It's not working. Donna, I think you might have to hit record. It won't let me do it. I see you. Okay. Yes, go right ahead. Okay, so I'm going to switch gears just a little bit and talk about gynecologic cancers in pregnancy, focusing on cervical cancer in pregnancy for sake of time. Very rare, but I hope interesting, and I have seen it more than I thought that I would as an attending thus far. So hopefully you can learn something today. I'm going to talk about the background, workup, treatment, and outcomes of gynecologic cancers and cervical cancer during pregnancy. Actually, can I? Sorry. Trying to move this so I can see. Okay. So how common is a gynecologic cancer during pregnancy? The actual incidence is hard to figure out, mostly because in many countries the obstetrical and oncological registries are not linked. And different papers and literature will use different denominators. So are we counting the number of cancer cases in all pregnancies, including miscarriages, abortions, etc.? Or are we counting the number of cancer cases in pregnancies that result in live births? So it's kind of hard to compare. But overall, the relative risk of cervical cancer during pregnancy is lower when compared to the risk of cervical cancer in non-pregnant women. Unclear if this is because of a delay in diagnosis detection. There aren't many speculum exams being performed in pregnancy, versus if this is a true lower risk and healthy mother effect. Healthy younger women tend to get pregnant and less often get a cancer. And then the data on how pregnancy affects outcomes of gynecologic cancers is limited, but literature does show overall similar prognosis and overall survival. So the majority of this talk actually comes from the most updated ESMO guidelines and the Annals of Oncology from 2019 about treating gynecologic cancers in pregnancy. And so here you can see the overall instances that we have in the literature. So cervical cancer is the most common cancer that is found during pregnancy, with 1.4 to 4.6 cases per 100,000 pregnancies. A little bit of a variation in this incidence, likely because there's just varying cervical incidence rates across different populations, different countries, as well as access to different screening programs in different countries as well. Next up is ovarian cancer, and followed by vulvar and vaginal cancer, which are least likely to be diagnosed during pregnancy and just more rare overall. As you can see, endometrial cancer is not on the list. We're not typically doing endometrial biopsies during pregnancy. Although interestingly enough, there are about up to 40 cases of endometrial cancer that has been found in association with pregnancy. Most of this is diagnosed on a DNC or suction curatage after an abortion or missed AB. So in terms of the workup and imaging, just general principles that apply to cancer or gynecologic cancers during pregnancy, in terms of imaging, so the threshold for significant risk to the fetus is set at 100 milligray. And just for reference, one x-ray with proper shielding has the radiation equivalent of less than 0.1 milligray. We like to avoid ionizing imaging procedures to decrease risk to the fetus. So CT scans with IV contrast are not really recommended unless it's very necessary or an emergency situation. Ultrasound is a number one preferred modality to start with, and after that, MRIs without contrast are preferred. Gadolinium, which is the contrast used with MRIs, has not been associated with congenital anomalies. It has been associated with some rheumatologic, inflammatory, or infiltrative skin conditions, as well as stillbirth and neonatal death, but very, very, very low likelihood. And most are done after the first trimester. We try to do that if possible. How about a PET-CT? So since we're talking mostly about cervical cancer, a PET-CT is used very commonly in the United States for workup and staging. The literature suggests that it is actually pretty safe in pregnancy. They just recommend adequate hydration and a bladder catheter so that you don't have your bladder filled up with contrast right next to the fetus there in the uterus. And then whole body diffusion-weighted MRI is becoming more popular in the United States to replace PET-CTs for staging and tumor response in pregnant women with cancer. Equal efficacy to PET when looking for distant metastases and nodal metastases. And interestingly enough, they use pineapple juice as a contrast to help delineate adhesions or peritoneal implants, so it's used more commonly in ovarian cancer in pregnancy. So this, again, is in the most up-to-date ESMO guidelines for managing GYN cancers in pregnancy. This is just an example of the cervical cancer algorithm. So obtaining the diagnosis and staging is relatively similar. Performing a colposcopy, doing a good exam, doing your biopsy or shallow cone, and an MRI or ultrasound for workup to get your diagnosis and stage. And then treatment is really going to depend on what the stage is and then the gestational age of the fetus. And so, for example, if you look over here on the left, if we're talking about an earlier stage cervical cancer, 1A2 or 1B1, you then go to see, OK, how far along is the pregnancy? Because if you're less than 22 weeks, you