Surgical management of cervical cancer complicating pregnancy: a case-control study

High-grade Cervical Squamous Intraepithelial Lesion during Pregnancy

Aims and Background

An increasing incidence of high-grade squamous intraepithelial lesion (HSIL) has been observed among young women. Consequently, an increased number of cases are being discovered during pregnancy. We analyzed the clinical and therapeutic management of HSIL during pregnancy.

Methods

A retrospective study was conducted from 1979 to 1998, and 58 registries of women with a cytological or histological diagnosis of HSIL during the pregnant-puerperal period were reviewed. Information obtained from medical records included age, gestational age at diagnosis, parity, age of first intercourse, number of sexual partners before pregnancy, tobacco use, cytologic and colposcopic findings, route of delivery, postpartum follow-up, and treatment. This information was compared with a non-pregnant control group with HSIL.

Results

The average age of pregnant women with HSIL was 27.9 ± 5.2 years. The cytologic or histologic diagnosis of HSIL was made in the first trimester in 12 (20.7%) women and in the second trimester in 30 (51.7%) women. Average parity was 2.8 ± 2 deliveries. Age of first intercourse ranged from 13 to 29 years (16.1 ± 3.3). Thirty-two women (55.1%) had more than one sexual partner before pregnancy. Thirty-seven (63.8%) refereed tobacco use. According to the aforementioned aspects, no statistical difference was found in relation to control, except to cervical ectopia, which was more frequent in pregnant women (56.9% versus 42.6%). From the total of 58 pregnant women with cytologic or biopsy HSIL diagnosis, 53 had HSIL diagnosis made on cervical biopsy directed by colposcopy performed during the pregnancy; 44 (83%) of them were submitted to conservative management. HSIL was diagnosed by cervical biopsy in postpartum evaluation in 76% pregnant women with vaginal delivery and 78.6% women who underwent cesarean section.

Conclusions

A conservative management of HSIL in pregnancy is proposed, with colposcopic evaluation during gestation and postpartum, regardless of route of delivery.

Simple trachelectomy during pregnancy for cervical cancer

Invasive cervical cancer is rare during a pregnancy, even though it is one of the most frequently diagnosed neoplasias during that time. It is noted that around 30% of women diagnosed with cervical cancer are of reproductive age. This means that up to 3% of cases of cervical cancer are found in pregnant women or those who are in the post-birth period. A cervicovaginal Pap smear is performed as part of the regular checkup for a pregnant woman during the first visit so that cervical cancer can easily be diagnosed early in these women, detecting it early in up to 70-80% of cases. We present here the case of a patient with initial diagnosis of cervical cancer made around 20th week of pregnancy. It was then treated by a simple trachelectomy and cerclage during week 24. The pregnant woman gave birth to a healthy baby at the end of her pregnancy. Definitive treatment was completed three months after giving birth with a total hysterectomy and laparoscopic bilateral salpingectomy while preserving both ovaries. After 17 months of monitoring the patient showed no signs of reoccurrence. In conclusion, during the early stage of cervical cancer conservative management may be a reasonable option to preserve the current 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.

Time to surgery and the risk of cancer progression in patients with gynaecologic cancers of the lower genital tract

OBJECTIVE

There is little current evidence to define an appropriate surgical wait time in patients with cancer. The aim of this study was to examine whether increased time to surgery in patients with early-stage lower genital tract cancers resulted in a risk of cancer progression. 

METHODS

We conducted a population-based retrospective cohort study of women presenting with stage I squamous cell carcinoma of the cervix, vulva, and vagina and undergoing surgical treatment in Calgary, Alberta between 2000 and 2010. Cancer stage and disease characteristics were compared at two time points: the time of initial presentation to the gynaecologic oncology service and the time of surgery. 

RESULTS

One hundred fifty-six patients met the inclusion criteria. There was progression of cancer stage in 10 cases (6.4%). In keeping with the current wait time targets, time to surgery was categorized as ≤ 28 days (59 patients; 38%) and > 28 days (97 patients; 62%). Progression occurred in seven of the 123 cases of cervical cancer (9%). In all seven cases, time to surgery was > 28 days (P = 0.095). None of the three cases of vaginal cancer had disease progression. Progression occurred in three (10%) of the 30 cases of vulvar cancer. In two of these three cases, time to surgery was > 28 days (P = 0.586). The relative risk for disease progression with prolonged time to surgery for all women in the cohort was 5.5 (95% CI 0.7 to 42.1) (P = 0.091). 

CONCLUSION

In patients with early squamous cell carcinoma of the lower genital tract, increased time to surgery (> 28 days) is not associated with cancer progression.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

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.

Robotic surgical staging for cervical cancer diagnosed during pregnancy: Immediate versus delayed definitive treatment

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Definitive treatment of cervical cancer in pregnancy poses a dilemma for patients desiring to continue gestation.

