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Le Guévelou J, Selleret L, Laas E, Lecuru F, Kissel M. Cervical Cancer Associated with Pregnancy: Current Challenges and Future Strategies. Cancers (Basel) 2024; 16:1341. [PMID: 38611019 PMCID: PMC11011172 DOI: 10.3390/cancers16071341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Cancer during pregnancy is defined as a tumor diagnosed in a pregnant woman or up to 1-year post-partum. While being a rare disease, cervical cancer is probably one of the most challenging medical conditions, with the dual stake of treating the cancer without compromising its chances for cure, while preserving the pregnancy and the health of the fetus and child. To date, guidelines for gynecological cancers are provided through international consensus meetings with expert panels, giving insights on both diagnosis, treatment, and obstetrical care. However, these expert guidelines do not discuss the various approaches than can be found within the literature, such as alternative staging modalities or innovative surgical approaches. Also, the obstetrical care of women diagnosed with cervical cancer during pregnancy requires specific considerations that are not provided within our current standard of care. This systematic review aims to fill the gap on current issues with regards to the management of cervical cancer during pregnancy and provide future directions within this evolving landscape.
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Affiliation(s)
- Jennifer Le Guévelou
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Department of Radiation Oncology, Centre Eugène Marquis, 35000 Rennes, France
| | - Lise Selleret
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, 75005 Paris, France
- Cancer Associé à La Grossesse (CALG), French CALG Network, 75005 Paris, France
| | - Enora Laas
- Breast, Gynecology and Reconstructive Surgery Unit, Institut Curie, 75005 Paris, France
| | - Fabrice Lecuru
- Breast, Gynecology and Reconstructive Surgery Unit, Institut Curie, 75005 Paris, France
- Université de Paris, 75006 Paris, France
| | - Manon Kissel
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France
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McGee AE, Alibegashvili T, Elfgren K, Frey B, Grigore M, Heinonen A, Jach R, Jariene K, Kesic V, Küppers V, Kyrgiou M, Leeson S, Louwers J, Mazurec M, Mergui J, Pedro A, Šavrova A, Siegler E, Tabuica U, Trojnarska D, Trzeszcz M, Turyna R, Volodko N, Cruickshank ME. European consensus statement on expert colposcopy. Eur J Obstet Gynecol Reprod Biol 2023; 290:27-37. [PMID: 37716200 DOI: 10.1016/j.ejogrb.2023.08.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/07/2023] [Accepted: 08/18/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease. AIMS To provide expert guidance on complex colposcopy cases through published evidence and expert consensus. MATERIAL & METHODS Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics. RESULTS & DISCUSSION The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.
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Affiliation(s)
- A E McGee
- Aberdeen Centre for Women's Health Research (ACWHR), University of Aberdeen, UK.
| | - T Alibegashvili
- Department of Gynaecology, Georgian National Screening Center, Tbilisi, Georgia
| | - K Elfgren
- Karolinska Institutet, Stockholm, Sweden
| | - B Frey
- Frauenklinik Baselland, Switzerland
| | - M Grigore
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Romania
| | - A Heinonen
- Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital
| | - R Jach
- Institute of Nursing and Obstetrics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - K Jariene
- Department of Obstetrics and Gynecology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - V Kesic
- Faculty of Medicine, University of Belgrade, Clinic of Obstetrics and Gynaecology, Clinical Center of Serbia, Belgrade, Serbia
| | - V Küppers
- Frauenheilkunde & Geburtshilfe, Zytologisches Labor, Dysplasie-Sprechstunde, Düsseldorf, Germany
| | - M Kyrgiou
- IRDB, MDR & Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - S Leeson
