Fertility-preserving Surgery Research Articles

A Successful Pregnancy Following Conservative Surgery and Chemotherapy in a Patient with Malignant Teratoma

Background: Fertility preservation is a major concern for a young woman who has ovarian cancer because of exposure to surgery and chemotherapy. Case: Fertility preservation for a patient with advanced malignant teratoma of the ovary is reported. The patient, a 30-year-old woman, delivered a preterm baby after having had malignant teratoma treatment at age 17. She was initially treated with a right ovarian cystectomy, followed by a 9-course cis platinum + Adriamycin® regimen. Results: The patient subsequently got pregnant following ovulation induction and delivered a preterm baby 13 years after the initial treatment with chemotherapy. Conclusions: Based on this successful case, intensive fertility-preserving surgery followed by chemotherapy, even for malignant teratoma of the ovary, may be effective for preserving the reproductive function of women with malignant immature teratomas of the ovary. (J GYNECOL SURG 32:236)

Preoperative risk stratification of children with ovarian tumors

BackgroundThe appropriate operative approach to pediatric patients with ovarian tumors must balance real risk of malignancy with maximal preservation of reproductive potential. We evaluate preoperative risk of malignancy in order to more precisely guide treatment, so as to err on the side of ovarian preservation if at all possible. MethodsWe retrospectively reviewed the records of all patients undergoing surgical intervention for ovarian tumors at a single institution. The primary endpoint was ovarian malignancy. ResultsOf 502 patients who underwent surgery for ovarian tumors, 44 (8.8%) had malignancies. Malignancy rate (95% confidence interval) was low for cystic lesions <9cm (0.0%, 0.0–2.9%) and for tumor marker-negative heterogeneous lesions <9cm (2.3%, 0.4–12.1%). High-risk profiles for malignancy included tumor marker-positive heterogeneous lesions (66.7%, 35.4–87.9%) and solid tumors ≥9cm (69.2%, 16.2–40.3%). Intermediate risk tumors included cystic tumors ≥9cm (6.8%, 3.5–20.7%), tumor marker-negative heterogeneous lesions ≥9cm (31.2%, 18.0–48.6%), and solid tumors <9cm (11.1%, 4.4–25.3%). ConclusionsWe developed a decision strategy to help determine who may and may not require an ovarian-sparing approach, which warrants prospective application and validation. Ultimately, the decision to pursue an oncologic surgery with oophorectomy and staging (as opposed to fertility-preserving surgery) should be made after individualized discussion involving the surgeon, patient, and family.

Spontaneous Bilateral Tubal Ectopic Pregnancy: Incidental Finding During Laparoscopy – Brief Report and Review of Literature

Objective: Bilateral tubal ectopic pregnancies are rare; the reported incidence is only 1 in 200 000 pregnancies. Detecting bilateral tubal ectopic pregnancy is urgent because of the associated morbidity and mortality. The appropriate fertility-preserving surgery must also be considered, as preservation of both tubes is presumed to offer better fertility prospects. Case Report: A 39-year-old gravida 2, para 1 presented with vaginal bleeding at 8 + 4 weeks of gestation. An approximately 18 mm adnexal mass in the right fallopian tube was detected on ultrasound. Laparoscopy was performed because ectopic pregnancy was suspected. This suspicion was confirmed during laparoscopy; the right fallopian tube was found to contain a mass measuring 20 mm in the isthmic part. Ultrasound of the left fallopian tube also showed a mass in the ampullary region (diameter: 10 mm), also suspicious for ectopic pregnancy. Bilateral salpingotomy was performed laparoscopically. Pathological examination confirmed the diagnosis. Conclusions for Practice: Although ectopic tubal pregnancy is seen more often after assisted reproductive techniques, bilateral spontaneous ectopic pregnancies must also be considered in other cases. Laparoscopic surgery is effective to confirm the diagnosis and treat heterotopic pregnancies. Further studies will be needed to confirm whether unilateral or bilateral conservative fertility-preserving surgery is more appropriate.