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Robotic surgical staging of cervical cancer diagnosed during pregnancy is feasible.

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Robotic surgical staging improves the prognostic assessment for pregnant patients when making a decision between immediate versus delayed treatment.

Cervical cancer in pregnancy: 3 cases, 3 different approaches

OBJECTIVE

Cervical cancer is one of the most common malignancies in pregnancy and one percent of women diagnosed with cervical cancer are pregnant or postpartum at the time of the diagnosis. We discuss how pregnancy will affect the management of cancer, and cancer will affect the management of the pregnancy.

MATERIAL AND METHODS

Three case reports.

RESULTS

We report three cases, with three different approaches of pregnant patient with cervical carcinoma stage IB1, diagnosed below-20 weeks gestation. In two cases, the patients decided to continue the pregnancy.

CONCLUSIONS

Cervical cancer in pregnancy is a clinical challenge. Once the diagnosis, the stage and the extent of invasive cervical cancer have been established, a multidisciplinary approach is required. Decisions regarding timing of treatment and delivery require careful considerations, as well as the trimester in which the diagnosis is made. Delaying definitive treatment to improve fetal outcome, may carry an additional risk of tumor progression, although a delay in definitive treatment is regarded as feasible. Delayed treatment is safe in patients with small sized, early stage disease, if there is no evidence of disease progression. Neoadjuvant chemotherapy during pregnancy is still controversial. Cesarean delivery followed by radical hysterectomy is recommended. The effect of cervical cancer on pregnancy outcome is still not clear.

Gynaecological cancers in pregnancy

Cervical and ovarian cancers are the most common gynaecological cancers diagnosed during pregnancy. In early-stage cervical cancer during the first and at the beginning of the second trimester, the two main considerations for management of the patient are the tumour size (and stage) and nodal staging. MRI and laparoscopic lymphadenectomy are useful for clinicians planning a potentially conservative approach. The management of patients with locally advanced cervical disease is controversial and should be discussed on a case-by-case basis according to the tumour size, radiological findings, the term of pregnancy, and the patient's wishes. Different histological types of malignant ovarian diseases arise during pregnancy and their management depends on the diagnosis (histological subtypes, tumour differentiation, and nodal status), the tumour stage, and the trimester of the pregnancy. In patients with peritoneal spread or high-risk early-stage disease, neoadjuvant chemotherapy with pregnancy preservation could be appropriate.

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.

Pregnancy-associated cervical cancer: Obstetric outcomes

OBJECTIVE

Describe the obstetric outcomes among women in California with pregnancy associated cervical cancer.

METHODS

Cases were identified utilizing computer-linked infant birth/death certificates, discharge records, and cancer registry files, and then assigned to a prenatal or post-partum cancer diagnosis group. Outcomes included cesarean delivery, hospitalizations, birth weight, prematurity, and infant mortality.

RESULTS

Among 434 cases identified, those diagnosed prenatally (136 cases) had higher rates of cesarean section (odds ratio 3.7; 95% CI 2.6, 5.2), hospitalization >5 days (maternal: odds ratio 14.1; 95% CI 9.2, 21.5 neonatal: odds ratio 5.2; 95% CI 3.6, 7.5), low birth weight (LBW) (odds ratio 5.5; 95% CI 3.7, 8.1), very LBW (odds ratio 6.9; 95% CI 3.7, 12.8), prematurity (odds ratio 4.7; 95% CI 3.2, 6.7), and fetal deaths (odds ratio 5.5; 95% CI 2.0, 14.8) compared to non-cancer pregnant controls. Very LBW (odds ratio 2.6; 95% CI 1.4, 4.8), prematurity (odds ratio 1.5; 95% CI 1.1, 2.1), and fetal death rates (odds ratio 3.0; 95% CI 1.2, 7.4) remained elevated among those diagnosed post-partum. No neonatal deaths were attributable to elective premature delivery.

CONCLUSIONS

We observed higher rates of fetal death and spontaneous prematurity among women with pregnancy-associated cervical cancer.

First case of vaginal radical trachelectomy in a pregnant patient

Women who present with cervical carcinoma during pregnancy pose for us a clinical problem. In general, three treatment options exist: (i) radical hysterectomy with termination of pregnancy, (ii) a planned delay, or (iii) chemotherapy until lung maturation has occurred, both followed by a radical hysterectomy. Vaginal radical trachelectomy is an alternative approach to preserve the pregnancy. We report on a woman with a stage IBI cervical carcinoma, diagnosed at 16 weeks of gestation treated with vaginal radical trachelectomy. At a gestational age of 36 weeks, a cesarean section was performed, followed by radical hysterectomy. Follow-up of 9 months is uneventful for both the mother and the child. The vaginal radical trachelectomy is a new approach in the treatment of cervical carcinoma during pregnancy.

