MALIGNANCY IN PREGNANCY

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MALIGNANCY IN PREGNANCY

• Michael Maddox
• M3 Gynecology/Oncology

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WHY IS IT IMPORTANT?

• What causes cervical cancer? HPV. How do we get
  HPV? Sex. How do we make babies? Sex. Hmmm?
• Peak incidence of HPV infection globally occurs
  in the 3rd decade of lifeincidentally the same
  time of maximum reproduction potential.
• Cancer is the leading cause of death in women
  aged 35-54, and therefore as reproductive
  technology expands the reproductive capabilities
  of older women, cancer in pregnancy will likely
  increase in prevalence.

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UNIQUE ISSUES

• Medicine is about the patientbut what happens if
  there are two patients with conflicting interests
  as is pregnancy?
• How far along is the pregnancy at diagnosis? Is
  the baby viable?
• Does the mother desire to maintain the pregnancy?
• Does treatment of the mother preclude a good
  outcome for the fetus?
• Should a cancer patient get pregnant? How do you
  maintain fertility following cancer treatment?

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Cervical Cancer in Pregnancy

• Cervical cancer is the most common malignancy in
  pregnancy. Why?
• It is recommended that as part of routine
  prenatal care, a pregnant woman undergo a Pap
  smear at the first prenatal visit as well as 6
  weeks post-partum. (DX OF PREGNANCY MUST BE SENT
  WITH PAP SPECIMEN).

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Signs and Symptoms of Cervical Cancer

• Watery vaginal discharge
• Intermittent spotting
• Post-coital bleeding
• Pelvic pain or pressure
• Rectal or urinary tract symptoms

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DIAGNOSIS

• Diagnosing cervical cancer is essentially done in
  the same manner as in the non-pregnant patient
  (often made earlier).
• However, pregnancy may mimic/mask signs of
  cancer, possibly delaying diagnosisthis shows
  the importance of screening women for this
  disease. Also, visualization of the cervix may
  be compromised by a pregnant state.
• Cyto-brush and liquid-based cytology have
  drastically improved screening leading to a
  decreased false negative rate (important)
• Cervical biopsy should only be performed on the
  worst visible lesion to prevent bleeding
  complicationsand repeat biopsies are generally
  discouraged unless the lesion progresses.

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TREATMENT IN PREGNANCY(before 20 weeks gestation)
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TREATMENT (cont.)

• Timing of diagnosis dictates much of the
  treatment strategy
• Before 20 weeks, the option to terminate the
  pregnancy is available.
• General conceptsin early lesions or minimally
  invasive disease, waiting for fetal maturity and
  delaying cancer treatment is standard. Why?
• LSIL or CIN has a relatively small risk of
  progression during the course of the pregnancyit
  takes 7 years for LSIL to progress to cervical
  cancer and 4 years for HSIL (on
  average).---Conservative management for
  intraepithelial lesions.

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Treatment (cont.)

• Close follow up with repeat cytology and
  colposcopy is recommended throughout gestation.
• Cervical conization is only performed with
  suspicion of invasive cancer due to risks such as
  hemorrhage, miscarriage, fetal loss, and
  increased perinatal death. Conization also
  increases the incidence of premature ROM in
  subsequent pregnancies.

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Treatment (cont.)

• Delivery, in a sense is the beginning of therapy
  for most mothers. Vaginal delivery is
  contraindicated when a gross tumor exists (IB)
  due to unfavorable maternal outcomes
• Radical Trachelectomy with Pelvic
  Lymphadenectomyremoval of cervix with adequate
  uninvolved margins while maintaining the uterine
  bodythis procedure is designed to preserve
  fertility.
• Radiationinduces abortion.
• Delayed therapy in advanced cervical cancer is of
  unclear benefit.

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PREVENTION

• HPV Vaccine
• Safe sex practices with routine pap smears

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BREAST CANCER in PREGNANCY (briefly)

• Second most common malignancy in pregnancy
• Hormonally sensitive cancer due to pregnancy?
• Breast cancer is considered to be by definition
  associated with pregnancy if it is diagnosed
  during the pregnancy or within one year of
  delivery. In pre-menopausal women, 1 in 3-4
  breast cancers are associated with pregnancy.

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Do Pregnancy Hormones Stimulate Breast Cancer
Growth?

• Interesting fact In women positive for the
  BRCA1 gene mutation who also have been pregnant
  4 times, there is a 38 reduction in incidence
  of breast cancer.
• However, in women with the BRCA2 gene mutation,
  increasing parity is associated with an increased
  risk of developing breast cancer in pregnancy.
• Physiologic breast changes of pregnancy my also
  mask a developing malignant mass in the breast
  leading to delay in diagnosis.

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Melanoma in Pregnancy

• Third most common malignancy in pregnancy and
  most common malignancy to metastasize to the
  placenta.
• Do hormones of pregnancy increase the risk of
  melanoma? Pregnancy is clearly associated with a
  hormonal change in skin attributed to stimulating
  melanocytes resulting in MELASMA. However,
  recent studies have shown that pregnancy does not
  influence the prognosis of melanoma.

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REFERENCES

• Leslie KK. Breast Cancer and Pregnancy.
  Obstetrics Gynecology Clinics of North America.
  01-DEC-2005 32(4) 547-558.
• Wiggins, Charles. Malignant Melanoma in
  Pregnancy. Obstetrics Gynecology Clinics of
  North America. 01-DEC-2005 32(4) 559-568.
• Muller, CT. Cervical Neoplasia Complicating
  Pregnancy. Obstetrics Gynecology Clinics of
  North America. 01-DEC-2005 32(4) 533-546.
• Chan, Paul D. Gynecology and Obstetrics A
  Current Clinical Strategies Medical Book.
• Sood AK, et al. Cervical cancer diagnosed shortly
  after pregnancy prognostic variables and
  delivery routes. Obstet Gynecol June
  200095832-8.
• Weiss, Boaz. Cancer in Pregnancy Maternal and
  Fetal Implications. Human Reproduction Update,
  Vol 7, No. 4 384-393.