Abstract
Endometrial cancer is the most frequent gynecological malignancy, and, although epidemiologically it mainly affects advanced age women, it can also affect young patients who want children and who have not yet completed their procreative project. Fertility sparing treatments are the subject of many studies and research in continuous evolution, and represent a light of hope for young cancer patients who find themselves having to face an oncological path before fulfilling their desire for motherhood. The advances in molecular biology and the more precise clinical and prognostic classification of endometrial cancer based on the 2013 The Cancer Genome Atlas classification allow for the selection of patients who can be submitted to fertility sparing treatments with increasing oncological safety. It would also be possible to predict the response to hormonal treatment by investigating the state of the genes of the mismatch repair.
Highlights
Endometrial cancer (EC) occurs after 50 years of age in approximately 80% of cases, affecting approximately 20% of women in premenopausal age, and only 5% of them under 40 years old [1,2].The actual delay in childbearing age is one of the reasons why EC is diagnosed before a first pregnancy more frequently, with respect to the past.In endometrioid EC, standard management involves total hysterectomy and bilateral salpingo-oophorectomy, leading to very high cure rates of 93% in low-risk disease [3].Medical treatment and uterine sparing management are accepted as reasonable short-term alternatives to definitive surgical management in highly selected patients [4]
The present review aims to establish the basis for further retrospective and prospective studies to verify how the new molecular classification of EC could really improve the selection of young patients eligible for a fertility sparing program, to guarantee both their oncological safety and the success of fertility sparing treatment (FST) response and subsequent pregnancy
A work by Leitao et al [22] compared grade 1 tumors diagnosed preoperatively with dilatation and curettage (D&C) to those diagnosed via pipelle biopsy, and the results showed that fewer tumors diagnosed by D&C were upstaged at surgery than those diagnosed by pipelle biopsy (8.7% vs. 17.4%; p = 0.007)
Summary
Endometrial cancer (EC) occurs after 50 years of age in approximately 80% of cases, affecting approximately 20% of women in premenopausal age, and only 5% of them under 40 years old [1,2]. The fertility sparing treatment (FST) in EC includes hysteroscopic resection and/or curettage, in combination with hormonal therapy with progestin In this setting, complete remission rates of 50–75% have been reported [5,6,7], and strict follow-up with hysteroscopic evaluation and endometrial sampling is recommended. Patients often present conditions that could contraindicate surgery and, these women would benefit from a conservative treatment allowing them to avoid the major surgical complications that are associated with surgery. These patients present an increased risk of intra- and post-operative complications that are associated with an increased operative stay [12,13,14]. As described in the National Comprehensive Cancer Network (NCCN-USA) guidelines for hereditary cancers, all women with EC should be genetically tested for MMR mutations, especially if diagnosed under 50 years of age, and if they are members of Lynch families [4]
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