Squamous Cell Vulval Carcinoma and Pregnancy – A Review
Table 2: Pregnancy Outcomes Following Treatment for Squamous Cell Vulval Cancer Publication Age Parity Months Mode of Delivery Prior Surgical Tumour FIGO Pregnancy
Year/
Reference 195331
195930 196049 19606 (Years) 37 27 Post- G3P1 15 P0 36 35 GO 24 19 G0 24 28 G0 30 30 G0 39 30 G3P2 24 32 G0 22 32 G1P1 26 33 G0 32 39 G0 36 200948 29 36 G2P1 24 P0 20 (Indication) diagnosis Gestation NVD 36 weeks
CS (obstetric) 38 weeks
RV + BL + VR NR RV + BIFL + PL 1
CS (Second-look RV + BIPL laparotomy) term
CS (vulval scarring) RV + BL term
CS (vulval scarring) RV + BL term
CS (obstetric) term RV + BFL NVD term NVD 36 weeks NVD term RV + BL RV + BL RV + BIL
CS (Vulval scarring) RV + BIL term
CS (obstetric) 36 weeks
NVD 29 weeks RV + BL NR 1 1 NR 1 1 NR 1 1
CS (vulval scarring) RV + BIL + VR 1 38 weeks
WLE + BIL 1 I I III I I I I I I I I I I Procedure Grade Stage Nil
Complications (Months Post- diagnosis) NR
Nil Nil NR NR Introital scarring CS (48) Introital scarring CS (60) Nil Nil Nil Nil No NVD (84) No NVD (38) Introital scarring NR Stillbirth No Introital scarring No IUD No
Further Pregnancy Maternal Outcome (Months)
A+W (28)
A+W (60)
A+W (122) A+W (108) A+W (156)
A+W (108)
A+W (84)
A+W (132)
A+W (72)
A+W (84)
A+W (120) A+W (228)
A+W (96)
A+W = alive and well; BFL = bilateral femoral lymphadenectomy; BIFL= bilateral inguinofemoral lymphadenectomy; BIL = bilateral inguinal lymphadenectomy; BIPL = bilateral inguino-pelvic lymphadenectomy; BL = bilateral lymphadenectomy; CS = Caesarean section; FIGO = International Federation of Gynecology and Obstetrics; IUD = intrauterine death; NR = not recorded; NVD = normal vaginal delivery; PL = pelvic lymphadenectomy; RV = radical vulvectomy; VR = vulval reconstruction; WLE = wide local excision.
report.27
In total, 21 cases of vulval carcinoma in pregnancy and 13 cases of pregnancy following vulval cancer were considered. Publication dates ranged from 1940 to 2008.
Vulval Carcinoma in Pregnancy
Regarding the 21 cases of vulval carcinoma presenting during pregnancy or the post-natal period (up to three months post delivery), mean age at presentation was 29 years (range 17–39 years), the majority were multiparous (n=17; 80%), none were HIV-positive and one was immunocompromised (pregnancy-related bone marrow hypoplasia).36 The majority of women presented in the second (n=9, 43%) or third trimester (n=9, 43%), with only three women (14%) presenting in the post-natal period.9,37,38
The presence of a vulval mass (n=11, 52%) was
the most common presenting complaint (n=5, 23%; vulval pruritus n=1, 5%; vulval pain 5%; vulval wart 5% incidental finding at delivery). All but one woman required some form of surgical management.
One woman diagnosed at 19 weeks’ gestation defaulted from surgery.25 In total, 11 of 18 women (61%) had a surgical procedure performed in the antenatal period: six of those (55%) were performed in the second trimester of pregnancy and five (45%) in the third trimester. Apart from the three women diagnosed in the post-natal period, one presenting at 16 weeks’ gestation39
had their surgery delayed until the post-natal
Following primary vulvar surgery in the antenatal period, two women had further post-natal lymphadenectomy surgery.27,43
The surgical
complication rate for the 11 women operated on in the antenatal period was 36%, with two women having significant haemorrhage37,44 and two incurring groin seromas.45,46
The surgical complication rate for
those operated on in the post-natal period was also 36% (one wound infection,37
one wound breakdown,38 groin haematoma).9
The majority of tumours were early stage (47% International Federation of Gynecology and Obstetrics [FIGO] I, 14% FIGO II, 24% FIGO III, 5% FIGO IV and 10% not recorded) and low grade (43% grade 1, 29% grade 2, 10% grade 3 and 18% not recorded). Background vulval pathology was inconsistently documented, with only four women (19%) noted as having VIN and one (5%) with HPV changes. Three women had pregnancy-related complications in the antenatal period: one had pregnancy-related bone marrow hypoplasia;36
one antepartum
haemorrhage resulting in an emergency Caesarean section at 36 weeks’ gestation;6 gestation.40
and one pre-term labour and delivery at 29 weeks’
A further woman undergoing a radical vulvectomy and lymphadenectomy at 23 weeks also developed a recurrence of her carcinoma at 34 weeks’ gestation.47
Mode of delivery was documented
had her surgery delayed until the post-natal period at approximately 22 weeks post diagnosis. She had stage IV disease and died 10 weeks post-treatment. Five further women diagnosed in the third trimester36,38,40–42
period. These patients were reported as alive and well at four to 60 months post-treatment; one was dead from disease at 48 months.
EUROPEAN ONCOLOGY
in 20 women: eleven (55%) delivered vaginally (10 spontaneously, one by forceps); of the remainder, three (33%) had a Caesarean section for obstetrical reasons and six (66%) had a Caesarean section due to either the presence of vulval scarring (n=2) or the presence or diagnosis of vulval cancer (n=4). One woman had a bilateral episiotomy performed37 and one sustained a fourth-degree perineal tear.43
49 one septicaemia39 and one
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