Neoadjuvant chemotherapy followed by radical hysterectomy for invasive cervical cancer diagnosed during pregnancy: report of a case and review of the literature

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.

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.

Treatment and clinical outcomes of cervical cancer during pregnancy

Background

This study aims to investigate clinicopathological factors associated with survival rate and treatment of patients with cervical cancer during pregnancy (CCP).

Methods

A total of 92 patients diagnosed CCP were retrospectively reviewed. One patient was from Nanfang Hospital of Southern Medical University, 5 patients were from Tongji Hospital, and 86 patients were from case reports in the PubMed database from 1961 to 2019. Patients and tumor characteristics were evaluated. Kaplan-Meier and Cox regression methods were used to analyze the 5-year disease-specific survival (DSS).

Results

Most patients (73 cases) were stage I according to the 2018 International Federation of Gynecology and Obstetrics (FIGO) standards. Twelve patients (13.04%) terminated pregnancy once diagnosed. These patients were diagnosed at the mean gestational age (GA) of 11±3 weeks, during early pregnancy. For the rest of the patients (80 cases) who continued pregnancy, the mean GA was 35±2 weeks at delivery. There was a significant difference in survival whether the treatment was performed once diagnosed or not. The 5-year DSS was 75% in adenocarcinoma (AC), 68.5% in squamous cell carcinoma (SCC), and 43.7% in the rare subtype. Among the 38 patients who underwent neoadjuvant chemotherapy (NACT), one patient suffered from spontaneous abortion, and one baby experienced acute myeloid leukemia (AML) ex-FAB (French-American-British)-M7 subtype and received bone marrow transplantation. Other delivered newborns showed no abnormality or malformation. Cox multi-factorial analysis demonstrated that tumor size (2 cm) was an independent overall survival predictor for CCP patients (P<0.05).

Conclusions

Tumor size was an independent prognostic factor of survival in CCP patients. Pregnancy has adverse effects on the prognosis of cervical cancer. Personalized treatment is a priority for CCP patients.

Efficacy of neoadjuvant platinum-based chemotherapy during the second and third trimester of pregnancy in women with cervical cancer: an updated systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of neoadjuvant platinum-based chemotherapy during pregnancy in women with cervical cancer.

METHODS

The PubMed, Embase, and Cochrane Library databases were fully searched to find eligible studies regarding platinum use during pregnancy in women with cervical cancer from January 1980 to September 2018. Data were extracted from the selected studies independently by two authors. Descriptive statistics were calculated for categorical data (frequency and percentage) and numeration data (mean and SD for normally distributed data and median and range for abnormally distributed data). Survival analyses were performed using Kaplan-Meier survival curves and log-rank tests to estimate overall survival and progression-free survival for all patients.

RESULTS

A total of 39 studies including 88 cervical cancer patients with platinum administration during pregnancy were selected in this meta-analysis, and 64 women provided International Federation of Gynecology and Obstetrics stage information. Among the latter, 56 of 64 (87.5%) were diagnosed with early stages (I and IIA) and the remaining 8 of 64 (12.5%) had advanced stages (IIB, III, and IV). In relation to cisplatin, 86 pregnant women were identified, whereas only 2 pregnant women with carboplatin application were retrieved. Overall, 88 newborns were delivered from 84 pregnancies, including two sets of twins and one set of triplets, among which 71 neonates (71 of 88, 80.7%) were completely healthy at birth. All children were healthy at the end of follow-up (median 17 months, range 0-149.5 months), except one who was diagnosed with retroperitoneal embryonal rhabdomyosarcoma at 5 years old and one who had acute myeloid leukemia at 22 months of age. At the end of follow-up (range 4.75-156 months), 16 of 81 (19.8%) patients were diagnosed with recurrence of cervical cancer, and 11 (90%) of those died because of cancer relapse. Neither median overall survival nor median progression-free survival were reached.

CONCLUSION

Our results demonstrated that neoadjuvant platinum-based chemotherapy could be a favorable choice for the management of patients with cervical cancer during the second and third trimesters. To reduce the side effects of chemotherapy, cisplatin might be good to use as monotherapy in these patients.

Management of Locally Advanced Cervical Cancer in Pregnancy: A Case Report

Background

Carcinoma of the cervix is the most common malignancy associated with pregnancy. In the first and second trimesters patients should receive the same treatment as is used in nonpregnant women and termination is advised. In selected cases neoadjuvant chemotherapy (NACT) could be proposed but only a few cases have been reported.

