Download Management of cervical cancer during Pregnancy

Management of gynecological tumours during
Pregnancy
Dr Ban Hadi
F.I.C.O.G. 2015
Objective: our aim from this lecture is to:
1. Get knowledge about the management of common gynecological
tumours in pregnancy
2. Understand the possible effects of these tumours on pregnancy and the
effect of pregnancy on its course
3. Be familiar with common breast diseases
Pregnancy does not alter the course of cancer but may cause a delay in
the diagnosis. Chemotherapy in the first trimester is associated with a
significantly increased risk of fetal abnormalities; treatment in the 2nd and
3rd trimester appears to be safer. Radiotherapy for pelvic, abdominal or
chest malignancies usually carries excessive fetal risk even with
shielding.
Adnexal mass in pregnancy:
Adnexal masses are found in approximately one in 100 pregnancies, the
most common causes are:
1. Functional cyst
2. Mature teratoma (dermoid)
3. Cystadenoma (serous and mucinous)
4. Paraovarian cyst
5. Endometrioma
6. Leiomyoma
7. Malignancy (3-6% of all cases)
Symptoms in pregnancy:
1. Most are asymptomatic and may be discovered accidently with
routine ultrasound in pregnancy or incidentally at caesarean section
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2. 10-15% will cause acute symptoms in form of rupture, torsion,
bleeding and infection; these acute events may increase the risk of
miscarriage and preterm labour.
3. In labour, adnexal mass may cause malpresentation and dystocia.
4. Virilization, if the tumour is hormone secreting
5. Malignant tumours are found in 3-6% of ovarian lesions,
dysgerminomas are the most common ovarian malignancy in pregnancy.
Management of adnexal mass in pregnancy:
1. Small <6 cm unilocular cysts are likely to resolve spontaneously before
16 weeks and should be left alone; a further ultrasound should be
performed at 16 weeks gestation.
2. A persistent complex mass should prompt a laparotomy, miscarriage is
less if intervention occurs in the 2nd trimester
3. A persistent simple cyst without ascites or thick septae within can be
treated conservatively
4. A dermoid cyst can be left but this increases the risk of miscarriage and
cyst accidents.
5. Tumour markers are of limited value in pregnancy because already
they are elevated in normal pregnancy but occasionally a dramatically
elevated maternal serum AFP (MSAFP) level is the presenting sign of a
malignant germ cell tumor
6. Surgery involves lower midline incision, peritoneal washings and
biopsies. Simple cystectomy, if not possible unilateral
salpingooophorectomy can be done, if malignancy detected
chemotherapy can be given after delivery.
7. An ovarian cyst in the first trimester may arise from the corpus luteum
so if we remove it we can give the patient progesterone supplementation
until the second trimester
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Management of ovarian cancer in pregnancy:
Initial surgical management including surgical staging is the same as
for the nonpregnant woman. Fortunately, very few patients have
advanced disease necessitating radical dissection for cytoreduction. The
decision to administer chemotherapy during pregnancy is controversial.
Malignant ovarian germ cell tumors have the propensity to grow rapidly,
and delaying treatment until after delivery is potentially hazardous.
Treatment with BEP (bleomycin, etoposide and cysplatin) appears to be
safe during pregnancy, but fetal complications are possible. For this
reason, some advocate postponing treatment until the puerperium.
Poor prognosis and incompletely resected tumours warrant strong
consideration of chemotherapy during pregnancy.
Management of cervical cancer during Pregnancy:
There is no difference in survival between pregnant and nonpregnant
women with cervical cancer when matched by age, stage, and year of
diagnosis. As with nonpregnant women, clinical stage at diagnosis is the
single most important prognostic factor for cervical cancer during
pregnancy.
Diagnosis
1. A Pap smear is recommended for all pregnant patients at the initial
prenatal visit.
2. Clinically suspicious lesions should be directly biopsied.
3. If Pap test results reveal LSIL then repeat pap smear in each
trimester.
4. If HSIL or suspected malignancy, then colposcopy is performed and
biopsies are obtained.
5. Endocervical curettage is avoided as it may cause miscarriage.
6. If Pap testing indicates malignant cells and colposcopic-directed
biopsy fails to confirm malignancy, then diagnostic conization may
be necessary. Conization is recommended only during the second
trimester and only in patients with inadequate colposcopic findings
and strong cytologic evidence of invasive cancer. Conization is
deferred in the first trimester, as this surgery is associated with
abortion rates of 30% in this part of pregnancy.
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Stage I Cancer in Pregnancy
- Women with microinvasive squamous cell cervical carcinoma
measuring 3 mm or less and no lymph involvement may deliver vaginally
and be re-evaluated 6 weeks postpartum.
