Int. J. Gynecol. Obstet., 1990.31: 317-323 International Federation of Gynecology and Obstetrics
317
Carcinoma of the cervix and pregnancy J. Baltzer, M.E. Regenbrecht,
W. Kopcke and J. Zander
First Department of Obstetrics and Gynecology. University of Munich, Maistrasse II, 8OtXIMunchen 2 and Institute for Medical Information Processing, Stat&tics and Biomathematics, University of Munich, Munich (FRG) (Received December 4th,, 1988) (Revised and accepted 7th February, 1989)
Abstract A simultaneous occurrence of carcinoma of the cervix and pregnancy is uncommon. In a cooperative study a total of 1092 patients treated for cervical cancer were examined. Forty of these women were either pregnant at the time of surgery or were operated on postpartum. The course of the disease for these patients was compared to that of 426 non-pregnant women with cervical cancer. The analysis of tumor grading and tumor growth revealed no remarkable differences. Remarkable, however, was the increased frequency of blood vessel invasion observed in pregnant patients, particularly in puerperal patients. Also the percentage of macrometastases was higher in puerperal and/or postpartum patients. These Jindings might explain the worse prognosis for these women. Keywords: Carcinoma; Cervix; Pregnancy. Introduction The simultaneous occurrence of carcinoma of the cervix and pregnancy is uncommon. Nonetheless, carcinoma of the cervix is the malignant process most frequently associated with pregnancy [8,14,16,18,28]. Kistner et al. [12] described 106 cases of these combined conditions prior to 1957; Kinch [ 1l] reported 0020-7292/90/so3.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
105 cases 4 years later. In 1982, Hacker et al. [6] compiled 1657 such cases from the literature. Based on more recent publications, Shingleton and Orr [21] analyzed 804 patients with carcinoma of the cervix during pregnancy. As a result of efforts toward early detection, a decrease in the absolute incidence of invasive cervical cancer in pregnancy has been described [4,19]. To date, none of the previously cited publications explicitly describes the influence of cervical cancer on the development of the fetus, and the following questions remain the subject of controversy: (1) does pregnancy influence the prognosis of cervical cancer? and (2) to what extent does the treatment of carcinoma affect the fetus? The present study deals with the first question only, via an analysis of observations in 40 patients who were operated on for cervical carcinoma, stage Ib, during pregnancy or postpartum. Patients and methods A cooperative study was conducted at the gynecologic departments of four universities. A total of 1092 patients treated for cervical cancer were examined [3]. Forty of these women were either pregnant [16] at the time of surgery or were operated on postpartum
PI. The course of the disease for these 40 Clinical and Clinical Research
3 18
Baker et al.
patients with cervical cancer and pregnancy was compared to that of 426 non-pregnant women with cervical cancer. Because the oldest pregnant patient was 43 years of age, this age was selected as the upper limit of the age in the non-pregnant controls; the ratio of the controls to pregnant patients was approximately 1O:l. Ten patients were 12 weeks, another ten 27 weeks, and four 36 weeks pregnant, respectively, at the time of their treatment. The 16 postpartum patients had delivered 5 weeks previously, on average. Eight of the 40 pregnant patients (20070)and 11.5% of the non-pregnant patients were free of symptoms. The most frequent reported symptom was bleeding in 55% and 55.6% of the cases and controls, respectively. All patients were treated by an extended abdominal hysterectomy with lymphadenectomy (Mackenrodt-Latzko-Meigs operation) as described by Ober and Meinrenken [ 171. In the case of young patients, the ovaries were preserved. If required, postoperative irradiation therapy was given as Supervolttherapy (40-60 GY at the pelvic wall). Respectively, 41.7% of the non-pregnant and 55% of the pregnant and/or postpartum
patients were irradiated (P = 0.001). All data on the subsequent disease course after initial treatment were derived from carefully documented follow-up. The histologic examination of the surgical specimens was performed according to a standardized method [3] on all but three patients. Results No significant differences were found between the tumor location in pregnant/ postpartum women compared to controls (Fig. 1, left). However, tumor localization differed somewhat for pregnant women and postpartum women (Fig. 1, right). Exo-endophytic tumor growth was somewhat more common in pregnant/postpartum patients than in non-pregnant patients (Fig. 2, left), but this trend was lost when pregnant patients were compared to postpartum women. Dissociated tumor growth (enclosed tumor formation versus a more diffuse spread) was not significantly different between the individual groups of patients (Fig. 3, left and right). Similarly, examination of the tumor center and invasion front
(p-0.765) ENDOCERVIX
EXT. 06
WRTK)
Fig. 1. Tumor localization in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. NO significant differences were found in pregnant/postpartum women compared to controls,
Int J Gynecol Obstet 31
Carcinoma of the cervix andpregnancy ,lOO%
KINPREGNANT PAT. n-366
PREGNANT POST PART PAT. n-37
loo%p$GNANT n=21
3 19
POST PART. PAT n -16
Exe- endophytio Tumor growth in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum Fig. 2. distinguishing between exo-, endo- and exo-endophytic carcinomas. There is no difference between the groups of patients.
