+ giorgia mangili md cristina sigismondi md irccs ospedale san raffaele, milan gynecology oncology...
TRANSCRIPT
+
Giorgia Mangili MDCristina Sigismondi MD
IRCCS Ospedale San Raffaele, MilanGynecology Oncology Department
Prof. M.Candiani
The presenter has no conflict of interest to declare.
Fertility-sparing surgery in borderline
and non epithelial ovarian tumors: State of the Art
ESGO 2013Liverpool
+
+ Borderline Ovarian
Tumors (BOT)
+Borderline Ovarian Tumors: Early Stage
Fertility-sparing treatment:
INDIPENDENT PROGNOSTIC FACTOR FOR RECURRENCE
Rate of recurrence
NO IMPACT ON SURVIVAL
Risk of lethal recurrence < 0.05%
Unilateral Salpingo-oophorectomy + peritoneal staging
0-5% Radical Surgery
0-25% Unilateral salpingo-oophorectomy
10-42% Cystectomy
Daraï et al. Hum Reprod Update. 2013Du Bois et al. Eur J Cancer. 2013
+Serous Borderline Ovarian Tumors
N°
Median Age
I st II st III stRelapse
sProgressio
nDeath
s
Cystectomy
18 30 13 0 56
(33%)2 0
USO 28 38 21 3 4 2 (7%) 0 2 DOC
Radical surgery
53 53 41 1 11 1 (1.8%) 17 DOC1 DOD
Total 99 40 75 4 20 9 (9%) 3 10
+Bilaterality in Borderline Ovarian tumors
BILATERAL CYSTECTOMY (experimental group, n = 15)
versus
SALPINGO-OOPHORECTOMY AND CYSTECTOMY (control group, n = 17)
No difference in cumulative recurrence rate
Shorter time to first recurrence and higher rate of radical treatment Better reproductive outcomes
Human Reproduction. 2010
+
26 patients
All patients had a borderline histology at first recurrence
11 patients relapsed at least twice
2 patients had an invasive histology at 2-3 recurrence (1 DOD)
“Fertility-preserving surgery remains a valuable alternative in young patients with recurrent BOT, in the form of a non-invasive ovarian lesion, who wish to start
a pregnancy.”Human Reproduction. September 25, 2013
+Advanced Stages BOT
Fertility-sparing Treatment
Series
N. of conservati
ve treatments
N. Non invasiv
e implant
s
N. Invasiv
e implant
s
N. Ns implant
sRelapses Deaths
Zanetta, 2001 25 15 7 2 10 0
Prat, 2002 10 9 1 3 1 (invasive imp.)
Longacre, 2005
21 NR NR NR 5 0
De Iaco, 2009 21 NR NR NR 4 0
Uzan, 2010 41 37 3 1 22 1 (non invasive
imp.)
Viganò, 2010 10 10 6 0
Song, 2011 5 1 0
Total 132 69 11 3 50 (38%)
2 (1.4%)
+
Stromal Ovarian Tumors
+Granulosa cell tumors
+Fertility-sparing Surgery in Granulosa Cell Tumors
Unilateral salpingo-oophorectomy
Peritoneal staging
Endometrial biopsy
NO contralateral biopsy
NO lymphadenectomy
Conservative surgery can be offered to young women who desire to retain fertility
Colombo et al. J Clin Oncol. 2007Thrall et al. Gynecol Oncol. 2012
+Sertoli-Leydig Cell Tumors
No difference in survival rate between conservative and radical surgery
Authors N. Stage I Conservative surgery
Young and Scully 1985
207 202 (97.6%) 143 (69%)
Gui 2012 40 40 (100%) 28 (70%)
Sigismondi 2012 21 18 (86%) 11 (52%)
Bath 2013 15 13 (86.7%) 13 (86%)
Weng 2013 23 18 (78%) 11 (47%)
+ Malignant germ cell ovarian tumors (MOGCT)
+Fertility-sparing Surgery in MOGCT
Study Conservative Demolitive Total Patient n°
Patient n° Survival n°(%)
Patient n° Survival n°(%)
Creasman et al. 1979 32 19 (59.3%) 19/19 (100%) 13 (40.6%) 11/13 (85%)
Gershenson et al. 1983
21 15 (71.4%) 12/15 (80%) 6 (28.5%) 3/6 (50%)
Schwartz 1984 19 17 (89.4%) 17/17 (100%) 2 (10.5%) 2/2 (100%)
Zanetta et al. 2001 169 138 (81.6%) 135/138 (98%)
31 (18.3%) 27/31 (87%)
Khi et al.2002 49 43 (93.4%) 43/43 (100%) 6 (13%) 6/6 (100%)
Chan et al. 2008 535 313 (58.5%) 306/313 (98%)
222 (41.5%) 212/222 (96%)
Tangjitgamol et al. 2010
124 89 (71. 7%) 83/89 (93%) 35 (28.2%) 32/35(91%)
Mangili et al. 2011 123 92 (74.8%) 84/92 (91%) 31 (25.2%) 25/31 (81%)
Total 1072726 (68%)
699 (96%)
346 (32%)
318 (91%)
Except for Stage IA dysgerminoma and stage I immature teratoma
CONSERVATIVE SURGERY + PEB
+Bilateral MOGCT
Bilaterality 4.3% (dysgerminoma 15%)
USO+CYS+staging
Residual disease could be intentionally left in order to
spare fertility3 patients reported
(2 OSR, 1 Vicus et al Gyn Onc 2010)
If CYS is not possible?
XY disgenetic gonads bilateral gonadectomy, spare the uterus!
2 patients conceived through IVF with donor oocyte
Mangili et al. Gyn ecol Oncol. 2011
+Fertility Outcome in MOGCT
Study n° n° getting pregnancy
Pektasides et al. 17 5/17 (29.4%)
Brewer et al 14 3/14 (21.4%)
Mitchell et al. 26 11/26 (42%)
Low et al. 74 16/74 (21.6%)
Zanetta et al. 138 32/138 (23.1%)
Tangir et al. 64 29/64 (45.3%)
Boran et al. 23 6/23 (26%)
de La Motte Rouge et al. 41 12/41 (29.2%)
Cicin et al. 29 7/29 (24.1%)
Zanagnolo et al. 75 15/75 (20%)
Weinberg et al. 22 10/22 (45.4%)
Mangili et al. 92 12/92 (13%)
Total 61
5
158/615
(25.7%)
Premature ovarian failure 3%
Small number of patients
Short follow-up
Young patients
+Reproductive function assessment after surgery plus chemotherapy for Germ Cell Ovarian Tumors: novel clues deriving from the field of fertility preservation
Age
Tumor characteristics
Stage
TreatmentAMH
(ng/ml)
16Mixed germ cell
tumor IIIIC
USO+ ovarian biopsy+
staging+ BEP0.1
18Mixed germ cell
tumorIIB
USO+ CYS+ staging+ BEP 0.7
21 Dysgerminoma IC USO+BEP 2.3
23 Dysgerminoma IVUSO+BEP
2.7
Oocytes cryopreservatio
n
Ottolina et al. Submitted
+The Fertility Window Evaluation of ovarian reserve
AMH
Preservation of fertility
Ovarian reserve
NO
DESIRE FOR PREGNANCY
Spontaneous conception/
ART
YES
La Marca et al. Eur J Obstet Gynecol Reprod Biol. 2012
+Conclusions
Fertility-sparing surgery in borderline ovarian tumors and non epithelial ovarian cancers is feasible
The fertility window may be shortened by oncological treatments
Reproductive function&Oncological follow-up is required
