Organ-specific management
Preinvasive cervical cancer
High-grade squamous intraepithelial lesions on cytology need to be referred to colposcopy to exclude invasive tumours. Colposcopy can be quite challenging during pregnancy due to increased vascularity and an increase in genital oedema (10).
In case of a visible tumour, a superficial cone biopsy (‘coin biopsy') can be performed. The risk for bleeding is increased in a pregnant patient due to vascularity. It may be necessary to repeat the colposcopy at 12-weekly intervals if an abnormality is found distant from term. Definitive treatment in the absence of an invasive tumour is usually delayed until after delivery. A biopsy can be performed by loop excision or by an old-fashioned cold knife method. The term ‘coin biopsy' is sometimes used in pregnancy to highlight the fact that the incision should not be deep enough to cause damage to the fetal membranes. This should beInvasive cervical cancer
Cervical cancer remains one of the most common malignancies in pregnancy. A conservative approach is only appropriate if the patient has a firm desire to continue with the pregnancy (11). Some patients and their care givers opt for ‘watchful waiting' due to the risks of therapy in pregnancy.
Uterus-conserving surgery is appropriate only in highly selected cases. A wide cone biopsy or a modified radical trachelectomy have been performed in pregnancy but outcomes so far have not been universally good due to significant bleeding during the procedures (12). Laparoscopic extraperitoneal or open lymphadenectomy has been described in small series for patients at less than 25 weeks' gestation (13). The pathological information about nodal status may influence management but imaging with MRI to determine nodal status is more widely used. Immediate, definitive treatment, regardless of gestational age, is generally appropriate in the following settings:
• Documented lymph node metastases
• Progression of disease during the pregnancy
• Patient choice to terminate the pregnancy (14).
Where the decision is made to sacrifice the pregnancy before 24 weeks' gestation and in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2- IIa and where surgery is possible, a radical hysterectomy and pelvic node dissection with the fetus in situ is the most common treatment pathway. After 24 weeks and viability, surgical treatment is usually delayed until 32-34 weeks at which time a classical caesarean section plus radical hysterectomy and pelvic lymphadenectomy is performed. This approach requires individualization and will be influenced by tumour size, patient's wishes, etc.
In more advanced stages where radiotherapy is indicated, the management of the termination of the pregnancy is dependent on the gestation. Before 12 weeks of gestation, radiotherapy can be given without removal of the fetus but often the patient prefers to start chemoradiation after medical termination of pregnancy. Between 12 to 24 weeks, hysterotomy is generally performed followed by chemoradiation 7-14 days later. This includes external beam therapy and high-dose intracavitary brachytherapy.
Chemotherapy is often used in a neoadjuvant approach until such time that definitive surgery or radiotherapy can be performed (15). Caesarean section is the preferred choice for delivery of the baby in the presence of bulky tumours. Vaginal delivery risks the possibility of catastrophic bleeding and implant metastases in vaginal tears or episiotomy scars. In locally advanced tumours, it is recommended that a lower segment transverse caesarean section is best avoided due to the risk of cutting or tearing into tumour tissue. A classical incision will minimize blood loss and avoid the large tumour vessels.
Ovarian cancer
Ovarian masses are often found incidentally during pregnancy ultrasonography. Most of these are benign and care should be individualized based on ultrasound and clinical features. Risks include torsion, rupture, and bleeding.
Laparoscopic removal is relatively contraindicated in masses suspicious of malignancy.Invasive epithelial ovarian cancer is exceedingly rare in pregnancy but proper surgical management remains the cornerstone of treatment. Proper surgical staging is often very difficult due to a lack of good exposure, especially the pouch of Douglas. Neoadjuvant chemotherapy is usually administered and completion surgery can be delayed until after the delivery of the baby.
Endometrial cancer associated with pregnancy is rare and is usually only diagnosed in postpartum patients with persistent vaginal bleeding. Other gynaecological cancers include vulval cancer where surgery is certainly possible. Each case should be individually managed. For very large, advanced-stage disease, abdominal delivery is preferred due to a risk of bleeding if the tumour is stretched or torn during vaginal birth.
Breast cancer
Normal pregnancy is associated with many physiological changes that affect the density and nodularity of the breast tissue. It is often difficult for patients and clinicians to determine abnormal, pathological breast masses from normal physiological changes. For this reason, the diagnosis of breast cancer is often delayed during pregnancy. It is estimated that approximately 1:3000 pregnancies will be complicated by breast cancer (16).
The diagnostic accuracy of mammography in pregnancy is generally low and the information gained from a mammogram is difficult to interpret due to the density of breast tissue in young, pregnant women. Fortunately, the risk of radiation to the fetus is low, especially when shielding is used for the uterus. Ultrasound examination of the breast is the preferred method and guided biopsies will often confirm the diagnosis.
The majority of breast tumours diagnosed in pregnancy are highgrade, infiltrating ductal carcinomas with lymphovascular space invasion. Up to 70% are oestrogen and progesterone receptor negative and nearly 70% will have lymph node involvement at the time of diagnosis (16).
Surgery, which may include mastectomy, lymphadenectomy, or lumpectomy, can be performed safely during pregnancy. Sentinel lymph node biopsies may also be used because the risk of radiation from technetium sulphur colloid is very low according to the National Council on Radiation Protection and Measurement (17). Blue dyes such as lymphazurin and methylene blue are best avoided due to the risk of fetal abnormalities.
Commonly used chemotherapeutic agents include 5-fluorourasil, doxorubicin, and cyclophosphamide, which have all been used safely during the second and third trimesters of pregnancy. Methotrexate should be avoided. Tamoxifen and Herceptin have both been associated with fetal complications and should therefore not be used during pregnancy.
The management of breast cancer should be individualized in a multidisciplinary team environment.