Case

A 27-year-old woman, gravida 1 para 0, at 15 weeks' gestation, was diagnosed with FIGO stage IB2 squamous cervical cancer. After refusing to terminate pregnancy, she was treated with neoadjuvant chemotherapy (cisplatin) starting at 18 weeks. A cesarean section with radical surgery was performed at 32 weeks and a healthy baby delivered. Four weeks later the patient started chemoradiation therapy. She relapsed 1 year after surgery and died when her child was 2 years old.

Conclusion

NACT followed by radical surgery was an unsuccessful treatment in our patient; platinum-based chemotherapy was harmless to the child up to the last follow-up.

Locally Advanced Cervical Cancer in Pregnancy: Overcoming the Challenge. A Case Series and Review of the Literature

OBJECTIVE

Cervical cancer is the most common gynecological cancer occurring in pregnancy, creating a complex situation both for patient and physician. Neoadjuvant chemotherapy is an innovative way of managing cervical cancer in pregnancy.

METHODS

In our paper, we report a retrospective case series of 4 women treated with chemotherapy for invasive cervical cancer during pregnancy in our center over the last 5 years, and we summarize the available literature and guidelines.

RESULTS

All the cases were locally advanced cervical cancers that received chemotherapy with platinum and/or taxanes. All patients showed a good response to chemotherapy and a radical surgery was performed with no additional morbidities at the cesarean delivery time in 3 of 4 cases. Three of 4 patients are alive and have a good outcome with no recurrence of disease up to date. One patient died because of recurrent disease 2 years after the first-line treatment during pregnancy. All babies are alive and well up to date (maximum follow-up, 63 months).

CONCLUSIONS

Even if there are no standardized practices in the treatment of cervical cancer in pregnancy, in our opinion, neoadjuvant chemotherapy can be a very useful strategy for patients and physicians facing the challenge.

Does Chemotherapy for Gynecological Malignancies during Pregnancy Cause Fetal Growth Restriction?

Cancer and pregnancy rarely coincide. Gynecological cancers are among the most common malignancies to occur during pregnancy, and chemotherapy with or without surgery is the primary treatment option. The main concern of administering chemotherapy during pregnancy is congenital malformation, although it can be avoided by delaying treatment until after organogenesis. The dose, frequency, choice of chemotherapeutic agents, time of treatment commencement, and method of administration can be adjusted to obtain the best maternal treatment outcomes while simultaneously minimizing fetal toxicity. Use of chemotherapy after the first trimester, while seemingly safe, can cause fetal growth restriction. However, the exact effect of chemotherapy on such fetal growth restriction has not been fully established; information is scarce owing to the rarity of malignancy occurring during pregnancy, the lack of uniform treatment protocols, different terminologies for defining certain fetal growth abnormalities, the influence of mothers' preferred options, and ethical issues. Herein, we present up-to-date findings from the literature regarding the impact of chemotherapy on fetal growth.

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.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

Cancer treatment in pregnant women

In general, strategies for the treatment of cancer in pregnancy should not differ significantly from the treatment regimens in non-pregnant women. However, this is difficult due to either the effects of anticancer drugs on the developing foetus or the possibility of long-term complications after the exposure to drugs and radiation. The decision about the introduction and continuation of treatment in the event of pregnancy should be preceded by a detailed analysis of the potential benefits and risks. There are no data to suggest that pregnancy termination alters the biological behaviour of the tumour or patient prognosis in the presence of appropriate antineoplastic therapy. All patients should be given appropriate advice and informed that there are insufficient scientific data to determine any generally accepted consensus. It is very important to always respect the will of the patient, and the moral judgment of the physician should have no impact on the decisions taken by the woman. If the woman decides to undergo active treatment and maintain her pregnancy, it is necessary to carry out consultations with experts in the field appropriate to the type of cancer. This paper presents a basic review of the literature on the targeted therapies currently used in selected cancers diagnosed during pregnancy: breast cancer, cervical cancer, Hodgkin's disease, melanoma, thyroid cancer, ovarian cancer, and colorectal cancer.

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.

