Radiotherapeutic management of cervical carcinoma that complicates pregnancy

Prognosis, counseling, and indications for termination of pregnancy

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

Gynecologic cancer in pregnancy

Cancer complicates 1 in 1000 pregnancies. Multidisciplinary consensus comprised of Gynecologic Oncology, Pathology, Neonatology, Radiology, Anesthesiology, Maternal Fetal Medicine, and Social Work should be convened. Pregnancy provides an opportunity for cervical cancer screening, with deliberate delays in treatment permissible for early stage carcinoma. Vaginal delivery is contraindicated in the presence of gross lesion(s) and radical hysterectomy with lymphadenectomy at cesarean delivery is recommended. Women with locally advanced and metastatic/recurrent disease should commence treatment at diagnosis with chemoradiation and systemic therapy, respectively; neoadjuvant chemotherapy to permit gestational advancement may be considered in select cases. Most adnexal masses are benign and resolve by the second trimester. Persistent, asymptomatic, benign-appearing masses can be managed conservatively; surgery, if indicated, is best deferred to 15-20 weeks, with laparoscopy preferable over laparotomy whenever possible. Benign and malignant germ cell tumors and borderline tumors are occasionally encountered, with unilateral adnexectomy and preservation of the uterus and contralateral ovary being the rule. Epithelial ovarian cancer is exceedingly rare. Ultrasonography and magnetic resonance imaging lack ionizing radiation and can be employed to evaluate disease extent. Tumor markers, including CA-125, AFP, LDH, inhibin-B, and even CEA and ßhCG may be informative. If required, chemotherapy can be administered following organogenesis during the second and third trimesters. Because platinum and other anti-neoplastic agents cross the placenta, chemotherapy should be withheld after 34 weeks to avoid neonatal myelosuppression. Bevacizumab, immune checkpoint inhibitors, and PARP inhibitors should be avoided throughout pregnancy. Although antenatal glucocorticoids to facilitate fetal pulmonary maturation and amniotic fluid index assessment can be considered, there is no demonstrable benefit of tocolytics, antepartum fetal heart rate monitoring, and/or amniocentesis. Endometrial, vulvar, and vaginal cancer in pregnancy are curiosities, although leiomyosarcoma and the dreaded twin fetus/hydatidiform mole have been reported. For gynecologic malignancies, pregnancy does not impart aggressive clinical behavior and/or worse prognosis.

Ionizing radiation for maternal medical indications

Ionizing radiation should be considered an avoidable exposure although all pregnant women receive some radiation from their environment. The potential effect of ionizing radiation on the fetus is determined by the dose and the timing of the exposure with growing interest in the potential risks of transgenerational effects of radiation as an epigenetic phenomenon. High dosage exposure is very unlikely in routine situations such as occupational, diagnostic, or therapeutic exposures. Individual diagnostic radiation procedures (fetal dosage <50 mGy), are not associated with any increase in lethality (miscarriage or stillbirth), genetic damage, teratogenicity, growth impairment, mental retardation, or sterility. More recent modeling has suggested that a 10 mGy fetal dose is associated with an excess risk of childhood cancer risk as low as 1 in 4545, well below historical estimates.When the mother's condition necessitates diagnostic radiation it is necessary to balance the risks of the procedure with the benefits to be gained. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld because of concerns regarding fetal radiation exposure. Even radiotherapy directed away from the abdomen or pelvis may be considered during pregnancy, if the benefits outweigh the risks and no suitable alternative is available.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

Modern radiotherapy in cancer treatment during pregnancy

Breast cancer, gynecological malignancies and lymphomas are the most frequently diagnosed tumors in pregnant women. The feasibility of radiotherapy during pregnancy remains a subject of debate and clinicians continue to hesitate on this approach, trying to avoid radiotherapy in most cases. Since the 1990s, several technological advances, including intensity modulated and image guided radiation delivery, have been implemented in radiation oncology to improve the radiation treatment in terms of effectiveness and tolerability. It remains uncertain which short- and long-term health effects the radiation exposure of the fetus may have through advanced radiotherapy techniques. The present systematic literature review aims to summarize the limited current evidences of the feasibility and clinical results of "modern" radiotherapy procedures for the treatment of the most frequently diagnosed tumors in pregnant women.

