EASO2011 PanArab 2 Halaska

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EASO2011 PanArab 2 Halaska

  1. 1. Gynecologic Cancer in Pregnancy. Michael J. Halaska Oncogynecology unit Dept. Of Obstetrics and Gynecology 2 nd Medical Faculty, Charles University in Prague Czech Republic
  2. 2. Epidemiology <ul><li>breast cancer 10-30 / 100 000 pregnancies </li></ul><ul><li>cervical cancer 6-20 / 100 000 pregnancies </li></ul><ul><li>ovarian cancer 2-5 / 100 000 pregnancies </li></ul><ul><li>endometrial cancer case reports </li></ul><ul><li>vulvar cancer case reports </li></ul>Pavlidis, NA, Oncologist, 2002 Rob,L , in textbook Gynaecological Oncology, 2009
  3. 3. Stensheim,H., J Clin Oncol, 2009 Statistical yearbook, Czech Republic, 2005 Epidemiology
  4. 4. Epidemiology
  5. 5. Management <ul><ul><ul><ul><ul><li>First non-viable f. </li></ul></ul></ul></ul></ul><ul><li>based on trimester Second </li></ul><ul><li>Third viable f. </li></ul><ul><li>pregnancy non-preserving </li></ul><ul><li>based on the fertility wish pregnancy preserving </li></ul><ul><li>based on the stage </li></ul>
  6. 6. Pregnancy and treatment modalities 0 40 20 28 12 viable fetus fetus „ready for d.“ 24 34 first trimester second trimester third trimester termination delay till 1st trimestr delay till delivery termination surgery lung maturation neoadjuvant/adjuvant chemotherapy radiotherapy
  7. 7. Pregnancy and treatment modalities 0 40 20 28 12 viable fetus fetus „ready for d.“ 24 34 first trimester second trimester third trimester termination delay till 1st trimestr delay till delivery termination surgery lung maturation neoadjuvant/adjuvant chemotherapy radiotherapy oncogynecologist perinatologist pathologist.. patient and her partner
  8. 8. Cervical cancer during pregnancy
  9. 9. Cervical cancer <ul><li>incidence of invasive cancer 6-20/ 100 000 pregnancies </li></ul><ul><li>incidence of preinvasive disease 2 000-8 000/ 100 000 </li></ul><ul><li>usually diagnosed at early stage </li></ul><ul><li>method of 1st detection </li></ul><ul><ul><li>asymptomatic - cytology 63% </li></ul></ul><ul><ul><li>post-coital bleeding/spotting 20% </li></ul></ul><ul><ul><li>Sood,AK, Gynecol Oncol, 1996 </li></ul></ul><ul><ul><li>Lee,RB, Obstet Gynecol, 1981 </li></ul></ul>
  10. 10. Diagnostics <ul><li>cytology </li></ul><ul><li>colposcopy </li></ul><ul><li>biopsy </li></ul><ul><li>conization </li></ul><ul><li>ultrasound </li></ul><ul><li>MRI </li></ul><ul><li>increased cervical volume </li></ul><ul><li>mucous, vaginal wall </li></ul><ul><li>increased vascularisation </li></ul><ul><li>stromal oedema </li></ul><ul><li>glandular hyperplasia </li></ul><ul><li>eversion </li></ul><ul><ul><li>Robova,H, Eur J Gynecol Oncol, 2005 </li></ul></ul>cervical ca during pregnancy
  11. 11. Diagnostics <ul><li>cytology </li></ul><ul><li>colposcopy </li></ul><ul><li>biopsy </li></ul><ul><li>conization </li></ul><ul><li>ultrasound </li></ul><ul><li>MRI </li></ul><ul><li>colposcopically guided </li></ul><ul><li>same risks as in non-pregnant women </li></ul><ul><ul><li>Michael,CW, Diagn Cytopathol,1997 </li></ul></ul><ul><ul><li>Paraskevaidis,E, Eur J OGRB, 2002 </li></ul></ul><ul><li>risk of bleeding 1-3% </li></ul><ul><ul><li>van Calsteren,K,Best Pract Res Clin OG, 2005 </li></ul></ul><ul><li>at oncogynecologic centers </li></ul><ul><li>vaginal packing for 6 hours </li></ul>cervical ca during pregnancy