- West London Gynaecological Cancer Centre, Imperial College NHS Trust, UK; Department of Obstetrics and Gynaecology, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Wales, UK
| | - J Louwers
- Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, the Netherlands
| | - M Mazurec
- Corfamed Woman's Health Center, Kluczborska, Wroclaw, Poland; Department of Pathology and Clinical Cytology, University Hospital in Wroclaw, Poland
| | - J Mergui
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris (AP-HP), University Hospital, Paris, France
| | - A Pedro
- Department of Obstetrics and Gynaecology, CUF Sintra Hospital, Sintra, Portugal
| | - A Šavrova
- Gynaecology Centre, North Estonia Medical Centre, Estonia
| | - E Siegler
- The Israeli Society of Colposcopy and Cervical and Vulvar Pathology, Peretz Berenstein St, Haifa, Israel
| | - U Tabuica
- Department of Obstetrics and Gynaecology, State University of Medicine and Pharmacy, Referral Center of Colposcopy, Chisinau, Moldavia
| | - D Trojnarska
- Institute of Nursing and Obstetrics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - M Trzeszcz
- Corfamed Woman's Health Center, Kluczborska, Wroclaw, Poland; Department of Pathology and Clinical Cytology, University Hospital in Wroclaw, Poland
| | - R Turyna
- Institute for the Care of Mother and Child, Prague 4, Czech Republic; Third Faculty of Medicine, Charles University, Prague 10, Czech Republic; Institute of Postgraduate Education in Health Care - IPVZ, Prague 10, Czech Republic
| | - N Volodko
- Department of Oncology and Radiology, Danylo Halytsky Lviv national medical university, Lviv, Ukraine
| | - M E Cruickshank
- Aberdeen Centre for Women's Health Research (ACWHR), University of Aberdeen, UK
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Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice? J Low Genit Tract Dis 2018; 21:299-303. [PMID: 28953123 DOI: 10.1097/lgt.0000000000000346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation. METHODS Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications. RESULTS In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%). CONCLUSIONS The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.
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Kyrgiou M, Athanasiou A, Kalliala IEJ, Paraskevaidi M, Mitra A, Martin‐Hirsch PPL, Arbyn M, Bennett P, Paraskevaidis E. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database Syst Rev 2017; 11:CD012847. [PMID: 29095502 PMCID: PMC6486192 DOI: 10.1002/14651858.cd012847] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The mean age of women undergoing local treatment for pre-invasive cervical disease (cervical intra-epithelial neoplasia; CIN) or early cervical cancer (stage IA1) is around their 30s and similar to the age of women having their first child. Local cervical treatment has been correlated to adverse reproductive morbidity in a subsequent pregnancy, however, published studies and meta-analyses have reached contradictory conclusions. OBJECTIVES To assess the effect of local cervical treatment for CIN and early cervical cancer on obstetric outcomes (after 24 weeks of gestation) and to correlate these to the cone depth and comparison group used. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 5), MEDLINE (up to June week 4, 2017) and Embase (up to week 26, 2017). In an attempt to identify articles missed by the search or unpublished data, we contacted experts in the field and we handsearched the references of the retrieved articles and conference proceedings. SELECTION CRITERIA We included all studies reporting on obstetric outcomes (more than 24 weeks of gestation) in women with or without a previous local cervical treatment for any grade of CIN or early cervical cancer (stage IA1). Treatment included both excisional and ablative methods. We excluded studies that had no untreated reference population, reported outcomes in women who had undergone treatment during pregnancy or had a high-risk treated or comparison group, or both DATA COLLECTION AND ANALYSIS: We classified studies according to the type of treatment and the obstetric endpoint. Studies were classified according to method and obstetric endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model and inverse variance. Inter-study