Treatment of gynecological cancers diagnosed during pregnancy

Because of a notable increase in age at delivery, the incidence of malignancy diagnosed during pregnancy has substantially increased. This review aims to summarize the literature and expert knowledge on gynecologic cancers diagnosed in pregnancy regarding epidemiology, examination and staging procedures, description of treatment modalities and management of gynecological malignancies with special interest in cervical and ovarian cancer. Thorough attention is paid to the surgery and chemotherapy administration for early-stage cervical cancer diagnosed during pregnancy.

Individual management of cervical cancer in pregnancy

Purpose

The management of cervical cancer in pregnancy persists to be challenging. Therefore, identification of factors that influence the choice of therapeutic management is pivotal for an adequate patient counseling.

Methods

We present a literature review of 26 studies reporting 121 pregnancies affected by cervical cancer. Additionally, we add a retrospective case series of five patients with pregnancy-associated cervical cancer diagnosed and treated in our clinic between 2006 and 2013.

Results

The literature review revealed that the therapeutic management during pregnancy varies according to the gestational age at diagnosis, while in the postpartum period no influence on the treatment choice could be detected. Also in our case series the choice of oncologic therapy was influenced by the gestational age, the wish to continue the pregnancy and the risks of delaying definitive treatment.

Conclusions

There are no standardized procedures concerning the treatment of cervical cancer in pregnancy. Therefore, in consultation with the patient and a multidisciplinary team, an adequate individualized treatment plan should be determined.

Electronic supplementary material

The online version of this article (doi:10.1007/s00404-015-3980-y) contains supplementary material, which is available to authorized users.

Management of cervical cancer during pregnancy

Cervical cancer (CC) is the most common gynaecological cancer during pregnancy. The rarity of the disease and lack of randomised control studies have prevented the establishment of treatment guidelines. The management of CC mainly follows the guidelines for the non-pregnant disease state, expert opinions and limited case reports. Although the management of CC diagnosed during pregnancy appears to be a significant dilemma for the patients and specialists, the prognosis of CC is not influenced by pregnancy. The treatment decision should be made collaboratively with a multidisciplinary team consisting of an obstetrician, gynaecologist, oncologist and paediatrician. The concerns of the patient should be taken into account.

Gynecologic Cancers in Pregnancy: Guidelines of a Second International Consensus Meeting

Objectives

This study aimed to provide timely and effective guidance for pregnant women and health care providers to optimize maternal treatment and fetal protection and to promote effective management of the mother, fetus, and neonate when administering potentially teratogenic medications. New insights and more experience were gained since the first consensus meeting 5 years ago.

Methods

Members of the European Society of Gynecological Oncology task force “Cancer in Pregnancy” in concert with other international experts reviewed the existing literature on their respective areas of expertise. The summaries were subsequently merged into a complete article that served as a basis for discussion during the consensus meeting. All participants approved the final article.

Results

In the experts’ view, cancer can be successfully treated during pregnancy in collaboration with a multidisciplinary team, optimizing maternal treatment while considering fetal safety. To maximize the maternal outcome, cancer treatment should follow a standard treatment protocol as for nonpregnant patients. Iatrogenic prematurity should be avoided. Individualization of treatment and effective psychologic support is imperative to provide throughout the pregnancy period. Diagnostic procedures, including staging examinations and imaging, such as magnetic resonance imaging and sonography, are preferable. Pelvic surgery, either open or laparoscopic, as part of a treatment protocol, may reveal beneficial outcomes and is preferably performed by experts. Most standard regimens of chemotherapy can be administered from 14 weeks gestational age onward. Apart from cervical and vulvar cancer, as well as important vulvar scarring, the mode of delivery is determined by the obstetrician. Term delivery is aimed for. Breast-feeding should be considered based on individual drug safety and neonatologist–breast-feeding expert’s consult.

Conclusions

Despite limited evidence-based information, cancer treatment during pregnancy can succeed. State-of-the-art treatment should be provided for this vulnerable population to preserve maternal and fetal prognosis.

Supplementary Information

Supplementary data on teratogenic effects, ionizing examinations, sentinel lymph node biopsy, tumor markers during pregnancy, as well as additional references and tables are available at the extended online version of this consensus article, go to http://links.lww.com/IGC/A197.

Impact and treatment of cancer during pregnancy

Cancer is the second most common cause of death in the reproductive years and complicates up to one in 1000 pregnancies. When cancer is diagnosed during pregnancy, the management strategy must take into account both the mother and developing fetus. In this article, the four most common malignancies diagnosed in pregnant patients--cervical and breast cancer, malignant melanoma and lymphoma--will be reviewed, with an emphasis on the impact of the diagnosis and management on the pregnant patient and the developing fetus.

