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Ali AYHAN, MD.

Fertility Sparing Surgery (FSS) in Gynecologic Oncology. Ali AYHAN, MD. Baskent University School of Medicine Department of Obstetrics & Gynecology Division of Gynecologic Oncology. The Main Purpose of Cancer Therapy. High cure Low morbidity

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Ali AYHAN, MD.

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  1. Fertility Sparing Surgery (FSS) in Gynecologic Oncology Ali AYHAN, MD. Baskent University School of Medicine Department of Obstetrics & Gynecology Division of Gynecologic Oncology

  2. The Main Purpose of Cancer Therapy • High cure • Low morbidity • High level of quality of life (as a mood, sexuel life, cosmetic appearence, fertility preservation...)

  3. All Therapeutic Modalities in Female Cancer Are associated with infertility (radiation, radical surgery, chemo...)

  4. Therefore Fertility saving surgery instead of radical in early stage selected gyn/cancer is performed by different centers

  5. FSS Objectives • Similiar oncologic outcomes to standard therapy • Favorable obstetric outcome • Benefits > risks • Low morbidity and cost

  6. Benefits Preservation of fertility Maintanence of endocrine function Risks Increase in probability of recurrence and death Additional surgery Benefits-Risks of FSS

  7. The Main Requirement of FSS Preserving of the uterus Preserving at least one ovary

  8. Fertility Saving Surgery Depends on • Type and origions of tumor • Stage, grade, histology • Age, performance • Fertility desire • Previous infertility problems • Close follow up

  9. Indications for Fertility Saving Surgery • All germ cell • Sex cord stromal (early stage) • Borderline ovarian tumor • Invasive EOC • Cervical Carcinoma • Endometrial Carcinoma

  10. Fertility Saving Surgery in Ovarian Tumors (EOC, BOT,MOGCT, Sex Cord Stromal) • Adequate surgical staging • Removal of affected ovary and tube • Preservation of uterus and contralateral ovary • Finally evaluation of normal appearing contralateral ovary* and endometrium (D&C)** * For occult metastases * Endometrioid type of epithelial tumors

  11. FSS in EOC • 25-30% of all EOC are early stage at the diagnosis • 14% of EOC will occur under 40 years • Of these 62% will be stage I and IIa • Not all, many of these desire to preserve fertility SO TODAY; PROBLEM IS SMALL

  12. Indication for Fertility Sparing Surgery in EOC 1. Stage Ia Grade 1 Stage Ia Grade 2 (limited) 2. Stage Ic, Grade 3, Clear cell + Chemotherapy

  13. Main Problems in FSS in EOC A) In preserved ovary 1) occult metastasis 2) Relapse in spared ovary B) Is there any relationship between relapse, death and preservation of ovary, uterus or other risk factors C) Is there a place of complementary surgery after childbearing

  14. Occult Metastasis in Normal Appearing Ovaries • Varies from 7-33% in old literature • In new literature, this figures are lower than older (about 2.5%)

  15. Survival 925 patients with early stage disease were subjected to Radical Surgery +Chemo (ICON1 and ACTION Studies) J Natl Cancer Inst, 2003:95:105-112

  16. FSS Does Not Affect Survival in Early Stage EOC • Survival after FSS in patients with early ovarian cancer • Without chemo is about 94%

  17. Recurrence, Death and Pregnancy After FSS in EOC Colombo N et al IJGC 2005, Monk BJ, DiSaia PJ, IJGC 2005, Farthing A, BJOG 2006

  18. Obstetric Outcome After Fertility Saving Surgery in EOC

  19. Fertility –Sparing Surgery in Borderline Tumors of the Ovary: • 15% of all EOC • Young age • Early stage • 95% serous - mucinous • Overall survival 95 %

  20. Fertility Sparing Surgery in Borderline Ovarian Tumors • Staging • Leaving the uterus • Some functional ovarian tissue in place • Evaluation of endometrial cavity?

