Squamous Cell Vulval Carcinoma and Pregnancy – A Review
contrast dyes and radiolabels should be used with caution, yet it has been reported that sentinel lymph node biopsy can be performed in pregnancy with negligible67,68
or very low risk69 to the foetus.
Adjuvant or neoadjuvant radiotherapy and chemotherapy may be utilised in the treatment of vulval carcinoma, with cisplatin and 5-fluorouracil (5-FU) being the more commonly investigated chemotherapeutic agents.70–75
cancer management within a cancer centre. Examination of the groin and vulva should be performed during pregnancy as prior recurrence of disease during pregnancy has been reported.47
Conclusion When considering the use of either
radiotherapy or chemotherapy in the pregnant patient, the risk of exposure to the foetus and neonate and the potential risks of delaying therapy to the mother in view of the pregnancy are highly significant matters. Radiotherapy should be avoided during pregnancy whenever possible76
and delayed until after delivery.77 potentially teratogenic.78 All chemotherapy agents are Although cisplatin is the most widely
researched and most commonly used chemotherapy agent during human pregnancy,79
5-FU has been less widely studied. Studies in rats suggest that the neuroembyopathic effect of 5-FU is severe when given in the early and late phases of pregnancy,80–82
so it is advisable
that the drug is avoided during pregnancy. Therapeutic abortion is a consideration for women presenting with advanced-stage or unresectable disease in early pregnancy.
The occurrence of vulval carcinoma in pregnancy or prior radical surgery for vulvar cancer may pose difficult decision-making when deciding upon the most appropriate mode of delivery. Prior reports advocate an attempt at normal vaginal delivery following radical surgery provided the vulval wounds are well healed,28,29,36,39,46,47,50,55 Caesarean section advocated for obstetric indications only.38,49
with delivery by When
larger vulval lesions are detected near to the time of delivery, consideration must be taken as to the possible risk of laceration and haemorrhage associated with vaginal birth.7
Also if the lesion is close to
the perineum then performance of episiotomy may be difficult due to potential encroachment onto the tumour.44
When vulval surgery is
performed later in the second and third trimesters, vaginal delivery runs the risk of wound dehiscence or wound complications; in these circumstances, delivery by Caesarean section may be appropriate.39,44 Vulva scarring or prior vulval plastic reconstructive surgery may influence the decision to perform a Caesarean section.29,45,50 Caesarean section may also be preferred by the woman.45,50
Delivery by
In the successfully treated vulval cancer patient there seems to be no contraindication to future pregnancy.36,39,40,50 Caesarean section6,49
Both vaginal delivery6,31 and have been reported. We found a 62% Caesarean
section rate in those having had prior treatment for vulval cancer, where four (50%) were performed in view of significant vulval scarring. It is possible that maternal vulval carcinoma or prior treated vulval cancer may increase the likelihood of delivery by Caesarean section. Therefore, it seems pertinent that women are advised of this likely risk.
Five-year relative survival rates for vulval cancer have been shown to decrease with increasing age at diagnosis.84
The reported mortality rate for vulval carcinoma is lower in women who are between 25 and 44 years of age than in those >45 years of age.83
It appears that
It is also likely that subsequent pregnancy following treatment for vulval cancer has no adverse effect and is not shown to increase the risk of recurrence.6,29,31
We are unable to draw any
conclusions regarding overall survival due to reporting variations in the duration of follow-up of these patients. For women diagnosed with vulval cancer in pregnancy, follow-up should run as standard vulval
EUROPEAN ONCOLOGY
pregnancy exerts no deleterious effects on the course of disease or prognosis.27,37,40,44
The diagnosis of vulval carcinoma during pregnancy is a rare event, as is pregnancy following treatment for vulval cancer. There is a suggestion that the incidence of vulval carcinoma is increasing in the younger age group. It is therefore likely that the incidence of vulval cancer in pregnancy will also increase. There is no single institution that can report a large series of maternal vulval cancer unless over an extended period of time, hence not allowing for significant changes in the management of vulval carcinoma and significant changes in obstetrical and neonatal care. Furthermore, multi-institutional co-operative groups could not study this issue. Only an extensive review could compile this information. We recommend that future case reporting contains detailed information on clinicopathological variables and treatment regimens. As longer-term maternal and neonatal outcomes are more difficult to substantiate in case reporting, the authors feel that data centralisation would be beneficial in identifying optimal management strategies in not only these rare tumours, but also in other malignant tumours diagnosed and treated during pregnancy. n
Julia Palmer is the Lead for Colposcopy Services and a recognised Specialist in Gynaecological Cancer Surgery at the Royal Hallamshire Hospital in Sheffield, where she was appointed Consultant after completing sub-speciality training in gynaecological oncology. She has a special interest in tumour markers and angiogenesis in gynaecological cancer and is a member of the Royal College of Obstetricians and Gynaecologists (RCOG), the British Gynaecological Cancer Society
(BGCS) and the British Society for Colposcopy and Cervical Pathology (BSCCP). During her post-graduate training, Dr Palmer was appointed as a clinical research fellow at the University Hospitals Coventry & Warwickshire NHS trust, and awarded an MD by the University of Warwick in 2007 for her work on the predictive values of morphometric assessments in clinical outcome in ovarian epithelial malignancy. She undertook undergraduate studies at the University of Wales, graduating in 1996.
Manu Vatish is a Senior Lecturer and Consultant at Warwick Medical School and Clinical Director of Obstetrics and Gynaecology. He specialises in high-risk pregnancies and leads a basic science obstetrics research group that investigates the underlying biology of obstetric disorders. He is a member of the Royal College of Obstetricians and Gynaecologists (RCOG), the Society for Reproduction and Fertility (SRF) and The American Endocrine Society. He is the 2008–2009
Fulbright Distinguished Scholar and is currently on sabbatical at Albert Einstein College of Medicine in New York. Dr Vatish underwent clinical training at Cambridge University following pre-clinical studies and an intercalated BA in physiology at Oxford University. His work on Ion Transport Across the Human Placenta was awarded a DPhil in 1992.
John Tidy is a Consultant Gynaecologist at the Royal Hallamshire Hospital in Sheffield and a certified Colposcopist and recognised Specialist in Gynaecological Cancer Surgery. He is Chairman of the NHS Cervical Screening Programme and National Advisory Committee for Colposcopy, and Secretary of the British Society for Colposcopy and Cervical Pathology. He is a Fellow of the Royal College of Obstetricians and Gynaecologists (RCOG) and a member
of the British Gynaecological Cancer Society (BGCS), the International Gynecologic Cancer Society (IGCS), the British Society for the Study of Vulval Disease (BSSVD), the International Society for the Study of Vulvo-vaginal Disease (ISSVD) and the International Society for the Study of Trophoblastic Disease (ISSTD). Dr Tidy is active in clinical research, attracting funding from Cancer Research UK, World Cancer Research Fund International, the NHS New and Emerging Technologies Programme and the pharmaceutical industry.
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