French Recommendations on the Management of Invasive Cervical Cancer During Pregnancy

Background:

Cervical cancer is one of the most frequently diagnosed cancers during pregnancy, but the management of such cases remains unclear. A Working Group was set up in 2007 in France to propose national recommendations for the management of pregnant patients with invasive cervical carcinoma.

Methods:

The recommendations are based on this literature review conducted by the members of the Working Group.

Results:

Management of cervical cancer during pregnancy depends on 5 factors: stage of the disease (and the tumor size), nodal status, histological subtype of the tumor, term of the pregnancy, and whether the patient wishes to continue her pregnancy. In patients with early-stage disease diagnosed during the first 2 trimesters of pregnancy, there is an increasing tendency to preserve the pregnancy while awaiting fetal maturity in patients with absence of nodal involvement. The delivery (when the fetal maturity is attained) should be then performed using a cesarean section.

Conclusions:

This article proposes recommendations for the management of pregnant patients with invasive cervical cancer. These recommendations have been validated by the 3 main scientific societies of gynecologic oncology, pelvic surgery, and obstetrics and gynecology in France.

Cervical neoplasia in pregnancy. Part 2: current treatment of invasive disease

Although the incidence of cervical cancer in the United States has declined sharply, many young women are diagnosed with the disease every year. Naturally, coincident pregnancies will occur in this subset of reproductively active patients. Although the treatment of cervical cancer has evolved under the drive of multicenter, randomized trials, the same level of evidence does not exist for the treatment of this malignancy in pregnancy. Treatment algorithms are therefore proposed as a series of modifications to the guidelines intended for the nonpregnant patient, taking into account the tremendous social, ethical, and emotional dilemmas specific to each trimester at presentation.

Chemoradiation therapy in pregnant patients treated for advanced-stage cervical carcinoma during the first trimester of pregnancy: report of two cases

Two patients treated using chemoradiation therapy (CRT) (with fetus in utero) for advanced-stage squamous cell cervical carcinoma diagnosed during the first trimester of pregnancy are reported. One patient with a stage IVA disease diagnosed at 12 weeks of gestation was treated by exclusive CRT with the fetus in utero. She recurred 20 months after the end of the treatment. The second patient had a stage IIB disease diagnosed at 12 weeks of gestation and was treated by CRT with the fetus in utero followed by completion surgery (radical hysterectomy and para-aortic lymphadenectomy) due to the presence of a suspicious residual disease. No residual disease was observed during the histologic analysis of hysterectomy and nodes specimens. This patient is alive and free of disease 24 months after surgery. Our observations could suggest that CRT in pregnant patients with fetus in utero is feasible without major short-term toxicity. Such management could be proposed in patients with a bulky cervical cancer diagnosed during the first trimester of the pregnancy. Management of the uterine evacuation depends on the local tumor spread.

Lésions cervicales utérines pendant la grossesse : diagnostic et prise en charge

OBJECTIVES

To define a practical attitude for the management of pregnant women with cervical intraepithelial neoplasia (CIN) and cervical cancer.

MATERIALS AND METHODS

Review of the literature indexed in Medline.

RESULTS

The prevalence of the HPV infections is unchanged among pregnant women with infection by low risk viruses. The viral load increases at the time of the pregnancy, and decreases in the post-partum period. Cervical cytology is easily to perform with reliable results: among the 5% of pathological cervical smears, low grade lesions predominate. The high grade smears require colposcopic exploration, usefully completed by directed biopsies to rule out invasive lesions. Surveillance of high grade CIN is required during pregnancy with post-partum control; most regress. In France during the year 2000, 189 cancers of the uterine cervix were detected during 774.782 pregnancies. Clinical diagnosis is delayed by the non specific clinical signs and the histological aspects of the lesions which are identical with those observed in young woman. The intrinsic outcome of cancer is not modified by pregnancy, and the cesarean section is often preferred (vaginal delivery likely facilitates vascular dissemination). For fetal reasons, a therapeutic delay can be proposed for small sized lesions with a favourable histological subtype and no progression after 20 weeks of gestation.

CONCLUSION

Pregnancy offers the opportunity to perform cervical smears in women not regularly followed. A conservative attitude with a revaluation in postpartum can be proposed in the event of diagnosis of CIN during pregnancy. Pregnancy has little influence on invasive cervical cancers. Management decisions must be made on a case-by-case basis.