- For those with stage IA or IB disease, studies find no increased
maternal risk if treatment is intentionally delayed to optimize fetal
maturity regardless of the trimester in which the cancer was diagnosed.
- A planned treatment delay is generally acceptable for women who are
20 or more weeks' gestational age at diagnosis with stage I disease and
who desire to continue their pregnancy. However, a patient may be able
to delay from earlier gestational ages if she wishes.
Advanced Cervical Cancer in Pregnancy
- Women with advanced cervical cancer diagnosed prior to fetal
viability are offered primary chemoradiation. Spontaneous abortion of the
fetus tends to follow whole-pelvis radiation therapy.
- If cancer is diagnosed after fetal viability is reached (24 weeks) and a
delay until fetal pulmonary maturity is elected, then a classical cesarean
delivery is performed. A classical cesarean incision minimizes the risk of
cutting through tumor in the lower uterine segment, which can cause
serious blood loss. Chemoradiation is administered after uterine
involution (6 weeks postpartum). For patients with advanced disease and
treatment delay, pregnancy may impair prognosis.
Gestational trophoblastic disease:
Subsequent Pregnancy Outcome
Patients may expect a normal reproductive outcome after achieving
remission from gestational trophoblastic disease. Women having a
pregnancy affected by a histologically confirmed complete or partial
mole may be counseled that the risk of a repeat mole in a subsequent
pregnancy is 1 to 2 percent. Pregnancy after combination chemotherapy
for GTN also has a high probability of success and a favorable outcome
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Breast Carcinoma
Breast cancer is the most common malignancy of women of all age
groups. It is also one of the more common malignancies encountered
during pregnancy, as more women choose to delay childbearing until a
later age, the frequency of associated breast cancer likely will increase
According to some studies, women with BRCA1 and BRCA2 breast
cancer gene mutations, as well as those with a family history of breast
cancer, are more likely to develop malignancy during pregnancy than
those without mutations.
There are usually slight delays in clinical assessment, diagnostic
procedures, and treatment of pregnant women with breast tumors.
The delay can partially be attributed to pregnancy-induced breast changes
that obscure breast masses. These changes are even more magnified
during lactation, when there is lobular hyperplasia and galactostasis.
Diagnosis:
The diagnostic approach in pregnant women with a breast tumor should
not differ significantly from that for nonpregnant women. Any suspicious
breast mass found during pregnancy should prompt an aggressive plan to
determine its cause. The "triple test" for a solid breast mass consists of
clinical examination, imaging, and needle biopsy:
1. Sonography is the initial diagnostic study performed.
2. Mammography can be used to evaluate a breast mass. Fetal radiation
risk is negligible with appropriate shielding. Because breast tissue is
denser in pregnancy, mammography is associated with a false-negative
rate of 35 to 40 percent
3. Magnetic resonance (MR) imaging is more sensitive than
mammography
4. Importantly, if a suspicious mass is present and imaging studies are
nondiagnostic, or if there are worrisome clinical features, then biopsy is
indicated, core biopsy is often recommended. Fine-needle aspiration for
cytology can be done; however false negative rate is high.
5. Once malignancy is diagnosed, a chest radiograph and a limited
metastatic search are performed. Although routine computed tomography
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(CT) scans of bone and liver are both sensitive and specific, they are
usually avoided during pregnancy because of excessive radiation.
Magnetic resonance imaging is a reasonable alternative to assess liver
involvement because it is sensitive and has excellent contrast resolution.
Treatment:
- The best clinical approach is by a multidisciplinary team with
obstetricians, surgeons, and medical oncologists. Breast conservation
surgery for small tumors, with or without adjunctive chemo- or
radiotherapy, is preferable in nonpregnant women. Surgical treatment
may be definitive for breast carcinoma during pregnancy. In the absence
of metastatic disease, wide excision, modified radical mastectomy, or
total mastectomy, each with axillary node staging can be performed.
During staging, sentinel lymph node biopsy appears safe to perform in
pregnant women
- Chemotherapy is recommended for node-positive disease if delivery is
not anticipated within several weeks. It is given for advanced disease, and
termination should be considered if pregnancy is early.
Cyclophosphamide, doxorubicin, and 5-fluorouracil are currently
recommended by most clinicians.
- Immunotherapy for breast cancers has become commonplace in the
past decade.
- Adjunctive radiotherapy is not recommended during pregnancy
because abdominal scatter is considerable.
