Management of cervical cancer during pregnancy

Question 1

A 39-year-old nulligravid woman undergoes cervical conization at 23 weeks of gestation during an otherwise uneventful pregnancy. The procedure reveals an International Federation of Gynecology and obstetrics stage IB1 cervical squamous carcinoma with 7-mm invasion and negative cone margins. The patient desires to preserve the pregnancy if possible. The most appropriate management strategy for this patient is:

(A) repeat cervical conization and cerclage placement
(B) neoadjuvant chemotherapy followed by delivery when fetal maturity is documented (C) external beam pelvic radiation (teletherapy) without vaginal brachytherapy
(D) termination of pregnancy followed by radical hysterectomy
(E) cesarean delivery and radical hysterectomy after documenting fetal lung maturity

Answer 1

(E) cesarean delivery and radical hysterectomy after documenting fetal lung maturity

Question 2

What is the most commonly diagnosed malignancy in pregnancy?

Answer 2

Cervical cancer

Question 3

How should invasive cervical cancer be treated in pregnant women <24w of gestation who do not want to continue their pregnancy?

Answer 3

Stage IB-IIA (IB - macroscopic but confined to the cervix; IIA - extends beyond uterus but not to pelvic wall or lower 1/3 of vagina, NO obvious parametrial involvement): radical hysterectomy, pelvic lymphadenectomy with fetus in situ

Stage IIB-IVA (obvious parametrial involvement and beyond): start with pelvic external beam RT plus chemo –> SAB or hysterectomy –> brachytherapy

Question 4

How should invasive cervical cancer be treated in women >24w gestation OR <24w but desire to continue pregnancy?

Answer 4

Consider neoadjuvant chemo (no evidence of adverse outcomes if cisplatin given in 2nd or 3rd trimesters) –> follow to fetal maturity –> classical C-section –> follow-up treatment depending on clinical stage