revealed no differences between the two groups of patients (Fig. 4, left and right). Blood vessel invasion tended to occur more frequently in pregnant patients, particularly in puerperal patients (Fig. 5, left and right). However, the observed differences were not
100%
statistically significant. Although a higher frequency of lymphatic macrometastases was observed among pregnant/postpartum patients, these differences were not significant (Fig. 6). No statistically significant differences in
PREGNANT POST PART PAT !F PREGNANT n=37
n.386
n=21
n-16
50%
(p - 0.683)
cl
ABSENT
Fig. 3. Degree of dissociated tumor growth in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum distinguishing between no, scarce or extensive tumor dissociation. No statistic difference could be shown. Clinical and Clinical Research
320
Baker et al. 100% NWSION
TUMOR CENTRE
FRONT
(p-0.992)
(p-0252) DIFFERENTIATED
cl
NON PREGNANT PAT. W3W
EB m
PAT. (n-37)
Tumor grading in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. NO Fig. 4. difference in the two groups.
survival rates were observed between the two treated groups. Nonetheless, the prognosis was certainly less favorable for puerperal patients than for non-pregnant patients (Fig. 7), and the prognosis for pregnant patients was best of all. m96
bK$PREGNANT n-386
PREGNANT POST PART. PAT. n-37
Discussion
The simultaneous occurrence of carcinoma of the cervix and pregnancy is rare but not unknown. Most practicing clinicians may expect to see one -case. However, the smah
ET? n-21
PAFR n-16
(P’ 0.804)
cl
ASSENT
Fig. 5.
TUMORNWSKIN INTO LYMPH VESSELS
TLMOFtBLOOOVESSELS
MT0
Tumor invasion in blood and lymph vessels in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. There is a tendency to tumor invasion in blood and lymph vessels in patients with cervical cancer during pregnancy and postpartum, however, the differences were not statistically significant.
Int J Gynecol Obstet 31
Carcinoma of the cervtk and pregnancy
loo% WPREGNANT
1
cl
n-386
PREGNANT POST PART. PAT n-37
Kx)s6 !??TFNT n-21
RT
32 1
pART. n=l6
M-TA
NO META.
TUM. CELLEMBOU
•l
MMXOMETA.
Morphology of lymph node metastases in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. There is a higher frequency of macrometastases among pregnant/postpartum patients. This difference was not significant.
Fig. 6.
total number of patients in the aggregate advises caution when speaking of the course and prognosis of the disease. It is striking that one-fifth of our patients were free of symptoms. The percentage of asymptomatic patients with cervical cancer during pregnancy, as reported in the literature, ranges from 3% [5] to 36.1% [13]. Despite this fact, bleeding occurs in 26.7% [14] to 87% [22] of the cases. However, this bleeding was often misinterpreted as being brought about by pregnancy [1,15].
The cytologic smear taken at the beginning of pregnancy is of great significance. If the Papanicolaou smear reveals an abnormal finding, a colposcopic biopsy is recommended. According to Shingleton and Orr [21], in cases of non-invasion, a cytological smear should be repeated after 6-8 weeks (Fig. 8). In the case of questionable invasion, conization is recommended. However, conization during pregnancy may bring about
. --------------POSTPARTPATh.161
Fig. 1. Survival rates of operated non-pregnant and/or pregnant and postpartum patients with cervical cancer.
