To the Editor:
We have read the paper by B. Zuckerman et al. (1) with interest. The authors present a case of a moderately differentiated endometrial carcinoma cured by conservative treatment using hysteroscopic resection and high dose progesterone therapy. In fact, there is evidence that early endometrial cancer may be controlled by conservative treatment by progestins(2-7).
In the presented case, however, the authors failed to show that progestin therapy was able to cure Grade II carcinoma; following hysteroscopic partial resection of an endometrial polyp, fragments of adenocarcinoma were found histologically. No control hysteroscopy or endometrial sampling had been performed prior to progesterone therapy. Therefore complete removal of the neoplastic lesion prior to endocrine therapy cannot be ruled out; a complete removal even may be assumed if the carcinoma was located on top of the resected polyp. Thus, the conclusion that grade II endometrial carcinoma has been cured by progesterone therapy may not be drawn from the presented case.
Nevertheless, it has been shown that conservative treatment combining tumor resection and progesterone therapy may be safely performed in a patient with moderately differentiated endometrial carcinoma. It has to be stressed, however, that with respect to safety both endoscopic and histologic control of treatment success prior to pregnancy are crucial, as we have already postulated when reporting on a triplet pregnancy following conservative treatment of endometrial cancer(8). As a consequence, the authors propose a "progressive plan with feedback."
We agree with this plan except for steps 3 and 4. In our opinion, there is no rationale to continue the progesterone treatment for another 6 months after successful completion of step 2 (8 weeks progesterone treatment and normal hysteroscopic and histologic findings at this time) in a patient desiring pregnancy. On the contrary, pregnancy should be achieved as soon as possible. In addition we don't feel that it is necessary to await recovery of natural cycles, especially in patients with fertility problems. First, chance of spontaneous conception is reduced and second, risk of reinduction of hyper/neoplastic endometrial changes rises with increasing time of estrogen exposure. Therefore, we recommend induction of ovulation and, if necessary, assisted reproductive therapy in patients with fertility problems as outlined in Ref. 8.
In summary, we congratulate the authors that they have given further evidence that conservative treatment may be safely performed in early endometrial cancer-even in a grade II lesion. This is another important contribution for individualization of cancer therapy in the fertile woman.
Department of Obstetrics and Gynecology; Klinikum Grosshadern; Ludwig-Maximilians-University Munich; Munich, Germany
1 Zuckerman B, Lavie O, Neuman M, Rabinowitz R, Ben-Chetrit A, Voss E, Rosenmann E, Beller U. Endometrial carcinoma Stage I - Grade II. Conservative treatment followed by a healthy twin pregnancy. Int J Gynecol Cancer
2 Varga A, Henriksen E. Histologic observation on the effect of 17-α-hydroxyprogesterone-17-n-caproate on endometrial carcinoma. Obstet Gynecol
3 Bokhman JV, Chepick OF, Volkova AT, Vishnevsky AS. Can primary endometrial carcinoma stage I be cured without surgery and radiation therapy? Gynecol Oncol
4 Thornton JG, Brown LA, Wells M, Scott JS. Letter to the, ed. Primary treatment of endometrial cancer with progestagen alone. Lancet
5 Lai C-H, Hsueh S, Chao A-S, Soong Y-K. Successful pregnancy after tamoxifen and megestrol acetate therapy for endometrial carcinoma. Br J Obstet Gynaecol
6 Fechner RE, Kaufman RH. Endometrial adenocarcinoma in Stein-Leventhal syndrome. Cancer
7 Niwa K, Yokoyama Y, Tanaka T, Murase T, Morishita S, Itoh M, Shimokawa K, Tamaya T. Successful pregnancy in a patient with endometrial carcinoma treated with medroxaprogestrone acetate. Arch Gynecol Obstet
8 Kimmig R, Strowitzki T, Müller-Höcker J, Kürzl R, Korell M, Hepp H. Case Report: Conservative treatment of endometrial cancer permitting subsequent triplet pregnancy. Gynecol Oncol