Chapter 67 Gershenson by E0sMP6M

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									                         Chapter 67 Gershenson
                     Gynecologic Cancer in Pregnancy
                          Bahador et al, summarized by Martin Martino MD

      Cervical cancer is most common of the cancer diagnosed in pregnancy
      Ovarian cancer - 2-5/100,000 deliveries.
      Endometrial/Vulvar = rare
      Adnexal Masses in Pregnancy -
       - The use of U/S has led to an increased diagnosis of adnexal masses in pregnancy
       - 1/81 - 1/80,000 depending on who is doing the U/S and how good the machine is.
       - Best average is 1/800 - 1/1400 pregnancies out of 250,000 studied.
       - The majority are benign, and the incidence of malignancy = 2-5%
               1. Most common diagnosis = functional cyst or corpus luteal cyst and do not persist into
               the 2nd trimester
               2. Dermoids/cystadenoma = make up 60%
               3. Most common malignancies: Germ cell tumor and EOC (most are LMP).
       - Germ cell tumors: These are the most common malignancy in women of reproductive age.
       - The incidence of emergency surgery due to pain/bleeding/torsion = 1-27%.

I. 3 issues to address:
       A. The role of tumor markers
       B. The role of imaging
       C. The timing of surgery

       A. The role of tumor markers -

              1. CA 125 - Peaks about week 10 at 1250 U/ml, then decreases to <35 until delivery,
              where there is a transient increase, and then it decreases again.
              2. LDH - varies little in pregnancy except in HELLP and Pre-eclampsia, and it has been
              useful to monitor 2 patients with a dysgerminoma in pregnancy.
              3. AFP - This is the predominant serous protein and is elevated in pregnancy, so it is
              difficult to use it to diagnose an Endodermal Sinus Tumor.
              4. B-HCG - This is also elevated to 110,000 at the end of the 1st trimester, so it is not
              that useful either.

       B. What is the role of imaging and safety of imaging?

              The most common radiation used are ionizing radiation or non-ionizing radiation
              1. There is an all or none phenomenon after 5-10 rads in the preimplantation period. It is
              generally best to avoid RT during pre-conception(Days 0-9) and organogenesis ( Days
              15-50).
              - It is best to avoid CT and CXR in the 1st trimester as these are both ionizing RT.
              2. TV U/S - This is the best way to image in pregnancy (it uses non-ionizing radiation)
              3. MRI - also is non-ionizing RT, but is best to avoid in 1st trimester b/c of magnetic
              fields and heat generated during study.
C. When is surgical intervention indicated in the pregnant patient with a pelvic mass?

       *** Questions to try to answer are:
             1. Has it increased in size?
             2. Is the lesion cystic/solid/complex?
             3. Are there internal septations/thick walls in the cyst?
             4. Is there ascites?
             5. Does the cyst have internal projections?

       1. Simple - usually go away after the 1st trimester, but if persistent into 2nd trimester,
       then it should be evaluated if > 5cm per Gershenson's text.
       - All masses >10cm warrant surgical evaluation.
       - Thronton looked at 5-9cm cysts and found LMP in 21% of those removed in the 2nd
       trimester, so the text recommends removal for this size until further data is available.

       2. Complex-
             - If diagnosed in the 3rd trimester, it is best to manage conservatively b/c only 2-
             5% will be malignant, and the risks of PTL outweigh the benefits of surgery at
             this trimester. Evaluation may be done at the time of C/S with staging done after
             frozen if positive.
             - If diagnosed in the 2nd trimester, then it is safe to operate at 16-18 weeks to
             establish a diagnosis and prevent risks of emergency surgery due to
             torsion/rupture that may be as high as 27% and a 10-15% chance of rupture or
             torsion/hemorrhage into the cyst.

D. What route of surgery is the best?

       - Traditionally laparotomy, but recent reports also include laparoscopy up until 14-16
       weeks. Most of the data using the scope in pregnancy began with Lap chole's done in
       pregnancy.
       - However, at this gestational age, in a study by Parker et al, 93% of cysts ruptured.
       Fortunately, all were benign, but this describes the difficulty in removing this
       laparoscopically in the 2nd trimester.

      There are also concerns regarding fetal acidemia due to CO2 and decreased uterine blood
       flow.
      It appears until more data is developed, laparotomy may be the safest route if you are
       going to operate in pregnancy.
II. Ovarian Cancer in Pregnancy
     * 1/12,000 - 1/50,000 pregnancies

     A. What is the appropriate surgery for Ovarian Cancer diagnosed during pregnancy?

                   If apparent stage I - then remove and do a staging with PPLND(Ipsilateral is
                    acceptable)
                   If greater stage, then this must be individualized based on patients wishes and
                    gestational age, extent of disease, and expertise of the surgeon.
                   If patient desires pregnancy, attempt to conservatively cytoreduce, then give
                    neoadjuvant chemotherapy.

     B. Chemotherapy in Pregnancy -

             - There is a lot of anecdotal reports that it can be given safely in the 2nd and 3rd
             trimester, most of the reports are based on leukemic patients.
             - There are no increased risks of congenital malformations due to chemo in the 2nd and
             3rd trimester when compared to non-chemo patients.
             - But exposure may result in IUFD, PTL, and Low birth weight, + fetal
             immunosuppression.

     C. Which Chemotherapeutic agents should be used in treating EOC during pregnancy?

            Treat Germ cells with the same chemo as in a non-pregnant patient.

            There are only 7 case reports with chemo and EOC in Pregnancy.
                   *** And only 2 reports regarding the use of taxanes in pregnancy

                    1. Was in a patient with recurrent breast cancer (Taxotere)

                    2. Sood et al - 3 cycles of Taxol/CDDP given at 27 weeks with a C/S at 37
                    weeks, then staging and cytoreduction. However, she recurred at 6 weeks and
                    died at 29 months. The fetus had normal growth and development at 30m of age.

                    3. Ever since GOG 111 proved that taxanes have a better outcome, and with these
                    2 reports, taxanes may be considered to be used in the future for treatment.

								
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