A report of two cases of the management of cervical cancer in pregnancy by cone biopsy and laparoscopic pelvic node dissection
Mr JJO Herod, Department of Gynaecological Oncology, Liverpool Womens’ NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. Email email@example.com
Please cite this paper as: Herod J, Decruze S, Patel R. A report of two cases of the management of cervical cancer in pregnancy by cone biopsy and laparoscopic pelvic node dissection. BJOG 2010;117:1558–1561.
Cervical cancer is the most common malignancy to present in pregnancy. It is diagnosed in one in 2205 pregnancies, and pregnancy complicates one in every 34 cases of cervical cancer.1,2 There is a wide variety of treatment options available dependent upon the stage of the disease, the gestation of the pregnancy and the patient’s wishes. These options range from termination of pregnancy followed by immediate treatment, to delay of treatment until fetal viability is achieved and the baby has been successfully delivered. Since the development of fertility-sparing surgery new options have become available with regard to treatment in pregnancy.
We report the management of two pregnant patients with stage-1a2 and -1b1 cervical cancer. Treatment was by way of cold-knife conisation and laparoscopic pelvic lymphadenectomy in the first trimester of pregnancy. Both women were treated successfully, with the delivery of a healthy term baby and no recurrence of disease to date, with a follow-up after treatment of 28 and 31 months, respectively. We believe this to be the first case report of its kind.
Case report 1
A 23-year-old woman was referred to the colposcopy clinic with a smear showing severe dyskaryosis. She had originally presented to her general practitioner with a 12-month history of post-coital bleeding. A cervical punch biopsy showed grade-3 cervical intraepithelial neoplasia (CIN3), and she was admitted for a loop excision biopsy of the cervix under general anaesthesia. Histology from the specimen measuring 30 × 18 × 9 mm (depth) revealed extensive CIN3 with invasive adenosquamous cell carcinoma. The invasive disease was measured at approximately 7 mm in width, with a depth of invasion of 4 mm. However, invasive disease was considered to focally involve the deep lateral diathermy margin. A preliminary diagnosis of ‘at least’ International Federation of Obstetrics and Gynecology (FIGO) stage-1a2 cervical adenosquamous carcinoma was made.
The patient was referred to a regional gynaecological oncology centre for further management. Although she had two children from two earlier successful pregnancies she stressed during her initial consultation that she was keen to pursue fertility-sparing surgery to allow her to complete her family in the future. An examination under anaesthesia (EUA), cystoscopy and magnetic resonance imaging (MRI) scan was arranged to confirm this was a stage-1a2 cervical cancer. The EUA showed the possibility of a small central cervical tumour, but no evidence of any parametrial involvement and a normal bladder. The MRI scan of the abdomen and pelvis showed no evidence of neoplastic disease. The cervical length on the MRI was not reported, but no cervical tumour was identified.
These findings were discussed with the patient during a review appointment at the oncology clinic. During the consultation the patient informed her consultant that a home pregnancy test she had taken was positive. The serum beta human chorionic gonadotrophin (hCG) level was 748 iu/ml and an ultrasound scan (USS) confirmed a single viable fetus of 5 weeks of gestation. The patient decided that if possible she would want to try and continue with the pregnancy. The gynaecological oncology team decided that, in light of the investigation findings and the patient’s wishes, a cone biopsy and laparoscopic pelvic lymphadenectomy would be performed. The operation was carried out at 9 weeks and 3 days of gestation. A knife cone biopsy was performed measuring 22 × 22 × 18 mm, followed by two further excisions of the anterior and right lateral cervix measuring 20 × 12 × 7 mm and 24 × 9 × 7 mm, respectively. The canal length measured 12 mm in the larger specimen, but it was not possible to measure in the other specimens because of the difficulty in orientating them. Histology from the cone biopsy specimen and the 15 lymph nodes removed from the pelvis were all negative for cervical carcinoma.
The patient had a postoperative USS to confirm fetal viability, and then commenced her antenatal care. During the pregnancy, cervical length was regularly assessed by USS. Following surgery at 10 weeks of gestation, a cervical length of 37 mm was measured. At 27 weeks of gestation the cervical length measured 4–5 cm, implying that the chance of extreme preterm labour was very unlikely, and as such cervical cerclage was unnecessary. The patient requested transfer back to her local obstetric unit for the rest of her antenatal care and delivery. The patient expressed concerns for cervical stenosis during labour, and wished to have multiple vaginal examinations for reassurance. She went into spontaneous labour at 36 weeks and 4 days of gestation, and a healthy baby boy weighing 2580 g was delivered by caesarean section. The patient was seen again 7 weeks after delivery for review; the reason for her caesarean section is unclear. We presume the unfamiliarity of the situation may have led to a caesarean section being performed. The patient has continued to be followed-up at the oncology/colposcopy clinic. The patient remains disease-free 28 months after treatment.
