Gynecologic Cancers in 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.

Cancer Treatment and Immunotherapy during Pregnancy

Background/aim: Immunotherapy has, in recent years, witnessed an expansion in its indications for the treatment of cancer. Coupled with the fact that, nowadays, even more women choose to postpone parenthood, thus increasing their chances of having some kind of malignancy during pregnancy, more and more women are eligible for receiving immunotherapy during this period of their lives. The cases of cancer diagnosed during pregnancy is an ever-increasing trend nowadays. Materials and methods: The oncologists and clinicians treating women often face a range of ethical and therapeutic dilemmas due to the particularity of the patient’s conditions. The primary concern is the protection of the mother, firstly, and then the fetus (through adjustments to the various treatment regimens) if possible. Results and conclusions: Oncological drugs, radiation therapy, surgery, or a combination of all the above methods are selected, depending on the case. In this project, we studied the oncology drugs used for various types of gestational cancer, their appropriateness and timing, as well as their possible effects on the parent and embryo upon their administration. Various studies have shown that the administration of oncological drugs should be postponed until at least after the first trimester of pregnancy.

Guidelines for Cancer Treatment during Pregnancy: Ethics-Related Content Evolution and Implications for Clinicians

Simple Summary

Clinical practice guidelines for cancer treatment during pregnancy have been available for the past 20 years; however, whether they contain bioethical guidance is currently unknown. A systematic medical literature review was performed to identify the presence of biomedical ethics principles present in guidelines published until 2021. Most of the included guidelines (25 out of 32) refer to biomedical ethics principles such as respect for patient’s autonomy, beneficence and justice. Earlier guidelines stress the importance of patient wishes and choices in light of limited evidence and vast unknowns while balancing maternal and fetal wellbeing. More recent guidelines tend to focus on evidence-based data to balance favorable outcomes for pregnant patients and their fetuses with counselling support to help the patients and their support network understand the rationale behind available treatment options. However, ethics-related content in such guidelines is not presented in a structured manner, indicating the need for methodological upgrades. Therefore, a more structured approach is needed when addressing existing and potential ethical issues in clinical practice guidelines for cancer treatment during pregnancy.

Abstract

(1) Background: Current scientific evidence suggests that most cancers, including breast cancer, can be treated during pregnancy without compromising maternal and fetal outcomes. This, however, raises questions regarding the ethical implications of clinical care. (2) Methods: Using a systematic literature search, 32 clinical practice guidelines for cancer treatment during pregnancy published between 2002 and 2021 were selected for analysis and 25 of them mentioned or made references to medical ethics when offering clinical management guidance for clinicians. (3) Results: Four bioethical themes were identified: respect for patient’s autonomy, balanced approach to maternal and fetal beneficence, protection of the vulnerable and justice in resource allocation. Most guidelines recommended informing the pregnant patient about available evidence-based treatment options, offering counselling and support in the process of decision making. The relational aspect of a pregnant patient’s autonomy was also recognized and endorsed in a significant number of available guidelines. (4) Conclusions: Recognition and support of a patient’s autonomy and its relational aspects should remain an integral part of future clinical practice guidelines. Nevertheless, a more structured approach is needed when addressing existing and potential ethical issues in clinical practice guidelines for cancer treatment during pregnancy.

Use of Positron Emission Tomography for Pregnancy-Associated Cancer Assessment: A Review

Background. Positron emission tomography (PET) has proven clinical utility both in the initial and relapse staging phase, but this technique is controversial during pregnancy. The objective of this review is to provide a compendium of available information on the use of PET during pregnancy. Materials and methods. A systematic literature review was conducted from 1 January 2004 until 20 May 2021. A total of 4 small series and 9 case reports consisting of 25 cases were selected. Results. During the first trimester, the fetus is most sensitive to ionization damage, so lower doses are recommended (2.6E-02 mGy/MBq). Fetal-effective doses are higher in this period and the average fetal dose (4.06 ± 3.22 mGy) remains significantly below the threshold for deterministic effects. During the second and third trimesters, recommended doses are higher (1.4E-02 mGy/MBq at 6 months, and 6.9E-03 mGy/MBq at 9 months of gestation). ¹⁸F-FDG activity was distributed to the whole fetus with a prevalence of myocardial tissue in seven cases. The use of special precautions, such as PET-magnetic resonance (MR) and urinary bladder catheterization, reduces the amount of radioactive tracer. Breastfeeding interruption is not recommended. Conclusions. ¹⁸F-FDG PET is not contraindicated in pregnancy, but multidisciplinary discussion is necessary and strict precautions are recommended.

