CARCINOMA CERVIX AND ITS MANAGEMENT WITH
- 9. Imaging CECT Dose allowed to fetus is 10-15cGY Pavlidis NA. co existence of pregnancy and malignancy. Oncologist.2002;7(4) Dose of 1 ct scan is just 1 cGY, so it canbe done USG/MRI To assess the tumour Size, adjacent organs(parametria/blad der/rectum), LymphNode metastasis Method of choice for staging in pregnant women
- 10. Treatment • precursor lesions Monitor 3-6 mnthly during pregnancy using cytology and colposcopy Re-evaluate 6-8wks after delivery using same methods. Biopsy if suscpicion. Low grade lesions Regress 48-62% Unchanged 29-38% Progression to severe lesions is infrequent during pregnancy (6%) Vlahos G, Rodolakis A. conservative management of CIN 2-3 in pregnancy. Gynecol Obstet Invest.2002;54(2) • – invasive Ca cervix depends on Gestational age at time of diagnosis Stage of disease and size of lesion Pts wish to maintain pregnancy and fertility • Microinvasive Ca cervix (Ia1) Colposcopy every 2 months during pregnancy Re- evaluate at 6wks after delivery with cytology & colposcopy Biopsy if suspicion Simcock B, Shafi M. Invasive cancer of the cervix. Obs, Gynecol, reproductive medicine. 2007;17(6).
- 11. Invasive ca cervix No evidence that pregnancy accelerates disease progression Survival doesn`t depend on trimester at diagnosis Postponing treatment for fetal maturity doesn`t affect recurrence rate (5%) Jacobs IA, Chang CK, Salti GI. Coexistence of pregnancy and cancer. Am Surg.2004;70(11 Traen K, Svane D et al. stage Ib cervical cancer during pregnancy. Eur J Gynaecol Oncol.2006;27(6) Invasive carcinoma Ia2, Ib, Iia diagnosed at < 20wks gestational age Immediate and definite treatment Radical Hysterectomy (fetus in situ)+ B/L Pelvic Lymphadenectomy EBRT which leads to spontaneous abortion or MTP( if reqd) + brachytherapy Complications – vaginal fibrosis, cystitis, enteritis
- 12. • 17. Classical Cesarian section + RH + B/L PLND In Locally advanced cases – Neoadjuvant chemotherapy (cisplatin) followed by surgery Chemotherapy should be avoided in 1st trimester due to fetal malformations In other trimesters it may cause Low birth weight (40%), Prematurity, IUGR, intrauterine death Chemo is avoided after 35 wks as delivery may occur in immunosupressed state If diagnosed between 28- 34 wks – corticosteroids given for fetal lung maturity before definitive t/t Invasive carcinoma Ia2, Ib, IIa > 20wks Cardonick E, Iacobucci A. use of chemotherapy during pregnancy. Lancet Oncol. 2004;5(5).
- 13. • 18. Invasive carcinoma – IIb, III, IV Rare during pregnacy Immediate t/t CT(cisplatin) +RT Adding chemo increases 5yr survival by 12% Van Calsteren K, Vergote I, Amant F. Cervical neoplasia during pregnancy; diagnosis, management and prognosis. Best Pract Res Clin Obstet Gynecol. 2005;19(4)
- 14. • 19. Fertility preservation Oocyte cryopreservation – standard treatment but delays t/t by 6 wks Ovary cryopreservation – upcoming Ovary transposition to areas far from site of RT allows subsequent retreival of oocyte for IVF Covens AL, van der Putten HW, Fyles AW. Laparoscopic ovarian transposition. Eur J Gynecol Oncol.1996;17(3) • 20.
- 15. • Route of delivery Choice is based on type and grade of lesion Vaginal delivery is safe in precursor lesion as it may also lead to regression In Advanced lesions cesarean is preferred • 21. Vaginal delivery Preferred in - Ia1 -CIS -microinvasion <3mm ? Promotes disease progression by lymphovascular dissemination ? Implantation at episotomy site Ceasarian section Preferred in advanced cases as bleeding/laceration/obstructio n of birth canal may occur in vaginal delivery Increase hospital stay Increased risk of neonatal prematurity Increase mortality Increase cost Route of delivery • 22.
- 16. • Prognosis – maternal Diagnosed usually in early stages Better than non pregnant ca cervix -prognosis is Not affected if postponed for fetal lung maturity • Prognosis - fetal Acc. To gestational age and type of t/t Increase neonatal morbidity & mortality may occur due to LBW, IUGR Chemotherapy may cause toxic effect on fetus
- 17. Conclusion • Antenatal checkup provides opportunity for early detection Precursor & microinvasive lesions can be monitored and managed postpartum Invasive lesions • <20wks – immediate and definitive t/t • >20wks – may wait for fetal lung maturity followed by delivery and definitive treatment