Pregnancy following radical trachelectomy and pelvic lymphadenectomy for Stage I cervical adenocarcinoma

Abstract

A 30-year-old nulliparous asymptomatic woman presented to a colposcopy clinic with severe dyskaryosis based on a cervical smear test report. The colposcopic impression was high-grade cervical lesion. A large loop excision of the transformation zone was performed. Histologic examination revealed an invasive well-differentiated papillary adenocarcinoma of the endocervix measuring 12 mm across and infiltrated to a depth of 3.5 mm (Stage IB1). The excision was incomplete at the endocervical margin of the lesion. There was no apparent lymph-vascular involvement. Magnetic resonance imaging revealed a small area of high signal in the cervix compatible with a small residual tumor confined to the cervix. The patient was advised to have a radical hysterectomy with pelvic lymph node dissection. However, the patient was anxious to maintain her fertility at all costs and to explore any other options. Subsequently she was referred to a regional gynecologic oncology unit (St Bartholomew's Hospital, London, UK) and was counseled about the possibility of fertility-preserving radical surgery. A radical trachelectomy with a retroperitoneal lymph node dissection was discussed and the patient underwent the procedure without complication. A no. 1 prolene suture was inserted into the lower segment of the uterus to provide sufficient mechanical support in the event of a pregnancy. Histologic analysis revealed no evidence of residual tumor or lymph node metastases, but there was an area of high-grade glandular cervical intraepithelial neoplasia which had been completely excised. The postoperative recovery was uncomplicated. The patient presented amenorrhea and the pregnancy test was positive. A retrospective estimation of the ultrasound dating scan suggested that she must have conceived during the month of the operation. There was no bacterial growth from vaginal swabs. A detailed scan at 19 weeks showed a fetus without anatomic anomalies. Colposcopy at 21 weeks did not show tumor recurrence or herniation of the amniotic membranes. At 23 weeks' gestation the patient presented with clear fluid loss per vaginam. A sterile speculum examination revealed intact membranes visible through a gap of the lower uterine segment. High water rupture of membranes was diagnosed. Chlamydial antigens tests and vaginal cultures were negative. Antibiotics and steroids were administered. The patient remained on bed-rest with compression stockings, and close observations were made to detect any sign of ascending uterine infection. An ultrasound scan at 25 weeks confirmed satisfactory growth with oligohydramnios. A few days later the patient had a small antepartum hemorrhage and painful uterine contractions. A classic cesarean section was performed under general anesthesia and a live female baby weighing 650 g was delivered in good condition. The delivery was effected through the anterior placenta that had clear signs of chorioamnionitis. This was confirmed on subsequent histologic examination. Funisitis was also identified. The suture was left in situ. The baby was transferred to the neonatal unit and despite developing septicaemia did well and was eventually discharged home 12 weeks later. The mother was discharged on the sixth day post delivery. Dargent introduced trachelectomy and pelvic lymphadenectomy as a fertility preserving treatment for early stage cervical cancer. This case describes a pregnancy following trachelectomy and pelvic lymphadenectomy combined with uterine cerclage for stage IB1 adenocarcinoma of the cervix. Less radical surgery (1,2) and radiotherapy (3) have been described for early stage cervical cancer, with subsequent successful pregnancies (4). Radical trachelectomy and pelvic lymph node dissection were found to have comparable efficacy and safety with standard treatment in a 5-year follow-up study (5). Pregnancies have been described following fertility preserving surgery for early stage cervical carcinoma (6). However, little detail is available to provide information to assist in the management of these pregnancies, and with the possibility of an increase in fertility preserving surgery for cervical cancer obstetricians will be left to manage subsequent pregnancies from first principles. This case highlights the difficulties in pregnancy management in these patients. The main risk with these pregnancies is the absence of the cervical canal, which results in a lack of mechanical support of the uterine isthmus and also to ascending infection. Consequently, preterm rupture of the membranes and/or preterm labor can occur. In this case study, prophylactic antibiotics were not prescribed antenatally because the vaginal swabs were negative. Spontaneous prelabor rupture of the membranes occurred at 23 weeks' gestation and expectant management attempted to delay the delivery of the baby in view of the prematurity. A course of antibiotics was prescribed on the basis that the cerclage suture might be harbouring pathogenic microorganisms. Inevitably, prolonged bed-rest was necessary. A second consideration in the management of this patient was thrombo-prophylaxis, especially in the presence of chorioamnionitis. Heparin was administered only in the puerperium because of concern that the antepartum hemorrhage might further complicate the pregnancy. Uterine trauma and hemorrhage are serious potential risks if uterine contractions commence, and so at the onset of labor early recourse to surgical delivery was recommended. The consultant performed a classical cesarean section (midline uterine incision) as there was no uterine lower segment and the uterine scar tissue and cerclage suture were to be avoided. However, it could be argued that a transverse incision on the upper part of the isthmus could also facilitate the safe delivery of the fetus. If this type of incision is used deflection of the bladder should not be undertaken because it could result in the opening of the anterior vaginal wall. The vertical uterine scar would be a complicating factor in the management of a subsequent pregnancy. Additionally, future pregnancy would encounter increased risk of preterm prelabor rupture of membranes and serious consequences for the fetus and the neonate. These risks should be highlighted in future counseling. The other potential complication is local recurrence, which in this case was not evident at colposcopy mid-way through the pregnancy. This case report discusses the management of pregnancy following novel, less radical surgery for early stage cervical cancer. This situation will become more prevalent for managing obstetricians as this procedure is performed more regularly. The consequences of novel therapies require careful consideration and discussion with patients. Although the outcome in this case was satisfactory further studies of pregnancy outcomes and interventions in women who have undergone less radical surgery to preserve fertility are needed if a realistic chance of success while reducing the risk of complications is to be achieved.