Laparoscopic fertility-sparing surgery for early ovarian epithelial cancer: A multi-institutional experience

ObjectiveThere is as yet limited evidence about fertility-sparing surgery for early ovarian cancer (EOC) carried out laparoscopically. We sought to investigate the safety, adequacy and fertility outcome of ovarian cancer patients who underwent fertility-saving laparoscopic surgical staging using a multi-institutional sample. MethodsProspectively collected data in five gynecologic oncology service databases were searched for epithelial EOC patients undergoing laparoscopic fertility-preserving surgery. Surgical, pathologic, oncologic and reproductive outcome data were analysed. ResultsThe study cohort consisted of 65 women. Median age of the patients was 33 (range: 21–42) years. In this cohort 36 (55.4%) and 29 (44.6%) patients were at low risk (FIGO stage IA G1–2) and high-risk (FIGO stage IA G3 or more), respectively. The disease was reclassified to a higher stage in 4 (6.1%) women. After a median follow up period of 38months (range: 2–144), the overall survival was 95.4% and recurrence-free survival 84.6%. Overall, there were 23 pregnancies in 22 women. After ovarian cancer treatment, 64.8% women reported pregnancy intent and 60% of these conceived spontaneously. ConclusionsLaparoscopic staging may represent a viable option for premenopausal women seeking fertility preservation in the setting of early ovarian cancer. More research is needed to determine whether laparoscopy may offer reproductive benefits to this particular population.

The effects of cancer therapy on women's fertility: what do we know now?

Due to the improvements of cancer treatment, the survival rate of cancer increased over the last decades. One of the detrimental side effects of cytotoxic treatment is the impairment or loss of fertility. Having a family is one of the important aspects for long-time survivors. The impact of gynecologic cancer on fertility depends on the site and kind of the cancer disease, the oncologic therapeutic regimen and additional the age of the patient. In cancer of the internal genital organs, fertility-preserving surgery techniques should be used, if possible. In case, that cytotoxic treatment has to be applied, fertility preservation techniques should be implemented into the oncologic treatment.

A retrospective review of 11 cases of villoglandular papillary adenocarcinoma of the uterine cervix and a review of the literature.

Villoglandular papillary adenocarcinoma (VGPA) of the uterine cervix is a rare subtype of cervical adenocarcinoma (AC) that accounts for 3.7-4.8% of cervical AC. Compared with ordinary adenocarcinoma, VGPA is associated with a lower incidence, younger age and better prognosis. Treatment with fertility-preserving surgery is also possible. The present study analyzed cases treated in The Second Hospital of Jilin University (Changchun, Jilin, China) between January 2010 and December 2014. A total of 11 cases were selected; of these, 7 cases were pathologically confirmed. The remaining 4 cases were diagnosed as VGPA upon the pathological examination of the biopsy, but confirmed as another type of adenocarcinoma upon analysis of the surgical pathology. The median age of the patients whose pathology was confirmed post-operatively was 36 years, and all cases were positive for human papillomavirus (HPV). As all 7 patients had no requirement for further fertility, a radical hysterectomy was performed, with or without adjuvant therapy. The follow-up time ranged from 7-57 months, with a mean time of 29 months. There was no evidence of recurrence in any of the patients. All the patients remain alive to date. The results of the present study indicated that HPV infection is likely to be the cause of VGPA, and the prognosis of VGPA tends to be better compared with other types of adenocarcinoma. However, the number of studies that have reported cases of VGPA remains small, and all are retrospective analyses with short follow-up times. Therefore, physicians selecting treatment options for patients with VGPA should exercise caution.

Yolk Sac Tumor of the Ovary in 18 Egyptian Cases: Does It Really Differ?