Neo-adjuvant chemotherapy for cervical cancer in pregnancy: a case report and literature review

Managing women who are pregnant and with a diagnosis of cervical cancer has many complex challenges. This case report describes the diagnosis and management of a patient presenting in her first trimester with stage 2B cervical cancer. In conjunction with this a literature review was undertaken using the following databases from the years 1970-2010: Embase, CINAHL, Medline and DARE. We examined the number of cases reported in the literature in which chemotherapy also was used in pregnant women with a cervical malignancy. Twenty-four papers were retrieved describing in total (including the present case) 35 cases of cervical cancer in pregnancy treated with this modality. Cisplatin therapy would seem the most reliable form of treatment, permitting a good outcome for most patients. The effect of delaying radiotherapy to permit pregnancy to fetal viability in larger tumours cannot be elucidated.

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.

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.

Obstetrical, fetal and postnatal effects of gestational antiblastic chemotherapy: how to counsel cancer patients

At least one in a thousand pregnancies is complicated by cancer and, as the maternal age at pregnancy increases, numbers are growing. If chemotherapy cannot be postponed, both doctors and patients face complex medical and ethical issues. There is a conflict between optimal maternal therapy and fetal wellbeing. Treatment during the first trimester increases the risk of congenital malformations, spontaneous abortions and fetal death. Second and third trimester exposure is less risky, but it can cause intrauterine growth retardation and low birth weight. Other effects on pregnancy after the first trimester include premature birth, stillbirth, impaired functional development, myocardial toxicity and myelosuppression. Counseling and management of these cases are difficult, because literature is mostly represented by case reports or retrospective series while randomized prospective studies or guidelines are lacking. Moreover, personal experience is often scanty due to the rarity of the condition. This article reviews the available data regarding the different aspects of systemic treatment of cancer during pregnancy to help oncologist and obstetricians in counseling their patients and treat them accordingly.

Antiblastic treatment, for solid tumors, during pregnancy: a crucial decision

Cancer is the second leading cause of death during the reproductive years complicating between 0.02 percent and 0.1 percent of pregnancies. The incidence is expected to rise with the increase in age of childbearing. The most common types of pregnancy-associated cancers are: cervical cancer, breast cancer, malignant melanoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma and ovarian cancer. The relatively rare occurrence of pregnancy-associated cancer precludes conducting large, prospective studies to examine diagnostic, management and outcome issues. The treatment of pregnancy-associated cancer is complex since it may be associated with adverse fatal effects. In pregnant patients diagnosed with cancer during the first trimester, treatment with multidrug anti-cancer chemotherapy is associated with an increased risk of congenital malformations, spontaneous abortions or fetal death, and therefore, should follow a strong recommendation for pregnancy termination. Second and third trimester exposure is not associated with teratogenic effect but increases the risk of intrauterine growth retardation and low birth weight. There are no sufficient data regarding the teratogenicity of most cytotoxic drugs. Almost all chemotherapeutic agents were found to be teratogenic in animals and for some drugs only experimental data exist. Moreover, no pharmacokinetic studies have been conducted in pregnant women receiving chemotherapy in order to understand whether pregnant women should be treated with different doses of chemotherapy. This article reviews the available data regarding the different aspects of the treatment of cancer during pregnancy.

Neoadjuvant Chemotherapy Followed by Cesarean Radical Hysterectomy in a Triplet Pregnancy Complicated by Clear Cell Carcinoma of the Cervix: A Case Presentation and Literature Review

Objective

To report a triplet pregnancy complicated by clear cell cervical carcinoma that was managed using neoadjuvant chemotherapy followed by caesarean radical hysterectomy.

Patient History

A 26-year-old woman had a diagnosis of cervical clear cell carcinoma, which was International Federation of Gynecology and Obstetrics stage IB1, at 18 weeks of gestation during a triplet pregnancy. Owing to the patient’s strong desire for full-term pregnancy, 3 cycles of neoadjuvant chemotherapy was administered after magnetic resonance imaging evaluation of the tumor. The patient underwent cesarean delivery and radical hysterectomy at gestational week 32. The hysterectomy specimen revealed stage IB1 clear cell adenocarcinoma of the cervix. The neonates and the mother did not have any complications related to the treatment during 36 months of follow-up.

Conclusion

To the best of our knowledge, this is the first report of a triplet pregnancy complicated by cervical clear cell carcinoma that was successfully treated with neoadjuvant chemotherapy and cesarean radical hysterectomy. Our experience and literature review suggest that neoadjuvant chemotherapy for cervical carcinoma diagnosed during pregnancy is associated with excellent oncologic and fetal outcome; therefore, it may be considered as a temporary fertility-sparing approach in selected patients with a strong desire for full-term pregnancy. Nonetheless, additional research and long-term follow-up are needed to reach a more definitive conclusion.

