Endometrial cancer ovaries: go or stay?

The standard surgical procedure for endometrial cancer treatment is a full hysterectomy and two-sided attachment removal.
this principle, even early patients should have their ovaries removed.
However, the removal of the ovaries means that the ovary function is completely lost after surgery, resulting in pre-menoptopathic patients will enter the menoque early, a series of low estrogen symptoms, such as sweating, fear of heat, irritability, rough skin, obesity, etc., seriously affecting their daily work and quality of life.
If one or both ovaries are retained during surgery, the occurrence of such symptoms can be largely delayed, which is undoubtedly a major "good thing" for the quality of life of endometrial cancer patients.
However, whether endometrial cancer patients can retain their ovaries, whether they increase the risk of metastasis, whether it affects survival and many other issues, there is still a lack of international consensus, so it is a controversial topic.
the incidence of endometrial cancer has been increasing year by year in recent years, and the incidence of young patients is increasing, so the problem of "going" and "remaining" of endometrial cancer ovaries has gradually received more and more attention from clinicians.
this paper discusses this hot issue in terms of the characteristics of young endometrial cancer patients, their benefits of retaining ovaries, safety, adaptability, and recommendations of the latest international clinical guidelines.
, young endometrial cancer patients characteristic endometrial cancer is common in post-menovascular women, more than 90% of patients are over 50 years of age, but still 4% of patients are diagnosed before the age of 40.
the number of young women suffering from endometrial cancer is on the rise as the incidence increases worldwide.
Such patients not only do not face menool, or still have reproductive functions and requirements, the general condition of the body is better, often not accompanied by high blood pressure, diabetes and other chronic diseases, its clinical stage earlier, histological differentiation is good.
young endometrial cancer patients often have more psychological appeals than older patients, and they tend to pay more attention to the quality of life after treatment.
Patients who have not completed childbirth tend to want to retain fertility, while those who have completed childbirth are concerned about accelerated aging after surgery due to loss of estrogen protection, menoptocracy symptoms, etc., and are eager to retain ovarian function on one or both sides during surgery.
should pay attention to these demands in the course of clinician diagnosis and treatment, and fully integrate the patient's wishes into the process of clinical decision-making.
II. The effect of ovarian excision on the quality of life of endometrial cancer patients Ovaries have two major functions, reproductive and endocrine functions, ovarian synthesis and secretion of hormones are mainly estrogen, progesterone and a small number of androgens, these hormones not only in maintaining women's second sexual characteristics, maintain normal reproductive system function, maintain normal function, but also have a series of metabolic functions such as regulating water sodium balance, regulating lipid metabolism, maintaining normal bone.
, the ovaries secrete peptide hormones, cytokines, and growth factors.
, having normal ovarian function is extremely important for women who are not menopian.
There are two distinct differences between postoperative and natural menoque surgery: first, postoperative hormone levels drop sharply, rather than slowly, in postoperative patients;
the symptoms of surgical menotinal patients tend to be more severe and difficult to accept in younger patients.
common complications are as follows: 1, vascular contraction symptoms are mainly shown as hot water, sweating, is one of the most important symptoms of menoanth.
symptoms of vasodilation occur earlier and more severely in patients who have surgery for menovascular surgery than in natural menocrosis.
2. Increased incidence of cardiovascular disease Cardiovascular disease is the leading cause of death in women over 65 years of age, but pre-menovascular women rare cardiovascular events occur because estrogen has a protective effect on the cardiovascular system.
incidence of cardiovascular events increased significantly after ovarian removal, with a meta-analysis reporting that post-surgical post-menopian women had a 2.62 times higher risk of cardiovascular events than normal women of the same age.
another U.S. nurse study reported a 2.2-fold increase in the risk of fatal heart attack in women after the removal of both ovaries.
3, the risk of osteoporosis increased after ovarian removal, the decline in sex hormone levels will lead to bone loss, the study reported that 18 months after the removal of the two-sided ovaries, bone loss can reach up to 20%.
this phenomenon occurs earlier, the greater the effect on bone density in later life, increasing the risk of fractures in old age.
4, Changes in nervous system and cognitive function Studies have shown that menotinal age is significantly associated with a decrease in cognitive function in patients undergoing surgery, as is not the situation in normal menoanthopaths.
, surgery may increase the risk of Alzheimer's and Parkinson's disease.
