| Background:The onset age of malignant ovarian tumor become younger,and the female fertility plan is postponed gradually.As a result,the requirement of reproductive function preservation is increasingly urgent.While improving the quality of life,it is particularly important to protect the fertility of young patients and assist reproduction ability.According to the 2021 NCCN Clinical Practice Guidelines for Ovarian Cancer,unilateral or bilateral adnexectomy with the uterus preserved could be considered in patients with invasive epithelial ovarian cancer whose initial treatment was limited to the ovaries or pelvis.Maximal efforts should be made to remove all pelvic lesions in these patients and to evaluate for occult lesions in the upper abdomen or retroperitoneal region.Fertility sparing surgery for borderline ovarian tumors was generally considered to be safe with good prognosis,and few patients might had postoperative recurrence or further malignant changes.As for malignant germ cell tumors,it was generally believed that fertility sparing surgery was feasible for young patients with fertility requirements in all stages,so long as the appearance of the uterus and the contralateral ovary were normal.The guidelines recommended comprehensive staging of fertility sparing surgery for patients with malignant sex cord stromal tumor that wished to preserve reproductive function and whose lesions were confined to the ovaries.Therefore,in patients of reproductive age with early stage epithelial ovarian cancer(FIGO stage IA-IB),borderline ovarian tumor,or malignant germ cell and sex cord stromal tumors,fertility sparing surgery could be selectively performed in clinical.At present,there had been various studies about the feasibility of fertility sparing surgery and the reproductive situation for different pathological types of malignant ovarian tumor,and there were also some studies about ovarian protection measures.However,it was still necessary to verify the effectiveness and safety of these solutions by analyzing the prognosis of patients.Objective:The clinical characteristics of young patients with malignant ovarian tumors were retrospectively analyzed to explore the treatment and prognosis of fertility sparing surgery.Methods:1.Clinical data collectionWe collected clinical data of 130 patients with malignant ovarian tumor who adopted fertility sparing surgery in Qilu Hospital of Shandong university between January 2005 to December 2018.The clinical data included the age of initial diagnosis,contact details,clinical manifestation,preoperative examination(serum tumor markers,ultrasound,CT and MRI examination),surgical method,rapid intraoperative pathology and routine postoperative pathology,immunohistochemical result,FIGO stage,and postoperative adjuvant treatment etc.Patients were followed up by telephone.We investigated the general information of patients after surgery,including survival and recurrence,pregnancy and birth information as well as fetal development.The end of follow-up was December 2020.In this study,the adverse outcome was defined as disease recurrence or death during the follow-up period.Progression free survival(PFS)was defined in months as the time between the date of surgery and the onset of disease progression or death from any cause.2.Statistical methodsAfter data collection,measurement data were described as mean ± standard deviation.By using SPSS software,binary-Logistic regression analysis was performed to assess the influence of risk factors such as age,surgical method,tumor size,tumor character,tumor position,FIGO stage,histological type,and chemotherapy status on adverse outcomes of patients.Binary-Logistic regression analysis was also performed for the influence of related factors on postoperative pregnancy rate.Kaplan-Meier survival analysis was performed by Origin software,and the differences in progression free survival(PFS)were compared by logarithmic rank test to evaluate the influence of different factors on PFS of malignant ovarian tumor.Patients with metastatic ovarian cancer were not included in the study on the effect of related risk factors on patient outcomes.Among the statistical methods involved,p<0.05 was statistically significant.Results:1.Age of onset and clinical manifestations of malignant ovarian tumorAmong the 130 cases of malignant ovarian tumor,there were 24 cases of epithelial ovarian cancer,76 cases of malignant germ cell tumor,26 cases of sexual cord stromal tumor,and 4 cases of metastatic tumor.All patients were aged 10-43 years at the time of consultation.The mean age of onset was 23.6±7.3 years old,and the median age was 23 years old.About 12.3%(16/130)of patients aged 10-15,and 26.9%(35/130)of patients aged 15-20.About 23.8%(31/130)of patients aged 20-25 and 16.2%(21/130)of patients aged 15-30,as well as 15.4%(20/130)of patients aged 30-35.Patients