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Journal of the Chinese Medical Association 76 (2013) 232e234

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Case Report

Successful conservative treatment of microinvasive cervical cancer during

pregnancy
Chih-Hsing Lin a, James Ching-Hung Hsieh a,b, Yao-Tai Li a,*, Tsung-Cheng Kuo a
a
Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan, ROC
b
Department of Obstetrics and Gynecology, Clinic of Fu Jen Catholic University, Taipei, Taiwan, ROC
Received October 14, 2011; accepted December 16, 2011

Abstract

Cervical cancer complicated by pregnancy is a rare event. While counseling patients with cervical cancer during pregnancy, many factors
must be considered, including the patient’s desire to continue the pregnancy, the stage of the disease, and the gestational age at diagnosis.
Pregnant women with microinvasive cervical cancer should be fully informed of all possible treatment options and consequences. Herein, we
report the case of a woman who was diagnosed with microinvasive cervical cancer during pregnancy at 10 weeks of gestation. After a com-
bination treatment of cervical conization, cervical cerclage, and cesarean section, she delivered a healthy baby and at 7 months postpartum there
was no indication of malignancy.
Copyright Ó 2013 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

Keywords: conization; pregnancy; uterine cervical cancer

1. Introduction 2. Case report

Although invasive cervical cancer is relatively uncommon, Our patient was a 32-year-old woman, who presented in the
it is still the most common malignancy associated with preg- 10th week of her first pregnancy for a routine Pap smear test,
nancy, with a reported incidence rate of 0.45e1 per 1000 the result of which showed a high-grade squamous intra-
pregnancies.1 The prevalence rate of abnormal Papanicolaou epithelial lesion. A colposcopic examination showed atypical
(Pap) test results during pregnancy does not differ from the vessels at the 1 o’clock position (Fig. 1), and results of
age-matched nonpregnant population. Among patients with a directed biopsy of tissues from this area revealed micro-
cervical cancer, approximately 1e3% are pregnant during invasive carcinoma. After a discussion of the different treat-
diagnosis.2 Diagnosis of cervical cancer during pregnancy ment options, the patient preferred a conservative approach.
presents a dilemmadhow to provide effective management of Four weeks later, at 14 weeks of gestation, under epidural
the cervical cancer without affecting the pregnancy. Herein, anesthesia, a loop electrosurgical excision procedure (LEEP)
we report the case of a patient with cervical cancer who for a shallow cervical conization was performed. Results of
received successful conservative treatment. a histological analysis confirmed invasive, well-differentiated
squamous cell carcinoma (SCC; depth: 2 mm; width: 4 mm)
with free margins, and invading into the cervical stroma
without lymphovascular involvement (Fig. 2).
Subsequently, the cervical length was measured by trans-
* Corresponding author. Dr. Yao-Tai Li, Department of Obstetrics and Gy-
vaginal sonographic measurement and was found to be
necology, Kuo General Hospital, 22, Ming-Sheng Road, Section 2, Tainan 700,
Taiwan, ROC. approximately 24 mm. The patient then underwent a Shirodkar
E-mail address: [email protected] (Y.-T. Li). cerclage at 18 weeks of gestation to prevent premature labor.

1726-4901/$ - see front matter Copyright Ó 2013 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
http://dx.doi.org/10.1016/j.jcma.2012.12.010
 C.-H. Lin et al. / Journal of the Chinese Medical Association 76 (2013) 232e234 233

of cervical cancer and the reduction in the morbidity and

mortality rates due to prompt treatment and the disease it-
self.3,4 A speculum examination and cervical smear are sug-
gested for all pregnant women. Our patient underwent
a routine Pap smear test, and her abnormal cytology was
identified incidentally.
All pregnant women with abnormal cytological findings
should undergo a colposcopy and, when indicated, directed
biopsies. Colposcopy and directed biopsies can be performed
safely during all trimesters, although most clinicians prefer to
wait until the second trimester when the risk of unrelated
spontaneous pregnancy loss is minimal. Our patient underwent
biopsies under colposcopic examination at 10 weeks of ges-
tation, which revealed the microinvasive cervical cancer.
Pregnant women with microinvasive cervical cancer should
be fully informed of all possible treatment options and con-
Fig. 1. Colposcopic cervical examination showing bleeding surface and a friable sequences. All decisions regarding therapy, such as balancing
lesion with atypical vessels at the 1 o’clock position. the risks to the fetus from therapy against the potential risk to
the mother from delaying therapy, should be addressed by
The postoperative course was unremarkable. A Pap smear was a multidisciplinary team. Our patient preferred a conservative
repeated two times in the 1st month and again at the 3rd month treatment with conization as the first step.
after operation without evidence of abnormal cells. At 38 Cervical conization performed during pregnancy is asso-
weeks of gestation, she received an elective cesarean section ciated with increased morbidity from hemorrhage and infec-
and delivered a male fetus weighing 3195 g with Apgar scores tion, as well as pregnancy loss or preterm delivery when
of 8 and 9 at 1 and 5 minutes, respectively. The 6-week compared with control nongravid patients.5 The only absolute
postpartum check-up, including a Pap smear, colposcopy, indication for conization in pregnancy is either to rule out
endocervical curettage, squamous cell antigen of the cervix a microinvasive lesion or to make a diagnosis that will change
(SCC), and a pelvic/abdominal computed tomography, was either the timing or the route of delivery. The indication for
normal without any evidence of malignancy. Presently, 7 conization of our patient in this case was to confirm the
months postpartum, the patient remains in good condition. microinvasive disease definitively. To accomplish this, either
a wedge or a shallow disk or coin-shaped specimen should be
obtained. Such a shallow excision will cause less disruption to
3. Discussion the endocervical canal and may decrease both bleeding and
preterm labor complications.6 LEEPs have been proposed as
It is unusual for cervical cancer to complicate a pregnancy. an alternative method to cold-knife conization, although
In Taiwan and in developed countries, the introduction of electrocautery artifacts may obscure the status of the cervical
cervical cytology has been associated with the early detection cone margins. Our patient underwent a shallow conization by
LEEP following this principle with unremarkable conse-
quences. We did not perform endocervical curettage on our
patient, as the procedure is discouraged during pregnancy due
to the risk of premature rupture of the membrane.
Some authors have indicated that cold-knife conizations,
laser conizations, or LEEP can be associated with a sig-
nificantly increased risk of preterm premature rupture of the
membrane. Consequently, cervical cerclage may play a role in
pregnant women who have undergone these procedures ear-
lier.7 Our patient underwent a Shirodkar cerclage at 18 weeks
of gestation and continued her course of pregnancy to term.
In all stages of pregnancy, the prognosis for women diag-
nosed with cervical cancer during pregnancy seems to be
similar to that of nonpregnant women. In our patient, the
diagnosis of stage IA1 cervical carcinoma after conization of
the cervix showed only microinvasion. If the margins of the
specimen are negative, several studies have demonstrated good
Fig. 2. Histopathological analysis of the cervix revealed microinvasive carci- outcomes with expectant management, using colposcopy and
noma. Microinvasive squamous cell carcinoma measured 2  4 mm pelvic examinations every trimester.8,9 Moreover, cervical
(depth  width) (hematoxylineeosin stain; original magnification 40). conization seems to be a standard treatment for stage IA1
234 C.-H. Lin et al. / Journal of the Chinese Medical Association 76 (2013) 232e234

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