Endometrial cancer

Inclusion criteria to consider fertility-sparing management of endometrial cancer consist in endometrioid intraepithelial neoplasia or grade 1 endometrial carcinoma without myometrial invasion (1,2). Young women with this oncological presentation and a desire of future pregnancy should be informed that the fertility-sparing approach is not the standard treatment of endometrial carcinoma and hence hysterectomy will be further considered in case of evidence of persistence or recurrence of the disease. Indeed, there is no diagnostic tool to predict with absolute certainty the grade and stage of endometrial carcinoma without performing a hysterectomy (3). 

For this reason, patients need accurate selection and extensive counseling to be referred to this therapeutical approach. Histological diagnosis needs to be obtained by endometrial sampling, ideally by hysteroscopy. Transvaginal ultrasound and/or magnetic resonance can be sued to identify those patients with the lowest risk of local invasion or metastatic lesions (4). 

However, these patients seem to have a greater chance of responding to a fertility-sparing approach, which involves the use of high-does oral progestins like megestrol acetate or medroxyprogesterone acetate or levonorgestrel-release intrauterine devices with or without associated hysteroscopic endometrial resection (5). Some studies evidence the potential beneficial effects of adjuvant use of metformin, gonadotropin-releasing hormone agonists (6) and aromatase inhibitors, but no prospective data are available to date (3,4). 

References:

1. Jadoul P, Donnez J. Conservative treatment may be beneficial for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma. Fertil Steril. 2003 Dec;80(6):1315-24.
2. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer. 2021 Jan;31(1):12-39. 
3. Rodolakis A, Biliatis I, Morice P, Reed N, Mangler M, Kesic V, Denschlag D. European Society of Gynecological Oncology Task Force for Fertility Preservation: Clinical Recommendations for Fertility-Sparing Management in Young Endometrial Cancer Patients. Int J Gynecol Cancer. 2015 Sep;25(7):1258-65. 
4. Leone Roberti Maggiore U, Khamisy-Farah R, Bragazzi NL, Bogani G, Martinelli F, Lopez S, Chiappa V, Signorelli M, Ditto A, Raspagliesi F. Fertility-Sparing Treatment of Patients with Endometrial Cancer: A Review of the Literature. J Clin Med. 2021 Oct 19;10(20):4784.
5. Koskas M, Uzan J, Luton D, Rouzier R, Daraï E. Prognostic factors of oncologic and reproductive outcomes in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma: systematic review and meta-analysis. Fertil Steril. 2014 Mar;101(3):785-94.
6. Tock S, Jadoul P, Squifflet JL, Marbaix E, Baurain JF, Luyckx M. Fertility Sparing Treatment in Patients With Early Stage Endometrial Cancer, Using a Combination of Surgery and GnRH Agonist: A Monocentric Retrospective Study and Review of the Literature. Front Med (Lausanne). 2018 Aug 27;5:240.