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Is it safe to preserve the ovary of premenopausal women with supposed early-stage endometrial cancer?
Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 1e2
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Editorial
Is it safe to preserve the ovary of premenopausal women with supposed early-stage endometrial cancer?
Many patients with endometrial cancer are diagnosed in their early stage, and the majority of them are found to belong to less invasive cell types [Grades 1 and 2, as well as Type I (endometrioid cell type)] [1]; all of which contribute to excellent outcome for these patients [2]. The excellent outcome is dependent on the final surgical and pathological findings, which include a small volume of tumor, tumor limited to the uterus with absent or superficial myometrium invasion and absent lympho-vascular space invasion and no cervical involvement, belonging to Grade 1 or 2 endometrioidcell-type endometrial cancer, and, of most importance, free of extrauterine spreading [3,4]. To obtain the aforementioned final surgico-pathological features, a thorough and complete staging surgery, mainly containing cytology, total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph-node dissection, para-aortic lymph-node dissection, and possible multiple random biopsies during operation, should be performed [3]. That is to say, the belief of excellent outcome for these patients might be much more acceptable in those women who have undergone a “thorough and complete staging surgery,” and their final surgico-pathological stage of the endometrial cancer is limited to International Federation of Gynecology and Obstetrics Stage IA, Grade 1 or Grade 2, and endometrioid cell type [4]. A recent paper has been published in the Taiwanese Journal of Obstetrics & Gynecology last year [5]. This study might challenge the necessity of a thorough and complete staging surgery for endometrial cancer. In Lau et al’s paper [5], 64 patients who did not receive a thorough and complete stating surgery were analyzed. Specially, all patients did not have the standard bilateral salpingooophorectomy. The results showed that these patients had an excellent prognosis with almost 100% survival rate (98.3% of the 5-year recurrence-free survival rate during a median follow-up period of 44.6 months) [5]. Therefore, the authors concluded that preservation of the ovaries does not increase the disease-related mortality, and further highlighted that a more conservative approach to surgical staging may be considered in premenopausal women with early-stage endometrial cancer without risk factors. In fact, Dr. Lau has published one paper based on the one of the largest medical centers in North Taiwan in 2014, and found that there were no statistically significant differences of disease-free survival between Stage I patients with and without oophorectomy (hazard ratio ¼ 2.72, 95% confidence interval ¼ 0.48e15.59), contributing the conclusion they made that ovarian preservation might be a suggestion for the premenopausal women with early-stage low-risk endometrial cancer [6].
This study, a multicenter retrospective study, was conducted by the Taiwanese Gynecologic Oncology Group (TGOG), and might be a good representative of the “real” situation of patients and provides useful information in the management of women with endometrial cancer, especially for those women with postoperatively accidental findings of “supposed” early-stage endometrial cancer. However, it is questionable that this suggestion could be accepted by the patients and/or the physicians. In fact, there are many uncertainties for the conclusion the authors made. First, although many strategies could be applied for women with endometrial cancers who want to maintain future fertility, a follow-up period was short and the results seemed to be “acceptable”. However, nearly all papers available still highly commented that total hysterectomy should be made after completing the births. In both publications by Dr. Lau [5,6], the authors did not focus on this part, and by contrast, they focused on the possibility of preservation of the ovary, which is the main source of the female sex hormone, contributing to maintain the general health of women, including a healthy cardiovascular system [7] and bone strength [8]. The discussion of the ovarian preservation in women with endometrial cancer, especially for those premenopausal women, can be found elsewhere [4]. The reasons for favoring preservation of the ovary include the following: (1) it is