Fig. 8. Diagnostic procedure in case of suspicious findings in the cytological smear of the cervix during pregnancy. Clinical and Clinical Research
322
Baltzer et al.
additional complications, mainly bleeding and premature delivery [2,7,10,20]. Microcarcinoma and invasive carcinoma require stage-dependent treatment. If carcinoma has been confirmed histologically, factors such as stage of the disease, trimester of the pregnancy, parity, and, last but not least, the patient’s attitude toward pregnancy must be considered when deciding the . treatment of choice. According to Shingleton and Orr [21], the survival rate of pregnant patients with cervical cancer correlates with the stage of the disease and not with the trimester of the pregnancy (Table I). However, unfavorable survival rates were more commonly observed in postpartum patients. The type of delivery does not influence survival rates [21]. Even though theoretically, one would expect vaginal delivery to spread the tumor, no worse survival rates have been observed following spontaneous delivery. The survival rate of patients with stage I carcinoma was 80.5% after abdominal delivery, and 7 1.5% after vaginal delivery. Taking all stages together, the survival rate for patients after abdominal delivery was 46.1070, after vaginal delivery 52.9%. Moreover, the survival rate of pregnant patients is independent of stage-dependent treatment. Following operative treatment, the 5-year survival rate was 89%, after radiation 87%, and after combined operative and radiation treatment 82% [21]. In young
patients, surgery may preclude castration. Furthermore, possible damage to the child by primary irradiation can be prevented by surgical treatment. It is difficult to assess the influence of pregnancy on the prognosis of cervical cancer. Evaluation of our identically treated patients shows similar survival rates for pregnant/ postpartum patients and non-pregnant patients (Fig.7). Our observations are in general agreement with the survival rates of pregnant and non-pregnant patients studied by Creasman et al. [5] (Fig. 9). The analysis of tumor grading and tumor growth revealed no remarkable differences. Noteworthy, however, was the increased frequency of blood vessel invasion observed in pregnant patients, particularly in puerperal patients. Also, the proportion of macrometastases was higher in puerperal and/or postpartum patients. These findings might explain the worse prognosis for these women. Conclusion The rarity of the simultaneous occurrence of cervical cancer and pregnancy makes it difficult to recommend universal guidelines for its treatment. Judging from the latest literature and our own treatment results, it becomes evident that in the case of an operable carcinoma, surgery is the preferable mode of treatment. In the first and the early second
Table 1. Survival rates of pregnant patients with cervical cancer in relation to the stage of the disease and the length of pregnancy.
Stage
Trimester
Survival rate Vo
I
1 2 3 Postpartum
84
89 II II
1 2 3 Postpartum
52 61 45.4 41
II
Int J Gynecol Obstet 31
m
--L-c-
P 50L
40
I
0
,
2
r
1
I
4
I
6
!
I1
I
8
10
YEARS
Fig. 9.
Survival rates of non-pregnant and/or pregnant patients with cervical cancer in clinical stages I and II.
Carcinoma of the cervix andpregnancy
trimester of pregnancy, extended abdominal hysterectomy with lymphadenectomy is the recommended procedure. In the third trimester, assuming a viable child, cesarean section is performed, followed by extended abdominal hysterectomy with lymphadenectomy. The situation is more difficult in the late second trimester when the fetus is still incapable of independent survival. Under these circumstances, it is possible to wait until the fetus is viable or proceed without delay with cesarean section, followed by extended hysterectomy with lymphadenectomy. It is generally agreed that postpartum patients should undergo extended hysterectomy with lymphadenectomy. In patients with advanced inoperable carcinoma, primary irradiation therapy is advised after evacuation of the uterus. The results of our study, as well as the evaluation of results reported in the literature, show that pregnancy has no influence on the prognosis of patients with carcinoma of the cervix. However, timing and type of therapy may have a crucial influence on the fate of the fetus.