Trends in Pregnancy-Associated Cervical Cancer in Japan between 2012 and 2017: A Multicenter Survey

Large-scale data on maternal and neonatal outcomes of pregnancy-associated cervical cancer in Japan are scarce, and treatment strategies have not been established. This multicenter retrospective observational study investigated clinical features and trends in pregnancy-associated cervical cancer treatments at 523 hospitals in Japan. We included cervical cancer cases that were histologically diagnosed (between 1 January 2012, and 31 December 2017), and their clinical information was retrospectively collected. Of 40 patients diagnosed with pregnancy-associated cervical cancer at ≥22 gestational weeks, 34 (85.0%) were carefully followed until delivery without intervention. Of 163 diagnosed at <22 gestational weeks, 111 continued and 52 terminated their pregnancy. Ninety patients with stage IB1 disease had various treatment options, including termination of pregnancy. The 59 stage IB1 patients who continued their pregnancy were categorized by the primary treatment into strict follow-up, conization, trachelectomy, and neoadjuvant chemotherapy groups, with no significant differences in progression-free or overall survival. The birth weight percentile at delivery was smaller in the neoadjuvant chemotherapy group than in the strict follow-up group (p = 0.029). Full-term delivery rate was relatively higher in the trachelectomy group (35%) than in the other groups. Treatment decisions for pregnancy-associated cervical cancer are needed after estimating the stage, considering both maternal and fetal benefits.

Neoadjuvant chemotherapy with paclitaxel plus cisplatin before radical surgery for locally advanced cervical cancer during pregnancy: A case series and literature review

RATIONALE

Despite the development of human papillomavirus vaccines and significant improvement in cervical cancer screening over the past few years, cervical cancer remains the fourth most common cancer in women of childbearing age after breast cancer, melanoma, and thyroid cancer.

PATIENT CONCERNS

In this case report, the patients are all cervical cancer with stage IB2 and IB3 during pregnancy, the management constitutes a major medical challenge related to the impact of treatment on both maternal and fetal outcomes. Neoadjuvant chemotherapy (NACT) is an innovative option for cervical cancer patients with stage IB2 and IB3 before cesarean delivery and radical hysterectomy, and many chemotherapeutic agents are available, cisplatin plus paclitaxel yielded good maternal and fetal outcomes to the authors' knowledge.

DIAGNOSES

Masses were discovered in the cervix of 4 pregnant women with a history of vaginal bleeding. Biopsy examination of the masses revealed cervical carcinoma, which was staged in accordance with the International Federation of Gynecology and Obstetrics (i.e., FIGO) system.

INTERVENTIONS

The patients were treated with paclitaxel plus cisplatin, followed by cesarean delivery and radical hysterectomy.

OUTCOMES

The 4 patients were treated successfully, with no recurrence during follow-up periods of 14 to 56 months, and all of the children were doing well with no anomalies.

LESSONS

Although further data are required, in pregnant women with invasive cervical cancer, NACT with cisplatin plus paclitaxel followed by cesarean delivery and radical hysterectomy was a practical treatment option.

Association of Chemotherapy Timing in Pregnancy With Congenital Malformation

IMPORTANCE

Chemotherapy during the first trimester of pregnancy should be avoided owing to the risk of congenital malformations. However, the precise gestational age at which chemotherapy can be initiated safely remains unclear.

OBJECTIVE

To assess congenital malformation rates associated with gestational age at initiation of chemotherapy among pregnant women with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study evaluated all pregnant women who received chemotherapy between 1977 and 2019 registered in the International Network on Cancer, Infertility and Pregnancy (INCIP) database. Data were analyzed from February 15 to June 2, 2020.

EXPOSURES

Cancer treatment with chemotherapy during pregnancy.

MAIN OUTCOMES AND MEASURES

Analysis was focused on major and minor structural malformations in offspring, defined by EUROCAT, detected during pregnancy or at birth.

