The purpose of this study was to assess obstetric and maternal outcome of pregnant patients with diagnosis of Hodgkin lymphoma (HL) to guide physicians in clinical management.
Methodology
Clinical data of pregnant patients diagnosed with HL between 1969 and 2018 were collected from the registry of the International Network on Cancer, Infertility and Pregnancy (INCIP). For survival analysis of classical HL treated with an ABVD-based regimen, non-pregnant controls were selected based on stage and prognostic score at diagnosis.
Results
The median gestational age at diagnosis of 134 eligible patients was 20 weeks (range: 3–37). Antenatal chemotherapy was initiated in 53.7% of patients. Ten (7.5%) early pregnancies were terminated. One foetus deceased in the third trimester after three cycles of chemotherapy. In total, 120 (89.6%) pregnancies ended in a live birth. Preterm delivery was observed in 47 (40.1%) singleton pregnancies. Birth weight percentiles were lower in children prenatally exposed to oncological treatment and 17.9% were small for gestational age at birth (figure 1). Four children (3.5%) had major congenital malformations. Five-year progression-free survival (PFS) for HL during pregnancy was 82.5% and 90.9% for early (n=62) and advanced stage (n=15). Five-year overall survival (OS) was 97.3% and 100%, respectively. Although not significant, patients with early stage HL appeared to have inferior PFS compared with matched non-pregnant controls (n=62, figure 2), more clearly seen in the subgroup that initiated chemotherapy during pregnancy (n=45). OS was comparable between both groups, supporting the effectiveness of salvage therapy. For advanced stage HL survival was similar to controls, albeit small numbers.
Conclusion
Survival of patients diagnosed with early stage HL during pregnancy appears not statistically different from matched non-pregnant controls, however future prospective research is necessary to investigate the efficacy of chemotherapy during pregnancy. Awareness of complications as preterm delivery and low birth weight is important.
Disclosure
This project has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 647047. We are grateful to the Research Foundation-Flanders (FWO., grant no G070514N) and ESGO (European Society of Gynaecological Oncology) for their support. FA is senior clinical investigator of the F.W.O. MJH was supported by Charles University research project Progres Q28 and Q34 and by grant MH CZ - DRO ('Kralovske Vinohrady University Hospital - FNKV, 00064173'). The funding sources did not influence study design. There are no conflicting interests to declare.
In our video we would like to demonstrate the technique of identification of sentinel lymph nodes and afferent lymphatic channels in paracervix using the combination of Tc radiocolloid and Patent Blue in patients with early stage cervical cancer.
Methodology
The patients included in this study were diagnosed with early stage spinocellular or adenocarcinoma of uterine cervix stage IA and IB1 up to 2 cm maximal diameter with maximal depth of invasion of less than half of the stroma. We use an ultrashort protocol consisting of application of 2 ml Tc (20 MBq) and 2 ml of Patent Blue diluted in 2 ml of saline. Tc is applicated in surgical theatre at the beginning of anaesthesia using 4 quadrant technique followed by the application of 1 ml Patent Blue into each quadrant. The surgical extirpation was performed in interval of 12 to 15 minutes after the application.
Results
During the period 2009–2018 we included 123 women. In this group we detected positive sentinel lymph nodes in 6 cases. The detection rate (DR) of sentinel lymph nodes was 122/123–99,2%, specific side detection rate (SSDR) 232/244–95,1% Our aim was to detect 246 channels in 123 women. No channels were detected in 6 women (4.9%), unilateral channel was detected in 25 women (20,3%) and bilateral channels were detected in 93 cases (75,6%).
Conclusion
Our video illustrates the safe technique of identifying and extirpation of sentinel nodes and afferent channels in the paracervix. In early stages of cervical cancers this technique can achieve very good detection rate of sentinel nodes on both sides of the pelvis. Work was supported Charles University research program PROGRES Q 28 (Oncology).
Cervical cancer is one of the most common cancers in women worldwide. Because it often affects women of childbearing age (19-45 years), fertility-sparing surgery is an important issue. The article reviews current viable fertility-sparing options with a special focus on trachelectomy, including vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy. Neoadjuvant chemotherapy is also discussed. Finally, the decision to proceed with fertility-sparing treatment should be a patient-driven process.