7
8
9 10 11
12 13 14
15 16 17
18 19 20
References Allen HA, Nisker JA: In: Cancer in Pregnancy - Therapeutic Guidelines (ed HA Allen, JA Nisker). Futura, Mount Kisco, NY, 1986. Averette HE, Nasser N, Yankow SL, Little WA: Cervical conization in pregnancy. Am J Obstet Gynecol 106: 543, 1970. Baltzer J, Kopcke W, Lohe KJ, Kaufmann C, Ober KG, Zander J: Die operative Behandlung des Zervixkarzinoms. Geburtsh Frauenheilk 44: 279,1984. Boutselis RJ: Intraepithelial carcinoma of the cervix associated with pregnancy. Obstet Gynecol40: 657, 1972. Creasman WT, Rutledge F, Fletcher 0: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol36: 495, 1970, Hacker NF, Berek JS, Lagasse LD, Savage CH, Moore JG: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol59: 735,1982.
21 22 23
323
Hannigan EV, Whitehouse HH, Atkinson WD, Becker St.N: Cone biopsy during pregnancy. Obstet Gynecol 60: 450,1982. Hesseltine HC, Loth MF: Malignant diseases associated with pregnancy. West J Surg Obstet Gynecol 64: 529, 1956. Hittmair A: Zervixkarzinom und Schwangerschaft. Geburtsh Frauenheilk 27: 513, 1967. Horowitz A, Sabatelle R, Sail S: The risk of cone biopsy during pregnancy. J Reprod Med 3: 265,1969. Kinch RAH: Factors affecting the prognosis of cancer of the cervix in pregnancy. Am J Obstet Gynecol 82: 45, 1961. Kistner RW, Gorbach RC, Smith GV: Cervical cancer in pregnancy. Obstet Gynecol9: 554, 1957. Lee RB, Neglia W, Park RC: Cervical carcinoma in pregnancy. Obstet Gynecol58: 584, 1981. Lutz MH, Underwood PB, Rozier JC, Putney FW: Genital malignancy in pregnancy. Am J Obstet Gynecol 129: 536,1977. Van Nagell JP, Barber HRK (eds): Modern Concepts of Gynecologic Oncology. Boston, Bristol, London, 1982. Nieminen V, Remes N: Malignancy during pregnancy. Acta Obstet Gynecol Stand 49: 315, 1970. Ober KG, Meinrenken H: Gynakologische Operation. In: Allgemeine und spezielle chirurgische Operationslehre (eds N Guleke, R Zenker). Springer, Berlin, Heidelberg, New York, 1964. Phelan JT: Cancer in pregnancy. New York State J Med 68: 3011, 1968. Sachs H, Espinola-Baez M: Graviditat und Zervixkarzinom. Fortschr Med 93: 169,1975. Schweppe KW, Beller FK: Schwangerschaft und maligne gynakologische Tumoren Erkrankungen wahrend der Schwangerschaft (eds GH Kyank, FK Beller) 4 Aufl. Thieme, Stuttgart, 1983. Shingleton HM, Orr JW Jr: Cancer of the Cervix. Churchill Livingstone, Edinburgh, 1983. Stander RW, Lein JN: Carcinoma of the cervix and pregnancy. Am J Obstet Gynecol79: 164, 1960. Verhagen A: Tumor und Graviditat. Springer, Berlin, Heidelberg, New York, 1974.