RESULTS

A total of 755 women in the INCIP database who underwent cancer treatment with chemotherapy during pregnancy were included in analysis. The median (range) age at cancer diagnosis was 33 (14-48) years. Among offspring, the major congenital malformation rate was 3.6% (95% CI, 2.4%-5.2%), and the minor congenital malformation rate was 1.9% (95% CI, 1.0%-3.1%). Chemotherapy exposure prior to 12 weeks gestational age was associated with a high rate of major congenital malformations, at 21.7% (95% CI, 7.5%-43.7%; odds ratio, 9.24 [95% CI, 3.13-27.30]). When chemotherapy was initiated after gestational age 12 weeks, the frequency of major congenital malformations was 3.0% (95% CI, 1.9%-4.6%), which was similar to the expected rates in the general population. Minor malformations were comparable when exposure occurred before or after gestational age 12 weeks (4.3% [95% CI, 0.1%-21.9%] vs 1.8% [95% CI, 1.0-3.0]; odds ratio, 3.13 [95% CI, 0.39-25.28]). Of 29 women who received chemotherapy prior to 12 weeks gestation, 17 (58.6%) were not aware of pregnancy, and 6 (20.7%) experienced a miscarriage (3 women [10.3%]) or decided to terminate their pregnancy (3 women [10.3%]).

CONCLUSIONS AND RELEVANCE

This cohort study found that chemotherapy was associated with an increased risk of major congenital malformations only in the first 12 weeks of pregnancy. The risk of congenital malformations when chemotherapy was administered during the first trimester and the high number of incidental pregnancies during cancer treatment in the INCIP registry underscore the importance of contraceptive advice and pregnancy testing at the start of chemotherapeutic treatment in young women with cancer.

Management Challenges of Metastatic Spinal Cord Compression in Pregnancy

Primary and secondary spinal tumours with cord compression often represent a challenging condition for the patient and clinicians alike, even more so during pregnancy. The balance between safe delivery of a healthy baby and management of the mother's disease bears many clinical, psychological, and ethical dilemmas. Pregnancy sets a conflict between the optimal surgical and oncological managements of the mother's tumour and the well-being of her foetus. We followed the CARE guidelines from the EQUATOR Network to report an exemplificative case of a 39-year-old woman with a 10-year history of breast cancer, presenting in the second trimester of her first pregnancy with acute onset severe thoracic spinal instability, causing mechanical pain and weakness in lower limbs. Neuroradiological investigations revealed multilevel spinal deposits with a pathological T10 fracture responsible for spinal cord compression. The patient was adamant that she wanted a continuation of the pregnancy and her baby delivered. After discussion with her oncologist and obstetrician, we agreed to perform emergency spinal surgery—decompression and instrumented fixation. The literature search did not reveal a similar case of spinal metastatic breast cancer undergoing spinal instrumentation and delivery of a healthy baby a few months later. Following the delivery, the patient had further oncological treatment, including chemotherapy and radiotherapy. The paucity of such reports prompted us to present this case and highlight the relevance of a multidisciplinary approach involving obstetrician, oncologist, spinal surgeon, and radiologist to guide the optimal decision-making process.

A fight-and-flight for life: A rare case of advanced cervical cancer in pregnancy

•

Advanced cervical cancer during pregnancy requires shared decision making and a multidisciplinary team approach.

•

If the pregnancy is continued, antepartum chemotherapy should be strongly considered.

•

Maternal prognoses tend to be poor, but neonatal outcomes appear to be favorable.

Background

Advanced cervical cancer during pregnancy is an extremely rare event. We describe a case of at least stage IIIB cervical squamous cell carcinoma during pregnancy. This may possibly represent the longest gestation from time of diagnosis to delivery in a case of advanced cervical cancer, with potentially the most advanced gestational age at delivery and a relatively favorable outcome in the current literature.

Case: A 29-year-old female at 20 0/7 weeks of gestation with at least stage IIIB squamous cell carcinoma of the cervix flew from Micronesia to Hawaii for oncologic treatment. After consultation with gynecologic oncology and maternal-fetal medicine, she opted to continue the pregnancy and began neoadjuvant chemotherapy with carboplatin and paclitaxel. At 33 2/7 weeks of gestation, she was admitted for preterm prelabor rupture of membranes and immediately underwent a cesarean delivery for heavy vaginal bleeding. Postpartum, she underwent cisplatin chemotherapy with concurrent radiation therapy. After 6 cycles of chemotherapy, the patient’s cancer had progressed to the point that hospice was recommended. She died 11 months after initial presentation.

Conclusion

Advanced cervical cancer during pregnancy requires individualized treatment, shared decision making, and a multidisciplinary team approach. If the pregnancy is continued, antepartum chemotherapy should be strongly considered. Maternal prognoses tend to be poor, but neonatal outcomes appear to be favorable.

