Hysteroscopic Resection Safely Preserves Fertility in Endometrial Cancer
No deaths or significant adverse effects were reported in the screened population among those who received hysteroscopic resection for endometrial cancer.
No deaths or significant adverse effects were reported in the screened population among those who received hysteroscopic resection for endometrial cancer.
For patients in which medical management (MM) failed them, hysteroscopic resection (HR) plus oral megestrol acetate (Magace) with or without levonorgestrel safely and effectively preserved fertility in patients with atypical hyperplasia or grade 1 endometrioid endometrial cancer, according to results from a real world study (NCT04362046) presented at 2025 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer (SGO).
Notably, of 9 patients who received HR eligible for analysis, 7 (78%) had achieved a complete remission. Additionally, of the 4 who attempted to conceive, 2 (50%) had achieved pregnancy through assisted reproduction. Furthermore, 2 patients who received HR had negative pathology on resection and an additional 2 were excluded due to advanced disease and were offered hysterectomies: local disease extent and positive deep myometrial excision margin, respectively.
“This multidisciplinary approach is a safe and effective fertility preservation treatment for patients with grade 1 [endometrial cancer] or [atypical hyperplasia],” Mark S. Carey, MD, FRCSC, clinical professor of Gynecologic Oncology at the University of British Columbia and Gynecologic Disease Site Chair of the Canadian Cancer Trials Group, said during the presentation. “Hysteroscopic assessment helps direct diagnosis, treatment planning, monitoring, and selection of patients for HR. Patients with grade 1 [endometrial cancer] represent a high subgroup with a 36% hysterectomy rate. This protocol has improved patient-engagement and decision making as part of their care.”
A total of 43 patients were screened by a multidisciplinary team comprising gynecologists, reproductive endocrinology, pathologists, and radiologists; a total of 33 patients entered the MM protocol of the study. Patients on study received 160 mg of daily oral megestrol acetate with or without 52 mg levonorgestrel intrauterine device (IUD) for a 6-month minimum. Monitoring occurred concurrently and consisted of a combination of endometrial biopsies and/or hysteroscopic assessment at 3-to-6-month intervals. HR was offered in the event that MM failed patients.
The study was conducted to evaluate HR as a fertility-sparing treatment for patients with atypical hyperplasia or persistent grade 1 endometrial cancer who experienced resistance to progestin-therapy, and accepted treatment in this patient population. Due to 40% failure rates observed with MM alone in previous studies, this study sought to assess indications for surgical interventions with progestin-therapy.
Patients included on trial were ages 18 to 40 and had either grade 1 endometrial cancer with less than 1/3 myometrial invasion confirmed by MRI or atypical hyperplasia. Additional inclusion criteria included an absence of significant surgical comorbidities, a desire to preserve fertility, adequate dose and duration of progesterone therapy, and progression following progesterone therapy.
Among patients evaluable in the MM group (n = 22), 18 had atypical hyperplasia and 4 had grade 1 endometrial cancer; in the HR group (n = 11), it was 4 and 7, respectively (P = .02).
Among the 22 patients who proceeded with MM protocol, 16 (73%) had experienced a complete remission, all 16 attempted to conceive, and of those, 10 (63%) achieved pregnancy through assisted reproduction.
Safety data showed that no deaths or significant adverse effects (AEs) occurred on trial in either cohort. In the MM group, 4 patients had a hysterectomy, 1 had an aneuploid fetus, and an additional 1 patient had an adherent placenta. In the HR group, 4 patients had a hysterectomy, and an additional patient developed minimal scarring following HR procedure.
For future research, investigators of this study seek to investigate the association between endometrial cancer molecular subtype and treatment response; examine the remission rate using levonorgestrel-IUD vs megestrol acetate vs megestrol acetate plus levonorgestrel-IUD; explore earlier HR in high-risk grade 1 endometrial cancer patients; and create a standardized guideline for fertility sparing treatment in this patient population.
Reference
Carey MS, Rojas-Luengas V, Jang J, et al. Endomyometrial resection for fertility preservation in patients with progestin-resistant atypical hyperplasia or grade 1 endometroid endometrial cancer. Presented at the 2025 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer (SGO); Seattle, WA, March 14-17, 2025.
