Fertility-sparing Management of Grade 2 and 3 Endometrial Adenocarcinomas

Discussion

Most studies suggest that conservative management is safe in patients with grade 1 adenocarcinoma limited to endometrium. Nevertheless, no prospective study of fertility-sparing management has included grade 2 and 3 adenocarcinomas. The decision to exclude grade 2 and 3 adenocarcinomas is based on a lower sensitivity of poorly differentiated adenocarcinoma when treated with progestin (2). Thigpen et al. showed that response rates were higher in grade 1 endometrial adenocarcinoma in comparison with grade 2 and 3 (response rates were respectively 37, 23 and 9%).

A review of the literature on fertility-sparing management of grade 2 and 3 endometrioid carcinomas (3-7) (Table I) shows an 9/13 complete response rate with an 4/9 relapse rate (3-7). In a review of 133 patients with adenocarcinoma treated conservatively with progestin, a lasting complete response was obtained in more than 50% of cases (8). One could argue that the less satisfactory outcome of grade 2 and 3 endometrial adenocarcinomas should discourage fertility-sparing management with similar lesions. However, the accuracy of dilation and curettage in histologic grading of endometrial carcinoma is poor and we can assume that subscribing to the principle of conservative management implies acceptance of a poor characterization of the endometrial lesion. In order to limit the impact of such poor characterization, close follow-up is mandatory to diagnose progression of the disease as early as possible.

Cases of death after conservative management have been reported for grade 1 endometrial adenocarcinoma (9) and atypical hyperplasia (10) but it has never been reported for patients with grade 2 and 3 lesions. Various reasons can explain this discrepancy. It is not possible to say if all unfavorable cases concerning fertility-sparing surgery have been published and no one can prove if deaths can be attributed to a conservative approach. It is probable, however, that the frequent use of hysterectomy has permitted a safe outcome for patients with grade 2 and 3 lesions.

Finally, the pregnancy rate of 4/13 revealed in this review concerning a limited number of grade 2 and 3 adenocarcinomas should encourage further evaluation of fertility-sparing management. Considering the lower sensitivity of poorly differentiated adenocarcinoma when treated with progestin, patients should be counseled regarding the need for close follow-up and should be prepared for the possibility of hysterectomy even when reproductive desires have not been fulfilled.