Quercetin and cancer: new insights into its therapeutic effects on ovarian cancer cells

Ovarian cancer is known as a serious malignancy that affects women's reproductive tract and can considerably threat their health. A wide range of molecular mechanisms and genetic modifications have been involved in ovarian cancer pathogenesis making it difficult to develop effective therapeutic platforms. Hence, discovery and developing new therapeutic approaches are required. Medicinal plants, as a new source of drugs, could potentially be used alone or in combination with other medicines in the treatment of various cancers such as ovarian cancer. Among various natural compounds, quercetin has shown great anti-cancer and anti-inflammatory properties. In vitro and in vivo experiments have revealed that quercetin possesses a cytotoxic impact on ovarian cancer cells. Despite obtaining good results both in vitro and in vivo, few clinical studies have assessed the anti-cancer effects of quercetin particularly in the ovarian cancer. Therefore, it seems that further clinical studies may introduce quercetin as therapeutic agent alone or in combination with other chemotherapy drugs to the clinical setting. Here, we not only summarize the anti-cancer effects of quercetin but also highlight the therapeutic effects of quercetin in the ovarian cancer.

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

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

A Japanese survey of malignant disease in pregnancy

BACKGROUND

In recent years, the incidence of malignant disease in pregnancy has been increasing, but there are few large-scale surveys of malignant disease in pregnancy in Japan. The aim of this study was to survey malignant disease occurring during pregnancy in Japan.

METHODS

Malignant disease in pregnancy was defined as diagnosis or treatment for malignant disease, except in situ carcinoma during pregnancy, or within 1-year postpartum. First, a primary survey questionnaire of the incidence of malignant disease in pregnancy and the number of deliveries over the course of 2014 was sent to 510 medical centers in Japan. Second, the survey questionnaires on the incidence of malignant diseases in pregnancy were collected and analyzed in detail.

RESULTS

Of the 510 medical centers, 411 (81%) responded to the survey. There were 215,372 deliveries and 189 incidents (0.09%) of malignant disease in pregnancy. Of the 189 patients with malignancy, 157 detailed responses about the patients were received. The most frequently encountered cancer types were cervical cancer (36%), breast cancer (24%), and ovarian cancer (15%). During the 2 years after delivery, 15 patients (1 with breast cancer, 2 with ovarian cancer, 3 with hematologic malignancy, 4 with intestinal cancer, and 5 with others) died of the disease; most of them had advanced disease. In particular, 88% of the patients with intestinal cancers at diagnosis had advanced disease, and half of them died of disease.

CONCLUSIONS

In Japan, the most common malignancies in pregnancy in order of frequency are cervical cancer, breast cancer, and ovarian cancer. Early diagnosis and appropriate management of cancer during pregnancy are important for improving maternal and neonatal outcomes, because advanced diseases have a poor prognosis.

The Role of Secondary Metabolites on Gynecologic Cancer Therapy: Some Pathways and Mechanisms

Gynecologic cancers are among the most common cancers in humans and animals. Treatment success depends on several factors including stage at diagnosis, tumor type, origin and metastasis. Currently, surgery, chemotherapy, and radiotherapy are preferred in the treatment of these cancers. However, many anticarcinogenic drugs can cause severe adverse effects and also the expected response to treatment may not be obtained. In recent studies, the importance of the relationship between cancer and inflammation has been emphasized. Therefore, several phytochemicals that exhibit beneficial bioactive effects towards inflammatory pathways were proven to have anticarcinogenic potential for gynecologic cancer therapy. This review summarizes the role of inflammatory pathways in gynecologic cancers and effective secondary metabolites for cancer therapy.

Effects of cancer treatment during pregnancy on fetal and child development

It has become clear that, for specific cancers and under well defined circumstances, oncological treatment in pregnancy is possible. In this Review, we summarise the evidence on fetal, neonatal, short-term, and long-term effects of prenatal exposure to cancer treatment on the child. So far, outcomes of children are generally reassuring, but long-term follow-up is insufficient. The most important risks of chemotherapy during pregnancy are preterm birth and babies being small for gestational age. Chemotherapy in the first trimester is contraindicated because of an increased risk of congenital malformations. Studies on outcomes of children exposed to radiotherapy, targeted therapy, or hormonal therapy in pregnancy are scarce. Careful registration of women undergoing cancer treatment in pregnancy and long-term follow-up of their children are important. Comprehensive documentation of the mental and physical status of children exposed to cancer treatment in utero will allow physicians and parents to best decide whether to treat cancer during pregnancy.

