1. Fertility Sparing in Gynecological Cancers
Melkeet singh
Department of O & G

2. Fertility Sparing Surgery in Gynecological Cancers
Most common gynaecological cancers in reproductive age group includes
- Cervical Cancer
- Endometrial Cancer
- Ovarian Cancer

3. Incidence of Gynaecological cancer in Reproductive age group.
Incidence for (age < 49 year) /100000
Cervical Cancer /100000
Endometrial cancer /100000
Ovarian Cancer /100000

4. Mean age of First Time Mothers
40% of first time births occurs beyond age of 30.
Among the reproductive age group, those beyond age of 30 are at greater risk of malignancy - which can jeopardize fertility.
Need for fertility Sparing Surgery.

5. Cancer Treatment Objective Fertility Impaired
Adverse Effects
Psychological effects
Cosmetic problems
Loss of organ function
Sexual and reproductive dysfunction
Cure
Fertility Impaired

6. Goals / Objectives of FSS
Preservation of reproductive potential
Preservation of hormonal function
Similiar outcomes to standard therapy
Favorable obstetric outcome
Benefits > risk

7. FSS - Counseling Patient & family aware of the problem.
Aware that they are assuming an undefined risk.
Aware of limited data on the options.
Options are not standard Therapeutic approaches.
Patient must be extremely compliant with follow up.
Once fertility completed, definitive procedure considered

8. FSS – Prerequisites
Realistic probabilities of achieving conception based on age, history and infertility evaluation
Desire to preserve fertility
Tumor factors-histologic type, grade.
Availability of ART

9. Nodes positive → Radiotherapy
Abnormal smear → Colposcopy + Biopsy → Cone Biopsy
No lesion
CIN
Microscopic CaCx
Horizontal ≤7mm + Invasion < 3 mm
≤ 7mm + Invasion 3-5 mm
>7mm > 5 mm
1A1
1A2
1B1-11A
LVSI -
LVSI +
RH + PLND
TAHBSO
Intracavitary RT
Modified RH +PLND RT
Fertility desired
CONE + PLND
Trachelectomy + PLND
Fertility desired
CONE Enough.
In selected cases if fertility desired - Trachelectomy + PLND
1A1- LN mets 0.5%
Recurrence 2%
LVSI 8-29%
1A2 LN mets 6-14%
Recurrence 4%
LVSI 53%
Nodes positive → Radiotherapy

10. Stage 1A1 – Squamous Carcinoma
A loop cone excision of the cervix is sufficient treatment .

11. Adenocarcinoma
Skip lesions can occur
? Just Pre-invasive

12. NO EFFECT 18% PROM Cone – Fertility & Pregnancy Outcome
(Clin. Exp. Obstet. Gynecol, 1992: 19(1):40-2)
NO EFFECT
Frencezy A, 1995
Haffenden DK, 1993
Tan L, 2004
< 15 mm
25% PRETERM LABOR
18% PROM
Sadler L. Et al., Am J Med Ass, 2004
> 15 mm

13. Trachelectomy Abdominal / Vaginal
Nodes must be assessed prior to procedure via frozen section
Includes resection of the cervix + upper 2-cm of vagina + parametrium, with preservation of the uterine corpus.
The uterine corpus is then sutured to the upper vagina.
Cervical Circulage

14. Trachelectomy - Criteria
A desire for fertility.
No documentation of infertility.
A proven diagnosis of cervical cancer
Stage IA2 disease to stage IB1 disease
Tumor limited to cervix.
Tumor less than 2 cm
No evidence of nodal metastases.
Limited endo cervical involvement - Upper endocervical margins free of tumour (Frozen section) & MRI

15. Trachelectomy -Results
Meta-analysis
Dargent (Lyon)
Plante and Roy (Quebec) 44
Covens (Toronto) 58
Shepherd (London, UK) 40
Total
Recurrences (5.8%)
Recurrences in Radical hysterectomy %
5 years survival in both group %
Pregnancy Outcome
Procedure 315
Documented 114 pregnancies in 97 patients
Live births 93
Fertil Steril 2005;84:156

16. Preserving Fertility in Endometrial Cancer
2% -14 % of endometrial cancer
 40 years
Up to 25% PCOS G1
Early stage
Respond to progestin treatment

17. Preserving Fertility in Endometrial Cancer
Early Stage Ca Endo (Ia, G1)
Standard treatment
TAH + BSO +/- PLND
Is there a fertility sparing surgery for cancer endometrium ?.

