Gynaecological Cancer


Six women underwent post-natal radiotherapy. Three further deliveries were recorded with two having a normal vaginal delivery37 and one Caesarean section 28 months after treatment.6


Maternal


outcomes were recorded in 81%, although duration of follow-up was highly variable. Five women were recorded as dead from disease (range nine weeks to 48 months) and 12 were recorded as alive and well anywhere from four to 96 months (see Table 1).


Pregnancy Following Vulval Cancer


Regarding the 13 cases of pregnancy following vulval cancer, mean age at pregnancy was 31 years (range 19–39 years), the majority were nulliparous (n=9; 69%) and none were immunocompromised. All women had undergone prior vulval surgery with lymphadenectomy, and none had prior radiotherapy. The majority had a prior diagnosis of early-stage (FIGO I n=12 [92%] FIGO III n= 1 [8%]), low-grade (grade 1 n=9[69%]) squamous cell carcinoma of the vulva. Two women suffered antenatal complications: one unexplained intra-uterine death at 29 weeks’ gestation48


and one stillbirth6 born by emergency


Caesarean section at 36 weeks’ gestation. In total, five women (38%) had a normal vaginal delivery. Of those delivered by Caesarean section, three (37%) were performed for obstetric reasons with the remainder performed for reasons related to the prior diagnosis of vulval cancer (n=4, 80% due to vulval scarring). Four further pregnancies were documented. Two were delivered by repeat Caesarean section, again due to vulval scarring, and two had normal vaginal deliveries. Maternal outcome was well documented with a mean follow-up period of 108 months (range 28–228 months). All women were reported as alive and well (see Table 2).


Discussion


Malignancy is uncommon in pregnancy and maternal vulval malignancy is rare. Diagnostic delay may occur when a low suspicion of malignancy exists in the younger patient age group, when confusion about symptomatology occurs in view of the physiological changes associated with pregnancy27


or if further investigation or treatment is


postponed until the post-natal period. Delay may result in inadequate management and disease progression. All vulval symptoms in pregnancy (of a non-infective cause) should be taken seriously and malignancy considered as a potential diagnosis so that both appropriate referral and treatment may occur when necessary. Prior case reports emphasise the importance of vulval biopsy for clinically suspicious lesions in the younger or pregnant patient9,10,27–29,32,50,51 in order to detect cancer early and offer radical treatments where appropriate. Where clinically suspicious vulval lesions are identified, biopsy should be performed and, as vulval carcinoma may be associated with other lower genital tract neoplasia, the entire lower genital tract should be evaluated.


Vulval cancer in young patients can occur without apparent predisposing factors.7,51


Hormonal changes and alterations in the


It is hypothesised that the ‘relative immunosuppressive state’ of pregnancy may allow HPV-infected areas of the vulva to rapidly progress through VIN to invasive carcinoma of the vulva.21,25,54


We found


only one immunocompromised patient (pregnancy-related bone marrow hypoplasia),36


and inconsistent documentation of background vulval pathology, hence no inferences can be made from this data.


When diagnosed with vulval malignancy a pregnant woman poses a significant challenge for both the obstetrician and gynaecological


50


immune system may influence the dysplastic potential of HPV-infected cells.52,53


oncologist. Multidisciplinary management should be instituted from the outset. The paucity of reported cases and larger data series in the literature has prevented the development of accepted management plans for either vulval carcinoma presenting in pregnancy or pregnancy following treated vulval cancer. Management of such cases must be individualised27,40,47 maternal age,40,50


gestational age,32,37,43 site, size and stage),32,50,55


with close attention paid to tumour characteristics (lesion


depth of invasion, lymphovascular space invasion (LVSI)32,40 lymph-node status.32


histopathological parameters (tumour grade, and


The potential psychological impact of a


diagnosis of vulval carcinoma in pregnancy and the potential long- term sequelae of therapeutic interventions in these younger patients must also be considered.50,56


When vulval carcinoma is diagnosed during pregnancy it is then recommended that the same treatment should be employed as in the non-pregnant state.29,45,50


When early-stage disease is diagnosed


during the first trimester of pregnancy there is no indication for therapeutic abortion.36,44


In early-stage disease (FIGO Ia), wide local


excision of the tumour alone may suffice as the risk of lymph node metastasis in these circumstances is negligible.57,58


For later-stage


disease, radical surgery remains the mainstay treatment in the first and second trimesters,38,47


with groin node dissection advocated when


the depth of invasion is >1mm (≥ FIGO Ib) or the maximum diameter of the tumour is >2cm (≥ FIGO II).58,59


The management of vulval cancer


has been modified in recent years to reduce associated surgical morbidity. Prior reports recommend radical vulvectomy up to 36 weeks’ gestation.28,29,37,44,47


partum period appears not to prejudice the course of disease.28,29,39,46,47,50 These recommendations hold well in the present day.


This literature review spans more than 65 years, hence we must take into account significant changes in the management of vulval cancer and changes in obstetrical and neonatal care. The practice of pelvic lymphadenectomy is now obsolete60


and, although surgery to the


primary tumour should be radical enough to remove the tumour with adequate margins, triple incision techniques are now employed. Compared with more recent modifications in surgical practice, it is likely that some of the reported cases in the literature underwent more radical surgery than would be performed in today’s environment. As wide local excision of the primary tumour in early-stage disease may suffice, and lymphadenectomy is less extensive, consideration should be given in pregnancy to the use of regional as compared with general anaesthesia. Surgical morbidity is reported as being proportional to genital vascularity, which increases throughout pregnancy,27,38


with


increased vascularity increasing the risk of surgical haemorrhage.39 Therefore, the risk for potential haemorrhage and increased risk of thromboembolic complications should be accounted for.


Sentinel node identification is currently the most promising diagnostic tool for the assessment of lymph node status in vulval carcinoma,62–66


but its safety is still to be proven.58 Clearly in pregnancy EUROPEAN ONCOLOGY


Inguinofemoral lymphadenectomy may be associated with considerable post-operative morbidity, hence the avoidance of more radical procedures where deemed unnecessary (i.e. in negative nodal disease). Currently, no non-invasive procedure available can reliably detect nodal metastases. Systematic review suggests that computerised tomography (CT), ultrasound, magnetic resonance imaging (MRI), positron emission tomography (PET) and fine-needle biopsy show inconsistent results and are not accurate enough for the routine assessment of groin node status.61


Delay after 36 weeks’ gestation into the post-


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