Address for reprints:
J. Baftzer Frauenklinik Stadt Krankenanstnlten Lutherplatz 40 4150 Krefeld, FRG
Clinical and Clinical Research
317
Carcinoma of the cervix and pregnancy J. Baltzer, M.E. Regenbrecht,
W. Kopcke and J. Zander
First Department of Obstetrics and Gynecology. University of Munich, Maistrasse II, 8OtXIMunchen 2 and Institute for Medical Information Processing, Stat&tics and Biomathematics, University of Munich, Munich (FRG) (Received December 4th,, 1988) (Revised and accepted 7th February, 1989)
Abstract A simultaneous occurrence of carcinoma of the cervix and pregnancy is uncommon. In a cooperative study a total of 1092 patients treated for cervical cancer were examined. Forty of these women were either pregnant at the time of surgery or were operated on postpartum. The course of the disease for these patients was compared to that of 426 non-pregnant women with cervical cancer. The analysis of tumor grading and tumor growth revealed no remarkable differences. Remarkable, however, was the increased frequency of blood vessel invasion observed in pregnant patients, particularly in puerperal patients. Also the percentage of macrometastases was higher in puerperal and/or postpartum patients. These Jindings might explain the worse prognosis for these women. Keywords: Carcinoma; Cervix; Pregnancy. Introduction The simultaneous occurrence of carcinoma of the cervix and pregnancy is uncommon. Nonetheless, carcinoma of the cervix is the malignant process most frequently associated with pregnancy [8,14,16,18,28]. Kistner et al. [12] described 106 cases of these combined conditions prior to 1957; Kinch [ 1l] reported 0020-7292/90/so3.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
105 cases 4 years later. In 1982, Hacker et al. [6] compiled 1657 such cases from the literature. Based on more recent publications, Shingleton and Orr [21] analyzed 804 patients with carcinoma of the cervix during pregnancy. As a result of efforts toward early detection, a decrease in the absolute incidence of invasive cervical cancer in pregnancy has been described [4,19]. To date, none of the previously cited publications explicitly describes the influence of cervical cancer on the development of the fetus, and the following questions remain the subject of controversy: (1) does pregnancy influence the prognosis of cervical cancer? and (2) to what extent does the treatment of carcinoma affect the fetus? The present study deals with the first question only, via an analysis of observations in 40 patients who were operated on for cervical carcinoma, stage Ib, during pregnancy or postpartum. Patients and methods A cooperative study was conducted at the gynecologic departments of four universities. A total of 1092 patients treated for cervical cancer were examined [3]. Forty of these women were either pregnant [16] at the time of surgery or were operated on postpartum
PI. The course of the disease for these 40 Clinical and Clinical Research
3 18
Baker et al.
patients with cervical cancer and pregnancy was compared to that of 426 non-pregnant women with cervical cancer. Because the oldest pregnant patient was 43 years of age, this age was selected as the upper limit of the age in the non-pregnant controls; the ratio of the controls to pregnant patients was approximately 1O:l. Ten patients were 12 weeks, another ten 27 weeks, and four 36 weeks pregnant, respectively, at the time of their treatment. The 16 postpartum patients had delivered 5 weeks previously, on average. Eight of the 40 pregnant patients (20070)and 11.5% of the non-pregnant patients were free of symptoms. The most frequent reported symptom was bleeding in 55% and 55.6% of the cases and controls, respectively. All patients were treated by an extended abdominal hysterectomy with lymphadenectomy (Mackenrodt-Latzko-Meigs operation) as described by Ober and Meinrenken [ 171. In the case of young patients, the ovaries were preserved. If required, postoperative irradiation therapy was given as Supervolttherapy (40-60 GY at the pelvic wall). Respectively, 41.7% of the non-pregnant and 55% of the pregnant and/or postpartum
patients were irradiated (P = 0.001). All data on the subsequent disease course after initial treatment were derived from carefully documented follow-up. The histologic examination of the surgical specimens was performed according to a standardized method [3] on all but three patients. Results No significant differences were found between the tumor location in pregnant/ postpartum women compared to controls (Fig. 1, left). However, tumor localization differed somewhat for pregnant women and postpartum women (Fig. 1, right). Exo-endophytic tumor growth was somewhat more common in pregnant/postpartum patients than in non-pregnant patients (Fig. 2, left), but this trend was lost when pregnant patients were compared to postpartum women. Dissociated tumor growth (enclosed tumor formation versus a more diffuse spread) was not significantly different between the individual groups of patients (Fig. 3, left and right). Similarly, examination of the tumor center and invasion front
(p-0.765) ENDOCERVIX
EXT. 06
WRTK)
Fig. 1. Tumor localization in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. NO significant differences were found in pregnant/postpartum women compared to controls,
Int J Gynecol Obstet 31
Carcinoma of the cervix andpregnancy ,lOO%
KINPREGNANT PAT. n-366
PREGNANT POST PART PAT. n-37
loo%p$GNANT n=21
3 19
POST PART. PAT n -16
Exe- endophytio Tumor growth in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum Fig. 2. distinguishing between exo-, endo- and exo-endophytic carcinomas. There is no difference between the groups of patients.