Cervical Neoplasia Complicating Pregnancy

This article reviews the key concepts regarding the counseling and management of cervical dysplasia and invasive cervical cancer diagnosed during pregnancy. Emphasis is placed on balancing the maternal and fetal well-being in collaboration with appropriate multidisciplinary teams. Information regarding appropriate diagnosis strategies and the impact of delay in treatment, subsequent prognosis, and treatment algorithms are discussed. Novel fertility-sparing techniques for cervical cancer and their impact on complications of future pregnancies are also discussed.

Cervical neoplasia during pregnancy: Diagnosis, management and prognosis

Pregnancy represents an exceptional opportunity for the early diagnosis of cervical cancer since visual inspection, cytological examination and bimanual palpation are considered to be part of routine antenatal care. An abnormal cervical smear should generally be managed as in the non-pregnant state. However, colposcopy and biopsies are mainly intended to exclude invasive disease because a conservative approach is preferred in cases of pre-invasive disease. The only absolute indication for conization in pregnancy is to rule out (micro-)invasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing or mode of delivery. Overall, earlier stages of cervical cancer are encountered during pregnancy compared with the general population. Although stage of disease and gestational age will largely influence the timing of the interventions, treatment of invasive cervical cancer is similar to the non-pregnant state. In strongly desired pregnancies, the use of neo-adjuvant chemotherapy in order to obtain fetal maturity should be considered and discussed with the patient. Although good evidence supports short-term safety, long-term data regarding the in-utero exposure of cytotoxic drugs need to be consolidated. After stratifying for stage, the outcome is similar to the non-pregnant state.

Management and clinical outcomes of pregnant patients with invasive cervical cancer

BACKGROUND

The objective of this study was to evaluate the clinical outcomes and to discuss the management of women presenting with an invasive cervical cancer during pregnancy.

PATIENTS AND METHODS

We retrospectively reviewed patients treated for an invasive cervical cancer diagnosed during pregnancy between 1985 and 2000 in our institution.

RESULTS

Twenty-one pregnant patients among a total of 487 women were treated. Thirteen, five, two and one, respectively, were diagnosed during the first, second and third pregnancy trimester and post-partum. The FIGO stage was IB in 15 cases, IIB in five cases and IVA in one case. Mean follow-up was 64 months (range 2-165). Overall and disease-free survival at 5 years were 82% and 79%, respectively. All five patients diagnosed in the second trimester were alive. Two of the 13 patients and one of the two patients diagnosed during the first trimester and the third trimester, respectively, died of their disease. No difference was observed between the nine patients whose treatment was delayed or not.

CONCLUSIONS

Invasive cervical cancer during pregnancy is rare but is a dilemma for women and their physicians. The present study and review of the literature suggest that pregnancy does not seem to influence the prognosis of cervical cancer. Delayed treatment could be proposed to selected patients diagnosed at the end of the second trimester or at the beginning of the third trimester, with a small tumor (<2 cm) and negative nodes, after a multidisciplinary approach.

Gynaecological malignancies in pregnancy: a review

Gynaecological malignancies frequently occur in women of reproductive age and are estimated to complicate approximately one in 1000 pregnancies. The incidence of gynaecological malignancies during pregnancy is expected to rise as more women delay childbearing into their later reproductive years, and maternal age is the most powerful predictor of cancer risk. Pregnancy-associated malignancies present significant challenges as a result of the conflict between optimal maternal therapy and fetal well-being. The lack of prospective randomised treatment studies has prevented the development of clinical guidelines for most of the issues complicating the management. In the present review, recent diagnostic and treatment strategies for cervical, ovarian, vulvar and endometrial carcinomas during pregnancy are presented.

Uterine evacuation with misoprostol during radiotherapy for cervical cancer in pregnancy

Radiotherapy as definitive treatment for invasive cervical cancer during pregnancy causes spontaneous abortion in most cases. Surgical evacuation of the uterus is indicated when abortion does not occur, exposing patients to additional morbidity. Two Latin American women, diagnosed with FIGO stage IB2 cervical cancer at approximately 15 weeks gestation, underwent radiotherapy with radiosensitizing chemotherapy. After intrauterine fetal demise was detected, both women underwent induction with misoprostol. Results included one complete abortion and one incomplete abortion without complications or delays in treatment. These cases demonstrate that induction with misoprostol appears to be a safe and effective alternative to surgical evacuation of the uterus when spontaneous abortion fails to occur during radiotherapy for locally advanced cervical cancer.