  12. 12. Diagnostics <ul><li>cytology </li></ul><ul><li>colposcopy </li></ul><ul><li>biopsy </li></ul><ul><li>conization </li></ul><ul><li>ultrasound </li></ul><ul><li>MRI </li></ul><ul><li>only when microinvasion is suspected </li></ul><ul><li>small risk of abortion when peformed between 12 th and 20 th week of pregnancy </li></ul><ul><ul><li>Robova,H, Eur J Gynecol Oncol, 2005 (1/44) </li></ul></ul><ul><ul><li>Seki,N, Eur J Gynaecol Oncol, 2010 (7/47) </li></ul></ul><ul><ul><li>van Calsteren,K,Best Pract Res Clin OG, 2005 </li></ul></ul><ul><li>ligature of a.uterina descendens </li></ul><ul><li>Terlipressin 4x4ml, 3 minutes </li></ul><ul><li>LLETZ flat cone, vaginal packing for 24 hours, (tocolytics) </li></ul>cervical ca during pregnancy
  13. 13. Diagnostics <ul><li>cytology </li></ul><ul><li>colposcopy </li></ul><ul><li>biopsy </li></ul><ul><li>conization </li></ul><ul><li>ultrasound </li></ul><ul><li>MRI </li></ul><ul><li>safe method </li></ul><ul><li>volumometry </li></ul><ul><li>parametrial involvement </li></ul><ul><li>needs an experienced examinator </li></ul><ul><li>safe after 1 st trimester </li></ul><ul><li>volumometry </li></ul><ul><li>parametrial involvement </li></ul>cervical ca during pregnancy
  14. 14. Management <ul><ul><ul><ul><ul><li>First </li></ul></ul></ul></ul></ul><ul><li>based on trimester Second </li></ul><ul><li>Third </li></ul><ul><li>pregnancy non-preserving </li></ul><ul><li>based on the fertility wish </li></ul><ul><li>pregnancy preserving </li></ul><ul><li>based on the stage </li></ul>cervical ca during pregnancy
  15. 15. Management- pregnancy non-preserving <ul><li>early stages: radical hysterectomy </li></ul><ul><ul><li>with fetus in utero* </li></ul></ul><ul><ul><ul><li>Monk,BJ, Obstet Gynecol, 1992, Sivanesaratnam,V, Gynecol Oncol, 1993 </li></ul></ul></ul><ul><ul><li>after hysterotomy </li></ul></ul><ul><li>advanced stages: chemoradiation </li></ul><ul><ul><li>with fetus in utero </li></ul></ul><ul><ul><ul><li>spontaneous abortion (24-34 days after radiotherapy) </li></ul></ul></ul><ul><ul><ul><li>Prem,KA, Am J Obstet Gynecol, 1966 </li></ul></ul></ul><ul><ul><li>after hysterotomy/abortion* </li></ul></ul><ul><ul><ul><li> Saunders,N, Gynecol Oncol, 1988 </li></ul></ul></ul>cervical ca during pregnancy
  16. 16. Management <ul><ul><ul><ul><ul><li>First non-viable f. </li></ul></ul></ul></ul></ul><ul><li>based on trimester Second </li></ul><ul><li>Third viable f. </li></ul><ul><li>pregnancy non-preserving </li></ul><ul><li>based on the fertility wish pregnancy preserving </li></ul><ul><li>based on the stage </li></ul>cervical ca during pregnancy
  17. 17. Management - pregnancy preserving <ul><li>IA1 </li></ul><ul><ul><li>conization </li></ul></ul><ul><ul><ul><li>Robova,H, Eur J Gynecol Oncol, 2005 </li></ul></ul></ul><ul><li>IA2 </li></ul><ul><ul><li>simple trachelectomy + lymphadenectomy </li></ul></ul><ul><ul><ul><li>Ben Arie,A, Obstet Gynecol, 2004 </li></ul></ul></ul><ul><li>IB1, IB2 </li></ul><ul><ul><li>conization + lymphadenectomy </li></ul></ul><ul><ul><ul><li>Van Calsteren,K, Acta Obstet Gynecol Scand, 2008 </li></ul></ul></ul><ul><ul><ul><li>Marnitz,S, Fertil Sterility, 2009, Herod,JJO, IJOG, 2010, own case </li></ul></ul></ul><ul><ul><li>vaginal radical trachelectomy + lymphadenectomy </li></ul></ul><ul><ul><ul><ul><li>van Nieuwenhof,HP, Int J Gynecol Cancer, 2008 </li></ul></ul></ul></ul><ul><ul><ul><li>Iwami,N, Int J Clin Oncol, 2011 </li></ul></ul></ul><ul><ul><li>abdominal radical trachelectomy + lymphadenectomy </li></ul></ul><ul><ul><ul><li>Ungar,L, Obstet Gynecol, 2006 </li></ul></ul></ul><ul><ul><ul><li>Abu-Rustum,N, Gynecol Oncol, 2009 </li></ul></ul></ul><ul><ul><ul><li>Mandic,A, Am J Obstet Gynecol, 2009 </li></ul></ul></ul>SURGERY – literature cervical ca during pregnancy