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.

Cervical cancer associated with pregnancy: results of a multicenter retrospective Korean study (KGOG-1006)

OBJECTIVE

The objective of the study was to analyze the characteristics of cervical cancer associated with pregnancy.

STUDY DESIGN

Forty patients with cervical cancer associated with pregnancy were retrospectively identified between 1995-2003. Three controls for each case were matched on the basis of age, stage, histology, and date of treatment.

RESULTS

Sampling of cervical cytology after the second trimester was the most common cause of delayed diagnosis. Among 12 patients who delayed treatment for fetal maturity, 2 died of disease. There was no difference in overall survival between pregnant and nonpregnant patients with stage Ib tumors. In contrast to nonpregnant patients, the depth of stromal invasion was not correlated with the incidence of lymph vascular space involvement and lymph node metastasis in pregnant patients.

CONCLUSION

Thorough evaluation is warranted before deciding whether to delay treatment until fetal maturity. Pregnancy does not adversely affect the prognosis of early-stage cervical cancer significantly.

Neoadjuvant cisplatin and radical cesarean hysterectomy for cervical cancer in pregnancy

BACKGROUND

A 28-year-old Hispanic gravida 1 was found to have a 4-5 cm cervical mass when she presented at 23 weeks gestation. On pelvic examination, the tumor was shown to encompass the entire circumference of the cervix without parametrial or vaginal involvement. A biopsy of the mass revealed a poorly differentiated squamous-cell carcinoma of the cervix. An MRI study of the abdomen and pelvis showed a 4 cm cervical mass that was suspicious for left parametrial and rectovaginal septal involvement. No hydronephrosis or lymphadenopathy was noted. The patient elected to proceed with her pregnancy.

INVESTIGATIONS

General physical and gynecological examinations, cervical biopsy, pelvic and obstetric ultrasound, histopathological examination, MRI of the abdomen and pelvis without and with gadolinium, neonatal hearing test and renal function studies.

DIAGNOSIS

Poorly differentiated stage IB2 squamous-cell carcinoma of the cervix with MRI imaging suggestive of parametrial and rectovaginal septal involvement.

MANAGEMENT

Neoadjuvant chemotherapy using weekly cisplatin from 24 to 30 weeks, bed rest and oral terbutaline at 31 weeks because of premature contractions, and a course of antenatal steroids to promote fetal lung maturity. At 33 weeks radical cesarean hysterectomy, bilateral pelvic and para-aortic lymphadenectomy and bilateral ovarian transposition were carried out, followed by adjuvant pelvic radiation therapy with cisplatin chemosensitization 4 weeks postpartum.

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.

Cancer and pregnancy: Poena magna, not anymore

Cancer diagnosed during pregnancy constitutes a difficult clinical condition with a devastating impact on the patient's somatic and psychosocial health and possibly on foetal integrity. This circumstance also raises several moral, religious, social and familial dilemmas. In this review we critically present available evidence regarding the incidence, epidemiology and genetics of cancer in pregnant women, its presentation, diagnosis and staging as well as therapeutic management. Issues such as maternal/foetal prognosis, need for termination of pregnancy, risk of foetal health injury and necessity of psychosocial support are reviewed. Recent accumulating evidence suggests that, with appropriate management, poena magna should not be used to define neither cancer nor pregnancy.

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.

Cancer in pregnancy: maternal-fetal conflict

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment

OBJECTIVE

To investigate patients with invasive cervical carcinoma associated with pregnancy, with special reference to the maternal and neonatal outcomes after planned treatment delay to improve fetal maturity.

METHODS

The medical records of 28 patients with invasive cervical carcinoma diagnosed during pregnancy or within 1 month after pregnancy were retrospectively reviewed.

RESULTS

Twenty-two patients (79%) had Stage I disease and 6 (21%) had Stage II or III disease. Tumor histology revealed squamous cell carcinoma in 27 cases and adenocarcinoma in 1. Twenty cases were diagnosed before 22 weeks gestation, 4 between 22 and 36 weeks, 1 after 36 weeks gestation, and 3 were diagnosed postpartum. In the immediate treatment group (n = 16), the diseases were Stage IA in 3 cases, IB in 7, and II or III in 6. In 11 patients, hysterectomy was performed after therapeutic abortion or with fetus in situ. In 2 patients, cesarean section was followed by hysterectomy or radiotherapy. Three patients diagnosed postpartum were treated with either hysterectomy or radiotherapy. Fifteen patients were free of disease during the follow-up of 27 to 114 months. In the delayed treatment group (n = 12), the diseases were Stage IA1 in 8 cases, IA2 in 1, IB1 in 2, and IB2 in 1 case. In 8 patients with Stage IA1 tumor, the treatment was deferred until term with a delay of 6 to 25 weeks, and hysterectomy or therapeutic conization was performed after delivery. In 4 patients with Stage IA2, IB1 or IB2 tumor, the treatment was postponed until after 30 weeks gestation with a delay of 6 to 15 weeks. No disease progression was documented. Cesarean delivery was followed by hysterectomy in these patients. All patients were free from disease during the follow-up of 70 to 156 months and their babies were well with no sequelae.

