Prognostic factors of oncologic and reproductive outcomes in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma: systematic review and meta-analysis

Objective: To evaluate the various possible prognostic factors on the fertility-sparing management of atypical hyperplasia and endometrial cancer; to generate survival curves to estimate remission and recurrence rates according to time. Design: Systematic review and meta-analysis. Registration number: CRD42013004557. Setting: University hospital. Patient(s): Patients who underwent fertility-sparing management for atypical hyperplasia and endometrial cancer. Intervention(s): All published studies were identified through MEDLINE and reported according to PRISMA guidelines. Main Outcome Measure(s): Remission, recurrence, progression, and pregnancy rates by age, obesity, infertility, previous pregnancy, histology, and medical treatment. Result(s): A total of 370 patients from 24 studies were included. The 12- and 24-month remission probabilities were 78.0% and 81.4%, respectively. In multivariate analysis, previous pregnancy (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.23-5.89), infertility (OR 2.26, 95% CI 1.05-4.87), and treatment with megestrol acetate (OR 2.70, 95% CI 1.20-6.02) were associated with higher remission probability. The 12- and 24-month recurrence probabilities were 9.6% and 29.2%, respectively. In multivariate analysis, none of the factors studied was associated with higher recurrence probability. Twenty-two studies totaling 351 patients were used to assess pregnancy rate; 111 subjects (32%) had one pregnancy or more. In multivariate analysis, none of the factors were associated with pregnancy probability. Among the 263 patients used to assess progression rate, 39 (15%) had a tumor with at least myometrial invasion on the hysterectomy specimen. Endometrial cancer and the use of other medical therapies (in comparison with megestrol acetate) were associated with an increased probability of progression. Conclusion(s): Fertility-sparing management should not be contraindicated in older patients with previous infertility or obesity. (C) 2014 by American Society for Reproductive Medicine.