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A case of cranial bone metastasis after fertility-sparing approach in endometrial cancer

Endometrial cancer is the most common gynecological cancer, moreover, it is the fourth most common type of cancer in women and its incidence is rising in developed countries (Siegel et al. 2021). The uptrend in the prevalence of endometrial cancer can be explained mostly by the increase in exogenous oestrogen use (in periand postmenopausal women) and endogenous oestrogen exposure (nulliparity, give birth less, early menarche age, and obesity) (Prat et al. 2014). Endometrial cancer is classified into two groups based on pathological and molecular characteristics. More than 80% of endometrial cancer cases are oestrogen-dependent named type 1 endometrial cancer (Prat et al. 2014). The remaining percentage is independent of oestrogen named type 2. Some risk factors associated with type 1 endometrial cancer, including low parity, early age in menarche, and diabetes. Although endometrial cancer is traditionally considered to be cancer of post-menopausal women, 14% of cases are diagnosed in pre-menopausal women, 5% are under the age of 40 years of age (Morice et al. 2016). A significant proportion of women at reproductive age delay childbearing leading to a large number of nulliparous women at diagnosis. Although the standard treatment of endometrial cancer is total hysterectomy and bilateral salphingooferectomy with lymph node assessment, the importance of preserving fertility has become more evident for these young women who refuse hysterectomy and desire pregnancy. Fertility-sparing treatments can be proposed to patients with early endometrial cancer who want to maintain their fertility. In the initial staging, magnetic resonance imaging (MRI) should be performed to exclude cervical and myometrial invasion. Candidates for fertility-sparing surgery should be those with a diagnosis of complex atypical endometrial hyperplasia and endometrial carcinoma with grade 1 well-differentiated tumour without lymphovascular space and myometrial invasion, no metastasis, and suspicion. The tumour should be confined to the endometrium on transvaginal ultrasound or preferably also on MRI. Other contraindications for fertilitysparing treatment are pregnancy and medical conditions inappropriate for progesterone treatment. Most clinicians agree that the ideal candidates for the fertility-sparing approach are the only ones whose biopsy samples revealed stage IA (without myometrial invasion) grade 1 endometrioid cancer (Rodolakis et al. 2015). Medical options are currently limited to treatment with continuous progestin-based therapy since they antagonise the growth-promoting action of oestrogens. The most widely preferred agents are 400–600mg of medroxyprogesterone acetate per day or 160–320mg of megestrol acetate per day. More recently, hormonal intrauterine devices (IUDs) releasing levonorgestrel following hysteroscopic resection of endometrial cancer have been reported (Casadio et al. 2019). Diagnostic hysteroscopy and imaging studies should be performed to evaluate the regression, recurrence, and relapse at 6-month intervals. If no response is achieved after 6 months, standard surgical treatment should be performed. Once the complete response is achieved, pregnancy should be encouraged and referral of women to a fertility centre is recommended. Hysterectomy and salpingo-oophorectomy should be recommended to women who fulfilled their desire to have children. To the best of our knowledge, since our 34year-old patient is the youngest patient reported in the literature, we aimed to present this young woman in this article by discussing with the literature.