Abdominal Radical Trachelectomy Performed During Pregnancy — Case Series

Introduction:Abdominal radical trachelectomy (ART) for tumors of the uterine cervix can be performed while the pregnancy is ongoing, but the success rates so far are reduced.

Case series presentation:ART was performed in three patients with cervical cancer diagnosed during pregnancy, with a triple aim to offer a radical surgery for cervical cancer, but also to preserve the ongoing pregnancy and fertility. The ART was successful in one patient, and she delivered a healthy baby at term, by cesarean section. The other 2 patients experienced obstetrical complications and lost their pregnancies after ART, but in one of the cases, fertility was preserved.

Conclusions:Radical trachelectomy could be performed as alternative therapy for pregnant women with invasive malignancies of the cervix. This procedure may prevent female patients to lose a much-desired pregnancy, their fertility, as well as their maternity.

Diffusion-weighted MR imaging and assessment of ovarian carcinomas with vaginal deposit accidentally detected during pregnancy

Ovarian cancer during pregnancy is a complex situation that endangers the lives of both the pregnant female and the fetus. We present a 40-year-old pregnant female in the third trimester with bilateral undifferentiated ovarian adenocarcinoma and vaginal metastasis. The case was evaluated by ultrasound and MRI supported with diffusion-weighted sequence.

Treatment of gynecological cancers diagnosed during pregnancy

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

Gynaecological cancers coexisting with pregnancy - a literature review

The coexistence of malignant tumour and pregnancy is a state of simultaneous occurrence of two completely contradictory philosophical and biological phenomena – the development of a new life and a life-threatening terminal illness. Finally, a physician – in fact the whole team of doctors – is facing the fight for two lives: of the mother and her unborn child.

The incidence of malignant disease in pregnancy is 0.05 to 0.1%. This condition is a major challenge for physicians because there are no randomised studies that could be the basis to choose the therapeutic methods – the medical knowledge merely comes from case reports, registries, and observational studies.

The following cancers most often coexist with pregnancy: gynaecological neoplasm (especially cervical and ovarian cancer), breast cancer, lymphatic system neoplasm, and melanoma.

Formerly, the diagnosis was clearly the necessity of abortion. Today – although unskilled doctors still propose the only therapeutic option – termination of pregnancy is not the only solution.

The past few years have seen the updating of reports and guidelines for the management of pregnant women with cancer. This paper is a review and summary of the information from these publications.

Management of Hematologic Malignancies: Special Considerations in Pregnant Women

The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.

Neoadjuvant chemotherapy for locally advanced cervical cancer

Neoadjuvant chemotherapy followed by surgery (NCS) has not been fully evaluated clinically. Currently, the main regimen of neoadjuvant chemotherapy (NAC) used in NCS includes cisplatin. The antitumor effects of NAC reduce lymph node metastasis and the tumor diameter in patients prior to surgery, and this can reduce the number of high risk patients who require postoperative radiation therapy. Many randomized controlled trials (RCTs) have examined the long-term prognosis of NCS compared to primary surgery, but the utility of NCS remains uncertain. The advent of concurrent chemoradiotherapy (CCRT) has markedly improved the outcome of radiotherapy (RT), and CCRT is now used as a standard method in many cases of advanced bulky cervical cancer. NCS gives a better treatment outcome than radiation therapy alone, but it is important to verify that NCS gives a similar or better outcome compared to CCRT.

Radical Trachelectomy Performed During Pregnancy: A Review of the Literature

Objective

Cervical cancer is one of the most frequent malignant diseases diagnosed during pregnancy. Abdominal or vaginal radical trachelectomies are fertility-preserving alternatives to radical hysterectomy for young women with early-stage cervical cancer that can be performed during ongoing pregnancy.

Methods

A literature review of articles on this subject was conducted through a Medline search for articles published in English or French.

Results

At this moment, 21 cervical cancer patients, including ours (4 stage IA2, 16 IB1, and 1 IB2) who underwent radical trachelectomy during pregnancy have been reported. Of these, 10 were performed by vaginal route and 11 were abdominal radical trachelectomies.