Background: Ovarian Yolk sac tumor (OYST) is a rare entity of malignant ovarian germ cell tumors (MOGCT). Abdominal pain, a rapidly growing distending mass or irregular vaginal bleeding is the main presentation. Serum AFP is elevated in nearly all cases. The standard management is fertility preserving surgery with adjuvant chemotherapy. Aim of Work: To report and analyze retrospectively recorded cases that were either treated at National Cancer Institute/Egypt or referred there for advice about therapy. Materials and Methods: This is a retrospective single-institutional analysis of 18 cases of OYST treated at National Cancer Institute-Cairo University from January 2011 till December 2015. The clinical and pathological characteristics, treatment, and outcomes of these patients were analyzed. Results: Data from eighteen patients were obtained. The median age was 18 years (range: 15 - 22). Abdominal pain was the most common presentation (89%). The mean tumor size was 21cm (range: 8 - 30 cm). Eleven of our cases (61%) were stage I, seven cases and (39%) were stage IV at presentation. Fifteen cases (83%) underwent fertility preserving procedure & the standard surgical staging. Panhysterectomy & formal staging procedure was done only in two cases (11%). One case (6%) underwent bilateral salpingo-oophorectomy. 2 cases (11.1%) only underwent lymph node biopsy. 11 patient (61.1%) showed pure type YST while mixed type was present in the remaining 7 cases (38.8%): Dysgerminoma (one case, 5.6%), Dysgerminoma + immature teratoma (one case, 5.6%), Immature teratoma (2 cases, 11.1%) and Teratoma (3 cases, 16.7%). AFP was extremely elevated in all cases at presentation (median 4191 ng/mL; ranging: 725 ng/mL - 402,908 ng/mL). It showed decreased level after surgery (median 145 ng/ mL; ranging: 2 ng/mL - 38,000 ng/mL) & normalized after chemotherapy except for progressive disease. All cases started BEP regimen after surgery with complete remission in twelve cases. In follow up period (median 17 months; ranging: 2 - 48 months) two patients relapsed; the mean overall survival time was 34.2 and progression free survival was 33.84 months respectively. Conclusion: Ovarian yolk sac tumors are rare neoplasms. Surgery with adjuvant chemotherapy is the standard management. AFP is important for diagnosis, monitoring response to treatment and predicting relapse.

MALIGNANT OVARIAN GERM CELL TUMOURS (MOGCT); SURVIVAL OUTCOMES FROM A SINGLE INSTITUTION IN PAKISTAN

Objectives: Malignant ovarian germ cell tumours (MOGCTs) are rare, but aggressive tumours seen mostly in young women or adolescent girls. The aim of our study was to evaluate the survival outcomes of MOGCT patients treated at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Materials and Methods: One hundred and nine females were retrospectively identi ed through hospital information system with MOGCT from 2007 to 2013. Histology was based on the WHO classi cation. Tumours were staged according to the Federation of Gynaecology and Obstetrics staging system. Overall survival (OS) and disease-free survival (DFS) were determined by the Kaplan–Meier method. All patients were included in the study. Patient who had been lost to follow-up was contacted through telephone. Results: Mean presenting age was 20 years (range 4–54). 38% of patients had Stage I, 7% had Stage II, 25% had Stage III and 30% of patients had Stage IV disease. Based on histology, 42% had dysgerminoma, 25% had mixed germ cell tumours, 18% had yolk sac tumour, 13% had teratoma and 2% had embryonal carcinoma. Median follow-up time was 41 months. All patients underwent initial surgery, of which 86 (79%) had fertility-preserving surgery. 91 (84%) patients received adjuvant chemotherapy and 18 (16%) were kept on surveillance. The chemotherapy regimen used was a combination of bleomycin, etoposide and cisplatin. 89 patients had a complete remission, 14 had partial response and one had progressive disease. Five patients had relapsed disease, four distant and one local. The 5 year OS was 91% and DFS was 88%. Conclusion: MOGCTs have a good prognosis. Fertility-sparing surgery was possible in the majority of cases. BEP regimen has excellent activity and acceptable toxicity in patients with MOGCT. Key words: Disease-free survival, malignant ovarian germ cell tumours, overall survival

Conservative Surgery for Early Cervical Cancer.

There is a rising incidence of early cervical cancer in young patients as a result of screening and early detection. Treatment of cervical cancer by surgery or radiotherapy results in permanent infertility which affects the quality of life of cancer survivors. Now with improved survival rates among early cervical cancer patients, conservative surgery aiming at fertility preservation in those desiring future pregnancy is an accepted treatment. Conservative surgery is possible in early cervical cancer including micro invasive cancer and stage IB cancers less than 2cm. Stage IA1 cervical cancer is treated effectively by cervical conisation. In stage IA2 cancers and stage IB1 cancers less than 2cm the fertility preservation surgery is radical trachelectomy. Radical trachelectomy removes the cervix with medial parametrium and upper 2cm vaginal cuff retaining the uterus and adnexa to allow future pregnancy. Radical trachelectomy is a safe procedure in selected patients with cancer cervix with acceptable oncologic risks and promising obstetric outcome. It should be avoided in tumours larger than 2cm and aggressive histologic types. This article focuses on the current options of conservative surgery in early cervical cancer.