Gynaecological cancers in pregnancy

Cervical and ovarian cancers are the most common gynaecological cancers diagnosed during pregnancy. In early-stage cervical cancer during the first and at the beginning of the second trimester, the two main considerations for management of the patient are the tumour size (and stage) and nodal staging. MRI and laparoscopic lymphadenectomy are useful for clinicians planning a potentially conservative approach. The management of patients with locally advanced cervical disease is controversial and should be discussed on a case-by-case basis according to the tumour size, radiological findings, the term of pregnancy, and the patient's wishes. Different histological types of malignant ovarian diseases arise during pregnancy and their management depends on the diagnosis (histological subtypes, tumour differentiation, and nodal status), the tumour stage, and the trimester of the pregnancy. In patients with peritoneal spread or high-risk early-stage disease, neoadjuvant chemotherapy with pregnancy preservation could be appropriate.

Gynaecological cancer in pregnancy

Cancer in pregnancy, fortunately, is uncommon. This is even more so for gynaecological cancer. Fertility preservation in gynaecological cancer is already a difficult issue, as the common gynaecological cancers affect organs intimately associated with conception and delivery. The presence of a viable pregnancy with gynaecological cancer presents tremendous challenges to the clinician, especially if the woman wants to conserve both her pregnancy and fertility. In this chapter, we address issues involved in such circumstances and suggest management decisions.

Simple trachelectomy of early invasive cervix carcinoma in the second trimester

Although cervical carcinoma is among the most frequently encountered malignancies during pregnancy only a small number of cases during pregnancy have been reported. Usually, the patients have been treated by radical trachelectomy with or without chemotherapy during the pregnancy. Laparoscopic pelvic lymph node dissection with frozen section, simple trachelectomy and cerclage were performed in the 22(nd) week of pregnancy. The histologic examination confirmed a squamous cell carcinoma of the cervix of 35mm diameter, lymphangioinvasion (L1), low grade, clear surgical margin, negative pelvic lymph nodes according to stage Figo IB. Adjuvant chemotherapy with three cycles of cisplatin was performed after surgery. Delivery was performed by cesarean section followed by radical hysterectomy in the the 32(nd) week of pregnancy. Recurrent adjuvant chemotherapy with three cycles of cisplatin and local vaginal iridium radiation were performed after surgery. Patient had no surgery related complications. No relapse of cancer has been diagnosed during the following 16 months. Simple trachelectomy may be alternative treatment option to radical trachelectomy for pregnant women with early stage cervical cancer without lymph node metastasis.

Addressing concerns about cisplatin application during pregnancy

INTRODUCTION

Cervical cancer in second trimester of pregnancy is an oncologic challenge. Cisplatin is recommended to prevent cancer progression. This is a series correlating in vivo cisplatin concentration in the fetomaternal compartment and in breast milk with child development.

METHODS

Eight consecutive patients with cervical cancer diagnosed during the second trimester underwent conization/biopsy and/or pelvic laparoscopic lymphadenectomy (LAE). Delay of pregnancy in combination with neoadjuvant monochemotherapy was performed. After 2-4 cycles of cisplatin monochemotherapy cesarean section followed by radical hysterectomy was performed above 31 weeks of gestation. Synchronous samples from maternal blood, umbilical cord blood, and amniotic fluid were taken and analyzed. A probe of breast milk was taken from three patients. Pediatric aftercare was done every three months postpartum.

RESULTS

Laparoscopic LAE was uncomplicated in all patients. In seven out of eight patients lymph nodes were tumor free. Nine healthy babies were delivered. Pediatric follow-up showed normal development. Cisplatin concentrations in the umbilical cord and amniotic fluid were 31-65% and 13-42% of the amount in maternal blood, respectively. In breast milk, cisplatin was detectable in 1-10% of maternal blood concentration.

CONCLUSION

Knowledge of significant lower cisplatin concentrations in fetal compartment and normal child growth provides additional security to apply cisplatin in pregnancy. Breastfeeding cannot be recommended.

Locally advanced cervical cancer: what is the standard of care?

PURPOSE OF REVIEW

Carcinoma of the cervix remains a significant health problem for women worldwide. Locally advanced cervical cancer (LACC) is a common presentation that has been extensively studied in the last three decades. This article reviews the standard of care and discusses current topics of clinical research.