heterogeneity was assessed with I2 statistics. We assessed maternal outcomes that included preterm birth (PTB) (spontaneous and threatened), preterm premature rupture of the membranes (pPROM), chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage and cervical stenosis. The neonatal outcomes included low birth weight (LBW), neonatal intensive care unit (NICU) admission, stillbirth, perinatal mortality and Apgar scores. MAIN RESULTS We included 69 studies (6,357,823 pregnancies: 65,098 pregnancies of treated and 6,292,725 pregnancies of untreated women). Many of the studies included only small numbers of women, were of heterogenous design and in their majority retrospective and therefore at high risk of bias. Many outcomes were assessed to be of low or very low quality (GRADE assessment) and therefore results should be interpreted with caution. Women who had treatment were at increased overall risk of preterm birth (PTB) (less than 37 weeks) (10.7% versus 5.4%, RR 1.75, 95% CI 1.57 to 1.96, 59 studies, 5,242,917 participants, very low quality), severe (less than 32 to 34 weeks) (3.5% versus 1.4%, RR 2.25, 95% CI 1.79 to 2.82), 24 studies, 3,793,874 participants, very low quality), and extreme prematurity (less than 28 to 30 weeks) (1.0% versus 0.3%, (RR 2.23, 95% CI 1.55 to 3.22, 8 studies, 3,910,629 participants, very low quality), as compared to women who had no treatment.The risk of overall prematurity was higher for excisional (excision versus no treatment: 11.2% versus 5.5%, RR 1.87, 95% CI 1.64 to 2.12, 53 studies, 4,599,416 participants) than ablative (ablation versus no treatment: 7.7% versus 4.6%, RR 1.35, 95% CI 1.20 to 1.52, 14 studies, 602,370 participants) treatments and the effect was higher for more radical excisional techniques (less than 37 weeks: cold knife conisation (CKC) (RR 2.70, 95% CI 2.14 to 3.40, 12 studies, 39,102 participants), laser conisation (LC) (RR 2.11, 95% CI 1.26 to 3.54, 9 studies, 1509 participants), large loop excision of the transformation zone (LLETZ) (RR 1.58, 95% CI 1.37 to 1.81, 25 studies, 1,445,104 participants). Repeat treatment multiplied the risk of overall prematurity (repeat versus no treatment: 13.2% versus 4.1%, RR 3.78, 95% CI 2.65 to 5.39, 11 studies, 1,317,284 participants, very low quality). The risk of overall prematurity increased with increasing cone depth (less than 10 mm to 12 mm versus no treatment: 7.1% versus 3.4%, RR 1.54, 95% CI 1.09 to 2.18, 8 studies, 550,929 participants, very low quality; more than 10 mm to 12 mm versus no treatment: 9.8% versus 3.4%, RR 1.93, 95% CI 1.62 to 2.31, 8 studies, 552,711 participants, low quality; more than 15 mm to 17 mm versus no treatment: 10.1 versus 3.4%, RR 2.77, 95% CI 1.95 to 3.93, 4 studies, 544,986 participants, very low quality; 20 mm or more versus no treatment: 10.2% versus 3.4%, RR 4.91, 95% CI 2.06 to 11.68, 3 studies, 543,750 participants, very low quality). The comparison group affected the magnitude of effect that was higher for external, followed by internal comparators and ultimately women with disease, but no treatment. Untreated women with disease and the pre-treatment pregnancies of the women who were treated subsequently had higher risk of overall prematurity than the general population (5.9% versus 5.6%, RR 1.24, 95% CI 1.14 to 1.34, 15 studies, 4,357,998 participants, very low quality).pPROM (6.1% versus 3.4%, RR 2.36, 95% CI 1.76 to 3.17, 21 studies, 477,011 participants, very low quality), low birth weight (7.9% versus 3.7%, RR 1.81, 95% CI 1.58 to 2.07, 30 studies, 1,348,206 participants, very low quality), NICU admission rate (12.6% versus 8.9%, RR 1.45, 95% CI 1.16 to 1.81, 8 studies, 2557 participants, low quality) and perinatal mortality (0.9% versus 0.7%, RR 1.51, 95% CI 1.13 to 2.03, 23 studies, 1,659,433 participants, low quality) were also increased after treatment. AUTHORS' CONCLUSIONS Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment appears to further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than it is for ablation. However, the results should be interpreted with caution as they were based on low or very low quality (GRADE assessment) observational studies, most of which were retrospective.