Detection of gynaecological cancer in pregnancy

Content organisation When a pregnant patient presents with gynaecological cancer several issues must be considered by the multidisciplinary team – disease stage, nodal status, gestational age, obstetric complications and, importantly, the patient’s wishes regarding treatment where a balance must be sought between foetal well-being and optimal maternal therapy. As always, diagnostic imaging is key to these decisions but in pregnant patients we are limited, we avoid CT and contrast agents and therefore ultrasound and MRI become paramount. We are further limited when diagnostic image quality is reduced by foetal movement artefact. We suggest and justify MR protocols written to maximise diagnostic yield. We will present a narrative on the incidence and presentation of cervical cancer and ovarian cancer in pregnancy followed by a pictorial description of their key imaging findings at various disease stages. In the context of cervical cancer we will discuss considerations post fertility-preserving surgery. Conclusion This educational poster will highlight the issues around imaging pregnant patients with gynaecological cancer, illustrate their imaging appearances and demonstrate the usefulness of MR imaging in this context.

Laparoscopy in uterine cervical cancer. Current state and literature review.

Cervical cancer remains the most frequent gynecological tumor in Brazil and other developing countries. Minimally invasive techniques, especially laparoscopy, have been increasingly employed in such tumors. This article aims to describe the main applications of laparoscopy in the treatment and staging of cervical cancer. In the early stages, it is possible to provide a fertility-preserving surgery in the form of radical trachelectomy and, in a study protocol, the function-preserving surgery, avoiding parametrectomy and the associated morbidity. A fully laparoscopic radical hysterectomy is fairly standard in the literature and has the tendency to become the standard of care in early cases, for patients who want to bear no more children. In advanced stages, minimally invasive surgery can offer ovarian transposition, with intent to prevent actinic castration, without upsetting the time for the start of radiotherapy and chemotherapy. Staging laparoscopic surgery, including pelvic and para-aortic lymphadenectomy, has been the subject of studies, since it has the potential to modify the extension of radiotherapy depending on the extent of lymph node spread.

Quimioterapia neoadyuvante como tratamiento para la preservación de la fertilidad en pacientes con cáncer de cérvix en estadio IB: reporte de un caso y revisión de la literatura

&lt;p class="Pa37"&gt;&lt;strong&gt;Objetivo: &lt;/strong&gt;presentar el caso de una paciente con cáncer de cérvix en estadio IB1 mayor de dos cen­tímetros, a quien se le administró quimioterapia neoadyuvante seguida de traquelectomía radical con linfadenectomía pélvica por laparoscopia, con el fin de preservar su fertilidad; hacer una revisión de los casos reportados en la literatura con énfasis en los resultados obstétricos y oncológicos.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales y métodos: &lt;/strong&gt;presentación del caso y búsqueda en Medline vía PubMed de los artículos publicados en inglés, francés y español desde enero de 2000 hasta agosto de 2014, sobre la administra­ción de quimioterapia neoadyuvante y cirugía con­servadora de la fertilidad en pacientes con cáncer de cérvix en estadio IB.&lt;/p&gt;&lt;p class="Pa37"&gt;&lt;strong&gt;Resultados: &lt;/strong&gt;se seleccionaron 12 artículos pertinen­tes, para un total de 55 pacientes. Con un seguimien­to entre 14 y 69 meses, se reportaron 4 recaídas y solo una muerte por enfermedad. Resultados obs­tétricos: 30 embarazos, 24 nacimientos, 3 abortos, 1 embarazo ectópico y 2 embarazos en curso.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusión: &lt;/strong&gt;la quimioterapia neoadyuvante, segui­da de cirugía conservadora de la fertilidad, puede considerarse como una alternativa de manejo en pacientes seleccionadas con cáncer de cérvix en estadio IB, con tumores voluminosos, que deseen preservar su fertilidad.&lt;/p&gt;

