Genital cancers and pregnancy Assoc. Prof. Gazi YILDIRIM.
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Transcript of Genital cancers and pregnancy Assoc. Prof. Gazi YILDIRIM.
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Genital cancers and pregnancy
Assoc. Prof. Gazi YILDIRIM
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Incidence by Age of the More Common Malignancies Seen in
Pregnancy
American Cancer Society, Facts and Figures, 1995
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Incidence of Tumor Types in
Pregnant Women
Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group.Ann Oncol. 2010 May;21 Suppl 5:v266-73.
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Cancer in pregnancy
• The incidence of cancer in pregnancy is approx 1 in 1000.
• The most common malignancy diagnosed during pregnancy is cervical cancer. (1 in 750)
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Cancer in pregnancy
• Cervical cancer (26 %)
• Breast cancer (26 %)
• Leukemias (15 %)
• Lymphomas (10 %)
• Malignant melanomas (8%)
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Cervical Cancer in Pregnancy
• Work-up• MRI of pelvis/abdomen• Chest X-ray• Carcinoembryonic Antigen (CEA)• CBC, BUN, Creatine, LFT’s
• Advanced disease• Urine cytology/ cystoscopy• Stool for occult blood/ sigmoidoscopy
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Cervical Cancer in
Pregnancy: Treatment by
Stage• Stage IA1 - <3mm invasion; < 7mm wide
• 1.2% positive nodes• Cone biopsy: no further treatment necessary • Vaginal delivery at term• Simple hysterectomy post-partum or Cesarian
hysterectomy at term
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Cervical Cancer in
Pregnancy: Treatment by
Stage• Stage IA2 (3-5mm invasion, no vascular inv.):
• 6.3% positive nodes
• Stage IB – Disease confined to cervix
• Stage IIA – vaginal extension• Vaginal delivery: increased risk of hemorrhage and
cervical laceration• Depends on desire for pregnancy
• First trimester: delay of up to 28 weeks – degree of risk unknown
• Radical hyst. and pelvic LND at diagnosis• “Radical” cone biopsy/ trachelectomy/ cerclage and
extraperitoneal pelvic and aortic LND at 16-18 weeks• C-Section and Radical hyst. and pelvic LND when mature
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Cervical Cancer in
Pregnancy: Treatment by
Stage• Stage IA2, IB, IIA
• Second trimester: delay of up to 22 weeks• Depends on desire for pregnancy
• Can probably safely wait until maturity
• Third trimester: delay of up to 10 weeks• C-section, Radical hysterectomy and pelvic
Lymph node dissection at maturity
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Cervical Cancer in Pregnancy:
Treatment by Stage• Stage IB (bulky) or Stages IIb-IV
• First trimester – delay of up to 28 weeks• Depends on desire for pregnancy
• Unwanted • Whole pelvic radiation therapy/ chemotherapy• If SAB occurs before XRT is finished – proceed with
cesium insertions (about 35 days)• Occasionally will need hysterotomy and pelvic LND
if no SAB and then cesium insertions; or a “small” radical hyst. & pelvic LND if small residual cervical disease
• Wanted• Consider chemotherapy until maturity at 34 weeks
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Cervical Cancer in
Pregnancy: Treatment by
Stage• Stage IB (bulky) or Stages IIb-IV
• Second trimester – delay of up to 22 weeks• Unwanted: pregnancy – Radiation therapy as above
• Spontaneous abortion at 35 days
• Wanted: pregnancy – consider chemotherapy until maturity
• Third trimester – delay of up to 10 weeks• C-Section at maturity/ staging lap; transpose ovaries• Start radiation therapy 2 weeks postpartum• Consider chemotherapy until maturity
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Ovarian masses
• Incidental finding in pregnancy is common (1-4%)
• Majority are functional or CL cysts and spontaneously resolve by 16 weeks gestation
• Unilateral
• Noncomplex 90% functional
• Less than 5 cm resolve spontaneously
• Noticed in 1st trim
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Ovarian masses
• Three main reasons for advising surgery for an adnexal mass in pregnancy are;
• Risk of rupture
• Risk of torsion
• Risk of malignancy
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Torsion of adnexa
• The most common time for occurrence is between 6 and 14 weeks and in the immediate puerperium.
• Commonly associated with a cystic neoplasm
• Symptoms are usually sudden onset abdominal pain and tenderness
• Right ovary is involved more frequently than left ovary
• Benign cystic teratomas and cystadenomas are most common..