revealed no differences between the two groups of patients (Fig. 4, left and right). Blood vessel invasion tended to occur more frequently in pregnant patients, particularly in puerperal patients (Fig. 5, left and right). However, the observed differences were not
100%
statistically significant. Although a higher frequency of lymphatic macrometastases was observed among pregnant/postpartum patients, these differences were not significant (Fig. 6). No statistically significant differences in
PREGNANT POST PART PAT !F PREGNANT n=37
n.386
n=21
n-16
50%
(p - 0.683)
cl
ABSENT
Fig. 3. Degree of dissociated tumor growth in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum distinguishing between no, scarce or extensive tumor dissociation. No statistic difference could be shown. Clinical and Clinical Research
320
Baker et al. 100% NWSION
TUMOR CENTRE
FRONT
(p-0.992)
(p-0252) DIFFERENTIATED
cl
NON PREGNANT PAT. W3W
EB m
PAT. (n-37)
Tumor grading in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. NO Fig. 4. difference in the two groups.
survival rates were observed between the two treated groups. Nonetheless, the prognosis was certainly less favorable for puerperal patients than for non-pregnant patients (Fig. 7), and the prognosis for pregnant patients was best of all. m96
bK$PREGNANT n-386
PREGNANT POST PART. PAT. n-37
Discussion
The simultaneous occurrence of carcinoma of the cervix and pregnancy is rare but not unknown. Most practicing clinicians may expect to see one -case. However, the smah
ET? n-21
PAFR n-16
(P’ 0.804)
cl
ASSENT
Fig. 5.
TUMORNWSKIN INTO LYMPH VESSELS
TLMOFtBLOOOVESSELS
MT0
Tumor invasion in blood and lymph vessels in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. There is a tendency to tumor invasion in blood and lymph vessels in patients with cervical cancer during pregnancy and postpartum, however, the differences were not statistically significant.
Int J Gynecol Obstet 31
Carcinoma of the cervtk and pregnancy
loo% WPREGNANT
1
cl
n-386
PREGNANT POST PART. PAT n-37
Kx)s6 !??TFNT n-21
RT
32 1
pART. n=l6
M-TA
NO META.
TUM. CELLEMBOU
•l
MMXOMETA.
Morphology of lymph node metastases in non-pregnant patients and in patients with cervical cancer during pregnancy and postpartum. There is a higher frequency of macrometastases among pregnant/postpartum patients. This difference was not significant.
Fig. 6.
total number of patients in the aggregate advises caution when speaking of the course and prognosis of the disease. It is striking that one-fifth of our patients were free of symptoms. The percentage of asymptomatic patients with cervical cancer during pregnancy, as reported in the literature, ranges from 3% [5] to 36.1% [13]. Despite this fact, bleeding occurs in 26.7% [14] to 87% [22] of the cases. However, this bleeding was often misinterpreted as being brought about by pregnancy [1,15].
The cytologic smear taken at the beginning of pregnancy is of great significance. If the Papanicolaou smear reveals an abnormal finding, a colposcopic biopsy is recommended. According to Shingleton and Orr [21], in cases of non-invasion, a cytological smear should be repeated after 6-8 weeks (Fig. 8). In the case of questionable invasion, conization is recommended. However, conization during pregnancy may bring about
. --------------POSTPARTPATh.161
Fig. 1. Survival rates of operated non-pregnant and/or pregnant and postpartum patients with cervical cancer.
Fig. 8. Diagnostic procedure in case of suspicious findings in the cytological smear of the cervix during pregnancy. Clinical and Clinical Research
322
Baltzer et al.