An Analysis of Prognostic Factors in Patients with Ovarian Malignant Germ Cell Tumors Who Are Treated with Fertility-Preserving Surgery

Background/Aims: To analyze the clinicopathological factors that affect the prognosis and fertility of patients with malignant ovarian germ cell tumors (MOGCTs). Methods: The medical records and follow-up data of 106 patients with MOGCTs who were treated at The Affiliated Tumor Hospital of Guangxi Medical University between January 1986 and December 2010 were enrolled in this study. A Kaplan-Meier analysis was used to analyze the survival curves. The different prognoses among the various clinicopathological factors were evaluated using a univariate analysis and a log-rank test. The multivariate analysis was performed using the Cox proportional hazard regression method. A logistic regression analysis was used to evaluate the influence of different factors on the prognoses and fertility. Results: The median age at primary treatment was 22 years (range: 9-61years). A total of 59 patients received fertility-preserving surgery, 45 received radical surgery and 94 received postoperative adjuvant chemotherapy. The median follow-up time was 56.5 months (range: 2-309 months). A total of 11 patients experienced a recurrence, and 23 patients died from their cancer. Of the 47 patients who are alive without tumor, 45 have normal menstruation. Of the 39 patients who wished to become pregnant, 31 patients had 33 successful pregnancies that resulted in 33 live births. No statistically significant difference (p > 0.05) was observed with respect to the progression-free survival (PFS; 67.6 vs. 63.3%), the overall survival (OS; 70 vs. 64.1%) and the mortality rate (15.3 vs. 31.3%) between patients who received fertility-preserving surgery and those who received radical surgery. The univariate analysis showed that the pathological types, postoperative residual tumor size, lymph node resection, and omental resection were associated with OS (p < 0.1), whereas postoperative residual tumor size, number of chemotherapy cycles, lymph node resection, and omental resection were associated with PFS (p < 0.1). The multivariate analysis showed that only the postoperative residual tumor size was an independent prognostic factor of OS, whereas the postoperative residual tumor size, number of chemotherapy cycles and lymph node resection were independent prognostic factors of PFS. No statistically significant difference (p > 0.05) was observed with respect to the OS, PFS and fertility between patients who received fertility-preserving surgery and those who were treated with or without comprehensive surgical staging. Conclusion: MOGCTs can achieve a good prognosis after surgery and chemotherapy. Postoperative residual tumor size was an independent prognostic factor of PFS and OS. Moreover, comprehensive surgical staging cannot improve the prognosis. Fertility-preserving surgery plus adjuvant chemotherapy appeared to have little or no effect on prognosis and fertility.

Abdominal radical trachelectomy for early stage cervical cancer: Fertility sparing approach

Objectives: The recommended surgical treatment for stages IA2–IB1 cervical cancer is radical hysterectomy with bilateral pelvic lymphadenectomy and consequent loss of fertility. Recent literature describes abdominal radical trachelectomy (ART) as a procedure that preserves the uterus without increasing the risk of recurrence while affording the opportunity to retain childbearing potential. This study was performed to assess the feasibility and safety of this fertility-preserving surgery for early-stage cervical cancer. We describe the surgical, oncologic, and fertility outcomes of patients treated with ART.

Trachelectomy in Early Cervical Cancer

Objectives: To review the role of trachelectomy as a method of fertility preservation instead of traditional radical hysterectomy in early cervical cancer. Materials and Methods: We conducted our original study through research in PubMed for all original studies and reviews published in the last 10 years. We reviewed the data available on trachelectomy in early stage cervical cancer whether through abdominal route or vaginal route and laparoscopic lymphadenectomy. Moreover, we reviewed the oncologic outcome, recurrence rate and its effect on subsequent pregnancies. Results: We found that recurrence and death rates seem to be comparable between radical trachelectomy (RT) and radical hysterectomy. Complications of RT include chronic vaginal discharge, abnormal uterine bleeding, dysmenorrhea, inflammation and ulcer due to cerclage, amenorrhea, and cervical stenosis. Although around 70% can get pregnant after RT, there are increased complications of pregnancy after this procedure mainly 2nd trimester miscarriages and preterm deliveries. Conclusion: RT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer. Selection of suitable patients for conservative treatment is the best important point for getting a good result without

