A case of successful maintained pregnancy after neoadjuvant
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A 36-year-old pregnant woman presented at our gynecological oncology department with vaginal bleeding after a TCT at 13 gestational weeks. She reported no abdominal/pelvic pain and no medical and surgical histories. Gynecologic pelvic examination revealed a cervical lesion 5 cm in diameter without the involvement of the vagina and parametrium. An ultrasound scan revealed an enlarged uterus for a pregnancy in the 13th week. MRI confirmed that no regional lymph node engagement was documented. Squamous cell carcinoma of invasive non-keratinizing type was confirmed by cervical biopsy. HPV DNA testing was positive for HPV 18. The case was diagnosed as stage IB3 according to the latest 2018 FIGO classification.

The patient strongly desired to maintain the pregnancy and refused to perform surgery. All the potential risks and complications of therapy were presented and the informed consent was signed. After a thorough discussion in a multidisciplinary team (MDT) meeting, the Author decided for NACT with carboplatin and paclitaxel, followed by cesarean section and radical hysterectomy with monitoring the evolution of the mass and pregnancy. The patient received 5 cycles of chemotherapy from 20 gestational weeks to 32 gestational weeks. The only toxic effects were slight nausea and vomiting. Concerning the advanced maternal age, prenatal screening for the common fetal autosomal aneuploidies was suggested. But malignancy among pregnant women could result in discordance between noninvasive prenatal testing (NIPT) results and the fetal karyotype.
Therefore, an amniocentesis was performed and revealed no chromosome anomalies at 24 gestational weeks. Fetal and maternal Doppler readings demonstrated no intrauterine growth restriction through pregnancy, Fetal lung maturity was achieved for babies at 35 weeks and a 3-week-interval between the last cycle of chemotherapy and delivery was recommended.

Thus, a caesarean section at 35 weeks’ gestation was performed 3 weeks after the last cycle of chemotherapy to allow both maternal and fetal bone marrow to recover, followed by radical hysterectomy and pelvic lymphadenectomy. The caesarean section was performed under locoregional anesthesia, with conversion to general anesthesia for the hysterectomy and lymphadenectomy [2]. The infant was a female, with an Apgar score at 1 and 5 min of 9 and 10, weighing 2060 g (21th percentile according to WHO growth curves). After placental expulsion, radical hysterectomy plus pelvic lymphadenectomy were performed. As no lymph node engagement was indicated by MRI and assessment during the surgery, para-aortic lymph nodes dissection was not considered. The patient and infant were discharged on the twelfth postoperative day in good general condition. The identifiable lesion was 3.5 cm in diameter during the surgery (Fig. 1).

The histologic report revealed a poorly differentiated cervical adenocarcinoma, locally adenosquamous carcinoma with 75% stromal invasion, invasion of the posterior vaginal wall, no lymphovascular space invasion, clear vaginal resection margins, and negative pelvic lymph nodes.

Postoperative radiotherapy was proposed. An extensive pathological examination of placenta and umbilical cord showed no metastasis of maternal malignancy. Neonate physical examination, blood count, biochemical analysis and auditory brain stem evoked potential test turned out to show no sign of abnormality. At last follow-up (4 months post-surgery) both the mother and infant are in good general condition.

Source: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-02895-y
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