aged 35 to 40 years accounted for 4.6%(6/130),and patients with over aged 40 accounted for 0.9%(1/130).Overall,the age of onset is concentrated between 15 and 25 years old.Among all patients,38.5%(50/130),25.4%(33/130)and 11.5%(15/130)of patients with abdominal pain or distension,pelvic mass and abnormal menstrual symptoms at the time of treatment,and 7.7%(10/130)of patients were hospitalized due to abnormal physical examination.2.Influence of different factors on adverse outcomes in patients with malignant ovarian tumorBy using Logistic regression,univariate analysis showed that there was a significant correlation between the surgical approach and the risk of adverse outcomes(recurrence OR death)(OR:8.930;95%CI:1.114-71.560,p=0.039),and laparoscopic procedure was associated with an increased risk of adverse outcomes.FIGO stage also had a significant correlation between adverse outcomes in patients with malignant ovarian tumors(p=0.002).3.Influence of different factors on PFS in patients with malignant ovarian tumorKaplan-Meier survival analysis showed that surgical approach,FIGO stage and pathological type were associated with progression free survival rate according to the survival analysis.There was a significant correlation in PFS among the surgical approach(p=0.027).There was a significant correlation in PFS among the FIGO stage(p<0.001).There were statistically significant differences in progression free survival rate among the different pathological types,and it was also a significant correlation between pathological types and PFS in patients with malignant ovarian tumors(p<0.001).4.Fertility of patients with malignant ovarian tumor after fertility sparing surgeryAbout the postoperative reproduction and pregnancy,a total of 70 cases were investigated with a median follow-up time of 55.5 months.Among 28 patients with birth planning,the total pregnancy rate was 71.4%,and the natural pregnancy rate was 60.7%.The total number of pregnancies was 26,including 20 full-term deliveries,among which 3 cases were successfully conceived by artificial assisted reproduction technology after surgery,and 2 patients were at the stage of pregnancy currently.None of the fetuses were found to be abnormal after birth,but one of them was died for leukemia at the age of 5.There was no significant difference in the natural pregnancy rate between the groups<30 years old and>30 years old(OR:0.538;95%CI:0.102-2.840,p=0.466).The natural pregnancy rates after transabdominal and laparoscopic procedure were 62.5%and 58.3%respectively,and the difference was not statistically significant(OR:0.840;95%CI:0.182-3.880,p=0.823).Postoperative natural pregnancy rates in the chemotherapy group and non-chemotherapy group were 59.1%and 60.0%respectively,and the difference had no statistically significant(OR:1.038;95%CI:0.143-7.527,p=0.970).Conclusion:1.Most of the patients with malignant ovarian tumors who underwent fertility preservation surgery were aged between 15 and 25 years old.Their clinical manifestations were common included abdominal pain or distension,pelvis or abdominal mass,and menstruation-related symptoms.2.Surgical procedure and FIGO stage were influencing factors for recurrence or death of patients with malignant ovarian tumor who underwent fertility sparing surgery.The risk of adverse outcomes in patients with laparoscopic procedure and advanced stage were increased.3.Surgical procedure,FIGO stage and pathological type were correlated with PFS of patients with malignant ovarian tumor who underwent fertility sparing surgery.4.Age distribution,surgical procedure and postoperative chemotherapy had no significant effect on the natural pregnancy rate after fertility sparing surgery in patients with ovarian malignant tumor.Artificial assisted reproductive technology could be considered after surgery if patient failed to natural pregnancy.Innovations:By analyzing the clinical characteristics of young patients with malignant ovarian tumors,this study discussed the treatment and prognosis of fertility sparing surgery.The comprehensive analysis of treatment effect and fertility situation,combined with the latest research and guideline recommendation,this study further deepened the understanding of the r fertility sparing surgery.It provided a theoretical basis for clinical decision-making and patient consultation.Limitations:This study was a single-center retrospective analysis with selection bias and recall bias.The loss of follow-up had a certain influence on the research results.The overall number was insufficient,so the results of the study should be cautious,which also reduced the reliability of analysis results.A large sample,multi-center case control trial was needed to verify the safety of fertility sparing surgery and the long-term fertility of patients. |
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