Conclusions

Radical trachelectomy could be offered as an option for pregnant patients with early invasive cervical cancer. It may help women avoid the triple losses of a desired pregnancy, fertility, and motherhood.

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.

Malignancies in pregnancy

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered. Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population. These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Acute myeloid leukemia in the pregnant patient

Although acute myeloid leukemia (AML) mostly occurs in older patients, it could be seen in women of childbearing age. It is therefore not surprising that in some patients, the management of AML will be complicated by a coexistent pregnancy. However, the association of leukemia and pregnancy is uncommon. Its incidence is estimated to be 1 in 75,000-100,000 pregnancies. During pregnancy, most leukemias are acute: two-thirds are myeloid and one-third are lymphoblastic. There is no standard approach for this clinical dilemma, in part because of variables such as the type of AML, the seriousness of the symptoms, and the patient's personal beliefs. In many cases, the diagnostic workup has to be altered because of the pregnancy, and often available treatments have varying risks to the fetus. While chemotherapy is reported to have some risks during the first trimester, it is admitted that it can be administered safely during the second and the third trimesters.

Treatment options for pregnant women with ovarian tumors

Diagnosis of ovarian mass during pregnancy is a rare event. Treatment of ovarian malignancies during pregnancy depends on histology, grade, stage, and gestational weeks. When possible, surgical excision is indicated, and sometimes, fertility-sparing surgery is recommended. Administration of systemic treatment before or after surgery is indicated as in nonpregnant women. Preliminary data suggest that platinum salts and taxanes are safe during pregnancy. Management of ovarian tumors in pregnancy requires a multidisciplinary approach to guarantee an optimal treatment for the mother and the fetus.

A child with severe hearing loss associated with maternal cisplatin treatment during pregnancy

BACKGROUND

Cisplatin is considered safe to use during the second and third trimesters of pregnancy in patients with cancer.

CASE

A 34-year-old pregnant woman was diagnosed with cervical cancer. She received five weekly dosages of cisplatin and paclitaxel, starting at 26 5/7 weeks of gestation. An elective cesarean delivery was performed at 34 4/7 weeks of gestation. After birth, the neonate was diagnosed with severe bilateral perceptive hearing loss.

CONCLUSION

Cisplatin during the second and third trimesters of pregnancy may lead to fetal ototoxicity.

Pregnancy during breast cancer: does a mother's parity status modify an offspring's mortality risk?

To assess whether children born to primiparous women around the time of a breast cancer diagnosis have an increased mortality risk. From the merged Swedish Multi-Generation and Cancer Registers, we identified 49,750 eligible children whose mother was diagnosed with breast cancer between 1958 and 2010. Mortality rates in offspring were compared to the background population using standardized mortality ratios (SMR), adjusted for calendar year of birth, attained age, and sex, and calculated for each category of timing of delivery (before, around, or after mother's diagnosis) and mother's parity status. Hazard ratios were assessed using a Cox proportional hazards model and adjusted for socioeconomic status, year of birth and mother's age at birth. Children born to a primiparous woman around a breast cancer diagnosis had a mortality rate five times greater than the background population (SMR 5.26, 95 % CI 1.93-11.5), whereas children born to a multiparous woman had a twofold increase (SMR 2.40, 95 % CI 1.10-4.55). Children of primiparous women born around diagnosis had an adjusted hazard ratio fourfold to that of children of primiparous women born before their mother's diagnosis (HR 4.29, 95 % CI 1.68-8.91), whereas hazard ratios for children of primiparous or multiparous women born at other times were not statistically significant. Children born to primiparous women around a breast cancer diagnosis have an increased relative mortality risk. Although relative risk is increased, in absolute terms children born from a cancer complicated pregnancy do relatively well. Additional investigations are needed to elucidate the reason(s) underlying this observation before the information can be used to inform patient counseling and clinical care.

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.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Laparoscopic Pelvic Lymphadenectomy in 32 Pregnant Patients With Cervical Cancer: Rationale, Description of the Technique, and Outcome

Objective

Individualized treatment of pregnant patients with cervical cancer is mandatory; hence, information on nodal status is pivotal to allow a waiting strategy in early-stage disease.

We aimed to verify the oncological safety and surgical reproducibility of a standardized laparoscopic pelvic lymphadenectomy in pregnant patients with cervical cancer.

Methods

We standardized laparoscopic pelvic lymphadenectomy during the first and second term of gestation in 32 patients with cervical cancer since 1999. According to gestational week (GW) of less than 16 GWs or more than 16 GWs, 2 different techniques were used.