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Affiliation(s)
- Maria Kyrgiou
- Imperial College London ‐ Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare TrustSurgery and Cancer ‐ West London Gynaecological Cancer CentreDu Cane RoadLondonUKW12 0NN
| | - Antonios Athanasiou
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45332
| | - Ilkka E J Kalliala
- Imperial College LondonThe Institute of Reproductive and Developmental Biology (IRDB), Surgery and CancerIRDB Building, 3rd floor, Hammersmith CampusDu cane RoadLondonUKW12 0HS
| | - Maria Paraskevaidi
- University of Central LancashirePharmacy and Biomedical SciencesFylde RoadPrestonLancashireUKPR1 2HE
| | - Anita Mitra
- Imperial College LondonThe Institute of Reproductive and Developmental Biology (IRDB), Surgery and CancerIRDB Building, 3rd floor, Hammersmith CampusDu cane RoadLondonUKW12 0HS
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Marc Arbyn
- Scientific Institute of Public HealthUnit of Cancer Epidemiology, Belgian Cancer CentreJuliette Wytsmanstreet 14BrusselsBelgiumB‐1050
| | - Phillip Bennett
- Imperial College LondonParturition Research GroupDu Cane RoadLondonUKW12 0NN
| | - Evangelos Paraskevaidis
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45332
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Kyrgiou M, Athanasiou A, Paraskevaidi M, Mitra A, Kalliala I, Martin-Hirsch P, Arbyn M, Bennett P, Paraskevaidis E. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ 2016; 354:i3633. [PMID: 27469988 PMCID: PMC4964801 DOI: 10.1136/bmj.i3633] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the effect of treatment for cervical intraepithelial neoplasia (CIN) on obstetric outcomes and to correlate this with cone depth and comparison group used. DESIGN Systematic review and meta-analysis. DATA SOURCES CENTRAL, Medline, Embase from 1948 to April 2016 were searched for studies assessing obstetric outcomes in women with or without previous local cervical treatment. DATA EXTRACTION AND SYNTHESIS Independent reviewers extracted the data and performed quality assessment using the Newcastle-Ottawa criteria. Studies were classified according to method and obstetric endpoint. Pooled risk ratios were calculated with a random effect model and inverse variance. Heterogeneity between studies was assessed with I(2) statistics. MAIN OUTCOME MEASURES Obstetric outcomes comprised preterm birth (including spontaneous and threatened), premature rupture of the membranes, chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage, and cervical stenosis. Neonatal outcomes comprised low birth weight, admission to neonatal intensive care, stillbirth, APGAR scores, and perinatal mortality. RESULTS 71 studies were included (6 338 982 participants: 65 082 treated/6 292 563 untreated). Treatment significantly increased the risk of overall (<37 weeks; 10.7% v 5.4%; relative risk 1.78, 95% confidence interval 1.60 to 1.98), severe (<32-34 weeks; 3.5% v 1.4%; 2.40, 1.92 to 2.99), and extreme (<28-30 weeks; 1.0% v 0.3%; 2.54, 1.77 to 3.63) preterm birth. Techniques removing or ablating more tissue were associated with worse outcomes. Relative risks for delivery at <37 weeks were 2.70 (2.14 to 3.40) for cold knife conisation, 2.11 (1.26 to 3.54) for laser conisation, 2.02 (1.60 to 2.55) for excision not otherwise specified, 1.56 (1.36 to 1.79) for large loop excision of the transformation zone, and 1.46 (1.27 to 1.66) for ablation not otherwise specified. Compared with no treatment, the risk of preterm birth was higher in women who had undergone more than one treatment (13.2% v 4.1%; 3.78, 2.65 to 5.39) and with increasing cone depth (≤10-12 mm; 7.1% v 3.4%; 1.54, 1.09 to 2.18; ≥10-12 mm: 9.8% v 3.4%, 1.93, 1.62 to 2.31; ≥15-17 mm: 10.1% v 3.4%; 2.77, 1.95 to 3.93; ≥20 mm: 10.2% v 3.4%; 4.91, 2.06 to 11.68). The choice of comparison group affected the magnitude of effect. This was higher for external comparators, followed by internal comparators, and ultimately women with disease who did not undergo treatment. In women with untreated CIN and in pregnancies before treatment, the risk of preterm birth was higher than the risk in the general population (5.9% v 5.6%; 1.24, 1.14 to 1.35). Spontaneous preterm birth, premature rupture of the membranes, chorioamnionitis, low birth weight, admission to neonatal intensive care, and perinatal mortality were also significantly increased after treatment. : CONCLUSIONS Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than for ablation.
