Surgical management of invasive carcinoma of the cervix in pregnancy

Radiation therapy during pregnancy

Malignant disease requiring radiation therapy during pregnancy presents an enormous challenge for the clinician. The optimal radiotherapeutic management of the patient and the optimal management of the pregnancy involve directly opposing demands. Ionizing radiation should be avoided during pregnancy whenever possible. Doses in excess of 0.1 Gy (10 rad) delivered during gestation have been associated with various detrimental effects, and therapeutic abortion has been recommended. If radiation is unavoidable, such as in the treatment of some gynecologic tumors, lymphomatous diseases, or other advanced solid tumors, it must be performed with extreme caution and maximal effort to reduce the dose to the fetus by special shielding techniques. Decisions regarding the use of radiation therapy during pregnancy, the delay of therapy, or pregnancy termination should be made by a multidisciplinary team and be guided by the prognosis of the disease, the stage of gestation, the risk to the fetus from the expected fetal radiation dose, and the patient's ethical and religious beliefs.

Invasive cervical cancer complicating pregnancy. How to manage the dilemma

Pregnancy presents an ideal time for cervical cancer screening, and all pregnant women presenting for prenatal care should be carefully examined. Most patients with pregnancy-associated cervical cancer present with early-stage disease. The prognosis for pregnant patients after stratification for stage is similar to that for nonpregnant patients. A management algorithm is presented in Figure 2. Patients with early-stage squamous cancers diagnosed in the late second and early third trimester may have cancer treatment delayed to increase the likelihood of fetal maturity without compromising maternal prognosis. Cesarean section in patients with pregnancy-associated cervical cancer should be the delivery method of choice. Early-stage cervical cancer should initially be treated surgically. In patients with advanced disease, primary radiation therapy is a safe and effective modality. In the first and second trimester, radiation therapy should be performed without hysterotomy.

Invasive cervical cancer in pregnancy

Cervical cancer is the commonest malignancy which complicates pregnancy, but the management remains controversial. We reviewed our patients in an attempt to identify the best management options which resulted in long-term survival for the mother and a live baby. The total number of pregnancies managed between January, 1981 and March, 1995 was obtained from the hospital records, and patients with invasive cervical cancer diagnosed during pregnancy or within 12 months of delivery were identified. The case records were reviewed. Between January, 1981 and March, 1995 there were 22 cases of cervical cancer diagnosed either during pregnancy or within 12 months postpartum. This gave an incidence of cervical cancer associated with pregnancy of 1 in 3,817 pregnancies or 0.26 per 1,000 pregnancies. Eleven patients had microinvasive disease. Nine were treated by cone biopsy and 2 by radical hysterectomy. Nine patients had Stage 1B and 1 had Stage 2A disease and all were treated with radical hysterectomy. One patient had Stage 3B disease and was treated with radiotherapy and chemotherapy followed by simple hysterectomy. Fourteen patients delivered vaginally. Twenty of the 22 patients were delivered of live babies which survived. The patients have been followed from 1 month to 13 years with only 1 recurrence, and all 22 remain alive. We conclude that all pregnant women should have a Pap smear performed antenatally. Cone biopsy can be safely performed in pregnancy and may be adequate treatment for microinvasive squamous cell carcinomas. Treatment, including the timing of delivery, must be individualized, with the patient playing an important decision-making role.

Cervical carcinoma associated with pregnancy

Because of the uncommon synchronous occurrence of pregnancy and invasive cervical carcinoma, this disease entity remains poorly understood. In addition inconsistent reporting has precluded meaningful meta-analysis. About 1 in 2000 pregnancies are associated with cervical cancer and pregnancy is a complication in approximately 3 percent of patients with cervical cancer. There is little evidence to suggest that the pregnancy has an influence on prognosis. Although not firmly established, vaginal delivery may have an adverse effect on outcome. Timing of delivery must be individualized inasmuch as there is a role for delaying treatment in order to achieve fetal lung maturity. Surgery and radiotherapy should be utilized in the same stage-dependent manner as in nonpregnant patients but management should be individualized and undertaken by a multidisciplinary team. These and other issues are discussed more fully in this review.

Surgical issues in the management of carcinoma of the cervix in pregnancy

Incorporating effective screening into preventive health care for women would theoretically eliminate the diagnosis of cervical cancer in pregnancy. Until this goal is reached, our management decisions are limited by the relatively small and retrospective studies that form the basis for our pertinent knowledge and the ethical issues that would complicate randomized trials of treatment in pregnancy. Limited data suggest that radical hysterectomy with pelvic lymphadenectomy might carry a more favorable therapeutic index than radiation therapy in early-stage disease. In general, improvements in neonatal management may allow earlier intervention, shortening the time between diagnosis and treatment in hope of improving maternal outcome. The actual survival impact of this information remains to be demonstrated. An algorithm has been provided in Figure 3 which summarizes the salient features of the clinical management of significantly abnormal cervical cytology in pregnancy. At many institutions the rate of "atypical" or other nonspecified cytologic abnormalities exceeds 10%, and low-grade dysplastic changes are common and less threatening. These conditions place the responsibility for cervical cancer detection firmly upon the clinician and his or her index of suspicion that a significant abnormality exists. Those directing prenatal care must remain compulsive in the proper use of cytologic screening and careful clinical examination. A diagnosis should be rapidly and vigorously pursued when a diagnosis of cancer is suspected, with timely referral when needed. These practices may have the most immediate impact upon both maternal and fetal outcome when facing cervical cancer in pregnancy.