  18. 18. Management - pregnancy preserving <ul><li>IB1 ( > 2 cm), IB2 </li></ul><ul><ul><li>postpone surgery/delivery </li></ul></ul><ul><ul><li>regimen: </li></ul></ul><ul><ul><ul><li>carboplatin 6 AUC + paclitaxel 175 mg/m 2 every 3 weeks </li></ul></ul></ul><ul><ul><ul><li>cisplatin 75 mg/m 2 + paclitaxel 175 mg/m 2 every 3 weeks </li></ul></ul></ul><ul><ul><ul><ul><li> Amant,F, Int J Gynecol Cancer, 2009 </li></ul></ul></ul></ul><ul><ul><li>other: cytostatics, interval </li></ul></ul><ul><ul><ul><li>cisplatin 75 mg/m 2 +doxorubicin 35 mg/m 2 every 2 weeks * </li></ul></ul></ul><ul><ul><ul><li>cisplatin 75 mg/m 2 +paclitaxel 175 mg/m 2 every 2 weeks * </li></ul></ul></ul><ul><ul><ul><li>cisplatin 75 mg/m 2 every 10 days </li></ul></ul></ul><ul><ul><ul><li>cisplatin 50 mg/m 2 + vincristine 1 mg/m 2 every 3 weeks </li></ul></ul></ul>NEOADJUVANT CHEMOTHERAPY cervical ca during pregnancy day 0 day 10 day 20 day 30
  19. 19. Management - pregnancy preserving NEOADJUVANT CHEMOTHERAPY - literature cervical ca during pregnancy NED 35 4x PA (2w) IB1 25 Rob,L, unpublished NED 37 3x PT (2w) IB2 27 Rob,L, unpublished DOD 32 3 x P IB2 27 Rabaiotti,E.,2010 NED 37 2x PT (3w) IB2 27 Chun,K, 2010 AWD 34 1x TC IIA 32 Chun,K, 2010 DOD 36 3x PT (3w) IB1 27 Chun,K, 2010 NED 31 6x VP IIA 30 Seamon, 2009 NED 32 3x P IB1 35 Marnitz,S, 2009 NED 35 3x P IIB 26 Boyd, 2009 NED 33 6x P IB2 28 Karam, 2007 NED 33 4x VP IIA 38 Bader, 2007 NED 35 3x P IIB 30 Palaia, 2007 DOD 28 2x P IIIB 30 Benhaim, 2006 NED 38 6x P (3w) IB1 28 Caluwaerts, 2006 DOD 38 2x BP (3w) IIB 26 Marana, 2001 NED 32 4x VP (3w) IB2 36 Tewari, 1998 DOD 34 6x VP (3w) IIA 34 Tewari, 1998 NED 32 3x P (3w) IB1 34 Giacalone, 1996 outcome surgery chemo stage age author
  20. 20. Management - pregnancy preserving <ul><li>IA1, IA2 relatively safe </li></ul><ul><li>IB1 max 12 weeks </li></ul><ul><li>IB2 max 6 weeks </li></ul><ul><li>II and higher max 2 weeks </li></ul><ul><ul><li>van Calsteren,K, Best Pract Res Clin OG, 2005 </li></ul></ul><ul><ul><li>Hunter,MI, Am J Obstet Gynecol, 2008 </li></ul></ul><ul><li>repeated MRI, lung maturation </li></ul>DELAY cervical ca during pregnancy delay (in weeks) follow-up (month) maternal outcome fetal outcome Sorosky,JI, 1995 15, 22, 29,16, 7, 3, 19 33 (13-68) NED 1xpneumothorax Takushi,M, 2002 13, 15, 6 97 (84-108) NED normal Ishioka,Y, 2009 19, 9, 6, 3 64 (10-111) NED normal
  21. 21. Delivery <ul><li>type of delivery </li></ul><ul><ul><li>Caesarean section </li></ul></ul><ul><ul><li>vaginal delivery when no tumour is present </li></ul></ul><ul><ul><ul><li>recurrence in episiotomy scar </li></ul></ul></ul><ul><ul><ul><ul><li>Gordon,AN Obstet Gynecol,1989, Goldman,NA, Gynecol Oncol, 2003 </li></ul></ul></ul></ul><ul><ul><ul><li>recurrence in laparotomic scar </li></ul></ul></ul><ul><ul><ul><ul><li>Tewari,K, Cancer, 1998, Sivanestaratnam,G, Obstet Gynecol, 1993 </li></ul></ul></ul></ul><ul><li>radical surgery combined with delivery </li></ul><ul><ul><li>yes: blood loss, fistula, embolism </li></ul></ul><ul><ul><ul><ul><li>Sivanestaratnam,G, Obstet Gynecol, 1993 </li></ul></ul></ul></ul><ul><ul><li>no: postpone 4-6 weeks </li></ul></ul>cervical ca during pregnancy