5, sexual function changes after ovarian excision of female vagina atrophy, dryness, resulting in sexual pain and other problems.
on the other hand, the libido of patients decreased and the sexual experience decreased.
3. The safety of endometrial cancer to retain the ovaries The removal of both sides of the ovaries is one of the steps of standard surgery, and its theoretical basis is as follows: (1) the uterine cavity is connected to the ovaries through the fallopian tubes, tumor cells may occur as a result Tiny metastasis of the ovaries, which cannot be judged by the naked eye during surgery, requires reliance on postoperative pathology; (2) Long-term estrogen stimulation is one of the pathogenesis of endometrial cancer, and after retaining the ovaries, the ovaries continue to secrete estrogen, increasing the risk of recurrence after surgery.
but whether ovarian removal affects the prognosis of young endometrial cancer patients also requires looking at data from large samples of clinical studies.
1, the incidence of endometrial-ovarian double cancer due to the low number of young endometrial cancer patients, so different researchers reported the incidence of endometrial-ovarian double cancer is also different.
Walsh and others included 102 young endometrial cancer patients between the ages of 24 and 45 and found 26 cases (25%) of double cancers, 4 of which detected normal ovarian appearance during surgery.
the authors selected 16 cases of IA or IB, in which the ovaries looked normal, for which the two-sided ovaries were preserved, after a medium time of 13 months follow-up, 3 cases due to abnormality found in the attachment area for re-surgical excision, one of which was confirmed as Ovarian cancer Ic1.
Evans and others reported an 11% incidence of endometrial-ovarian double cancer in patients under the age of 45, compared with only 2% in patients over 45.
, Navarria and others reported a 14 percent incidence of double cancer in patients under 45 and 2 percent in patients over 45, similar to Evans' report.
thus, young patients are more likely to have ovarian metastasis or endometrial-ovarian bigeneroma than those over 45 years of age, and even if the ovaries look normal, there is a risk of missed diagnosis.
the above literature suggests that if you choose to keep your ovaries for young patients, you will have to take some risks.
Lee and others found 19 cases (7.31%) of both cancers in 260 cases of endometrial cancer, but the authors stressed that for patients who did not find high risk factors for extraterrestrial metastasis before and during surgery, the probability of conjunctivular ovary malignancies was only 0.97% (2/206), and that detailed preoperative and in-operative evaluation before retaining the ovaries might reduce this risk.
2, the effect of retaining the ovaries on prognosis Wright, etc.
5 years after follow-up after surgery, it was found that there was no significant difference between total survival and tumor-specific survival in patients with IA phase.
Since then, Matsuo and others have conducted a larger sample size study based on the SEER database of the National Cancer Institute, which included 86,005 cases of endometrial cancer in stage I, including 1,242 cases of retained ovaries under the age of 50.
found that the overall survival rate of patients who retained their ovaries for 10 years was even higher than that of the non-reserved group (95.6% and 93.7%, respectively), possibly due to the relatively younger and better physical fitness of patients who chose to retain their ovaries.
Lee and others observed 176 patients with retained ovaries in South Korea and found no significant difference between ovarian removal and retention, whether re-occurring or total survival.
Koskas and others conducted a cohort study in France that included 101 patients under the age of 40 with low-level endometrial-like cancer retaining ovaries, and the results also concluded that retaining the ovaries did not increase disease-related mortality, and therefore considered it safe and feasible to strictly select suitable patients to retain their ovaries.
However, there are dissenters, richter and others who reviewed 20 patients under the age of 45 who retained their ovaries and found that for patients with stage IA, double ovary excision provided a longer disease-free life, on the basis of which comprehensive phased surgery was more likely to benefit patients.
there are also reports of clinical studies of endometrial cancer retaining the ovaries.
Li Lin collected 20 patients with stage I endometrial cancer under 40 years of age, analyzed that there was no significant difference in clinical prognosis, and concluded that the retention of ovaries had no significant effect on the survival of young patients with endometrial-like adenocarcinoma with good differentiation.
Wang Jia, etc., included in 10 Chinese and English cohort studies for meta-analysis, and finally concluded that the recurrence rate of 5-year tumors in patients with early stage endometrial cancer retaining ovaries and removing ovaries was 2.58% and 4.4%, respectively. 3%, the difference is not statistically significant, the total five-year survival rate of the two is 96.00% and 96.51%, respectively, the difference is not statistically significant, so it is believed that young patients with early endometrial cancer surgery to retain the ovaries, its prognosis has no significant effect.