Ruptured ipsilateral ectopic pregnancies: a rare emergency case series

Ectopic pregnancy is one of the most important causes of maternal mortality in first trimester pregnancy. Several etiologic factors are suspected for ectopic pregnancy. Fertility-saving surgery in ectopic pregnancy is associated with recurrent ectopic pregnancy. Most common site of ectopic pregnancy is in the fallopian tube, especially in the ampullar region. Ipsilateral tube is rare site for ectopic pregnancy. Previous tubal surgery, especially partial salpingectomy, is an important factor in this disease.

The prevalence of primary neck and shoulder pain, and its related factors in Japanese postpartum women

Ectopic pregnancy is one of the most important causes of maternal mortality in first trimester pregnancy. Several etiologic factors are suspected for ectopic pregnancy. Fertility-saving surgery in ectopic pregnancy is associated with recurrent ectopic pregnancy. Most common site of ectopic pregnancy is in the fallopian tube, especially in the ampullar region. Ipsilateral tube is rare site for ectopic pregnancy. Previous tubal surgery, especially partial salpingectomy, is an important factor in this disease.

Live Births after Fertility-saving Surgery in Ovarian Borderline Tumor and Oocyte Donation: Case Report

A left borderline serous ovarian tumor stage I (FIGO) was discovered and treated in a 26-year-old black nulliparous woman, by conservative approach (laparotomy, salpingo- oophorectomy). In a six months interval she had a 7.5 x 7.1 x 5.7cm multilocular contralateral tumor with septa and vegetative areas and in a year interval a CT showed a 8.4 x 7.4 x 7.0 lesion that precluded a follicular aspiration. The authors discuss the multidisciplinary strategy and the approach with the couple: the best option considered would be the resection of the tumor remaining attached to a new study pelvic. If possible uterine conservation should be held for further procedure of oocyte donation. Two years from the first surgery she had the second laparotomy and six months later she had an ICSI with oocyte donation. She became pregnant and delivered two 34 week-pregnancy boys through C-section due to hypertension plus preeclampsia. There happened a post- operative intestinal obstruction that required a new surgical approach to adhesions lysis. There was no report of tumor lesions then. Seven months later, mother and children are doing well. Comments are made about borderline ovarian tumors and fertility-sparing approaches.

Fertility Saving Surgery for Adenomyosis: Results of Prospective Clinical Comparative Trial

Fertility Saving Surgery for Adenomyosis: Results of Prospective Clinical Comparative Trial

Fertility preservation in young patients with ovarian cancer – a retrospective analysis of patients from a university hospital and from the FertiPROTEKT network

Ovarian cancer is generally depicted as being a rare disease, however with the highest mortality rate. Nevertheless, women of fertile age must be informed about the possibility of fertility preserving surgery and fertility preservation methods. The aim of this study was to investigate the incidence of the different histological types of ovarian tumours in young women and to determine and discuss the possibility of fertility preservation. This is a retrospective analysis of all patients under the age of 40 who presented to the University Hospital for Women in Tuebingen for an ovarian tumour between January 2001 and December 2010, including data from the FertiPROTEKT network. The patient's age and pregnancy history, the type of surgery, subsequent chemotherapy and radiotherapy, were considered. A total of 51 patients were treated in Tuebingen within this period. The mean age of the patients was 29.3 years. 41.2% patients underwent primary fertility preserving surgery. A total hysterectomy and bilateral adnexectomy was performed primarily in 58.8% of the women. In the fertility preservation surgery group, 52.4% received adjuvant chemotherapy. After successful treatment, a total of seven pregnancies were recorded in five patients. From the FertiPROTEKT network, 26/41 patients (63.4%) decided to undergo fertility preservation. There were no complications and postponement of chemotherapy in any patients as a result of the fertility preservation procedures. With careful consideration of the risks, the correct indication and diligent aftercare, the realisation of conception is possible also for patients with ovarian cancer.