Safety of fertility-sparing surgery for stage I ovarian clear cell carcinoma.

Fertility-sparing surgery can be performed safely in selected women with stage I epithelial ovarian cancer [1]. However, the safe indications for fertility-sparing surgery for stage I epithelial ovarian cancer vary from study to study. There has never been a well designed randomized controlled trial. Recent largest 2 retrospective studies reported different indications. In a Japanese study, fertility-sparing surgery can be performed safely only in stage IA, IC, grade 1–2, non-clear cell carcinoma and stage IA clear cell carcinoma [2]. In an Italian study, in the contrary, fertility-sparing surgery can be performed safely in all patients with stage I epithelial ovarian cancer except grade 3 disease [3]. In addition, indications for safe fertility-sparing surgery for stage I epithelial ovarian cancer vary slightly from one treatment guideline to another. The National Comprehensive Cancer Network (NCCN) treatment guideline suggests that fertility-sparing surgery can be performed in all patients with stage IA and IC epithelial ovarian cancer [4], but Gynecologic Cancer InterGroup (GCIG) consensus review suggests that fertility-sparing surgery is not recommended for stage IC, clear cell carcinoma [5]. The main issue is whether fertility-sparing surgery is safe for stage I ovarian clear cell carcinoma (OCCC). However, only few studies introduced this issue until now, and all of them included only small number of patients with stage I OCCC [267].

In this issue, Nasioudis et al. [8] reported the safety of fertility-sparing surgery in stages IA and IC OCCC in a large cohort using the National Cancer Institue's Surveillance, Epidemiology, and End Results (SEER) data base in this issue. This study includes the largest cohort of stage I OCCC treated with fertility-sparing surgery ever reported. The preservation of uterus and ovary in stage I OCCC did not affect on the survival outcomes in this cohort. The indications for fertility-sparing surgery can be extended to stage I OCCC [8]. The main reason for not recommending fertility-sparing surgery in OCCC was the concern about poor survival outcomes. However, recent studies suggested that the survival outcomes of early stage OCCC are similar with other histologic types [59]. Therefore, the indication for fertility-staging surgery for OCCC needs not to be different from other histologic types. Nasioudis et al.'s study [8] supported this well. However, it is not clear whether fertility-sparing surgery was performed in young women who want to preserve their fertility in this study. Further studies are needed to confirm the safety of fertility-sparing surgery in OCCC.