Ovarian Autotransplantation Prior to Pelvic Radiation: A Novel Strategy to Preserve Hormonal Function in Premenopausal Patients

Abstract & Commentary

Synopsis: In a single case report of young woman with cervical cancer, an autologous transplant of one ovary to an area outside of proposed radiation therapy was demonstrated to be effective at maintaining ovarian function. The procedure was done at the time of radical hysterectomy by a second surgical team. Thus, a novel approach may ultimately be available for preserving hormonal and reproductive ovarian function and quality of life for premenopausal patients requiring pelvic radiation.

Source: Hilders CG, et al. Cancer. 2004;101:2771-2778.

With the addition of radiation and chemotherapy to the standard surgical treatment, young women with cervical cancer are now experiencing higher complete remission and cure rates.1 These benefits, however, are often clouded by the morbidity associated with early menopause and loss of fertility.2 Depending on dose, duration and extent of treatment, radiation results in direct cellular damage—causing atrophy and reduced follicle stores.3 Attempts at gonadal functional maintenance, such as by cryopreservation or transplantation have been examined extensively, but follicular loss secondary to ischemia has remained a rate-limiting factor in their success.4 Thus, Hilders and colleagues studied the role of heterotopic autotransplantation using microscopic anastomosis to protect and maintain ovarian function and vitality.

The results from a single patient were extensively detailed in this report. The patient was found to have a large squamous cell carcinoma (FIGO Stage Ib2) and was treated by ovarian transplantation, followed by radical hysterectomy with pelvic node dissection. The patient’s left ovary was transplanted to her left upper arm, and vascular anastomosis was successfully achieved by microsurgical techniques. Using different diagnostic modalities, the transplanted ovary was demonstrated to have preserved ovarian function, including adequate blood flow, regularity in cycle and normal follicular growth for greater than one year. Thus, autotransplantation was successful and found to spare the ovary from potential radiation induced cellular damage.

Comment by William B. Ershler, MD

This detailed report is the second case in which an ovary was excised and transplanted outside of a radiation field in an effort to preserve reproductive and hormonal function. The procedure was performed coincident with radical hysterectomy and there was no added anesthesia or postoperative complication. It is encouraging that at one year, the organ continues to function although additional follow-up is clearly needed to establish an expected duration benefit. Nonetheless, this procedure, once developed and demonstrated to be safe and effective, may well enhance the quality of life for female patients with pelvic disease requiring radiation therapy for cure.

William B. Ershler, MD, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC, is Editor for Clinical Oncology Alert.

References

1. Boring CC. CA Cancer J Clin. 1994;44:7-26.

2. Meirow D, Nugent D. Hum Reprod Update. 2001;7:535-543.

3. Meriow D, et al. Hum Reprod. 1996;11:2119-2121.

4. Jeremias E, et al. Fertil Steril. 2002;7:1278-1282.