18. FSS in Endometrial Cancer
I. Mazzon, et al (2010) described a three-step Technique , each characterized by a pathologic analysis.
(1) removal of the tumor,
(2) removal of endometrium adjacent to tumor
(3) removal of the myometrium underlying the tumor.
Followed by megestrol acetate 160 mg/day x 6 /12
Biopsies at 3, 6, 9, and 12 months were negative
4/6 (66%) achieved childbearing.
I. Mazzon, G. Corrado, V. Masciullo, D. Morricone, G. Ferrandina, and G.Scambia “Conservative surgical management of stage IA endometrial carcinoma for fertility preservation,” Fertility and Sterility, vol. 93, no. 4, pp. 1286–1289, 2010.

19. Conservative Management Endometrial Cancer Criteria
Patient and family aware of the possible risk
Nulliparous Status.
History (infertility )
Histology type- Endometroid type. Clear cell and UPSC excluded .
Grade 1 malignancy.
Tumour size
Myometrial invasion excluded.
ART facilities available
After single delivery –hysterectomy

20. Complex Atypical Hyperplasia
Precursor to cancer.
Commonly detected in patients with PCOS.
30-60 % of hysterectomy performed for CAH are found to have frank malignancy.
Standard recommendations is hysterectomy.
Fertility preservation -hormonal therapy is an option after formal D&C

21. Hormonal therapy
No consensus on type, dosage, duration, frequency, route and maintainance therapy
Hormonal Therapy
Endometrial Hyperplasia
Endometrial Cancer
With out Atypia
With Atypia
Medroxyprogestrone Acetate
10-30 mg PO
100 mg PO
mg in divided dose daily
Megestrol Acetate
40 mg PO
160 mg PO
Depo-Provera
Mirena coil
Various dosages used in trials

22. Endometrial Cancer Literature Overview (1961-2003) Patients = 81
62 (76%) responded
Median time to response 12/52 (range 4-60/52)
15(24%) recurrence
7 retreated with hormones -5 responded.
20 patients conceived by ART
31 life births. ( some conceived more than once)
Ramirez PT, Frumovitz M, Bodurka DC et al. Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol 2004;95:133–138.

23. Preserving Fertility in Epithelial Ovarian Cancer
Standart treatment
TAH BSO + Omentec + append + PLND + PAND + washings + peritoneal biopsies
Fertility Sparing Surgery
Preserve Uterus and contra-lateral Ovary
118 early ovarian cancers that appeared to have disease limited to one ovary were however subjected to full staging. 3/118 (2.5%) of contra-lateral ovary were found to have microscopic disease. This risk must be conveyed to patients concerned. ( Bejamin et al)

24. FSS-Epithelial Ovarian Cancer
Histology type
Endometroid,
Mucinous,
Serous (Clear cell excluded)
Stage 1A
Grade 1 and possibly 2.
After completion of fertility residual ovary and uterus should be taken out

25. Invasive Epithelial Ovarian Cancer
Modified Staging
Histology
Stage IA G1
Stage IA
G2, G3
Stage IC-III
Selected cases
requested by patients
No further treatment
Chemotherapy
Chemotherapy

26. Chemotherapy and Fertility
Premature ovarian failure after chemotherapy is more common with alkylating agents cyclophosphamide ( upto 68%)
Ovarian failure less common with taxol and carboplatin (15-25%)

27. Epithelial Ovarian Cancer Treatment with Fertility-Sparing Therapy
Stage IA and IC epithelial ovarian cancer
1965 to 2000, n=52
20 (%38) received chemotherapy
9 (17%) eventual TAH
5(10%) recurred, 2 died
24 (46%) attempted, 17 (33%) conceived
26 term
Schilder et al., Gynecol Oncol, 2002

28. Germ Cell Tumors of the Ovary
Age - first and second decade
Usually unilateral
Highly chemo sensitive to BEP
Even advance stage responds well
Fertility preserving surgery is the norm
A Report of 28 germ cell / Cancer 42,
- 26 received chemotherapy except two with stage I immature teratoma.
- 7 of 12 married patients, became pregnant, all had term delivery.

29. Borderline ovarian tumour
Oophorectomy is not necessary if the initial operation was a cystectomy
Surgical staging is not indicated
Risk of recurrence- 6% for ipsilateral ovary ,3% for contralateral ovary and 3% for bilateral recurrence
5 Years survival 95-97%
Recurrence higher in those with fertility sparing surgery but survival is similar to those who had a TAHBSO.

30. Border-line Tumors of the Ovary Conservative Management and Pregnancy Outcome
Cancer 1998 Jan, 1;82(1):141-6
Retrospective review
82 patients
39 patients conservative management
Three patients contralateral recurrence (7%)
22 pregnancies were achieved.

31. Thank you…

32. Cancer Treatment Objective Fertility Impaired
Adverse Effects
Psychological effects
Cosmetic problems
Loss of organ function
Sexual and reproductive dysfunction
Cure
Fertility Impaired