Cervical cancer during pregnancy

Cervical cancer is one of the most devastating conditions that can complicate a pregnancy. Stage for stage, treatment for squamous cell cervical cancer is the same as that given in the non-pregnant patient. Radical surgery is the treatment of choice for the early stages of the disease. Although a planned delay in therapy may be considered for up to 20 weeks, for stages IA and IB1, it should be implemented cautiously and with the patient's full awareness of the risks. If delay is considered for higher stages, the patient must be aware of the paucity of data to support this plan. Chemoradiation is the standard treatment for advanced cancer of the cervix. When acceptable fetal maturity has been reached, a classical Caesarean section is usually performed prior to definitive treatment.

Management of the pregnant mother with malignant conditions

A malignancy discovered in pregnancy is often difficult to manage; the optimal maternal therapy has to be balanced with the fetal well-being. Generally, the cancer is managed as though the patient is not pregnant. For the various site-specific cancers, surgery is the main modality of treatment; this should be individualized. Chemotherapeutic agents are highly teratogenic in the first trimester, with some adverse effects when used after 12 weeks' gestation. The overall survival rate for pregnancy-associated breast cancer is poor; the reasons for this are discussed. For cervical cancer, delivery by caesarean section appears to be the method of choice, with significantly better survival rates compared with those who deliver vaginally. Other gynaecological and non-gynaecological malignancies are discussed.

Chemotherapy in the treatment of locally advanced cervical cancer and pregnancy

BACKGROUND

Carcinoma of the cervix is the most common malignant tumor associated with pregnancy. The initial stages and premalignant lesions apparently present the same prognosis in pregnant and nonpregnant women; however, there are limited data regarding outcome for locally advanced cervical cancer in pregnancy.

CASE

A 26-year-old woman, gravida 4, para 3, at 14 weeks and 4 days' gestation, was diagnosed with a FIGO stage IIB squamous cell carcinoma of the cervix, treated by primary chemotherapy with cisplatin and bleomycin, until pregnancy resolution at 38 weeks. The newborn infant is currently 3 years old and presents no evidence of abnormalities in neuropsychomotor development.

CONCLUSION

The present case demonstrates that chemotherapy was harmless for the child up to the present time. However, a longer follow-up is needed to determine the safe outcome of this child.

Pregnancy and radiation

The risk of foetal irradiation during pregnancy is discussed. It seems that, due to the low level of X-ray exposure to the foetus, neither diagnostic radiography nor nuclear diagnostic examination justifies termination of pregnancy. Radiotherapy for breast cancer, Hodgkin's disease and cervical cancer in pregnant women is reviewed. Radiation therapy for breast cancer is not an absolute contraindication for pregnancy and the risk-benefit assessment should be discussed with the mother. The risk to the foetus during radiotherapy for supradiaphragmatic Hodgkin's disease appears to be minimal, provided special attention is paid to the treatment techniques and the foetus is adequately shielded. Radiotherapy for the treatment of cervical cancer may be necessary during pregnancy, but the timing should be adjusted taking into consideration gestational age. Offspring of cancer patients who were treated by radiotherapy appear to be at little risk of childhood cancer or birth defects. Cancer patients should not be discouraged from having children and can expect a good outcome of pregnancy. However, in the non-pregnant woman, to further reduce any risk it is advisable to delay pregnancy for 12 months following completion of radiation therapy.