Wang Li, etc. was included in 105 cases of endometrial cancer aged 18-51 years, divided into a total excision group, ovary retention group, ovarian retention and radiotherapy group and ovarian retention and radiotherapy and hormone group, to give the corresponding initial treatment.
Its method of retaining ovaries is to detect patients with no abnormalities in the ovaries, to retain one side of the ovaries, to fully separate the ovaries and protect the ovary blood vessels, to shift the ovaries to the abs of the oblique fascia below, more than 5cm from the exposure to the upper field.
results found that the five-year survival rate of additional radiotherapy patients after ovarian retention was significantly higher than that of those who did not receive radiotherapy, and that postoperative hormone addition therapy did not affect total survival, and ovarian retention significantly reduced the occurrence of symptoms such as rough skin, obesity, sweating, irritability, etc.
this suggests that not only can Patients with Phase I retain their ovaries, but also phase II or even Phase III patients can have ovarian metastasis excluded during surgery, or that ovarian retention can be achieved through ovarian displacement and radiotherapy.
another problem that cannot be ignored is that some young endometrial cancer patients with Lynch syndrome have significantly increased the incidence of ovarian double cancer and long-term ovarian cancer, which is not suitable for retaining ovaries.
At present, China's Lynch syndrome gene screening time is long, expensive, has not been popularized, so before making a decision should pay attention to ask in detail family history, if the patient's relatives have ovarian cancer, endometrial cancer, colon cancer and other medical history, choose to retain ovarian surgery should be more careful.
4. There is insufficient evidence on the safety of ovarian function in young women with endometrial cancer in young women at present, but comprehensive domestic and foreign research results and expert consensus show that the indications of early endometrial cancer patients retaining ovarian function are: (1) the age of the patient is 45 years old ;(; Differentiation, LVSI-positive) ;(4) celiac cytology to test negative; (5) preoperative examination or inoperative detection of no suspicious post-peritoneal lymph nodes; (6) ovarian caesarean section, rapid freezing pathological examination, exclusion of ovarian metastasis; (7) estrogen-positive; (8) patients have an urgent need to retain the ovaries, and agree to close follow-up.
, it is important for young women to communicate positively with patients before surgery for endometrial cancer.
For patients who require the retention of their ovaries, it is important to inform them of the risk of micro-transfer of the ovaries and the stimulating effects of estrogen on the recurrence of endometrial cancer, and to inform ovarian removal patients of the risks of cardiovascular disease, osteoporosis, fractures, cognitive impairment and depression after ovary removal.
the patient's full and informed consent before making the appropriate surgical choice.
5. The guidelines give different opinions and arguments for retaining ovaries for endometrial cancer, and the following are recommendations for the latest guidelines: 1, National Comprehensive Cancer Network (NCCN) Uterine Oncology Guidelines 2016 2nd edition . . . .
other studies also suggest that it is safe to retain the ovaries for early endometrial cancer.
2, the International Union of Obstetricians and Gynecologists (FIGO) reported in 2015 that large sample data showed that patients with endometrial-like adenocarcinoma, confined to the endometrial and G1 levels, had retained ovarian surgery, and there was no significant increase in tumor-related mortality after surgery.
3, the European Society of Oncology (ESMO) 2015 Endometrial Cancer Conference Consensus . endometrial cancer standard surgical method for uterine and double fallopian tube ovary removal.
for some patients who are not menopedal, the issue of retaining the ovaries needs to be discussed.
young endometrial cancer patients are usually early, highly differentiated types.
, in order to avoid temporary or prolonged postoperative hormone status, they can be operated on to preserve their ovaries.
several forward-looking studies have provided evidence that ovarian retention does not affect the overall survival of young patients with early endometrial cancer.
but must be closely evaluated and observed and ovarian-endometrial double cancer eliminated.
for endometrial cancer patients aged <45 years, high differentiation, muscle immersion depth <50%, no ovaries and other uterine lesions may consider retaining their ovaries.
who retain the ovaries are advised to have their double fallopian tubes removed.
not recommended for patients with a family history of cancer and a high risk of ovarian cancer (BRCA mutation, Lynch syndrome, etc.) retaining their ovaries.
such patients should be genetically consulted or genetically tested.
for patients with non-endometrial-like adenocarcinoma