  22. 22. Ovarian cancer during pregnancy
  23. 23. Ovarian cancer <ul><li>incidence 4-5 / 100 000 </li></ul><ul><li>2-5 % of pregnancies are complicated by ovarian mass (25 000pt) </li></ul><ul><li>90 % of cases regress spontaneously till 12th week of pregnancy </li></ul><ul><ul><ul><ul><li>Giuntoli,RL, Clin Obstet Gynecol,2006, Berhard,LM, Obstet Gynecol, 1989 </li></ul></ul></ul></ul><ul><li>10 % risk of torsion, rupture, malignancy </li></ul><ul><li>ovarian malignancy is usually diagnosed at early stage(60-80% in stage I) </li></ul><ul><ul><li>ultrasound CA 125, AFP, HCG, CEA </li></ul></ul><ul><li>histopathology: </li></ul><ul><ul><li>50-60% epithelial tumours </li></ul></ul><ul><ul><li>25-40% germ cell tumours </li></ul></ul><ul><ul><li>5-10% sex cord tumours </li></ul></ul><ul><li>difficult peroperative histopathological examination of ovarian masses </li></ul><ul><li>difficult to perform adequate staging </li></ul>
  24. 24. Management <ul><li>IA, G1 / borderline tumours </li></ul><ul><ul><li>adnexectomy, omentectomy, peritoneal washings, bs </li></ul></ul><ul><ul><li>postdelivery restaging </li></ul></ul><ul><li>IA, G2, G3, IB, IC, IIA </li></ul><ul><ul><li>performance of lymphadenectomy (till 20th week of pregnancy) </li></ul></ul><ul><ul><li>postpone lymphadenectomy and radical surgery after the delivery* </li></ul></ul><ul><ul><li>adjuvant chemotherapy </li></ul></ul><ul><li>IIB and higher </li></ul><ul><ul><li>radical surgery + termination of pregnancy </li></ul></ul><ul><ul><ul><li>Tewari,K, Gynecol Oncol, 1997 </li></ul></ul></ul><ul><ul><li>cytoreductive surgery + chemotherapy + surgery during pregnancy </li></ul></ul><ul><ul><ul><li>Machado,F, Gynecol Oncol, 2007 </li></ul></ul></ul><ul><ul><li>cytoreductive surgery + chemotherapy during pregnancy + restaging after the pregnancy* Picone,O, Gynecol Oncol, 2004 </li></ul></ul>ovarian ca during pregnancy
  25. 25. Management <ul><li>NEOADJUVANT / ADJUVANT CHEMOTHERAPY </li></ul><ul><li>Epithelial ovarian tumours </li></ul><ul><ul><li>Paclitaxel 175 mg/m 2 + Carboplatin 6 AUC </li></ul></ul><ul><ul><li>Paclitaxel 175 mg/m 2 + Cisplatin 75 mg/m 2 </li></ul></ul><ul><li>Non-epithelial ovarian tumours </li></ul><ul><ul><li>1 st choice: Paclitaxel + Carboplatin </li></ul></ul><ul><ul><li>2 nd choice: Bleomycin, Etoposide ? , Cisplatine </li></ul></ul><ul><ul><ul><li>Amant,F, Int J Gynecol Cancer, 2009 </li></ul></ul></ul><ul><ul><li>alternative: Cisplatine + Bleomycin </li></ul></ul>ovarian ca during pregnancy
  26. 26. Endometrial cancer during pregnancy
  27. 27. Endometrial cancer <ul><li>endometrial cancer diagnosed during pregnancy or within 6 weeks post partum </li></ul><ul><li>36 case reports (uterus empty) </li></ul><ul><ul><li>20 during I st trimester after spont ab. </li></ul></ul><ul><ul><li>6 during 2 nd and 3 rd trimester </li></ul></ul><ul><ul><li>10 during postpartal period </li></ul></ul><ul><li>paradoxal incidence because of high progesteron levels </li></ul><ul><li>usually well differentiated </li></ul><ul><li>therapy </li></ul><ul><ul><li>non fertility preserving treatment: as in non pregnant women based on the stage </li></ul></ul><ul><ul><li>fertility preserving treatment: progesteron therapy in IA, endometroid, G1, fertility wish </li></ul></ul>
