Invasive cervical cancer complicating pregnancy. How to manage the dilemma

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

Treatment and prognosis of cervical cancer associated with pregnancy: analysis of 20 cases from a Chinese tumor institution

This study was designed to investigate the therapeutic approaches and prognosis for cervical cancer associated with pregnancy. Clinical information, therapeutic strategies, and follow-up results of 20 patients with cervical cancer associated with pregnancy from Jan. 2000 to June 2009 in the Zhejiang Cancer Hospital were retrospectively analyzed. The International Federation of Gynecology and Obstetrics (FIGO) stages were: in situ (n=1), stage IA1 (n=1), stage IB1 (n=5), stage IB2 (n=1), stage IIA (n=8), stage IIB (n=3), and stage IIIB (n=1). Eight patients were in the first trimester of pregnancy, four in the second, two in the third, and six at postpartum when diagnosed. The therapeutic strategies were either single or combined modalities, including surgery, radiotherapy, and chemotherapy. Fourteen patients survived, five patients died (four of remote metastasis and one of uremia), and one patient was lost to follow-up. One newborn from a patient at stage IIA carcinoma in the third trimester with postponed therapy six weeks after diagnosis survived. Retarded fetal growth was observed in one patient receiving neoadjuvant chemotherapy and cesarean section. Out of the six postpartum patients, three underwent cesarean section and survived, whereas only one out of the three who underwent vaginal delivery survived. The remaining two died of remote metastasis. Therefore, personalized treatment is necessary for cervical cancer associated with pregnancy. Cervical cancer patients in the third trimester of pregnancy can continue the pregnancy for a short period of time. There may be potential risk for the fetus by chemotherapy during pregnancy. Cesarean section is the preferred mode of delivery for pregnant cervical cancer patients.

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.

Cervical Carcinoma in Early Pregnancy - Successful Birth by Caesarean Section Followed by Radical Hysterectomy

A cervical carcinoma was diagnosed in a 32-year-old patient in the 17th week of her pregnancy. The histological confirmation revealed a well-differentiated squamous cell carcinoma. It was a clinical stage Ib1 tumour, without enlarged lymph nodes according to the image. After a staging MRI, intensive education of the patient and case discussion at the interdisciplinary tumour board as well as consultation with the neonatologist, it was agreed to prolong the pregnancy under close monitoring. The carcinoma was confined to the cervix in the further course of the pregnancy. The elective delivery was planned after 32 weeks of gestation. The primary Caesarean section followed by radical hysterectomy Piver II were carried out without complications. After regular postoperative progression of the mother, brachytherapy was performed at the appropriate time. The premature newborn was under neonatal care and exhibited good postnatal adaptation. Mother and child were discharged in good health.

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.

Cancer and pregnancy: a comprehensive review

BACKGROUND

Pregnancy complicated by cancer is relatively rare but, as women in western societies tend to delay childbearing to the third and fourth decade of life, this phenomenon is going to be encountered more often in the future.

MATERIAL AND METHODS

Review of the literature and description of the different diagnostic and therapeutic approaches which are required to diagnose and treat pregnant mothers with cancer.

RESULTS

As in non-pregnant patients, every effort should be made to provide the maximal benefit and best prognosis to the pregnant patient. In most cases, in order to avoid any harm to the fetus, different diagnostic approach should be incorporated and treatment should be tailored to each pregnant woman. Cooperation of multidisciplinary teams, incorporating medical and radiation oncologists, surgeons, obstetricians, neonatologists and experienced nursing staff, is required to provide optimal care for the patient. The benefits from use of surgery, chemotherapy and/or radiotherapy as well as the mother's wishes and beliefs need to be factored into recommendations and treatment planning.

CONCLUSIONS

With the experience gained, the developments in clinical and radiation oncology and the cooperation of multidisciplinary teams, treatment of cancer during pregnancy with normal fetal outcome is feasible.

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.