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Affiliation(s)
- Maria Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | | | - Maria Paraskevaidi
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Anita Mitra
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Ilkka Kalliala
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Pierre Martin-Hirsch
- Department of Gynaecological Oncology, Lancashire Teaching Hospitals, Preston, UK Department of Biophotonics, Lancaster University, Lancaster, UK
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
| | - Phillip Bennett
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
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Cervical intraepithelial neoplasia 2, 3 in pregnancy: time to consider loop cone excision in the first trimester of pregnancy? J Low Genit Tract Dis 2013; 18:162-8. [PMID: 23994950 DOI: 10.1097/lgt.0b013e318299c0af] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To report the outcome of patients diagnosed with cervical intraepithelial neoplasia 2, 3 (CIN 2, 3) during pregnancy, who were treated by large loop excision of the transformation zone (LLETZ) in the first trimester or were followed up conservatively and treated after delivery. METHODS Patients diagnosed with CIN 2, 3 during pregnancy who were treated with LLETZ or were conservatively followed up were included. Complications of the LLETZ, pathologic results, and pregnancy outcome of both groups were examined after delivery. RESULTS Thirty-one patients were included in the study. Eighteen were conservatively followed up and 13 underwent LLETZ during the first 14 weeks of pregnancy. Four patients (12.9%) in the study group were diagnosed with invasive cervical cancer. From women who underwent LLETZ, 9 patients continued their pregnancy, 7 of which had term normal deliveries and 2 had late preterm deliveries. No complications of severe bleeding or miscarriage were reported in any of the treated patients. CONCLUSIONS Large loop excision of the transformation zone procedure in the first trimester of pregnancy is a safe procedure, with the advantage of treating definitively CIN 2, 3 lesions and preventing the devastating consequences of undiagnosed cervical cancer. We suggest that LLETZ should be performed more liberally in the first trimester of pregnancy.
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Tseng JY, Bastu E, Gungor-Ugurlucan F. Management of precancerous lesions prior to conception and during pregnancy: a narrative review of the literature. Eur J Cancer Care (Engl) 2012; 21:703-11. [PMID: 22966861 DOI: 10.1111/ecc.12002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Special considerations aiming at preserving reproductive function have to be implemented when treating young patients with precancerous lesions of the lower genital tract. These high-grade lesions may progress into invasive cancer if left untreated. Currently, there are limited data on the impact of vulvar and vaginal precancerous lesions on fertility and its management during pregnancy. However, management and outcomes for cervical lesions have been extensively reported. The main approach for vulvar and vaginal lesions are maintaining anatomical function and cosmetics; whereas, treatment options for cervical precancerous lesions range from observation, cryotherapy or the more aggressive conisation. Gestational age is the most important factor in determining expectant management or surgical intervention. This narrative review draws attention to the relevant aspects of precancerous lesions of the lower genital tract, the potential effects and management prior to conception and during pregnancy.
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Affiliation(s)
- J-Y Tseng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
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Value and feasibility of LLETZ procedures for pregnant women with suspected high-grade squamous intraepithelial lesions and microinvasive cervical cancer. Int J Gynaecol Obstet 2012; 118:141-4. [DOI: 10.1016/j.ijgo.2012.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 02/20/2012] [Accepted: 04/24/2012] [Indexed: 11/21/2022]
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Freeman-Wang T, Walker P. Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause. Best Pract Res Clin Obstet Gynaecol 2011; 25:653-65. [PMID: 21843974 DOI: 10.1016/j.bpobgyn.2011.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 04/26/2011] [Accepted: 05/09/2011] [Indexed: 10/17/2022]
Abstract
The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.
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McIntyre-Seltman K, Lesnock JL. Cervical Cancer Screening in Pregnancy. Obstet Gynecol Clin North Am 2008; 35:645-58; x. [DOI: 10.1016/j.ogc.2008.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hunter MI, Monk BJ, Tewari KS. Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease. Am J Obstet Gynecol 2008; 199:3-9. [PMID: 18585520 DOI: 10.1016/j.ajog.2008.04.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 03/07/2008] [Accepted: 04/04/2008] [Indexed: 10/21/2022]
Abstract
Cervical cancer screening is an essential component of prenatal care. The diagnosis and management of cervical intraepithelial neoplasia (CIN) during pregnancy are challenging, and sufficient information does not exist to allow for a definitive evidence-based approach. The American Society for Colposcopy and Cervical Pathology has recently published guidelines regarding the evaluation of abnormal Papanicolaou tests and the treatment of CIN in this setting. Many techniques traditionally recommended in the evaluation of abnormal cervical cytology and the treatment of CIN in the nonpregnant woman, such as colposcopy, cervical biopsy, and electrosurgical excision, can be applied to the pregnant patient with important exceptions. The vascular cervix associated with the gravid condition and the risk of premature pregnancy loss mandates deviation from existing consensus guidelines in screening for cervical cancer in pregnancy and treating associated CIN. In the present review, current guidelines regarding cervical cancer screening are reviewed, and data from studies of pregnant populations are summarized.