  21. Ovarian procedures in BOT • BSO (very rare) • USO • Cystectomy • Partial excision • Cortical ovarian biopsy for cryopreservation

  22. After FSS • Recurrence 7.7-31 % • Donnez, 2003 • Morriu, 2001 • Cutlieb, 1998 • Disease related death 0 • Pregnancy rates 31.8, 38.5 and 63.3 %Donnez, 2003

  23. Ovarian Tumors of Low Malignant Potential

  24. FSS in MOGCTs • 20-25 %of all ovarian neoplasm • Only 3 % of these are malignant • Young age • Early stage • Generally unilateral (Dysgerminoma 12%)

  25. Fertility Sparing Surgery Full staging Removal of affected ovary Preserving the contraleral ovary Preserving of the uterus + Chemo • In early and selected advanced stage

  26. Survival in MOGCTs The survival in FSS is similar to radical surgery in MOGCTs

  27. Pregnancy after surgery in MOGCTs Low et al, Zanette et al Gerhenson et al

  28. Obstetric Outcome in MOGCT

  29. After Fertility Sparing Surgery: MOGCTs EOC BOT Oncologic Outcome: Survival is similiar to radical surgery

  30. FSS in LMS • 25% ofuterine sarcomas • 1% of all uterine malignancies • 0.29 of all myomectomies • (6815 myoma) • 25% premenopausal

  31. FSS in LMS Local excision (at least 0.5-1cm tumor free border )

  32. Endometrial Cancer Most frequent Gyn.Ca 25% premenopausal 5% under 40 age Type I good prognosis (PCOS) Grade I, EPR + Cure rate %95

  33. Pretreatment Evaluation History (infertility...) Physicial Examination TVUSG D&C Abdominopelvic/ endovajinal coil MRI Ca-125 Laparoscopic evaluation Response to Progesterone or Staging Laparotomy

  34. MRI Sensitivity %80 Specifity %100 Before and After Treatment

  35. Progestogenic Agents MPA 200-600 /mg/ day Megace 40-160 /mg/day IUD / Prog Response Rate Hyperplasia with Atypia %83-94 End. Ca %57-75.6 Duration of Treatment Range 3-6 months Median 9 months Recurrens Hyperplasia with Atypia % 13 End. Ca % 11-50

  36. Response Rates to Progesterones in Endometrial Cancer Kım 1997, Randal-Kurman 1997, Kaku 2001, Wang 2002, Gotlieb 2003 *Jadoul-Donnez 2003 Fertil Steril 2005;84; 1564

  37. FSS in Endometrial Cancer • At young age • Well differantiated End. Ca • Stage IA, Grade I-II • Progestin therapy • Evaluation of end with 3 months interval • Fertility desire

  38. FSS in Cervical Cancer • %27.9 patients < 40 age (SEER) • Cx Ca most prevalant in 35-39 years of age • Adenocarcinoma is a problem • Squam/ Adeno (except neuroendocrine type) • IA-IB1* *Tumor <2 cm, Deep Stromal Inv. <1 cm

  39. FSS in Cervical Cancer • Preinvazive Ia1 LVSI (-) • 1a1 LVSI (+) • 1a2 • 1b1 2 cm Der:1 cm • In selected cases with stage Ib-IIA ovarian transposition,oocyte and/or embryo criopreservation Cone Only Pelvic LND* + Radikal Trachelectomy** *Endoscopic/ Laparotomy / Sentinel Node **Vaginal /Abdominal

  40. In IA1 LVSI (-) CONE Tumor free margin and post-cone negative ECC Positive margin or positive ECC RE-CONE

  41. Clinical importance of margin and ECC

  42. Pelvic Node Metastasis in Stage IA1

  43. Stage IA1 with LVSI (+)IA2 Pelvic lymphadenectomy Radical trachelectomy* plus Cervical cerclage *Free margin >at least 5mm-1 cm

  44. Why lymphadenectomy in Stage IA2 Van Nagell et al..... Creasman et al

  45. FSS in Stage IB1 Lesion ≤ 2cm Depth of Inv ≤ 1cm LNM negative Upper cervical involvement (-) Pelvic lymphadenectomy + Radical trachelectomy

  46. Radical trachelectomy (1994 Dargent) • Removal of primary tumor • Parametrectomy • 1/3 upper vaginectomy • Preserving uterine fundus • Pelvic lymphadenectomy

  47. Radical trachelectomy • Abdominal • Vaginal • Lymphadenectomy (Open and Endoscopic)

  48. Nodifference between Radical trachelectomy and Radical hysterectomy for Recurrence and Death

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