extremely low risk for cancer-related morbidity and mortality, such as an extremely low incidence of extrauterine spreading (occult ovarian metastases), and a similar 5-year disease-free survival or overall survival between patients with and without ovarian preservation; and (2) it is beneficial for the presence of the female sexual hormone for the general health of premenopausal women. By contrast, the reasons against the preservation of the ovary include the following: (1) high possibility of synchronous ovarian cancer with endometrial cancer; and (2) endometrial cancer is a female sex-hormonedependent disease. Therefore, preservation of the ovary in women with endometrial cancer during operation, especially for young women and “supposed” early-stage endometrial-cancer patients, might not be a standard therapy. Finally, it is still uncertain that patients with endometrial cancer could be managed by incomplete staging surgery. In addition, it is also controversial that the postoperative adjuvant therapy, including radiotherapy and/or chemotherapy for these women with endometrial cancer, could play a rescue method in place of a thorough and complete staging surgery. According to the results of the TGOG, the answer to the first question might be acceptable, because among 64 patients, 50 patients did not have data about
http://dx.doi.org/10.1016/j.tjog.2015.12.002 1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Editorial / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 1e2
lymph nodes. The answer to the second question might be acceptable, because one-eighth of the patients received postoperative adjuvant therapy, and the outcome seemed to be excellent in the current TGOG study [5]; the role of postoperative adjuvant therapy for these supposed early-stage endometrial-cancer patients is still being argued. It raised the following question: “is it really acceptable by the majority of gynecological oncologists?” We are afraid that none could respond to it. We are happy to learn the readers' interest [9], and also encourage that the principal investigators of the TGOG study share their opinions on this [10]. Any finding by a study should be carefully evaluated, and if it is to change our daily practice, much more evidence is required.
[4] Lee FK, Lee WL. Is it possible to preserve the ovaries during surgical intervention in younger women diagnosed with endometrial cancer? J Chin Med Assoc 2014;77:341e2. [5] Lau HY, Chen MY, Ke YM, Chen JR, Chen IH, Liou WS, et al. Outcome of ovarian preservation during surgical treatment for endometrial cancer: a Taiwanese Gynecologic Oncology Group study. Taiwan J Obstet Gynecol 2015;54:532e6. [6] Lau HT, Twu NF, Yen MS, Tsai HW, Wang PH, Chung CM, et al. Impact of ovarian preservation in women with endometrial cancer. J Chin Med Assoc 2014;77:379e84. [7] Huang BS, Lee WL, Wang PH. The slowing down of renal deterioration but acceleration of cardiac hypertrophydis estrogen receptor a a hero or villain? Am J Physiol Renal Physiol 2014;307:F1352e4. [8] Lee WL, Huang BS, Chen YJ, Wang PH. Overcoming the barriers of osteoporosis treatmentda better route and a longer use. J Chin Med Assoc 2015;78:567e8. [9] Li YT, Teng SW. Surgery for endometrial cancer. Taiwan J Obstet Gynecol 2016;55(1):152. [10] Wang KL. Authors' reply. Taiwan J Obstet Gynecol 2016;55(1):153.
Conflicts of interest Fa-Kung Lee Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan
The authors have no conflicts of interest relevant to this article. Acknowledgments This paper was supported by grants from the Ministry of Science and Technology, Executive Yuan (MOST 103-2314-B-010-043MY3), and Taipei Veterans General Hospital (V104C-095 and V105C-096). The authors thank the Medical Science and Technology Building of Taipei Veterans General Hospital for providing experimental space and facilities. References [1] Lee WL, Yen MS, Chao KC, Yuan CC, Ng HT, Chao HT, et al. Hormone therapy for patients with advanced or recurrent endometrial cancer. J Chin Med Assoc 2014;77:221e6. [2] Wen KC, Sung BL, Wang PH. Re: the revised 2009 FIGO staging system for endometrial cancer: should the 1988 FIGO stages IA and IB be altered? Int J Gynecol Cancer 2012;22:178e9. [3] Lee WL, Lee FK, Su WH, Tsui KH, Kuo CD, Hsieh SL, et al. Hormone therapy for younger patients with endometrial cancer. Taiwan J Obstet Gynecol 2012;51: 495e505.
Ming-Shyen Yen, Peng-Hui Wang* Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan *
Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. E-mail addresses: [email protected], [email protected] (P.-H. Wang).