Recurrent cervical carcinoma after radical hysterectomy

The characteristics of recurrent carcinoma following radical hysterectomy and pelvic lymphadenectomy for cervical carcinoma are not well known. Disease recurrence was noted in 27 of 249 patients (11%) with stage IB cervical carcinoma who were treated with a primary surgical approach between January 1962 and December 1984. Fourteen recurrences (52%) occurred within 1 year of surgery, and 24 (89%) within 2 years. Patients with pelvic node metastases or adenocarcinoma had a significantly higher recurrence rate than did patients with negative nodes (33% vs 8%) or with squamous carcinoma (22% vs 8%). Seventeen patients (63%) had disease recurrence in the pelvis or vulva and 12 of these patients had recurrences within 1 year. Eight patients developed asymptomatic pelvic or vulvar recurrences, and all were diagnosed within 1 year. Ten patients (37%) developed recurrences outside the pelvis and 8 of these experienced recurrence after 1 year. Successful treatment after recurrence was independent of clinical or histopathologic parameters except site of recurrence. Eight of 15 patients (53%) who were treated with irradiation for a recurrence in the pelvis or vulva are free of disease 10 to 126 months (median, 48 months) after recurrence. Since irradiation can aid in salvaging patients with recurrent cervical carcinoma confined to the pelvis following radical surgery, clinical vigilance for this site of recurrence is emphasized.

Stage IB cervical carcinoma and pregnancy: report of 49 cases

In a study of 49 cases of Stage IB cervical carcinoma associated with pregnancy, the 5-year survival rate was 69.8%, the incidence of tumor-positive pelvic lymph nodes was 25.0%, and the posttreatment serious complication rate was 22.4%. These were significantly different from parameters generated in our center's overall experience with Stage IB cervical carcinoma (p less than 0.001, p less than 0.05, and p less than 0.001). When associated with pregnancy, the 28.8% serious complication rate in patients receiving radiotherapy was significantly higher (p less than 0.025) than the 6.7% rate observed in patients undergoing radical hysterectomy and lymph node dissection. No effect on 5-year survival was observed regarding time of gestation when diagnosis was made, method of delivery, or treatment modality. A subgroup of patients with diagnosis made in the second or third trimester all underwent cesarean section and appeared to have improved survival when radical hysterectomy and lymph node dissection accompanied this procedure as compared to those patients having postpartum radiotherapy.

Surgical treatment of stages IB and IIA invasive carcinoma of the cervix by radical abdominal hysterectomy

From 1963 to 1977, 349 radical abdominal hysterectomies with bilateral pelvic lymphadenectomy were performed for Stage IB (331 patients) and Stage IIA (18 patients) cervical cancer at the New York Medical College, with no operative deaths. Definitive diagnosis was obtained from the biopsy specimen in 281 patients. Twenty-nine patients were pregnant when the diagnosis was established. The average operating time was 4 hours and 48 minutes with an average blood loss of 900 ml. Eleven fistulas were noted: ureterovaginal, 7; vesicovaginal, 3; rectovaginal, 1. Since 1972, there have been no fistulas in 130 radical hysterectomies. Metastatic carcinoma of the regional lymph nodes was discovered in 27 patients for an incidence of 7.7%. Postoperative total pelvic external irradiation was utilized in 40 patients (27 with positive nodes, 10 with microscopic carcinoma in vascular channels, and an additional three patients with an inadequate vaginal extirpation margin). A total of 62% of those patients with poor prognostic criteria receiving postoperative irradiation are alive and well. Two hundred nineteen patients have been followed up for at least 5 years and the survival rate was 90%. Our data support the view that radical abdominal hysterectomy with bilateral pelvic lymphadenectomy is the treatment of choice for patients with Stages IB and IIA cervical cancer in the nonpregnant state, unless there are major medical contraindications.

The 'problem' radical hysterectomy

This is a study of 243 radical hysterectomy and pelvic lymphadenectomy procedures performed for gynecologic malignancy. The term 'problem' radical hysterectomy was applied to those patients with one of the following conditions: (1) recent cervical conization (within 21 days). (2) previous total or supravaginal hysterectomy, (3) pregnancy, or (4) previous pelvic radiation. There were 88 patients in theses categories. One hundred and fifty-five patients had none of these predisposing problems which might influence operative or postoperative complications. There were two deaths (0.82 per cent). There was no statistically significant difference in operative injuries to the bladder, ureters, or rectum or in the mean operative time and mean blood loss across the categories. However, there was a statistically significant difference across the categories in postoperative complicatons, both major and minor. The greatest incidence of such complications occurred in patients who had previous radiation therapy and the second greatest incidence was in patients who had recent cervical conization. Pregnant patients had the least number of complications.