Treatment and delivery management of pregnant women with cervical cancer
Cervical cancer associated with pregnancy (CCP) refers to cervical cancer that is discovered during pregnancy, during childbirth, or within 6 months after childbirth. For patients who maintain pregnancy, individualized treatment is performed according to cervical cancer stage, tumor size, gestational age, fetal development, and lymph node metastasis. According to the guidelines for the management of cervical cancer during pregnancy proposed by the International Gynecologic Cancer Society (IGCS) and the European Society of Gynecological Oncology (ESGO), patients are divided into two groups according to the weeks of gestational age.
Treatment of patients with gestational age less than 22-25 weeks
Stage ⅠA1 cervical cancer
Since the patient’s condition changes slowly, the treatment can be delayed. During this period, cytological examination and colposcopy should be taken every 6 to 8 weeks. If no tumor progression is found, the treatment can be postponed till after delivery, but the patient and family members need to be informed.
Stage ⅠA2 and ⅠB1 cervical cancer
Pelvic lymph node dissection (PLND) should be performed first. If there is no lymph node metastasis, a simple cervical resection or a larger cervical conization is feasible. The conization range depends on the size of the tumor. For patients with stage IB1 cervical cancer, tumor diameter larger than 2 cm and less than 22 weeks of gestation, pelvic and abdominal lymph node resection or direct neoadjuvant chemotherapy (NACT) can be performed. If the lymph nodes are positive, it is recommended terminating pregnancy. If lymph nodes are negative or the patient has a strong desire for pregnancy, NACT can be used until after labor.
Stage Ib2 and above cervical cancer
Pelvic lymph node resection should be performed first. If lymph nodes are negative, NACT can be used to maintain the pregnancy. After the lung of the fetus is mature, cesarean section should be applied to end the pregnancy and standardized tumor treatment should be performed.
Treatment of patients with gestational age more than 22-25 weeks
Stage ⅠA2 and ⅠB1 cervical cancer
Ensure close monitoring, check colposcopy every 6 to 8 weeks and magnetic resonance imaging (MRI) every 4 weeks until the fetus matures. Operate radical hysterectomy and pelvic lymphadenectomy at the same time during the cesarean section, or apply surgical treatment after a limited period. When disease progression is found, delivery or NACT should be performed early. Spontaneous preterm birth is more likely to occur after 34 weeks of gestation, so NACT is not recommended after 33 weeks of gestation. Treatment should be applied after careful consideration of the safety of the patient and ethical issues of the fetus.
Stage ⅠB2 and above cervical cancer
The only way to keep the fetus is to maintain pregnancy with NACT. As chemotherapy may cause bone marrow suppression to the mother and baby, leading to increased risks of bleeding and infection during childbirth, patients who are in 22 to 30 weeks of gestation can be performed NACT for 2 to 3 times, and patients over 30 weeks of gestation generally receive NACT once at the utmost. The interval between the last chemotherapy and delivery should be more than 3 weeks. If the disease progresses and deteriorates during pregnancy or requires radiotherapy, the pregnancy should be terminated as soon as possible and apply standardized treatment.
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