additional complications, mainly bleeding and premature delivery [2,7,10,20]. Microcarcinoma and invasive carcinoma require stage-dependent treatment. If carcinoma has been confirmed histologically, factors such as stage of the disease, trimester of the pregnancy, parity, and, last but not least, the patient’s attitude toward pregnancy must be considered when deciding the . treatment of choice. According to Shingleton and Orr [21], the survival rate of pregnant patients with cervical cancer correlates with the stage of the disease and not with the trimester of the pregnancy (Table I). However, unfavorable survival rates were more commonly observed in postpartum patients. The type of delivery does not influence survival rates [21]. Even though theoretically, one would expect vaginal delivery to spread the tumor, no worse survival rates have been observed following spontaneous delivery. The survival rate of patients with stage I carcinoma was 80.5% after abdominal delivery, and 7 1.5% after vaginal delivery. Taking all stages together, the survival rate for patients after abdominal delivery was 46.1070, after vaginal delivery 52.9%. Moreover, the survival rate of pregnant patients is independent of stage-dependent treatment. Following operative treatment, the 5-year survival rate was 89%, after radiation 87%, and after combined operative and radiation treatment 82% [21]. In young
patients, surgery may preclude castration. Furthermore, possible damage to the child by primary irradiation can be prevented by surgical treatment. It is difficult to assess the influence of pregnancy on the prognosis of cervical cancer. Evaluation of our identically treated patients shows similar survival rates for pregnant/ postpartum patients and non-pregnant patients (Fig.7). Our observations are in general agreement with the survival rates of pregnant and non-pregnant patients studied by Creasman et al. [5] (Fig. 9). The analysis of tumor grading and tumor growth revealed no remarkable differences. Noteworthy, however, was the increased frequency of blood vessel invasion observed in pregnant patients, particularly in puerperal patients. Also, the proportion of macrometastases was higher in puerperal and/or postpartum patients. These findings might explain the worse prognosis for these women. Conclusion The rarity of the simultaneous occurrence of cervical cancer and pregnancy makes it difficult to recommend universal guidelines for its treatment. Judging from the latest literature and our own treatment results, it becomes evident that in the case of an operable carcinoma, surgery is the preferable mode of treatment. In the first and the early second
Table 1. Survival rates of pregnant patients with cervical cancer in relation to the stage of the disease and the length of pregnancy.
Stage
Trimester
Survival rate Vo
I
1 2 3 Postpartum
84
89 II II
1 2 3 Postpartum
52 61 45.4 41
II
Int J Gynecol Obstet 31
m
--L-c-
P 50L
40
I
0
,
2
r
1
I
4
I
6
!
I1
I
8
10
YEARS
Fig. 9.
Survival rates of non-pregnant and/or pregnant patients with cervical cancer in clinical stages I and II.
Carcinoma of the cervix andpregnancy
trimester of pregnancy, extended abdominal hysterectomy with lymphadenectomy is the recommended procedure. In the third trimester, assuming a viable child, cesarean section is performed, followed by extended abdominal hysterectomy with lymphadenectomy. The situation is more difficult in the late second trimester when the fetus is still incapable of independent survival. Under these circumstances, it is possible to wait until the fetus is viable or proceed without delay with cesarean section, followed by extended hysterectomy with lymphadenectomy. It is generally agreed that postpartum patients should undergo extended hysterectomy with lymphadenectomy. In patients with advanced inoperable carcinoma, primary irradiation therapy is advised after evacuation of the uterus. The results of our study, as well as the evaluation of results reported in the literature, show that pregnancy has no influence on the prognosis of patients with carcinoma of the cervix. However, timing and type of therapy may have a crucial influence on the fate of the fetus.
7
8
9 10 11
12 13 14
15 16 17
18 19 20
References Allen HA, Nisker JA: In: Cancer in Pregnancy - Therapeutic Guidelines (ed HA Allen, JA Nisker). Futura, Mount Kisco, NY, 1986. Averette HE, Nasser N, Yankow SL, Little WA: Cervical conization in pregnancy. Am J Obstet Gynecol 106: 543, 1970. Baltzer J, Kopcke W, Lohe KJ, Kaufmann C, Ober KG, Zander J: Die operative Behandlung des Zervixkarzinoms. Geburtsh Frauenheilk 44: 279,1984. Boutselis RJ: Intraepithelial carcinoma of the cervix associated with pregnancy. Obstet Gynecol40: 657, 1972. Creasman WT, Rutledge F, Fletcher 0: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol36: 495, 1970, Hacker NF, Berek JS, Lagasse LD, Savage CH, Moore JG: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol59: 735,1982.
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