Cancer presenting during pregnancy: radiological perspectives

Malignancy presenting during pregnancy is rare. When it does, there are important considerations and challenges for the radiologist. The physiological changes of pregnancy may mask signs and symptoms of malignancy leading to delayed presentation. Endocrine and physiological changes during pregnancy can interact with tumour biology to alter the behaviour and patterns of growth of certain tumours. The timing and choice of imaging technique pose potential risks to the foetus, but this must be weighed against the risks to both mother and foetus of inadequate investigation or misdiagnosis. This review outlines the general principles and approach to imaging the pregnant patient with suspected malignancy, following which there is a more detailed discussion of the effects of pregnancy on tumour biology and presentation of specific tumours. Imaging strategies are discussed for the different entities, and where possible, evidence-based imaging recommendations are made.

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.

Conflicting priorities in surgical intervention for cancer in pregnancy

Cancer in pregnancy is uncommon, with an incidence of about one to two cases in every 1000 pregnancies. There are no randomised trials on any aspect of the management of cancer in pregnancy. Stage for stage cancer outcomes are similar in women who are pregnant compared with those who are not. Misdiagnosis and delayed diagnosis are common where the index of suspicion by the mother and health carers is low. Surgical interventions pose some risk to the fetus, especially laparotomy for abdominal tumours and procedures undertaken during the first trimester. Chemotherapy is teratogenic in the early stages, but seems to be safe in later pregnancy, and radiotherapy can be used for localised tumours remote from the uterus, such as head and neck or limb neoplasms. Suspicious symptoms should be appropriately investigated during pregnancy, and recent advances in non-ionising-radiation staging techniques, such as MRI and ultrasound, are especially helpful. Surgical interventions can be safely undertaken with minimum risk, although there is almost always some element of maternal-fetal conflict.

Gynaecological malignancies in pregnancy

PURPOSE OF REVIEW

To review the management of gynaecological cancers occurring in association with pregnancy. To consider the impact of the cancer on the pregnancy, and the impact of the pregnancy on the cancer.

RECENT FINDINGS

The management of gynaecological cancers in pregnancy remains, fortunately, a rare problem for the gynaecological oncology team. This inevitably means that many management decisions will be informed by relatively small case series and case reports. There have been interesting reports where pregnancy has been prolonged to achieve fetal viability in both cervix and ovary cancer in pregnancy, and these are discussed below.

SUMMARY

Any cancer in pregnancy is a catastrophic event for the woman and her partner, and poses great challenges for the multidisciplinary team responsible for her care. Gynaecological cancers in pregnancy are even more stressful as the woman will naturally worry about the survival of her baby, and the implications for her future fertility. Fortunately the outcome for most women and their babies is favourable.

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.

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.

Microinvasive cervical cancer in pregnancy

Cervical cancer is the most frequently diagnosed malignant disease in pregnancy. The clinical symptoms are scarce or none. The diagnosis is made primarily with a cervical smear, as well as a colposcopic examination and directed cervical biopsy. The treatment of cervical cancer depends on the stage of the disease, the gestation period, and a patient?s wish to carry a pregnancy to term. The illustrated case is of a patient who with the diagnosed presence of microinvasive squamous cell cancer, due to cervical biopsy, in the 1st trimester of pregnancy. In the 2nd trimester, diagnostic conization was performed in order to exclude the presence of the invasive disease. The definite histopathologic findings indicated the presence of cancer in situ. The conization margins were negative and thus the patient was successfully cured. The patient had a cesarean birth in the 36th week of pregnancy and she gave birth to an alive female newborn. Women are given the chance to have cervical cancer diagnosed and treated in the early stages of pregnancy owing to the introduction of a cervical smear in the modern protocol of antenatal protection.

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.

Cancer and pregnancy

Carcinoma of the cervix is the most frequently diagnosed cancer in pregnancy. Still, it is an unusual situation. An abnormal Pap smear during pregnancy is a much more common occurrence and fortunately one that can be managed conservatively. Although definitive treatment for intraepithelial disease can be delayed until the postpartum period, diagnostic evaluation should be done when the abnormal Pap smear is present. Invasive cancer management is dependent on gestational age of the fetus. Pregnancy affords an excellent opportunity to screen for cervical neoplasia.

Current trends in the management of carcinoma of the cervix, vulva, and vagina

In this review, current basic and clinical literature that describes innovative strategies for staging diagnosis and management of cancers of the cervix, vulva, and vagina are reviewed. The reviewed literature includes investigations of viral oncogenesis, the role of angiogenesis in tumor development, pretreatment staging, and the emerging role of chemotherapy in the treatment of locally advanced disease.