Pregnancy Following Breast Cancer:
Some women are rendered infertile by chemotherapy, for those who can
choose pregnancy, there is little evidence to suggest that pregnancy
adversely affects survival in women who have undergone prior breast
cancer treatment
No data suggest that lactation adversely affects the course of breast
cancer. Successful lactation and breast feeding are possible after
conservative surgery and radiation for breast cancer, even from the
treated side.
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Recommendations for future pregnancies in women successfully treated
for breast malignancy are based on several factors, including
consideration of recurrence risk. It seems reasonable to advise a delay of
2 to 3 years, which is the most critical observation period. Women who
conceive before this time, however, do not appear to have diminished
survival.
Finally, it is reassuring that women who undertake pregnancy after a
diagnosis of breast cancer have birth outcomes comparable with those
without cancer
Benign Gynecological conditions during pregnancy:
Genital prolapse during pregnancy:
Uterine Prolapse
The cervix, and occasionally a portion of the uterine body, may
protrude to a variable extent from the vulva during early pregnancy. With
further growth, the uterus usually rises above the pelvis and may draw the
cervix up with it. If the uterus persists in its prolapsed position, symptoms
of incarceration may develop from 10 to 14 weeks. To prevent this, the
uterus is replaced early in pregnancy and held in position with a suitable
pessary. Successful pregnancy and vaginal deliveries have been reported
following sacrospinous uterosacral fixation done before pregnancy
Cystocele and Rectocele:
Attenuation of fascial support between the vagina and the bladder can
lead to prolapse of the bladder into the vagina, that is, a cystocele.
Urinary stasis with a cystocele predisposes to infection. Pregnancy may
worsen associated urinary stress incontinence .
Attenuation of rectovaginal fascia results in a rectocele. A large defect
may fill with feces that occasionally can be evacuated only manually.
During labor, cystocele and rectocele can block fetal descent unless they
are emptied and pushed out of the way. Surgical repair is usually
postponded until after the puerperium.
Enterocele
In rare instances, an enterocele of considerable size may complicate
pregnancy. If symptomatic, the protrusion should be replaced, and the
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woman kept in a recumbent position. If the mass interferes with delivery,
it should be pushed up or held out of the way
Effects of Myomas on Pregnancy:
These common tumors are associated with a number of obstetrical
complications including miscarriage, preterm labor, placental abruption,
fetal malpresentation, obstructed labor, cesarean delivery, and postpartum
hemorrhage .
The two factors most important in determining morbidity in pregnancy
are myoma size and location. Abortion, placental abruption, preterm
labor, and postpartum hemorrhage all are increased if the placenta is
adjacent to or implanted over a myoma. Tumors in the cervix or lower
uterine segment are particularly troublesome because they may obstruct
labor, unless myomas clearly obstruct the birth canal, or there is another
indication for cesarean delivery, we allow a trial of labor.
Resection of myomas during pregnancy is generally contraindicated. In
some cases, severe pain from infarction and degeneration prompts
surgical treatment. Surgery should be limited to tumors with a discrete
pedicle that can be clamped and easily ligated. Resection of intramural
myomas during pregnancy or at the time of delivery usually stimulates
profuse bleeding and may lead to hysterectomy, so at time of caesarean
section try to avoid the site of fibroid.
Intramural myomectomy in nonpregnant women can be hazardous
for subsequent pregnancy when myoma resection results in a defect into
or immediately adjacent to the endometrial cavity, uterine rupture may
occur remote from labor and sometimes even early in pregnancy.
Prevention depends on cesarean delivery before active labor begins.
Benign tumors of the breast
Fibroadenomas: are the most common benign tumors of the breast
On physical examination, they are firm, smooth, and rubbery. They do
not elicit an inflammatory reaction, are freely mobile, and cause no
dimpling of the skin or nipple retraction
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A suspected fibroadenoma should be confirmed by FNAC
or CNB and observed for increase in size or excised based on patient
preference
Fibrocystic disease of the breast:
Fibrocystic change is not associated with an increased risk of breast
cancer unless there is histologic evidence of epithelial proliferative
changes, with or without atypia
Management of Fibrocystic Change
Fibrocystic change is a normal evolutionary change in breast
development and involution and does not require a specific treatment
other than a good clinical breast examination and age-appropriate
mammographic screening or imaging studies directed to signs and
symptoms.
A number of nutritional and dietary supplements have been investigated
to relieve symptoms. The role of caffeine consumption in the aggravation
of fibrocystic change is controversial, many patients report relief of
symptoms after discontinuing intake of coffee, tea, and chocolate.
Similarly, many women find vitamin E or B6 helpful
A patient with fibrocystic changes should be advised to examine her own
breasts each month just after menstruation and to inform her physician if
a mass appears
Thank you
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