Case report 2
A 32-year-old woman with no past gynaecological or medical history of significance was referred by her GP to her local hospital following an abnormal cervical smear test suggesting severe dyskaryosis. On colposcopic examination a large area of aceto-white staining, consistent with high-grade dysplasia, was identified. This lesion extended into the cervical canal and the upper limit was not visible. Diagnostic punch biopsies were taken, which confirmed at least high-grade cervical glandular intraepithelial neoplasia (CGIN), with the possibility of invasive endocervical adenocarcinoma. The patient was then admitted for a cervical cone biopsy using a loop excision diathermy. Histology from the specimen, which measured 27 mm in horizontal diameter and 15 mm in depth, showed areas of high-grade CGIN and an invasive, moderately differentiated endocervical adenocarcinoma. The carcinoma appeared to be multifocal, with the largest focus within the deep endocervical canal. It was reported that the deep resection margin was likely to be involved by invasive disease. No lymphovascular involvement was observed.
The patient was referred to the regional gynaecological oncology centre and her management was discussed in the weekly multidisciplinary team meeting. A review of the pathology slides confirmed the presence of moderately differentiated adenocarcinoma present in four consecutive blocks, giving a horizontal diameter of 12 mm and depth of 5 mm, with no lymphovascular invasion. A decision was made to perform an examination under anaesthesia and a repeat cone biopsy. On admission for this procedure the patient was found to be pregnant. She had had one previous pregnancy delivering a healthy infant approximately 2 years earlier. An ultrasound scan showed a single viable fetus and dated the pregnancy at approximately 8 weeks and 2 days of gestation. Following discussion with the gynaecological oncology team, and in light of her diagnosis, the patient opted to continue with the surgical treatment agreed.
The procedure was uncomplicated and a cone biopsy measuring 25 × 20 × 31 mm was obtained, with the latter measurement representing the cervical length. Histology showed no residual invasive disease, but indicated focal low-grade and high-grade CGIN, and surrounding decidualised cervical stroma. CGIN was close to, but clear of, the endocervical margin. She was classed as FIGO stage-1b1 cervical adenocarcinoma. Three weeks later at 11 weeks and 1 day of gestation a laparoscopic pelvic lymphadenectomy was performed. A total of 12 lymph nodes were removed: six from each side of the pelvis. Histology showed no evidence of neoplasia.
Routine antenatal care was commenced following treatment. The pregnancy was otherwise uneventful. The cervical length was monitored during the pregnancy by the obstetric team because of the possibility of preterm delivery. The mean length was 43, 41, 35 and 32 mm at 15, 20, 25 and 28 weeks of gestation, respectively. As spontaneous labour did not occur, an induction of labour was commenced at 41 weeks and 1 day of gestation. The induction of labour was not successful and it was decided to deliver the baby by caesarean section. A healthy baby girl was delivered weighing 3480 g. The patient’s postoperative recovery was unremarkable, and so she was discharged 3 days later.
An MRI scan 2 months postpartum confirmed no evidence of neoplastic disease. The patient reported at her next appointment that her family was now complete, and because her concerns about the risk of disease recurrence a decision was made to proceed to a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The surgery took place 4 months postpartum. There was no residual CIN, CGIN or invasive neoplasia in the operation specimen. The patient to date remains disease-free at 31 months from her original excisional procedure.
Fertility-sparing surgery for early-stage cervical carcinoma has become an accepted part of gynaecological oncology practice during the last two decades.3–6 There have been a number of large series reported that demonstrate the efficacy and safety of radical trachelectomy, and confirm that this procedure can deliver a realistic chance of future pregnancy for many women treated for this disease.3,4 Cervical cone biopsy is regarded as standard treatment for stage-1a1 cervical cancer, but some authors have questioned whether this procedure could be used for the treatment of highly selected stage-1a2 and -1b1 tumours that may not require as radical an excision as that offered by trachelectomy.3,7
Shepherd et al.3 reported fertility rates, complications and recurrences in their series of radical vaginal trachelectomy (RVT) performed in non-pregnant women with early-stage cervical cancer. Over a 9-year period, 123 women had RVT and laparoscopic pelvic lymphadenectomy. The mean follow-up period was 45 months (range 1–120 months). Fifty-five pregnancies occurred in 26 of 63 (41.3%) women who attempted to conceive. The 5-year probability of conception was 52.8%. Of the 55 pregnancies, 28 (50.9%) resulted in livebirths in 19 women. Seven of these 28 children (25%) were born before 32 weeks of gestation. Apart from the higher incidence of premature labour, other complications occurred at similar rates to that seen in radical vaginal or abdominal hysterectomy. There were three (2.7%) recurrences in women who did not require completion treatment, and two (18.2%) recurrences in those who did. This study confirmed that RVT is a safe treatment option for non-pregnant women with early-stage cervical cancer, with low recurrence rates and reasonable conception rates.
