Advanced Carcinoma Cervix In Pregnancy: A Case Report

Author Information

Fernandes S*, Cardoso M**. 
(* Assistant Professor, Department of Obstetrics and Gynaecology, Father Muller Medical College, Mangalore; ** Associate Professor, Department of Obstetrics and Gynaecology, Goa Medical College, Goa, India.)

Abstract

Cervical cancer is the most common malignancy diagnosed during pregnancy; its incidence however, is low. The case of a pregnant lady at 37 weeks of gestational age is presented who came with abdominal pain and intermittent bleeding per vaginum. By pelvic examination the cervix was replaced by a growth 6x6 cm which bled on touch. Cesarean section was done. Intra operative findings revealed involvement of right parametrium upto lateral pelvic wall, left parametrium just short of lateral pelvic wall. A cervix biopsy was taken on 9th postoperative day which revealed non keratinising squamous cell carcinoma. A FIGO stage 3b was established. Postoperative period was uneventful. Patient was referred for radiotherapy. Most cases present in the preinvasive or early stage. The case reported has presented in an advanced stage of malignancy in labor. 

Introduction

Cervical cancer is the most common malignancy in pregnancy, with an incidence of 0.8 to 1.5 cases per 10 000 births. [1,2]  One third of cases occur during the reproductive period[.3,4] About one-half of these cases are diagnosed prenatally and the rest within 12 months following delivery.[1]
Most patients are diagnosed at an early stage of disease,[5,6]  probably a result of routine prenatal screening, but it is also possible that advanced stage disease interferes with conception. 
Studies have shown that 76% of lesions diagnosed during pregnancy are in stage 1b[5,6].  Several reports have been identified in literature of preinvasive or early stage carcinoma in pregnancy. However, there is noticeable absence of literature which mentions presentation of an advanced stage of ca cervix in labor. Hence, this case is reported. 
The presenting symptoms of cervical carcinoma in pregnancy are dependent upon the clinical stage and lesion size. The diagnosis is often delayed in pregnant women since many of the symptoms are similar to those associated with normal pregnancy.

Case Report

A 30 year old female, gravida 4 para 3, presented at 37 weeks period of gestation with complaints of abdominal pain and intermittent bleeding per vaginum since 1 day. She gave no prior history of bleeding or discharge per vaginum. Her previous pregnancies were uneventful full term normal deliveries. She had no ongoing medical problems.
On examination, the patient had mild uterine contractions. Pelvic examination revealed the cervix being replaced by a large mass of around 6x6 cm, indurated, which bled on touch. The right parametrium was indurated up to the lateral pelvic wall. The left parametrium was indurated just short of the lateral pelvic wall. On rectovaginal examination, the rectal mucosa was free. General investigations showed no abnormality.
As the patient was in labor, an emergency cesarean section was done with bilateral tubal ligation. A male, 2.9 kg baby was delivered with an Apgar of 7/9. Intraoperative findings revealed the cervix being completely replaced by a large indurated mass of around 6x6cm extending posteriorly up to the junction of the body of the uterus and cervix. Right parametrium was involved upto the lateral pelvic wall. There was no ascites and no lymph nodes involvement. Postoperative course was uneventful. On the 9th postoperative day, a cervical biopsy was taken. Histopathological examination revealed non keratinizing squamous cell carcinoma. A CT scan was done revealed an irregular polypoidal mass replacing the cervix superiorly involving the body of uterus and inferiorly involving the vagina. Fat planes between the mass and rectum and bladder were indistinct in places. Iliac lymph nodes and a few mesenteric were enlarged. A FIGO stage 3b was established. The patient was referred for radiotherapy.


Figure 1. Intraoperative findings: there is a mass arising from the cervix.


Figure 2. MRI of the pelvis.

Discussion

Advanced cervical cancer despite being the most commonly diagnosed carcinoma in pregnancy, is a rarity. Cesarean section followed by radical hysterectomy and chemoradiation is the treatment of choice.[7] However, in this case as the patient came directly in labor with no prior clinical staging or biopsy report, the decision to go ahead with the definitive treatment was deferred at that time. MRI is the diagnostic method of choice which enables to identify tumor dimensions,stromal invasion ,vaginal and parametrial invasion and lymph node infiltration. [8] There however, exists no protocol for management of such cases.[2]

References
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  8. Nicolet V., Carigan L., Bourdon F., Prosmanne O.(2000) MR imaging of cervical carcinoma: a practical staging approach. Radiographics 20: 1529-1549.
Citation

Fernandes S, Cardoso M.  Advanced Carcinoma Cervix In Pregnancy: A Case Report.  JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/advanced-carcinoma-cervix-in-pregnancy.html