Results

The International Federation of Gynecology and Obstetrics stages were IA in 10 patients, IB1 in 17 patients, IB2 in 4 patients, and IIA in 1 patient. Mean (SD) GW was 17.5 (5.1) weeks. Mean (SD) operative time was 105.4 (29) minutes. Mean (SD) blood loss was 5.3 (10.2) mL. There were no conversion to laparotomy and no intraoperative complications. A median number of 14 pelvic lymph nodes (range, 8–57) were harvested. Median hospital stay was 6 days. Median follow-up is 42.5 months (range, 17–164). Four patients had lymph node metastases. Five patients interrupted their pregnancy. Fourteen patients were given neoadjuvant platin-based systemic therapy. All patients are alive and disease free. All children born through cesarean delivery at a mean (SD) 34 (1.9) GWs are well and show normal clinical neurological development.

Conclusions

To the best of our knowledge, this is the largest series so far reported on laparoscopic pelvic lymphadenectomy during pregnancy. This procedure is safe and associated with good oncological and obstetrical outcomes.

Effects of fetal exposure to maternal chemotherapy

Approximately 1 in 1,000-2,000 pregnancies are complicated by cancer. Today, different treatment options are considered as safe during pregnancy: chemotherapy, radiotherapy, surgery, or a combination of these. Surgery is considered safe during all trimesters of pregnancy; radiotherapy can be administered during the first and the second trimester, and chemotherapy after the first trimester of pregnancy. The placenta, acting as a barrier between the mother and the fetus, plays a key role in the safe administration of chemotherapy during pregnancy. A few studies have investigated the short- as well as the long-term health, general development, and cognitive and cardiac outcomes on children exposed to chemotherapy in utero. In general, these results were reassuring. Nevertheless, better safety data are required. This means data with longer follow-up periods and comparison with appropriate control groups. Moreover, important biasing factors should be taken into account when interpreting these results. Firstly, a great proportion of children were born prematurely due to the maternal condition. Preterm birth in general has been associated with cognitive impairment. Secondly, cancer during pregnancy is clearly a stressful situation, and maternal stress is associated with attention deficits. In sum, we state that chemotherapy can be administered safely after the first trimester of pregnancy. Moreover, iatrogenic prematurity in order to start postpartum administration of chemotherapy should be avoided. Nonetheless, decisions concerning treatment in these specific cases should always be made in a multidisciplinary setting with internationally recognized expertise in the coexistence of cancer and pregnancy.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Cervical cancer in pregnant women: treat, wait or interrupt? Assessment of current clinical guidelines, innovations and controversies

Cervical cancer during pregnancy is relatively uncommon. However, the incidence is expected to increase as more women delay childbearing. When preservation of the pregnancy is desired, optimal treatment is a major challenge to all. Whereas delay of treatment is an option for pre-invasive disease, and also small invasive carcinomas without lymph node involvement, management of tumours >2 cm remains experimental. Type of treatment needs to be individualized and depends mainly on gestational age, disease stage, and histology. Extensive counselling regarding the maternal and foetal risks is required. In this current review, we aim to summarize available data and treatment guidelines concerning cervical cancer in pregnancy. Controversies and research priorities are also identified.

Robotic-assisted surgery for the treatment of pelvic masses in pregnant patients: a series of four cases and literature review

The purpose of this study was to assess the safety and feasibility of robotic-assisted surgery for the treatment of a pelvic mass in gravid patients. We retrospectively reviewed the charts of all pregnant women who were diagnosed with a pelvic mass by individual obstetric physicians and referred to our gynecologic oncology service from January 2009 until March 2012; four patients were identified and treated with robotic-assisted surgery by the same group of gynecologic oncologists. The following patient data were collected: age, disease origin, histology, tumor size, gravid status at surgery, surgical procedure, intra- and postoperative surgical complications, and both maternal and fetal outcomes. The gynecologic lesions comprised an immature teratoma, a mucinous cystadenoma, a hemorrhagic cyst and an ovarian endometrioma; in each case, blood loss was minimal and no maternal or fetal intra-operative complications were encountered. All patients had normal, spontaneous vaginal deliveries at term. Robotic-assisted surgery for the treatment of pelvic masses in pregnant patients is ostensibly feasible and associated with favorable outcomes for both the patient and fetus.