  28. 28. Vulvar cancer during pregnancy
  29. 29. Vulvar cancer <ul><li>32 case reports </li></ul><ul><li>19 % of vulvar carcinoma occure under the age of 40 </li></ul><ul><li>usually HPV positive, smokers, G1 </li></ul><ul><li>therapy: </li></ul><ul><ul><li>no data on delay </li></ul></ul><ul><ul><li>stage I, II </li></ul></ul><ul><ul><ul><li>standard surgical treatment, bleeding </li></ul></ul></ul><ul><ul><ul><li>SLNM – Tc </li></ul></ul></ul><ul><ul><li>stage III (urethra, vagina, anus or involved LN) </li></ul></ul><ul><ul><ul><li>promote termination of pregnancy </li></ul></ul></ul><ul><li>Caesarean section is preferable </li></ul>
  30. 30. <ul><li>prof. Frederic Amant, M.D., Ph.D. </li></ul><ul><li>Belgium, Czech Republic, Netherlands </li></ul><ul><li>now ESGO task force group </li></ul><ul><li>pharmacocinetics of chemotherapy </li></ul><ul><li>during pregnancy </li></ul><ul><li>follow-up of the patient </li></ul><ul><li>follow-up of the child </li></ul><ul><ul><li>18 m onth </li></ul></ul><ul><ul><ul><li>Bayley , echocardiography </li></ul></ul></ul><ul><ul><ul><li>neurologic examination </li></ul></ul></ul><ul><ul><li>6 years </li></ul></ul><ul><ul><ul><li>WISC III , ANT (Amsterdam Neuropsycholog y test ), echo c ardiogra phy , audiometr y , neurologic examination   </li></ul></ul></ul><ul><ul><li>9 /12/15/18 years </li></ul></ul><ul><ul><ul><li>WISC III , TEA – Ch , ANT , Children´s memory scale test , </li></ul></ul></ul><ul><ul><ul><li>AVLT , echo cardiography , audiometr y , neurologic exam. , </li></ul></ul></ul><ul><ul><ul><li>M RI at 9 years </li></ul></ul></ul>www.cancerinpregnancy.org
  31. 31. Conclusions <ul><li>increasing incidency of malignancies during pregnancy </li></ul><ul><li>more data on epidemiology </li></ul><ul><li>more data on treatment possibilities </li></ul><ul><ul><li>surgery, chemotherapy, radiotherapy </li></ul></ul><ul><li>close follow-up of the mother, fetus, child </li></ul><ul><li>specialized centers with dedicated teams and perinatologic unit </li></ul>
  32. 34. <ul><ul><li>Oncogynecology </li></ul></ul><ul><ul><li>Lukas Rob, prof. M.D., Ph.D. </li></ul></ul><ul><ul><li>Michael Halaska, M.D. Ph.D. </li></ul></ul><ul><ul><li>Helena Robova, M.D., Ph.D. </li></ul></ul><ul><ul><li>Marek Pluta, M.D., Ph.D. </li></ul></ul><ul><ul><li>Jiri Skultety,M.D. </li></ul></ul><ul><ul><li>Perinatology </li></ul></ul><ul><ul><li>Radek Vlk, M.D. </li></ul></ul><ul><ul><li>Matej Komar, M.D. </li></ul></ul><ul><ul><li>Oncology </li></ul></ul><ul><ul><li>Hana Stankusova, M.D., Ph.D. </li></ul></ul><ul><ul><li>Cardiology </li></ul></ul><ul><ul><li>Viktor Tomek, M.D. </li></ul></ul><ul><ul><li>Radiodiagnostics </li></ul></ul><ul><ul><li>Jiri Lisy, M.D. </li></ul></ul><ul><ul><li>Neurology </li></ul></ul><ul><ul><li>Jitka Zackova </li></ul></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Alena Puchmajerova, M.D. </li></ul></ul>
  33. 35. <ul><li>[email_address] </li></ul><ul><li>www.halaska.eu </li></ul>www.cancerinpregnancy.org
