Fertilitätserhaltung und Ovarprotektion bei Tumorerkrankungen: Bereits ein Standard?

Zusammenfassung

Die Therapie gynäkologischer und nicht gynäkologischer Tumoren bei prämenopausalen Patientinnen steht in unmittelbarem Zusammenhang mit der Erhaltung der Fertilität bzw. der ovariellen Hormonproduktion. So werden beim prämenopausalen Mammakarzinom derzeit die Ovarprotektion mit GnRH-Agonisten, Kryokonservierung von Ovarialgewebe, Eizellen oder Embryonen diskutiert. Beim Mammakarzinom gibt es derzeit keine evidenzbasierte Empfehlung für die Erhaltung der Fertilität oder Ovarialfunktion. Mit Ausnahme der Kryokonservierung von befruchteten Eizellen sind alle anderen Verfahren experimentell. Insbesondere ist die wiedereinsetzende Hormonproduktion und deren möglicher negativer Einfluss auf okkulte hormonrezeptorpositive Tumorzellen noch unklar. Patientinnen mit einer chemotherapieinduzierten Amenorrhö scheinen gegenüber weiter menstruierenden Frauen einen Vorteil im Überleben zu haben. Bei gut differenzierten Frühstadien des Endometriumkarzinoms (G1) und fehlender Myometriuminfiltration ist eine zeitlich begrenzte Remission unter Gestagen, mit nachfolgender Schwangerschaft, möglich. Die radikale vaginale Trachelektomie beim frühen Zervixkarzinom (FIGO Ia - b1) stellt eine Option zur Fertilitätserhaltung dar, wobei als wesentlicher Nachteil Zervixstenosen und die hohe Rate an Frühgeburten zu nennen ist. In Abhängigkeit vom FIGO-Tumorstadium, Grading, Ploidie-Status, histologischem Subtyp und dem Wunsch der Patientin ist bei Borderline-Tumoren, FIGO Ia(-c)-Ovarialkarzinomen und malignen Keimzelltumoren ein organerhaltendes Vorgehen mit einfacher Tumorektomie, ein- oder beidseitiger Ovarteilresektion oder unilateraler Adnexexstirpation möglich. Die Rezidivrate nach organerhaltender Operation eines Borderline- oder FIGO Ia low-grade Tumors sind mit 10 % gegenüber radikaler OP erhöht, während das Gesamtüberleben vergleichbar ist. Bei nicht gynäkologischen Tumoren geht es um den Schutz der Ovarien vor Radiatio und Chemotherapie. Hierzu können alle genannten Verfahren Anwendung finden, wobei die wiedereinsetzende Hormonproduktion keine Bedeutung hat.

Abstract

The treatment of most gynecological and non-gynecological tumors and breast cancer in premenopausal patients may influence fertility and ovarian function. In patients with breast cancer who wish to avoid a chemotherapy-induced amenorrhea (CIA) and to preserve their fertility, ovarian protection by GnRH agonists, cryoconservation of operatively sampled ovarian tissue, fertilized or unfertilized eggs, or embryos obtained by in vitro fertilization are all potential options. But there is no evidence-based recommendation for the preservation of fertility or ovarian function in breast cancer patients. Except for cryoconservation of embryos all other procedures are under investigation. The reappearance of premenopausal ovarian hormone levels may influence occult hormone-sensitive tumor cells. In patients with early stage and well differentiated endometrial cancer (G1) and no myometrium invasion a complete remission is possible by progestagens. Because of the high recurrence rate the patient must get pregnant immediately after remission. Radical vaginal trachelectomy is suitable to preserve the uterus in early cervical cancer (FIGO Ia - b1) patients. However, the rates of cervical stenosis and very early preterm deliveries are not negligible. Depending on the FIGO-stage, grade, ploidy status, histological subtype in compliant patients with borderline tumors, FIGO Ia(-c) stage ovarian cancer and malignant germ cell tumors, fertility preservation surgery consisting of unilateral adnexectomy, uni- or bilateral partial ovary resection or tumorectomy is possible. Recurrence rates after fertility preserving surgery of borderline or FIGO Ia low-grade tumors amounted to 10 % over that after radical surgery, however the overall survival rates are comparable. In cases of non-gynecological cancer ovarian protection and fertility preservation in advance of radio- or chemotherapy is unlimitedly possible, because the reappearance of ovarian hormones is harmless.

Schlüsselwörter

Mammakarzinom - Ovarialfunktion - Fertilität - Ovarprotektion - Kryokonservierung - Amenorrhö - Zervixkarzinom - Endometriumkarzinom - Ovarialkarzinom

Key words

breast cancer - ovary function - fertility - ovary protection - cryopreservation - amenorrhea - cervical cancer - endometrial cancer - ovarian cancer

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