The International Network of Cancer, Infertility and Pregnancy was launched in order to register women of reproductive age with a cancer diagnosis. Over the years, the project has expanded with currently 2653 cases registered by 114 centres and an annual registration rate of 150 patients. The expected rising numbers of cancer diagnosis during pregnancy as a result of an increased age at first childbirth and the possibility of early cancer detection by the non-invasive prenatal testing calls for an ongoing evaluation of clinical practice. Moreover, women might become pregnant while exposed to new target therapies that are being introduced into oncological practice.
Methodology
The INCIP database consists of a secured on-line registration tool. Oncological, obstetric and neonatal data are registered by members. Annual scientific meetings give updates on the ongoing research projects.
Results
Most patients were registered in Belgium, the Netherlands, Italy and USA and one third of participating centres are non-European. Currently 2059 patients with a cancer diagnosis or treatment during pregnancy are registered, 395 women that received fertility preservation and 199 patients with a postnatal cancer diagnosis (figure 1). Breast cancer, lymphoma and cervical cancer are the most frequent registered cancer types and the majority of patients (67%) received antenatal cancer treatment (figure 2). Most women delivered a live born baby (88%), however 47% delivered preterm and 80% of preterm deliveries were medically induced. One-fifth of neonates (21%) were small for gestational age. Congenital malformations were reported in 3% of live births.
Conclusion
Cancer occurring in women endangers obstetrical and neonatal outcome and potentially future fertility. The INCIP registry is open for further collection of data since for such a relatively rare situation, only a large scale project will provide better insights on maternal and foetal risks assessment, which is essential for optimal patient counselling and care.
Disclosure
The INCIP network would not be able to operate without the ongoing support of ESGO. Furthermore the project is supported by the Research Foundation—Flanders (FWO) in Belgium (grant no G070514N) and the European Union's Horizon 2020 research and innovation program under grant agreement No 647047. There are no conflicting interests to declare.
Mortality is high in advanced vulvar cancer and treatment associate with several adverse events. Neoadjuvant chemotherapy (NAC) administered before surgery is successful in patients with bulky squamous cervical cancer. We used NAC in 10 women with advanced squamous cell vulvar cancer.
Methods
Women with advanced vulvar cancer (bulky nodes and/or T3 tumors) were included in prospective study. Combination chemotherapy (cisplatin 75 mg/m2and ifosfamide 2 g/m2) was given in 10-day intervals. Radical surgery was performed after chemotherapy.
Results
Ten women were included into study (six with bulky nodes, two with T3 tumors and two with combination of bulky nodes and T3 tumors). Hematological toxicity (grade 3–4) occurred in two patients after chemotherapy. Radical vulvectomy with inguinofemoral lymphadenectomy was performed in nine patients, posterior exenteration in one. Response of more than 50% was found in eight patients (one complete); we did not observe any response in two patients. Six patients underwent adjuvant radiotherapy, two had adjuvant chemotherapy and two were not administered adjuvant treatment. Two patients had recurrence (both with no response to chemotherapy) and died of disease. Six patients are alive without evidence of disease and two died of internal disease without evidence of disease.
Conclusions
Response rate for NAC in squamous cell vulvar cancer was 80% while the recurrence rate was only 20% in such an unfavorable group of patients. High-dose density NAC seems to be a viable option to neoadjuvant radiotherapy in advanced vulvar cancer with lower morbidity. This work was supported by the Charles University research program PROGRES Q 28 (Oncology).
The purpose of the study is to present our clinical experience, pregnancy management and long term obstetrical outcome after less radical fertility sparing surgery SLNM + laparoscopic lymphadenectomy + simple trachelectomy or large recone.
Methodology
From 1999–2018, 91 women with squamous or adenocarcinoma with tumor less than 20 mm in the largest diameter and infiltration less than half of cervical stroma underwent laparoscopic SLNI and select extirpation of afferent parametrial channel and frozen section (FS) of SLN and laparoscopic pelvic lymphadenectomy or only SLN. Second step is simple trachelectomy without cerclage or large recone.
Results
Fertility was definitely spared in 76 women. 3 women (3.3%) not plan pregnancy, 9 currently plan pregnancy in future (9.9%), 64 women (84.2%) wish to be pregnant and 53 was pregnant (82.8%). From 76 fertility spared, 53 was pregnant - pregnancy rate 69.7%, 44 women have 50 baby - delivery rate was 57.9%. 37 was term pregnancy (74%), extreme premature 24–27w - 2 baby (4%), premature (28–32w) - 2 baby (4%), premature (33–37w) - 9 baby (18%). 22 unsuccessful pregnancy (5 artericial abortion, 11 spontaneus abortion in 1 trimestr, 4 spontaneus abortion in 2 trimestr, 2 GEU. Two women after hysterectomy have two baby with donor mother.
