Staging of cervical cancer complicating pregnancy

Palaia et al report a case of a patient with locally advanced cervical carcinoma without lymph node metastasis treated by neoadjuvant chemotherapy during pregnancy followed by cesarean section and radical surgery.

The pretherapeutic tumoral staging of this patient by cervical biopsy and pelvic magnetic resonance imaging as locally advanced stage is insufficient to specify the prognosis and to guide the therapeutics. Indeed, there was no lymph node staging for this patient before the chemotherapy. However, the knowledge of the pelvic lymph node status is a major element of prognosis of cervical cancers.

The lymph node staging could have been carried out by laparoscopic lymphadenectomy during the pregnancy. Indeed, certain teams showed the safety and feasibility of the pelvic laparoscopic lymphadenectomy and its interest to guide therapy during pregnancy. Only surgical staging before treatment gives complete information about tumor extension and status of the pelvic/paraaortic lymph nodes. In the absence of lymph node involvement (as it is the case presented), a radiotherapy could have been proposed to the patient.

It has also been recently shown that radiotherapy during the second and third trimester of pregnancy is relatively harmless when patients are very keen to maintain their pregnancy. The chemotherapy could have been delayed after the fetal extraction and would have probably been better tolerated and thus more effective. Moreover, although trials of neoadjuvant chemotherapy seem promising, we do not have enough distance to conclude about its safety on the fetus in the medium and long term. It will be necessary to follow up this child during several years to conclude about the safety of the chemotherapy on her mental and physical state.

The absence of lymph node involvement would be rather a good prognosis; nevertheless, the lymph node staging after the chemotherapy is not satisfactory because chemotherapy might have sterilized lymph nodes that had been involved.

Finally, the follow-up of this patient is too short (only 10 months) to draw conclusions about the success of the treatment. It would be necessary to have news from this patient in a few years.

References

1. Palaia I, Pernice M, Graziano M, Bellati F, Panici PB. Neoadjuvant chemotherapy plus radical surgery in locally advanced cervical cancer during pregnancy: a case report. Am J Obstet Gynecol. 2007;197:e5–e6.

2. NCCN physician guidelines for cancer care. cervical cancer, practice guidelines in oncology-v.1.2007.

3. Hertel H. Laparoscopic lymph node staging of cervical cancer in the 19th week of pregnancy (A case report). Surg Endosc. 2001;15:324.

4. Stan C, Megevand E, Irion O, Wang C, Bruchim I, Petignat P. Cervical cancer in pregnant women: laparoscopic evaluation before delaying treatment. Eur J Gynaecol Oncol. 2005;26:649–650.