue. Palomba et al. showed no significant variation of serum follicle-stimulating hormone (FSH) levels during the 11-year follow-up after bilateral cystectomy. Patients who underwent ultra-conservative surgery had better response to ovarian stimulation in IVF cycles, showing less cancelled cycles, shorter stimulation time, and use of lower dose of gonadotrophins. This study demonstrated that in well-selected patients (women without history of infertility, younger than 35-year-old and with basal FSH lower than 15 IU/l) with bilateral Stage I BOT, ultra-conservative fertility-sparing approach followed by a fertility programme gives real reproductive advantages. The higher risk of recurrence of the bilateral cystectomy could be managed with a close follow-up and completion surgery after childbearing.
IVF is a good option for infertility problems in patients previously diagnosed of BOT, due to the high pregnancy rate of this procedure and the fact that no adverse effect of IVF has been demonstrated in patients in the early stages. Fatemi et al. reported a pregnancy rate of 40% after IVF. They observed four recurrences over 25 patients but no death from the disease, and no intraperitoneal or vaginal dissemination occurred after oocyte collection. The patient discussed above managed to conceive by IVF post bilateral salpingo-oophorectomy with no postchemotherapy for early stage ovarian cancer and borderline tumor.
Although ovarian cancer is usually seen in postmenopausal women, it is also present time and again in young women before their family planning is completed. Several studies show that when ovarian cancer is diagnosed at a nearly stage, a high survival rate of 62%–85% for epithelial and up to 90% for germ cell tumors can be expected. This also applies for a fertility-preserving approach. In case of pregnancy, no relapse occurred and the children had a good outcome. Therefore, counseling on fertility-preserving surgery as well as further fertility preservation methods before subsequent chemotherapy is important.
We thank patient for providing consent to publish this report. We also thank Dr Vijay M Katekhaye (Quest MedPharma Consultants, Nagpur, India) for his assistance in writing, editing, and reviewing the manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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