Cervical intraepithelial neoplasia 2, 3 in pregnancy: time to consider loop cone excision in the first trimester of pregnancy?

Cervical Cancer Associated with Pregnancy: Current Challenges and Future Strategies

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.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

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.

Glycodelin expression in pregnant patients with cervical intraepithelial neoplasia: a case-control study

We aimed to evaluate glycodelin immunostaining in pregnant women with a first diagnosis of cervical intraephitelial neoplasia (CIN) and to correlate the expression of CIN with Ki-67 and glycodelin immunostaining. A retrospective case-control study was performed including 20 patients with natural pregnancy and with first time onset of CIN occurring not later than 16 gestational weeks. The control group included 20 non-pregnant patients matched for age, parity, smoking status and number of previous sexual partners. Exclusion criteria included previous cervical treatment, immunocompromised status and chronic hepatitis B and/or C. Staining for Glycodelin and for Ki-67 was expressed using a classification based on the distribution of positivity on a semi-quantitative three-point scale. An inverse relationship was observed between glycodelin immunostaining and CIN grade in pregnant patients (p = 0.01), with a significantly higher expression in CIN1 than in CIN2 and CIN3, but not in non-pregnant patients (p = 0.81). Positivity for Ki-67 was less intense in pregnant than in non-pregnant patients. A significant inverse relationship was observed between glycodelin immunostaining and Ki-67 expression (p = 0.02). We suggest that the higher expression of glycodelin in pregnancy is related to a lower proliferative activity in CIN, which is probably associated to hormonal status of pregnancy. Further clinical studies are needed to support these findings.