In a premenopausal woman with prior hemicolectomy for stage II moderately differentiated colon adenocarcinoma and splenectomy, who now has a 6‑cm moderately vascular uterine fibroid scheduled for myomectomy and wishes to resume embryo transfer, how should I coordinate colon‑cancer surveillance, the myomectomy, and timing of fertility treatment?

Management of Myomectomy and Fertility Treatment in a Patient with Prior Stage II Colon Cancer

Immediate Priority: Proceed with Myomectomy Before Embryo Transfer

Your patient should undergo myomectomy for the 6-cm intramural fibroid before attempting embryo transfer, as intramural fibroids of this size significantly impair implantation rates (6.4% vs 15.7% in controls) and pregnancy rates (16.4% vs 30.1% without fibroids), even without cavity distortion 1. Post-myomectomy pregnancy rates reach 54-59.5% in women with no other infertility factors 1.

Surgical Approach Selection

Recommended Technique

• Laparoscopic myomectomy is the preferred approach for this 6-cm intramural fibroid, offering shorter hospital stay (1-2 days), faster return to activities (2-3 weeks), and lower wound infection rates compared to open surgery 1, 2.
• Open myomectomy should be reserved only if multiple fibroids or technical factors preclude laparoscopy 1, 2.
• Robotic-assisted laparoscopy provides equivalent outcomes to conventional laparoscopy 1, 2.

Pre-operative Optimization

• Correct any anemia with iron supplementation before surgery to reduce perioperative transfusion risk 2, 3.
• Consider autologous blood storage given the 6-cm size and moderate vascularity 2.
• Short-term GnRH antagonist therapy (relugolix, elagolix, or linzagolix) can reduce fibroid volume by approximately 40% if you need to shrink the fibroid before surgery, though this delays fertility treatment 1, 3, 4.

Timing of Embryo Transfer After Myomectomy

Wait 2-3 months after myomectomy before embryo transfer to allow adequate uterine healing and minimize uterine rupture risk in subsequent pregnancy 2. Both laparoscopic and open myomectomy carry measurable risk of uterine rupture in later pregnancies 1, 2.

Colon Cancer Surveillance Integration

Stage II Colon Cancer Follow-up

Your concern about "relationship syndrome" likely refers to hereditary cancer syndromes (Lynch syndrome, familial adenomatous polyposis). However, moderately differentiated adenocarcinoma at her age with isolated colon involvement does not automatically indicate hereditary syndrome 5.

Surveillance Schedule

• Stage II colon cancer has approximately 75% cure rate with surgery alone 5.
• Standard surveillance includes:
  • Colonoscopy at 1 year post-resection, then every 3-5 years if normal 5, 6
  • CEA levels every 3-6 months for first 2 years, then every 6 months for years 3-5 6
  • CT chest/abdomen/pelvis every 6-12 months for first 3 years 6

Coordination with Myomectomy

• Schedule myomectomy to avoid conflict with surveillance imaging windows (ideally perform myomectomy when next surveillance CT is not due for at least 3-4 months) 5, 6.
• Post-myomectomy pelvic changes on CT should not interfere with colon cancer surveillance, as recurrence patterns involve liver, lungs, and peritoneal disease rather than uterine involvement 5, 6.

Post-Splenectomy Considerations

Infection Prophylaxis

• Ensure vaccination status is current (pneumococcal, meningococcal, Haemophilus influenzae type B) before elective surgery.
• Consider antibiotic prophylaxis during myomectomy given asplenic status.
• Counsel on lifelong infection risk and need for early treatment of febrile illnesses.

Pregnancy Planning

• Asplenic status increases risk of overwhelming post-splenectomy infection (OPSI) during pregnancy.
• Ensure she understands the need for aggressive treatment of any fever during pregnancy.

Algorithmic Management Plan

Step 1: Pre-operative Workup (Weeks 1-2)

• Complete blood count to assess anemia 2, 3
• Pelvic MRI to precisely map fibroid location and plan surgical approach 2, 3
• Verify vaccination status (pneumococcal, meningococcal, H. influenzae B)
• Confirm next colon cancer surveillance imaging is not due within 4 months 5, 6

Step 2: Myomectomy (Week 3-4)

• Laparoscopic approach with intramyometrial vasopressin injection to reduce bleeding 2
• Apply adhesion barriers (oxidized regenerated cellulose or hyaluronic acid-carboxymethylcellulose) to minimize postoperative adhesions 2
• Multilayer uterine closure to reduce rupture risk 2

Step 3: Recovery Period (Weeks 5-12)

• Return to normal activities by week 5-6 2
• Mandatory 2-3 month waiting period before embryo transfer 2
• Continue colon cancer surveillance per standard schedule 5, 6

Step 4: Fertility Treatment (Week 13+)

• Proceed with embryo transfer once uterine healing is complete 2
• Pregnancy rates after myomectomy: expect <50% pregnancy rate within 3 years, with <50% of pregnancies resulting in live birth 1, 2

Critical Pitfalls to Avoid

• Do not proceed with embryo transfer before myomectomy – the 6-cm intramural fibroid will significantly reduce implantation success 1.
• Do not consider uterine artery embolization – it has higher miscarriage rates (33% vs 14% with myomectomy) and is not preferred for fertility preservation 7.
• Do not delay myomectomy with prolonged medical management – GnRH agonists/antagonists suppress fertility during treatment and fibroids rapidly regrow after discontinuation 1, 4, 8.
• Do not perform myomectomy during pregnancy if she conceives before surgery – this is especially hazardous due to heightened uterine vascularity 2.
• Do not assume hereditary cancer syndrome without genetic testing – isolated stage II colon cancer does not mandate genetic evaluation unless family history or young age (<50) suggests Lynch syndrome 5.

Realistic Expectations

Counsel your patient that even after successful myomectomy, fewer than 50% of women attempting conception achieve pregnancy within 3 years, and fewer than half of those pregnancies result in live birth 1, 2. Large prospective registries show no significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy approaches 1, 2. The miscarriage rate after myomectomy is approximately 14%, comparable to the general obstetric population 7.