  34. 36. Case - trachelectomy + LAP <ul><li>35 years old women, GIII, PIII </li></ul><ul><li>6 th week of preg. – punch b.: CIS </li></ul><ul><li>13 th week of preg. – conization </li></ul><ul><ul><li>SCC – invasion into the border of margin (8 mm deep), G3, IB1 </li></ul></ul><ul><ul><li>extreme fertility wish </li></ul></ul><ul><li>Next step </li></ul><ul><ul><li>termination of pregnancy </li></ul></ul><ul><ul><li>follow-up and delay of the treatment </li></ul></ul><ul><ul><li>surgery a) laparotomic radical trachelectomy </li></ul></ul><ul><ul><li>b) laparoscopic/robotic laparotomy </li></ul></ul><ul><ul><li>c) laparoscopic lymphadenectomy + vaginal trachelectomy </li></ul></ul><ul><ul><li>neoadjuvant chemotherapy + delay of the surgery till delivery </li></ul></ul>
  35. 37. Case - trachelectomy + LAP <ul><li>16 th week of preg.: laparotomic lymphadenectomy </li></ul><ul><li>+ simple trachelectomy + cerclage </li></ul><ul><li>36 th week of preg. - Caesarean section + </li></ul><ul><li>hysterectomy, 2380g, male </li></ul><ul><li>histopathology: no residual disease </li></ul><ul><li>follow-up: 24 month postpartum - NED </li></ul>
  36. 38. Case - NAC <ul><li>21 years old women, GI, P1 </li></ul><ul><li>every 6 month LSIL/LGL </li></ul><ul><li>12 th week of preg: LSIL, LGL </li></ul><ul><li>28 th week of preg – atypical v., punch biopsy – SCC, G2 </li></ul><ul><li>US biometry – pregnancy corresponding to 26 th week of pregnancy </li></ul><ul><li>MRI: IB1 – invasion 23 x 10 mm, more than half of the stroma </li></ul><ul><li>Next step </li></ul><ul><ul><li>termination of pregnancy (preterm delivery) </li></ul></ul><ul><ul><li>follow-up and delay of the treatment </li></ul></ul><ul><ul><li>surgery </li></ul></ul><ul><ul><li>neoadjuvant chemotherapy + delay of the surgery till delivery </li></ul></ul>cervical ca during pregancy
  37. 39. Case - NAC <ul><li>3x NAC – paclitaxel 175 mg/m 2 </li></ul><ul><li>+ cisplatine 75 mg/m 2 every 2w </li></ul><ul><li>37 th week of preg: Caesarean section </li></ul><ul><li>+ radical hysterectomy </li></ul><ul><ul><li>female, 3200g, 10, 10, 10 </li></ul></ul><ul><ul><li>histopathology: 5 mm invasion </li></ul></ul><ul><li>follow-up: 8 month NED, child developing normally </li></ul>cervical ca during pregancy
  38. 40. Case - NAC Before 1st chemotherapy (29+0) Before 2nd chemotherapy (31+0) Before 3rd chemotherapy (33+0) After radical hysterectomy cervical ca during pregancy
  39. 41. Case - delay <ul><li>33 years old women, X/VI </li></ul><ul><li>history of smoking </li></ul><ul><li>21st week of preg: cytology ca </li></ul><ul><li>24th week of preg: conization </li></ul><ul><li>SCC, G2, IB1 – invasion 11 x 6 mm </li></ul><ul><li>Next step: </li></ul><ul><ul><li>immediate termination + surgery </li></ul></ul><ul><ul><li>neoadjuvant chemotherapy </li></ul></ul><ul><ul><li>delay of the treatment till delivery </li></ul></ul>cervical ca during pregancy
  40. 42. Case - delay <ul><li>33 years old women, X/VI </li></ul><ul><li>history of smoking </li></ul><ul><li>21 st week of preg: cytology ca </li></ul><ul><li>24 th week of preg: conization </li></ul><ul><li>SCC, G2, IB1 – invasion 11 x 6 mm </li></ul><ul><li>wish of termination of pregnancy </li></ul><ul><li>30 th week of preg: lung maturation </li></ul><ul><li>30 th week of preg: </li></ul><ul><li>Caesarean section + </li></ul><ul><li>radical hysterectomy </li></ul><ul><li>male, 1400g, 5, 7, 7 </li></ul>cervical ca during pregancy

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