Conclusion
SLNM and laparoscopic pelvic lymphadenectomy with simple trachelectomy or large recone in small volume cervical cancer (less than 2cm in the largest diameter and less than half of stromal invasion) have excellent pregnancy result. This work was supported by Charles University research program PROGRES Q 28 (Oncology).
Fertility-sparing surgery is safe only if tumor doesn't exceeded 2 cm in the biggest diameter. When the tumor bigger, surgery must be more radical (abdominal trachelectomy type C2), but pregnancy results aren't promising. Neoadjuvant chemotherapy (NAC) followed by simple trachelectomy could be option.
Methodology
Women with squamous cell, adeno and adenosquamous cancers IB2 and IB3 infiltrated less than two third of cervical stroma, were included to prospective study. They received 3 cycles of NAC in ten-days interval (cisplatin 75 mg/m2, ifosfamide 2g/m2 (max. 3g) in squamous cancers, cisplatin 75 mg/m2, doxorubicin 35 mg/m2 in adeno and adenosquamous cancers). Women underwent sentinel lymph node mapping and laparoscopic pelvic lymphadenectomy. When lymph nodes were negative, simple trachelectomy were performed after one week.
Results
Forty women were included in to study (28 IB3 and 12 IB3). Fertility was saved in 29 women (72.5%), five (17.2%) of them recurred (4local and 1 distant) and tree (10.3%) patient died (10.3%). Three women lost fertility after treatment of recurrence; definitively fertility was saved in 26 women. Twenty women want be pregnant until now and 18 (90.0%) became pregnant. Fifteen women delivered 18 babies (1 in 24 weeks, 4 in 28–34 weeks, 3 in 34–36 weeks, 10 in terms). One woman miscarried in first trimester, one in second trimester and one is now pregnant.
Conclusion
Oncological results in NAC followed by simple trachelectomy in cervical cancers bigger than 2cm are acceptable (mortality rate 10.3%) and pregnancy results are excellent (pregnancy rate 90.0%), but still it is experimental protocol for full instructed women. Work was supported Charles University research program PROGRES Q 28 (Oncology).
Purpose of study was to determine long term experience of less radical surgery, sentinel lymph node identification (SLNI) with Tc99+blue day with laparoscopic surgery.
Methods
From 1999 to 2018, 91 women with tumor less than 20 mm in largest diameter, infiltration less than half of cervical stroma underwent SLNI, frozen section (FS) of SLN, extirpation of afferent parametrial lymphatic channel, pelvic lymphadenectomy or only SLN. FS SLN positive patients underwent radical hysterectomy. Seven days after final histopathological processing of dissected nodes, large cone or simple trachelectomy was performed.
Results
15 women (16.5%) lost fertility. 9 women had positive lymph nodes (9.9%), 2 close invasive margin (2.2%), so radical hysterectomy was performed. Four cases had SIL in margin or patient decision, had laparoscopic hysterectomy. One patient N1 had recurrence and died of disease. All other are in complete remission. Fertility was save in 76 cases. Three central recurrences (isthmic part of uterus) were observed (3.9%), one died (1.3%), 2 are in CR 15 and 7 years. We have no distant recurrence. 62 of 76 women whose reproductive ability had been maintained tried to conceive (82%). Of these 62 women, 49 became pregnant (79%) in total 76 pregnancies. 43 mothers gave birth to 48 children, two children were by surrogate mothers.
Conclusions
Less radical fertility sparing surgery in early cervical cancer can be feasible method that yields high, successful pregnancy rate. This work was supported by the Charles University research program PROGRES Q 28 (Oncology).
'/%3e%3cuse xlink:href='%23a' transform='rotate(23.036 .093 25.536)'/%3e%3cuse xlink:href='%23a' transform='rotate(45.87 1.273 16.18)'/%3e%3cuse xlink:href='%23a' transform='rotate(69.945 .996 12.078)'/%3e%3cuse xlink:href='%23a' transform='rotate(20.66 -19.689 31.932)'/%3e%3c/svg%3e)