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Invasive cervical cancer in pregnancy.pdf
- 1. Cervical cancer in pregnancy Dr. Sowjanya Kurakula
- 2. Case presentation • 33-year-old woman G3P1L1A1, HIV positive (on ARV treatment) with 26 weeks gestation • Admitted to in-patient unit with PPROM • Registered pregnancy with few prenatal visits with midwife and underwent laboratory investigations at a community health center • Menstrual cycles - regular 3/28, changed around 4 pads per day, painless. • Hx of one living 8 year old child + 1st trimester spontaneous abortion in the past • She missed the ultrasound appointment at 20 weeks gestation • On triple drug ARV regimen since 4 years (doubtful adherence) • No significant surgical history in the past • No other chronic medical disorders or receiving any chronic medication apart from ARV drugs
- 3. • No drug allergies • Pap smear results 1 year ago reported as CIN-3 • Started on Injectable antibiotics • Patients spontaneously developed labor pains and started draining blood stained liquor • On call doctor had examined the patient (for lack of progress) and found a suspicious cervical growth along with 26weeks uterus palpable per abdomen with absent fetal heart rate • Gynecologist was called for an assessment • Pallor +, thin built, breasts- N, heart and lungs- N, Review of systems- N. No lymphadenopathy. Abd- 26 weeks gravid uterus, contractions +, fetal heart sounds absent. No asictes or organomegaly. • On P/E- 6x8cm oval shaped mass in area of cervix, cervix lips or opening os couldn’t be appreciated, smooth surface, regular borders, mobility restricted, non tender, firm in consistency, bleeds on touch) • Per rectum- cervical mass felt, mild restriction in mobility, no parametrial or uterosacral nodularity noted
- 4. • After imaging confirmed cervical mass with pregnancy, patient was taken up for TAH+BSO due to ongoing blood loss • Patient Hemoglobin dropped from 8g/dl to 5g/dl • Arrangement for referral to a higher facility- anticipated to be 5 hours • Blood transfusion arranged. • TAH+BSO done under spinal anesthesia and a portion of cancerous tissue (2.5cm in largest dia) was left behind- posterior wall of urinary bladder due to dense adherence.
- 5. `
- 7. Following should have been done • Follow up of pap smear report (CINIII) prior to pregnancy • Monitoring ART response- CD4, Viral load • Importance of contraception usage in HIV • Educating nurses at ART clinic and community clinics about cancer cervix presentation during pregnancy. • Pap smear in first trimester/1st Prenatal visit • Biopsy of the mass • Imaging studies with radiologist to know the extent of lesion • Option of early termination of pregnancy • PLND before 22 weeks • Radical surgery + PLND • Chemotherapy + Radiotherapy
- 8. Limitations • Lack of Oncology unit in the facility • Lack of MRI/CT scan at the facility • Limited blood supply from blood bank due to heavy HIV burden population • Prompt referral for emergency cases • Non-availability of HPV DNA testing and vaccine • 400 bed hospital, 1 gynecologist covering- 50,000 population (3rd country with highest HIV positive population)
- 9. Cervical cancer in pregnancy • Cervical cancer is the most commonly diagnosed gynaecological malignancy during pregnancy. • Gold standard treatment is yet to be established due to absence of prospective studies and clinical trials • Incidence rates vary from 1.2 per 10,000 pregnancies La Russa M, Jeyarajah AR. Invasive cervical cancer in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2016;33:44-57. doi:10.1016/j.bpobgyn.2015.10.002 Berek & Novak’s gynecology 16th edition
- 11. • Signs and symptoms – Early stages- asymptomatic, incidental finding on P/E or cytology – Advanced stages-urinary dysfunction, pelvic pain, changes in bowel habit, back pain, swelling of legs • Pelvic examination- speculum and bimanual examination • Triple C – Cervical cytology – Colposcopic biopsy- safe during pregnancy – Cervical biopsy
- 12. Staging • FIGO- common for both pregnant and non- pregnant • MRI • PET-CT SCAN • Chest X-ray Imaging – metastatic disease- immediate TOP
- 14. Pathology • Squamous cell carcinoma – Verrucous – Papillary (transitional) • Adenocarcinoma – Villoglandular papillary adenocarcinoma • Carcinosarcoma • Adenosquamous carcinoma – Glassy cell carcinoma – Adenoid basal – adenocystic • Sarcoma • Malignant melanoma • Neuroendocrine – Small cell – Large cell – Classic carcinoid – Atypical carcinoid
