Within the past year, I helped the GYN Oncologist at our institution care for a pregnant woman who had cervical cancer. She was 33 years old and pregnant with her third child. At her intake OB visit she had a Pap test done that returned with a diagnosis of a high-grade lesion (HSIL). Her physician performed a colposcopic examination (looked at the cervix through a magnifying scope), and did multiple biopsies of the cervix in "the most abnormal appearing areas." He made a comment that, despite best efforts, the "upper limits of the transformation zone (TZ) could not be completely seen." This means that the junction of the TZ and the columnar epithelium up in the cervical canal could not be adequately visualized. This is a concern, because there could be disease lurking inside the cervix itself that could not be adequately assessed and there is no place for complacency under these circumstances.
The biopsies of the outer cervix (ectocervix) returned from the pathologist with the diagnosis of "squamous cell carcinoma in situ and microinvasive carcinoma." The patient was then referred to the GYN Oncologist for further evaluation. His recommendation was that she should have a ‘cold knife conization’ (wide wedge-shaped excision of the transformation zone and portion of the cervical canal) of the cervix performed to more thoroughly evaluate both the depth of invasion and the cervical canal that could not be visualized at the time of her original colposcopy. Further recommendations would be based on those results. She was sent to me at about 13 weeks for additional thoughts on management before the conization was performed.
We reviewed her medical history and performed an ultrasound examination of the baby and the cervix. Her previous two pregnancies had delivered vaginally at term and had been uncomplicated. She had no ongoing medical problems. The current baby was normally grown and no gross physical abnormalities were seen within the limits of an anatomical survey for this early gestational age. The cervix measured 40 mm in length; no obvious adnexal abnormalities were seen. We offered her "combined first trimester screening for aneuploidy" to which she readily agreed. She had made it quite clear that if this baby was at increased risk for a chromosomal abnormality, she would want that diagnosis ascertained before making any decisions regarding therapy for her cervical cancer.
The oncologist had also asked that we discuss with her the option of placing a ‘cervical cerclage’at the time the conization was performed. A cerclage is a stitch placed around the cervix that is usually reserved for women with cervical incompetence (a weak cervix that results in premature cervical effacement and early delivery). Women who have a past history of cervical conization (or conization during pregnancy) that has resulted in significant shortening of the cervical canal are at increased risk for premature rupture of membranes and premature labor and delivery. In her case, placement of the cerclage during the conization procedure would have the added benefit of helping to reduce the risk of bleeding. Remember, during pregnancy, blood flow to the cervix goes up dramatically.
She was scheduled for the conization with cerclage two weeks later. A week after I saw her, the first trimester aneuploidy screening test result had returned very reassuring (less than 1 in 4000 risks for trisomies 21, 18, and 13), so the patient elected not to proceed with an invasive diagnostic study (genetic amniocentesis) before the conization. On the day of her surgery, I placed the cerclage around her cervix as high as we could get transvaginally (about 30 mm up the cervix) but did not tie the suture until the oncologist had performed the conization. Once that was done, the cerclage was tied snugly and this immediately controlled the bulk of the bleeding from the conization. The patient was discharged from the hospital the same day.
She returned to our office at about 18 weeks for another ultrasound. The pathology report had confirmed "extensive carcinoma in situ and multifocal microinvasive squamous cell carcinoma with a depth of invasion less than 3 mm. The margins were clear, but there was some evidence of lymph vascular space invasion." Technically, these findings classified her as a stage 1A1 (lowest grade) cancer of the cervix. The baby looked fine by ultrasound and the cervical cerclage was in good position with no loss of integrity at the internal cervical os (opening) to suggest incompetence.
During the pregnancy, her own obstetrician continued to follow her for routine care, she was seen every 4-6 weeks by the GYN Oncologist and had periodic colposcopic exams performed, and we followed the growth of the baby and maternal cervical length. She was presented with the pros and cons of several options for delivery, ranging from a vaginal delivery with evaluation and management by the oncologist following delivery to a cesarean delivery with coincident hysterectomy and lymph node dissection. Because of her desire for no future pregnancies and because we could not guarantee that she didn’t have a higher grade cancer and lymph node involvement, even with the diagnosis of a stage 1A1 cancer, she elected to proceed with the latter. At 38 weeks, we performed an amniocentesis to confirm fetal lung maturity. The next day, her obstetrician delivered her baby by cesarean and the oncologist completed his part of the procedure.
The final pathology report on the surgical specimen showed only a few areas of carcinoma in situ on the cervix, no evidence of residual invasive disease, all surgical margins free of disease, and most importantly, no evidence of lymph node involvement. Mother and baby have both done well. This is one of those cases of cervical cancer during pregnancy that epitomizes the value of a medical care ‘team’ and that had a very happy ending…