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Ovarian Masses in Pregancy
• Overall incidence• 1:500 pregnancies• Increased incidence secondary to sonography
• Incidence of true neoplasms• 1:1,000 pregancies
• Incidence of ovarian cancer• 1:10,000 – 1:25,000 pregancies
• Unexpected adnexal mass at C-Section• 1:700 pregnancies
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Ovarian Masses in
Pregnancy Frequency by
Type• Non-neoplastic – 33%• Corpus luteum cyst• Follicular cyst
• Neoplastic – Benign – 63%• Dermoid (36%)• Serous cystadenoma (17%)• Mucinous cystadenoma (8%)• Others (2%)
• Neoplastic – Malignant – 5%• Low malignant potential (3%)• Adenocarcinoma (1%)• Germ cell / Stromal tumor (1%)
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Management of Ovarian
Masses in Pregnancy• Generalizations• Symptoms• Ultrasound/ MRI appearance• Size• Gestational age• Tumor markers
• B-HCG, AFP, CA-125 all increased in pregnancy• CA-125 should be normal after 1st trimester
• Fear of missing cancer or development of complications• Corpus luteum resolves by 14th week• Ovarian cysts “benign” by Ultrasound or MRI, < 6 cm,
that do not change over time, do not require surgery• Cysts greater than 6-8 cm or inc. in size: “usually”
operated on• Cysts which persist after 18th week are “usually”
operated on
• Usually operate at 18 weeks to minimize fetal loss
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Complications of Ovarian
Masses in Pregnancy: 10%
Total• Severe pain: 25%
• Obstruction of labor: 15% – C-Section
• Torsion: 10% of cases• Sudden pain, Nausea & Vomiting etc.• Most common at:
• 8-16 week – rapid uterine growth (60%)• Postpartum – involution (40%)
• Hemorrhage: 10% of cases• Ruptured corpus luteum• Germ cell tumor
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Complications of Ovarian Masses in
Pregnancy• Rupture/ tumor dissemination (10%)
• Anemia
• Malpresentations
• Necrosis
• Infection
• Ascites
• Masculinization of female fetus• Hilar cell tumor• Luteoma of pregnancy • Sertoli-Leydig cell tumor
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Work-up of Ovarian Cancer
• Pelvic ultrasound
• MRI pelvis/ abdomen
• Chest X-ray
• CA-125: elevated in normal pregnancy, should normalize after 12 weeks
• AFP, B-HCG, LDH – predominantly solid mass
• Liver FunctionTests, BUN, Creatinine
• GI studies only if clinically indicated
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Management of Ovarian Cancer
• Prognosis not affected by pregnancy
• Tumors of Low Malignant Potential – all stages (20%)
• Adenocarcinoma Stage I, grade 1 or 2 (10%)
• Germ cell tumors (5%) – may require chemotherapy
• Gonadal stromal tumors (15%)
• Surgery at 16-18 weeks if possible
• Frozen section: beware of inaccuracies
• Conservative ovarian surgery• Adnexectomy/ Oophorectomy/ Cystectomy
• Hysterectomy not indicated
• Thorough staging:• Pelvic/ aortic node disection/ Omentectomy/ peritoneal biopsies
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Management of Ovarian Cancer
• Epithelial Ovarian Cancer Stage IC – IV• Try to delay chemotherapy until 12-16 weeks of
pregnancy• Try to delay removal of corpus luteum until 14
weeks• First trimester
• TAB followed by appropriate surgery and chemotherapy• Chemotherapy after FNA:
• C-Section and appropriate management at maturity
• Second and Third Trimester• Chemotherapy first
• C-Section and appropriate surgical management at maturity
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Malignant Germ Cell Tumors
• Dysgerminoma• 30% of Ovarian malignant neoplasms in
pregnancy• Most stage IA• Average 25cm; solid• Therapy
• Surgery: USO, wedge biopsy of opposite ovary, surgically stage• 25% are bilateral
• Stage IA & IB: No further treatment• Advance stages
• Hysterectomy not required• Chemotherapy
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Malignant Germ Cell Tumors
• Endodermal sinus tumor
• Grade 2-3 malignant teratoma
• Choriocarcinoma (non-gestational)
• USO and staging for early disease
• All require chemotherapy regardless of stage
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Tumor like Ovarian
Lesions Associated with
Pregnancy• All resolve spontaneously after delivery
• Conservative surgical approach: frozen section +/- oophorectomy• Luteoma of pregnancy - usually an incident. finding at C-
Section• Microscopic. -20cm – multiple nodules• Bilateral: 1/3 of cases• 25% have increased. testosterone• Maternal masculinization. – later ½ of pregnancy• Fetal virilization – 70% of female infants
• Hyperreactio Luteinalis - Bilateral multicystic theca lutein cysts• Large solitary luteinized follicular cyst of pregnancy• Hilar Cell Hyperplasia – masculinized fetus• Intrafollicular Granulosa cell proliferations• Ectopic Decidua
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Breast Cancer in
Pregnancy
(2nd most common cancer in
pregnancy)• 20% of cases are in women <40 years old
• 1-2% of cases are pregnant at time of diagnosis
• One case/1500-3000 pregnancies
• Often difficult to diagnose
• Low dose mammogram with appropriate shielding of fetus is “safe”
• MRI – probably best
• Diagnosis often delayed
• Increase incidence of positive nodes (80%)
• Termination of pregnancy & proph. castration is not beneficial
• No adverse effects on prognosis from subsequent pregnancies
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Treatment of Breast Cancer
• Treatment same as non-pregnant
• Lumpectomy
• Sentinal node biopsy • 2.5mCi technetium 99 – 4.3 mGy at worst. Usually contraindicated.• +/- radiation• Chemotherapy
• Modified radical mastectomy and nodes
• Adjuvant chemotherapy after 16 weeks• CAF better than CMF in 1st trimester
• Axillary or localized chest wall RXT is probably safe after the first trimester but can be difficult to shield fetus.
• Prognosis:5 Yr Disease Free
Survival
Stage I 85%
Stage II 60%
Stage II 40%
Stage IV 5%
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Metastases to Fetus/Placenta
Only 50 cases in literature
• Melanoma (50% of reported cases)
• Leukemia: 1/100 affected pregnancies
• Lymphoma
• Breast
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Gestational Age and Effects of
Antineoplastic Therapy
Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group.Ann Oncol. 2010 May;21 Suppl 5:v266-73.