RECENT FINDINGS

A multidisciplinary approach to the treatment of cervical cancer has led to marked improvement in outcome. Main advances are with neoadjuvant chemotherapy, chemoradiation, and preventive vaccination. Concurrent chemoradiation with a platinum-based agent is the recommended treatment for LACC. Palliation with platinum agent remains the standard of care for inoperable patients who have metastatic or recurrent disease.

SUMMARY

This is a review of published and ongoing studies testing multidisciplinary and medical management of LACC, with a focus on newer chemotherapeutic approaches. Optimal multidisciplinary treatment planning improves the outcome of each patient diagnosed with cervical cancer.

Neoadjuvant chemotherapy with paclitaxel plus platinum followed by radical surgery in early cervical cancer during pregnancy: three case reports

To date, only seven women with Stage Ib1 to IIb cervical cancer during pregnancy treated with neoadjuvant chemotherapy followed by radical surgery have been reported. We describe three cases of pregnant women with Stage Ib1 to IIa cervical cancer who were treated with paclitaxel plus platinum neoadjuvant chemotherapy followed by radical surgery. The first patient had a Stage Ib1 small cell neuroendocrine carcinoma of the cervix, the second had a Stage IIa, 8 cm squamous cell carcinoma of the cervix and the third had a Stage Ib2 squamous cell carcinoma and positive lymph nodes. The three patients and their newborns were followed up. All patients had a partial or complete response to neoadjuvant chemotherapy. Two of these patients developed recurrences and one died due to progressive disease at 49 months. All neonates were healthy and had no abnormalities. In conclusion, neoadjuvant chemotherapy with paclitaxel and platinum followed by radical surgery may be an option for pregnant women with invasive cervical cancer.

Treatment of the pregnant mother with cancer: a systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part I: Solid tumors

The association of cancer and pregnancy is increasingly encountered nowadays in clinical practice. Due to the relative rarity of the situation, it lacks a systematized approach. Different systemic therapies are used in managing cancer with uncertainty regarding the potential hazards they could pose on the pregnancy and/or the fetus. We have performed a systematic review of literature to identify all reports addressing cancer patients who were exposed to any of the known systemic therapies during the course of the pregnancy. The results were discussed in two parts; part I addresses pregnant patients with solid tumors while part I for those with hematological malignancies. In part I, we identified different solid tumors diagnosed and treated during the course of pregnancy. Breast cancer was the most commonly treated followed by ovarian cancer. Other tumors were treated as well including lung cancer, cervical cancer, sarcoma and melanomas. It is important to acknowledge the intent of therapy (palliative vs. curative) and the patients has to be properly counseled to reach an informed decision. We aim to provide a more robust consensus on how to approach these cases and provide a higher degree of evidence to support the safety of applying certain management strategies over the other.

French recommendations on the management of invasive cervical cancer during pregnancy

BACKGROUND

Cervical cancer is one of the most frequently diagnosed cancers during pregnancy, but the management of such cases remains unclear. A Working Group was set up in 2007 in France to propose national recommendations for the management of pregnant patients with invasive cervical carcinoma.

METHODS

The recommendations are based on this literature review conducted by the members of the Working Group.

RESULTS

Management of cervical cancer during pregnancy depends on 5 factors: stage of the disease (and the tumor size), nodal status, histological subtype of the tumor, term of the pregnancy, and whether the patient wishes to continue her pregnancy. In patients with early-stage disease diagnosed during the first 2 trimesters of pregnancy, there is an increasing tendency to preserve the pregnancy while awaiting fetal maturity in patients with absence of nodal involvement. The delivery (when the fetal maturity is attained) should be then performed using a cesarean section.

CONCLUSIONS

This article proposes recommendations for the management of pregnant patients with invasive cervical cancer. These recommendations have been validated by the 3 main scientific societies of gynecologic oncology, pelvic surgery, and obstetrics and gynecology in France.

Diagnosis and treatment of cervical cancer during pregnancy

CONTEXT AND OBJECTIVE

One third of all cervical carcinomas occur during the reproductive period. Cervical carcinoma is the second greatest cause of death due to cancer during this phase. The estimated frequency of cervical cancer during pregnancy is one case for every 1,000 to 5,000 pregnancies. The aim here was to provide information about the difficulties in diagnosing and managing cervical neoplasia during pregnancy.

MATERIALS

A systematic review of the literature was undertaken through the PubMed, Cochrane, Excerpta Medica (Embase), Literatura Latino Americana e do Caribe em Ciências da Saúde (Lilacs) and Scientific Electronic Library Online (SciELO) databases, using the following words: pregnancy, cervical cancer, diagnosis and management.