Naik et al.8 reported an audit/retrospective review of women with small-volume stage-1b1 cervical cancer managed by conservative surgical treatment. They found through careful identification of eligible patients that they were able to conservatively manage women with minimal if any consequences to their fertility. Seventeen women aged 25–67 years were identified with small-volume stage-1b1 cervical carcinoma over a 6-year period. Of these, four women chose to complete their treatment with a loop cone biopsy and pelvic lymphadenectomy in order to retain their fertility. Where the first loop cone biopsy showed incomplete excision, a second loop cone biopsy was performed. Fertility was not an issue in 13 women: 12 of them chose to have treatment with simple hysterectomy and pelvic lymph node dissection, and one woman chose to have treatment with loop cone biopsy alone. Follow-up ranged from 9 to 66 months, with a median of 29 months. No women developed recurrent disease.
The relevance of fertility-sparing surgery for cervical cancer has become increasingly significant as women delay childbearing and present in increasing numbers before they have completed their families. We would expect that there will also be increasing numbers of women who present with a cervical cancer coincident with pregnancy who may also wish to retain their fertility if possible. A number of authors have hence turned their attention to the application of fertility-sparing techniques to cervical cancer treatment during pregnancy.9,10
Although trachelectomy carries a higher rate of premature labour and miscarriage, there is evidence of its successful use in cervical cancer in pregnancy. A study by Ungar et al.11 presented five patients who underwent abdominal radical trachelectomy in pregnancy. The patients were between 7 and 18 weeks of gestation. Following treatment two miscarriages occurred on the first postoperative day, at 7 and 8 weeks of gestation. Another occurred on the 17th postoperative day, with the patient at 15 weeks of gestation. Two patients continued their pregnancy successfully, delivering two healthy singleton babies via caesarean section. A 40-month follow-up programme did not reveal any recurrence of disease.
The first case of vaginal radical trachelectomy during pregnancy was reported by van de Nieuwenhof et al.12 This was performed on a patient with stage-1b1 cervical carcinoma at 18 weeks of gestation. The vaginal approach was used as the authors felt that the risk of fetal loss was reduced because it involved less manipulation of the gravid uterus than an abdominal procedure. Delivery occurred by caesarean section at 35 weeks and 6 days of gestation, and a radical hysterectomy was simultaneously performed. Histology from the operative specimen found no evidence of neoplastic disease. The patient was monitored for 9 months, with no relapse.
In the two cases reported above we were presented with two women diagnosed with early-stage cervical cancer during the first trimester of pregnancy. Following a careful evaluation of their disease we considered that a large cervical cone biopsy together with a laparoscopic pelvic lymphadenectomy would offer them a high chance of cure, whilst limiting any risk to the successful continuation of the pregnancy. This would be the standard treatment for non-pregnant women wishing to retain their fertility with similar early-stage cervical cancer. Both women were advised that if there were any adverse findings at operation suggesting a worse prognosis, then further consideration would have to be given to their management. In these two cases all results from the surgical procedures confirmed our impression that they had early-stage, small-volume disease with a favourable prognosis. No complications occurred in relation to the treatment, and a satisfactory outcome was therefore achieved for both women and their babies.
With the advent of fertility-sparing surgery and a multitude of surgical approaches in the management of early-stage cervical cancer, the opportunity exists to identify and treat selected patients conservatively.13 We believe this to be the first case report of the management of cervical cancer during pregnancy by cone biopsy and laparoscopic pelvic lymphadenectomy. This was an approach to treatment that allowed early intervention with good outcomes for both mother and baby. It would appear that this approach may be suitable for highly selected cases. Given their rarity we would recommend that such cases should be managed in specialised gynaecological cancer centres.
Disclosure of interests
The authors declare that they have no competing interests.
Contribution of authorship
SBD and RP reviewed the case notes and prepared the initial manuscript. JJH revised the manuscript and approved the manuscript as submitted.
Details of ethics approval
Ethics committee approval was not required. Permission was obtained from both patients to allow the publication of their management and outcomes.