Won Seyeon, Kim Mi Kyoung, Seong Seok Ju
Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Korea.
Clin Exp Reprod Med. 2020 Dec;47(4):237-244. doi: 10.5653/cerm.2020.03629. Epub 2020 Nov 10.
Endometrial cancer (EC) in young women tends to be early-stage and low-grade; therefore, such cases have good prognoses. Fertility-sparing treatment with progestin is a potential alternative to definitive treatment (i.e., total hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and/or lymphadenectomy) for selected patients. However, no evidence-based consensus or guidelines yet exist, and this topic is subject to much debate. Generally, the ideal candidates for fertility-sparing treatment have been suggested to be young women with grade 1 endometrioid adenocarcinoma confined to the endometrium. Magnetic resonance imaging should be performed to rule out myometrial invasion and extrauterine disease before initiating fertility-sparing treatment. Although various fertility-sparing treatment methods exist, including the levonorgestrel-intrauterine system, metformin, gonadotropin-releasing hormone agonists, photodynamic therapy, and hysteroscopic resection, the most common method is high-dose oral progestin (medroxyprogesterone acetate at 500-600 mg daily or megestrol acetate at 160 mg daily). During treatment, re-evaluation of the endometrium with dilation and curettage at 3 months is recommended. Although no consensus exists regarding the ideal duration of maintenance treatment after achieving regression, it is reasonable to consider maintaining the progestin therapy until pregnancy with individualization. According to the literature, the ovarian stimulation drugs used for fertility treatments appear safe. Hysterectomy should be performed after childbearing, and hysterectomy without oophorectomy can also be considered for young women. The available evidence suggests that fertility-sparing treatment is effective and does not appear to worsen the prognosis. If an eligible patient strongly desires fertility despite the risk of recurrence, the clinician should consider fertility-sparing treatment with close follow-up.
年轻女性的子宫内膜癌（EC）往往处于早期且分级较低；因此，这类病例预后良好。对于部分患者，孕激素保留生育功能治疗是确定性治疗（即全子宫切除术、双侧输卵管卵巢切除术、盆腔冲洗和/或淋巴结切除术）的一种潜在替代方案。然而，目前尚无基于证据的共识或指南，且该话题存在诸多争议。一般而言，建议保留生育功能治疗的理想候选者为患有局限于子宫内膜的1级子宫内膜样腺癌的年轻女性。在开始保留生育功能治疗前，应进行磁共振成像以排除肌层浸润和子宫外疾病。尽管存在多种保留生育功能的治疗方法，包括左炔诺孕酮宫内节育系统、二甲双胍、促性腺激素释放激素激动剂、光动力疗法和宫腔镜切除术，但最常用的方法是高剂量口服孕激素（醋酸甲羟孕酮每日500 - 600毫克或醋酸甲地孕酮每日160毫克）。治疗期间，建议在3个月时进行刮宫术以重新评估子宫内膜。尽管对于病情缓解后维持治疗的理想时长尚无共识，但合理的做法是考虑个体化地维持孕激素治疗直至怀孕。根据文献，用于生育治疗的卵巢刺激药物似乎是安全的。生育后应进行子宫切除术，对于年轻女性也可考虑不切除卵巢的子宫切除术。现有证据表明保留生育功能治疗是有效的，且似乎不会使预后恶化。如果符合条件的患者尽管有复发风险但强烈希望生育，临床医生应考虑进行保留生育功能治疗并密切随访。