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Fambrini M, Penna C, Fallani MG, Pieralli A, Mattei A, Scarselli G, Taddei GL, Marchionni M. Feasibility and outcome of laser CO2conization performed within the 18th week of gestation. Int J Gynecol Cancer 2007; 17:127-31. [PMID: 17291242 DOI: 10.1111/j.1525-1438.2007.00802.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.
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Affiliation(s)
- M Fambrini
- Department of Gynecology, Perinatology and Human Reproduction, School of Medicine, University of Florence, Via Morgagni 85, 50134 Florence, Italy.
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Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 2006; 367:489-98. [PMID: 16473126 DOI: 10.1016/s0140-6736(06)68181-6] [Citation(s) in RCA: 748] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Conservative methods to treat cervical intraepithelial neoplasia and microinvasive cervical cancer are commonly used in young women because of the advent of effective screening programmes. In a meta-analysis, we investigated the effect of these procedures on subsequent fertility and pregnancy outcomes. METHODS We searched for studies in MEDLINE and EMBASE and classified them by the conservative method used and the outcome measure studied regarding both fertility and pregnancy. Pooled relative risks and 95% CIs were calculated with a random-effects model and interstudy heterogeneity was assessed with Cochrane's Q test. FINDINGS We identified 27 studies. Cold knife conisation was significantly associated with preterm delivery (<37 weeks; relative risk 2.59, 95% CI 1.80-3.72, 100/704 [14%] vs 1494/27 674 [5%]), low birthweight (<2500 g; 2.53, 1.19-5.36, 32/261 [12%] vs 905/13 229 [7%]), and caesarean section (3.17, 1.07-9.40, 31/350 [9%] vs 22/670 [3%]). Large loop excision of the transformation zone (LLETZ) was also significantly associated with preterm delivery (1.70, 1.24-2.35, 156/1402 [11%] vs 120/1739 [7%]), low birthweight (1.82, 1.09-3.06, 77/996 [8%] vs 49/1192 [4%]), and premature rupture of the membranes (2.69, 1.62-4.46, 48/905 [5%] vs 22/1038 [2%]). Similar but marginally non-significant adverse effects were recorded for laser conisation (preterm delivery 1.71, 0.93-3.14). We did not detect significantly increased risks for obstetric outcomes after laser ablation. Although severe outcomes such as admission to a neonatal intensive care unit or perinatal mortality showed adverse trends, these changes were not significant. INTERPRETATION All the excisional procedures to treat cervical intraepithelial neoplasia present similar pregnancy-related morbidity without apparent neonatal morbidity. Caution in the treatment of young women with mild cervical abnormalities should be recommended. Clinicians now have the evidence base to counsel women appropriately.
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Affiliation(s)
- M Kyrgiou
- Department of Obstetrics and Gynaecology, Central Lancashire Teaching Hospitals, Preston, UK.
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Abstract
Cervical carcinoma is staged clinically by examination and simple radiological procedures. CT and MRI can, however, be used to guide management. Prognosis is best made by tumor size. depth of invasion, parametrial involvement, nodal status, LVSI, and histology. CIN III and CIS can be treated by ablative or excisional procedures. Hysterectomy should not be the primary treatment. Microinvasive (<3 mm) Stage IA cervical carcinoma can be treated conservatively with conization in patients who desire fertility, but the standard of care remains simple hysterectomy. Stages IB and IIA can be treated with either radical hysterectomy or radiation therapy dependent upon the patient's health and preference. Risk factors after radical hysterectomy (eg, bulky tumors, deep invasion, involved nodes or margins. LVSI) might warrant adjuvant radiation therapy. Chemoirradiation is the current standard of care for treatment for Stages IIB, III, and [VA. Some clinicians also use this modality in patients with Stage IB disease who are undergoing radiation as the primary treatment. Locally recurrent disease can be treated with either radiation (after radical hysterectomy) or pelvic exeteration (after primary radiation therapy). Exenteration in appropriately selected patients yields 5-year survival rates up to 82% with low complication rates. Many exenterations are aborted intraoperatively because of distant or unresectable disease, however. The incidence of glandular carcinoma of the cervix is rising, particularly in younger women. Cervical carcinoma detected during pregnancy requires the combined efforts of the gynecologic oncologist and the maternal-fetal medical specialist to determine the timing and method of treatment.
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Affiliation(s)
- David O Holtz
- Department of Obstetrics and Gynecology, Jefferson Medical College, 111 South 11th Street, Philadelphia, PA 19107, USA
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