CONCLUSION

Delay in treatment to allow for fetal maturity is safe in patients with early Stage I cervical carcinoma associated with pregnancy.

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.

Cervical carcinoma: contemporary management

Cervical carcinoma is prevented easily with proper screening. Unfortunately, many women in industrialized countries continue to have poor access to adequate medical care. In many third-world countries, cervical cancer is one of the top malignancies diagnosed. Screening should be provided for all women to prevent or diagnose cervical cancer at an early, treatable stage.

Obstetrical deliveries associated with maternal malignancy in California, 1992 through 1997

OBJECTIVE

This study aims to characterize the rate of occurrence and nature of outcomes associated with obstetrical deliveries in women with malignant neoplasms among 3,168,911 women who delivered in California in 1992 through 1997.

DESIGN

The study is a population-based retrospective review of infant birth and death certificates and maternal and neonatal discharge records. Cases of malignant neoplasms associated with obstetrical delivery were attributed to 1 of 3 categories, depending on the earliest documented hospital discharge diagnosis, as follows: "prenatal" if the diagnosis was first documented by hospitalization within 9 months preceding delivery, "at delivery" if the diagnosis was established from the delivery hospitalization, or "postpartum" if the diagnosis was first documented by hospitalization within 12 months after delivery.

METHODS

Computer-linked infant birth and death certificates and maternal and neonatal discharge records were used to identify cases and outcomes. Cases of malignant neoplasms were identified by using International Classification of Diseases, Ninth Revision codes (140-208). Noninvasive neoplasms and carcinoma in situ neoplasms were excluded. In analysis of outcomes, the Mantel-Haenszel estimate for adjusted odds ratios was used.

RESULTS

Among 3,168,911 obstetrical deliveries over the 6-year span, a total of 2247 cases of primary malignancy were identified. The observed rate of occurrence for primary malignant neoplasms was 0.71 per 1000 live singleton births. Most cases (53.3%) were first documented in the postpartum period as follows: prenatal, 587 cases (0.18 per 1000); at delivery, 462 cases (0.15 per 1000); and postpartum, 1198 cases (0.38 per 1000). The most frequently documented primary malignant neoplasms associated with obstetrical delivery were breast cancer (423 cases, 0.13 per 1000), thyroid cancer (389 cases, 0.12 per 1000), cervical cancer (266 cases, 0.08 per 1000), Hodgkin's disease (172 cases, 0.05 per 1000), and ovarian cancer (123 cases, 0.04 per 1000). Odds ratios for a variety of demographic factors identified maternal age as the most significant risk factor for development of malignant neoplasms (age greater than 40 vs 20-25, odds ratio 5.7, CI 4.6-6.9). Age-adjusted odds ratios for maternal cancer of any type suggested significantly elevated risks for cesarean delivery (odds ratio 1.4, CI 1.3-1.6), blood transfusion (odds ratio 6.2, CI 4.5-8.5), hysterectomy (odds ratio 27.4, CI 20.8-36.1), and maternal postpartum hospital stay greater than 5 days (odds ratio 30.6, CI 27.9-33.6), but not for postpartum maternal death (odds ratio 0.8, CI 0.6-1.0). Odds ratios also suggested significantly elevated risks for premature newborn (odds ratio 2.0, CI 1.8-2.2), very low birth weight (odds ratio 2.9, CI 2.2-3.8), and newborn hospital stay longer than 5 days (odds ratio 2.6, CI 2.4-3.0), but not for neonatal death (odds ratio 1.6, CI 0.8-3.1) or infant death (odds ratio 1.2, CI 0.5-3.3). However, several types of malignant neoplasms did confer significant elevations in risk for neonatal death. Hospital charges for both maternal and neonatal care were significantly elevated in the maternal malignant neoplasm group.

CONCLUSION

A lower than expected occurrence rate of obstetrical delivery associated with maternal malignancy was seen when compared with previously published hospital-based reports. Malignant neoplasms associated with obstetrical delivery were most frequently first documented in the postpartum period. Maternal and neonatal morbidity were significantly increased, yet the risk of in-hospital maternal death was not significantly elevated. A significant increase in risk of neonatal death for infants of mothers with cervical cancer was found.

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.

Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.