RESULTS

There was a consensus in the literature regarding diagnosis of cervical carcinoma and management of preneoplastic lesions during pregnancy. However, for management of invasive carcinoma, there was great divergence regarding the gestational age taken as the limit for observation rather than immediate treatment.

CONCLUSION

All patients with cytological abnormalities should undergo colposcopy, which will indicate and guide biopsy. Conization is reserved for patients with suspected invasion. High-grade lesions should be monitored during pregnancy and reevaluated after delivery. In cases of invasive carcinoma detected up to the 12th week of pregnancy, patient treatment is prioritized. Regarding diagnoses made during the second trimester, fetal pulmonary maturity can be awaited, and the use of chemotherapy to stabilize the disease until the time of delivery appears to be viable.

Radical abdominal trachelectomy in the 19th gestation week in patients with early invasive cervical carcinoma: case study and overview of literature

Treating pregnant patients with a verified malignant disease represents a great clinical problem. Pregnancy-associated invasive cervical cancer is usually diagnosed at an early stage (approximately 70%). A 27-year-old patient was given the diagnosis of a pathohistologically verified cervical carcinoma, International Federation of Gynecology and Obstetrics stage IB1, in the 17th gestational week (GW). A radical abdominal trachelectomy was performed in the 19th GW. The patient was undergoing regular examinations at our institute of oncology while the Clinic of Gynecology and Obstetrics in Novi Sad, Serbia, monitored the pregnancy. In 36th GW, the patient had a cesarean section, with no visible traces of relapse, with good postoperative recovery and normal results in the newborn. The patient was discharged on the fifth postoperative day and advised to have her condition monitored at our institute of oncology. One year after radical trachelectomy, the patient is in the 15th GW of a new pregnancy with a normal Papanicolaou smear result.

Gynecologic cancers in pregnancy: guidelines of an international consensus meeting

BACKGROUND

Gynecologic cancer during pregnancy is a special challenge because cancer or its treatment may affect not only the pregnant women in general but directly involve the reproductive tract and fetus. Currently, there are no guidelines on how to deal with this special coincidence.

METHODS

An international consensus meeting on staging and treatment of gynecological malignancies during pregnancy was organised including a systematic literature search, and interpretation followed by a physical meeting of all participants with intensive discussion. In the absence of large trials and randomized studies, recommendations were based on available literature data and personal experience thus representing a low but best achievable level of evidence.

FINDINGS

Randomized trials and prospective studies on cancer treatment during pregnancy are lacking. Gynecological cancer during pregnancy is a demanding problem, and multidisciplinary expertise should be available. Counseling both parents on the maternal prognosis and fetal risk is needed. When there is a firm desire to continue the pregnancy, gynecological cancer can be treated in selected cases. The staging and treatment should follow the standard approach as much as possible. Guidelines for safe pelvic surgery during pregnancy are presented. Mainly in cervical and ovarian cancer, chemotherapy and an alternative surgical approach need to be considered. Administration of chemotherapy during the second or third trimester may probably not increase the incidence of congenital malformations. Until now, the long-term outcome of children in utero exposed to oncological treatment modalities is poorly documented, but preterm birth on its own is associated with cognitive impairment. Delivery should be postponed preferably until after a gestational age of 35 weeks.

INTERPRETATION

Further research including international registries for gynecologic cancer in pregnancy is urgently needed. The gathering of both available literature and personal experience allowed only suggesting models for treatment of gynecologic cancer in pregnancy.

The use of cisplatin to treat advanced-stage cervical cancer during pregnancy allows fetal development and prevents cancer progression: report of a case and review of the literature

BACKGROUND

Cervical cancer is one of the most frequently encountered malignancies in pregnancy. For early-stage disease arising in late second/third trimester, treatment may be delayed until delivery. However, in advanced disease, data are lacking.

CASE

A 26-year-old woman presented at 21 weeks gestation with a stage IIB high-grade clear cell cervical carcinoma. At 25 + 1 weeks gestation, cisplatin 100 mg/m(2) every 21 days was commenced. One month after cycle 3, a healthy infant was delivered. Thereafter, further cisplatin, intracavity cesium, and chemoradiation were administered. Findings from subsequent clinical examination and magnetic resonance imaging were normal. Fifteen months post treatment, both patient and baby remain well.

CONCLUSION

Neoadjuvant cisplatin chemotherapy can be used in stage IIB cervical carcinoma during pregnancy to allow fetal development and prevent disease progression before delivery.