- 16. LSIL
- 17. HSIL
- 18. SCC
- 20. Ideal management- multidisciplinary • Gyn-oncologist • Obstetrician • Neonatologist • Clinical nurse specialists • Pathologist • Radiologist • counsellors
- 21. Treatment of CIN during pregnancy • Patients with cervical histology LSIL (CIN1 grade) in pregnancy can be postponed to 6 weeks postpartum for review • Patients with cervical histology HSIL (CIN2/3 grade) in pregnancy should be reviewed every 12 weeks after excluding invasive cervical cancer, and cervical cytology and colposcopy should be reevaluated until 6 weeks postpartum • If pregnancy or postpartum reexamination indicates that the disease progresses to suspicious invasive cancer, repeated biopsy should be taken. • If highly suspected of cervical invasive cancer, cervical loop electrosurgical excision (LEEP) or cervical cold knife
- 23. Women wishing to go for pregnancy termination • LOW STAGES – <12 weeks- medical TOP – 12-14 weeks- hysterotomy – Stage 1A1- cone biopsy- curative – Stage 1A2 and 1B1 tumors- radical trachelectomy (vaginal/laparoscopic/robotic), radical hysterectomy • HIGH STAGES – 1B2 and beyond- medical TOP or D/E followed by chemo/radiotherapy – After 12-14 weeks- hysterotomy before oncology treatment – Risk of D/E of diseased cervix far outweigh the risk of hysterotomy followed by radiotherapy (adhesions)
- 24. Women who wish to continue pregnancy • First, early-mid trimester- TOP (Counseling) • For >24 weeks gestation – For stage 1A1- cone biopsy – For stage 1A1-1B1- Delay surgical cancer RX till fetal maturity (25-34 weeks) • Early stage tumors- Histological assessment of LN is gold standard serves as guide for management • Early delivery for advanced stage tumors detected in late second or third trimester • NACT during pregnancy – no imaging evidence of metastasis – no LN involvement • Radiation therapy after delivery • Imaging – metastatic disease- immediate TOP
- 25. Role of NACT • Purpose – Reduce tumor size, prevent disease dissemination till fetal viability is achieved • Platinum based cisplatin or in combination- paclitaxel, bleomycin, vincristine, 5-fu, vincristine • Administered once every 3 weeks • Contraindicated in 1st trimester- miscarriage/malformations • Neonatal outcome (if chemo in last trimester)– controversial-lack of long term follow up data • NACT –effective –for microscopic nodal disease
- 26. Role of PLND in pregnancy • Ideal befor 22 weeks of pregnancy • Laparoscopic/robotic • Retroperitoneal LN involvement –poor prognosis- TOP is advised irrespective of fetal viability • If LN are negative for metastatic disease, NACT can be commenced
- 28. Mode of delivery • Cesarean delivery- preferred route – Classical incision/ high transverse incision • Vaginal delivery- risk of tumor dissemination and hemorrhage (tumor recurrence at episiotomy site)
- 29. HPV-HIV-CERVICAL CANCER • There is 2-22 fold increase in cervical cancer in HIV positive women compared to HIV negative women • Low CD4 found to be associated with increased risk of HPV infection • ACOG recommendation- women with HIV should undergo cervical cytology for cancer screening twice in the first year after diagnosis of HIV, then annually, provided the test results are normal Reusser NM, Downing C, Guidry J, Tyring SK. HPV Carcinomas in Immunocompromised Patients. J Clin Med. 2015;4(2):260-281. Published 2015 Jan 29. doi:10.3390/jcm4020260 Chakravarty J, Chourasia A, Thakur M, Singh AK, Sundar S, Agrawal NR. Prevalence of human papillomavirus infection & cervical abnormalities in HIV-positive women in eastern India. Indian J Med Res. 2016;143(1):79-86. doi:10.4103/0971-5916.178614
- 30. Chakravarty J, Chourasia A, Thakur M, Singh AK, Sundar S, Agrawal NR. Prevalence of human papillomavirus infection & cervical abnormalities in HIV-positive women in eastern India. Indian J Med Res. 2016;143(1):79-86. doi:10.4103/0971-5916.178614 • Human immunodeficiency virus (HIV) - positive women have the highest risk for increased incidence and rapid progression of HPV-induced cervical precursor lesions, cervical intraepithelial neoplasia (CIN) and invasive cervical cancer • Prevalence of high-risk HPV is lower (20-40%) among HIV-infected women in countries having low level HIV epidemic as compared to countries with high level epidemic like Africa (45-90%)