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Editorial
Is it safe to preserve the ovary of premenopausal women with supposed early-stage endometrial cancer?
Many patients with endometrial cancer are diagnosed in their early stage, and the majority of them are found to belong to less invasive cell types [Grades 1 and 2, as well as Type I (endometrioid cell type)] [1]; all of which contribute to excellent outcome for these patients [2]. The excellent outcome is dependent on the final surgical and pathological findings, which include a small volume of tumor, tumor limited to the uterus with absent or superficial myometrium invasion and absent lympho-vascular space invasion and no cervical involvement, belonging to Grade 1 or 2 endometrioidcell-type endometrial cancer, and, of most importance, free of extrauterine spreading [3,4]. To obtain the aforementioned final surgico-pathological features, a thorough and complete staging surgery, mainly containing cytology, total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph-node dissection, para-aortic lymph-node dissection, and possible multiple random biopsies during operation, should be performed [3]. That is to say, the belief of excellent outcome for these patients might be much more acceptable in those women who have undergone a “thorough and complete staging surgery,” and their final surgico-pathological stage of the endometrial cancer is limited to International Federation of Gynecology and Obstetrics Stage IA, Grade 1 or Grade 2, and endometrioid cell type [4]. A recent paper has been published in the Taiwanese Journal of Obstetrics & Gynecology last year [5]. This study might challenge the necessity of a thorough and complete staging surgery for endometrial cancer. In Lau et al’s paper [5], 64 patients who did not receive a thorough and complete stating surgery were analyzed. Specially, all patients did not have the standard bilateral salpingooophorectomy. The results showed that these patients had an excellent prognosis with almost 100% survival rate (98.3% of the 5-year recurrence-free survival rate during a median follow-up period of 44.6 months) [5]. Therefore, the authors concluded that preservation of the ovaries does not increase the disease-related mortality, and further highlighted that a more conservative approach to surgical staging may be considered in premenopausal women with early-stage endometrial cancer without risk factors. In fact, Dr. Lau has published one paper based on the one of the largest medical centers in North Taiwan in 2014, and found that there were no statistically significant differences of disease-free survival between Stage I patients with and without oophorectomy (hazard ratio ¼ 2.72, 95% confidence interval ¼ 0.48e15.59), contributing the conclusion they made that ovarian preservation might be a suggestion for the premenopausal women with early-stage low-risk endometrial cancer [6].
This study, a multicenter retrospective study, was conducted by the Taiwanese Gynecologic Oncology Group (TGOG), and might be a good representative of the “real” situation of patients and provides useful information in the management of women with endometrial cancer, especially for those women with postoperatively accidental findings of “supposed” early-stage endometrial cancer. However, it is questionable that this suggestion could be accepted by the patients and/or the physicians. In fact, there are many uncertainties for the conclusion the authors made. First, although many strategies could be applied for women with endometrial cancers who want to maintain future fertility, a follow-up period was short and the results seemed to be “acceptable”. However, nearly all papers available still highly commented that total hysterectomy should be made after completing the births. In both publications by Dr. Lau [5,6], the authors did not focus on this part, and by contrast, they focused on the possibility of preservation of the ovary, which is the main source of the female sex hormone, contributing to maintain the general health of women, including a healthy cardiovascular system [7] and bone strength [8]. The discussion of the ovarian preservation in women with endometrial cancer, especially for those premenopausal women, can be found elsewhere [4]. The reasons for favoring preservation of the ovary include the following: (1) it is extremely low risk for cancer-related morbidity and mortality, such as an extremely low incidence of extrauterine spreading (occult ovarian metastases), and a similar 5-year disease-free survival or overall survival between patients with and without ovarian preservation; and (2) it is beneficial for the presence of the female sexual hormone for the general health of premenopausal women. By contrast, the reasons against the preservation of the ovary include the following: (1) high possibility of synchronous ovarian cancer with endometrial cancer; and (2) endometrial cancer is a female sex-hormonedependent disease. Therefore, preservation of the ovary in women with endometrial cancer during operation, especially for young women and “supposed” early-stage endometrial-cancer patients, might not be a standard therapy. Finally, it is still uncertain that patients with endometrial cancer could be managed by incomplete staging surgery. In addition, it is also controversial that the postoperative adjuvant therapy, including radiotherapy and/or chemotherapy for these women with endometrial cancer, could play a rescue method in place of a thorough and complete staging surgery. According to the results of the TGOG, the answer to the first question might be acceptable, because among 64 patients, 50 patients did not have data about
http://dx.doi.org/10.1016/j.tjog.2015.12.002 1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2
Editorial / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 1e2
lymph nodes. The answer to the second question might be acceptable, because one-eighth of the patients received postoperative adjuvant therapy, and the outcome seemed to be excellent in the current TGOG study [5]; the role of postoperative adjuvant therapy for these supposed early-stage endometrial-cancer patients is still being argued. It raised the following question: “is it really acceptable by the majority of gynecological oncologists?” We are afraid that none could respond to it. We are happy to learn the readers' interest [9], and also encourage that the principal investigators of the TGOG study share their opinions on this [10]. Any finding by a study should be carefully evaluated, and if it is to change our daily practice, much more evidence is required.
[4] Lee FK, Lee WL. Is it possible to preserve the ovaries during surgical intervention in younger women diagnosed with endometrial cancer? J Chin Med Assoc 2014;77:341e2. [5] Lau HY, Chen MY, Ke YM, Chen JR, Chen IH, Liou WS, et al. Outcome of ovarian preservation during surgical treatment for endometrial cancer: a Taiwanese Gynecologic Oncology Group study. Taiwan J Obstet Gynecol 2015;54:532e6. [6] Lau HT, Twu NF, Yen MS, Tsai HW, Wang PH, Chung CM, et al. Impact of ovarian preservation in women with endometrial cancer. J Chin Med Assoc 2014;77:379e84. [7] Huang BS, Lee WL, Wang PH. The slowing down of renal deterioration but acceleration of cardiac hypertrophydis estrogen receptor a a hero or villain? Am J Physiol Renal Physiol 2014;307:F1352e4. [8] Lee WL, Huang BS, Chen YJ, Wang PH. Overcoming the barriers of osteoporosis treatmentda better route and a longer use. J Chin Med Assoc 2015;78:567e8. [9] Li YT, Teng SW. Surgery for endometrial cancer. Taiwan J Obstet Gynecol 2016;55(1):152. [10] Wang KL. Authors' reply. Taiwan J Obstet Gynecol 2016;55(1):153.
Conflicts of interest Fa-Kung Lee Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan
The authors have no conflicts of interest relevant to this article. Acknowledgments This paper was supported by grants from the Ministry of Science and Technology, Executive Yuan (MOST 103-2314-B-010-043MY3), and Taipei Veterans General Hospital (V104C-095 and V105C-096). The authors thank the Medical Science and Technology Building of Taipei Veterans General Hospital for providing experimental space and facilities. References [1] Lee WL, Yen MS, Chao KC, Yuan CC, Ng HT, Chao HT, et al. Hormone therapy for patients with advanced or recurrent endometrial cancer. J Chin Med Assoc 2014;77:221e6. [2] Wen KC, Sung BL, Wang PH. Re: the revised 2009 FIGO staging system for endometrial cancer: should the 1988 FIGO stages IA and IB be altered? Int J Gynecol Cancer 2012;22:178e9. [3] Lee WL, Lee FK, Su WH, Tsui KH, Kuo CD, Hsieh SL, et al. Hormone therapy for younger patients with endometrial cancer. Taiwan J Obstet Gynecol 2012;51: 495e505.
Ming-Shyen Yen, Peng-Hui Wang* Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan *
Corresponding author. Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. E-mail addresses: [email protected], [email protected] (P.-H. Wang).