Chien-Tien Hsu Memorial Lecture. Fertility and gynaecologic malignancies

Fertility and gynaecological malignancies have an important relationship. A clear inverse relationship exists between family size and the incidence of ovarian and endometrial cancer. Current methods of fertility control have an influence on subsequent development of various gynaecological malignancies. A slightly increased risk of breast cancer has been reported in current users and those who had used hormonal contraceptives (OCs) within 10 years; this risk declined with time and disappeared after 10 years. Women who started OC before age 20 had a higher relative risk; the disease did not spread beyond the breast in the majority. Most studies found OC to reduce the risk of ovarian and endometrial cancer. The relative risks of squamous cell carcinoma and adenomatous carcinoma of the cervix have been reported to be 1.3 and 1.5, respectively in ever-users of OCs; however, the aetiology of cervical cancer is multifactoral. Several reports suggest the beneficial effect of tubal ligation and breast feeding in reducing the risk of ovarian cancer. Therapy of gynaecological malignancies may have an influence on subsequent fertility. Amenorrhoea developing after treatment of hydatidiform mole may be due to choriocarcinoma, recurrent mole or a normal pregnancy. Choriocarcinoma can also develop after a partial mole. The risk of fetal teratogenicity from chemotherapy is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTD including cerebral metastases. In the young patient with gynaecological malignancy preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian epithelial cancers and even in advanced germ cell tumours. Recently, the fertility-sparing surgery of radical trachelectomy and pelvic lymphadenectomy has been carried out for early invasive cervical cancer in young women. Gynaecological cancer occurring in pregnancy is uncommon; it presents the clinician with a difficult situation to manage. In most instances the cancer is treated as though the patient is not pregnant; the timing and mode of delivery needs individualization. The overall prognosis for breast cancer complicating pregnancy is poor. Survival in cervical cancers diagnosed antepartum is similar to the non-pregnant patient. Ovarian cancer in pregnancy has a good prognosis because of the early stage at diagnosis.

Triage of the abnormal Papanicolaou smear in pregnancy

Triage of the abnormal Papanicolaou smear in pregnancy requires colposcopic evaluation and directed biopsy. If histologic cervical intraepithelial neoplasia is confirmed, the patient can be managed with observations and can be re-evaluated in the postpartum period. If evidence of microinvasion is present, conization must be performed. For patients with invasive disease, a delay in therapy until fetal maturity is achieved does not compromise survival.

Radiation therapy during pregnancy

Malignant disease requiring radiation therapy during pregnancy presents an enormous challenge for the clinician. The optimal radiotherapeutic management of the patient and the optimal management of the pregnancy involve directly opposing demands. Ionizing radiation should be avoided during pregnancy whenever possible. Doses in excess of 0.1 Gy (10 rad) delivered during gestation have been associated with various detrimental effects, and therapeutic abortion has been recommended. If radiation is unavoidable, such as in the treatment of some gynecologic tumors, lymphomatous diseases, or other advanced solid tumors, it must be performed with extreme caution and maximal effort to reduce the dose to the fetus by special shielding techniques. Decisions regarding the use of radiation therapy during pregnancy, the delay of therapy, or pregnancy termination should be made by a multidisciplinary team and be guided by the prognosis of the disease, the stage of gestation, the risk to the fetus from the expected fetal radiation dose, and the patient's ethical and religious beliefs.

Invasive cervical cancer complicating pregnancy. How to manage the dilemma

Pregnancy presents an ideal time for cervical cancer screening, and all pregnant women presenting for prenatal care should be carefully examined. Most patients with pregnancy-associated cervical cancer present with early-stage disease. The prognosis for pregnant patients after stratification for stage is similar to that for nonpregnant patients. A management algorithm is presented in Figure 2. Patients with early-stage squamous cancers diagnosed in the late second and early third trimester may have cancer treatment delayed to increase the likelihood of fetal maturity without compromising maternal prognosis. Cesarean section in patients with pregnancy-associated cervical cancer should be the delivery method of choice. Early-stage cervical cancer should initially be treated surgically. In patients with advanced disease, primary radiation therapy is a safe and effective modality. In the first and second trimester, radiation therapy should be performed without hysterotomy.

Initiation process of earthquakes and its implications for seismic hazard reduction strategy

For the average citizen and the public, "earthquake prediction" means "short-term prediction," a prediction of a specific earthquake on a relatively short time scale. Such prediction must specify the time, place, and magnitude of the earthquake in question with sufficiently high reliability. For this type of prediction, one must rely on some short-term precursors. Examinations of strain changes just before large earthquakes suggest that consistent detection of such precursory strain changes cannot be expected. Other precursory phenomena such as foreshocks and nonseismological anomalies do not occur consistently either. Thus, reliable short-term prediction would be very difficult. Although short-term predictions with large uncertainties could be useful for some areas if their social and economic environments can tolerate false alarms, such predictions would be impractical for most modern industrialized cities. A strategy for effective seismic hazard reduction is to take full advantage of the recent technical advancements in seismology, computers, and communication. In highly industrialized communities, rapid earthquake information is critically important for emergency services agencies, utilities, communications, financial companies, and media to make quick reports and damage estimates and to determine where emergency response is most needed. Long-term forecast, or prognosis, of earthquakes is important for development of realistic building codes, retrofitting existing structures, and land-use planning, but the distinction between short-term and long-term predictions needs to be clearly communicated to the public to avoid misunderstanding.