could still consider surgical evaluation of the lymph nodes. And the lymph nodes are really important to determine if we can counsel the patient that continuing the pregnancy is safe or if we need to counsel the patient that we should consider termination of pregnancy. So if you have a patient who has an early stage cervical cancer and they're less than 22 weeks, performing a laparoscopic lymph node evaluation is recommended. I recently did this for one of my patients at 14 weeks. I did a sentinel node evaluation laparoscopically to ensure that the lymph nodes were negative. And then we delayed treatment until after delivery. And I performed a radical hysterectomy after delivery. If the lymph nodes are positive, then the treatment is really standard of care with chemo and radiation. And so you really want to counsel that patient on termination of pregnancy. If the patient is greater than 22 weeks gestational age, operating gets trickier, especially performing a lymph node dissection. So here, you're kind of counseling the patient on whether or not you want to give neoadjuvant chemotherapy or delay treatment until after delivery. 1B2 is kind of similar management. 1B3, where the tumor size gets greater than 4 centimeters, again, divided into less than or greater than 22 weeks gestation. At this point, we're really not going after the lymph nodes because we're kind of talking either about neoadjuvant chemotherapy or termination of pregnancy if less than 22 weeks. But if the pregnancy is further along where termination of pregnancy is not an option, then you're talking about chemotherapy or delaying treatment until after delivery. I don't mean to get too much into the nuances, but basically, it really depends on the stage, the gestational age, and lymph node evaluation kind of being most paramount in determining how to manage these patients. In terms of just basic principles of operating during pregnancy, the ideal time to operate, we're talking specifically about cancer and pregnancy, and lymph node evaluation is about 14 to 16 weeks. You want to wait until you're after the first trimester to minimize your miscarriage risk and fetal risk from anesthesia. And at this point, the uterine size is still acceptable and feasible. Laparoscopy is always preferred. The ESMO guidelines do say that laparotomy may be more appropriate the higher gestational age you get based on uterine size. But laparoscopy is associated with less fetal adverse effects, shorter operative time, and shorter hospital stays. General laparoscopy guidelines for operating during pregnancy are not exceeding an operative time more than 120 minutes and keeping your intra-abdominal pressure to around 12 millimeters of mercury as opposed to the standard 15 millimeters of mercury that we typically use. And they recommend an open introduction with a Hassan technique as opposed to just a blind varus entry. And laparotomy has been associated with more preterm contractions, but not necessarily more preterm delivery. In terms of evaluating the lymph nodes and use of sentinel mapping with ICG, we know that it's become standard of care if accessible in the United States, but still experimental in pregnancy just because we don't have the amounts of people to really give us the data that says it's OK. But limited literature suggests that it is safe, and I used it in my patient, and she did just fine. In terms of radiation and gynecologic cancers, there really is no role unless fetal death is considered unavoidable. We are radiating the pelvis in most gynecologic cancers. So there is no safe threshold for radiation in GYN cancers. It is radiations associated with fetal death, malformations, growth disturbances, et cetera. And it is also associated with decreased obstetrical outcomes in future and subsequent pregnancies for patients who receive radiation for gynecologic cancer. So important to counsel your younger patients about that. However, non-pelvic radiation during pregnancy seems to be OK out of the scope of this talk. But obviously, head, neck, something like that seems to be relatively OK. You're not targeting the fetus. In terms of chemotherapy administration during pregnancy, it is contraindicated in the first trimester due to an up to 20% risk of major fetal malformations. But after the first trimester, it's overall considered safe. Dosing should be based on your actual pregnancy weight, not the ideal or pre-pregnancy weight. And also, it's really not recommended to give chemo beyond 34 to 35 weeks because you really want to allow a three-week window between the last cycle and delivery to up the mother's counts. And also, it's important in preterm infants because they don't have the enzymes to properly metabolize that chemotherapy adequately. So you really want the mom and the placenta to do their job to get rid of that before delivery. Cisplatin is, of course, the most standard of care chemotherapy for cervical cancer. But there is a significant risk of ototoxicity in the fetus when given during pregnancy. And so carboplatin is the preferred substitution. A multidisciplinary team is always important, but very important if you have a pregnant patient diagnosed with a cancer. So to have your general OBGYN involved, as well as MFM, GYN, NICU, anesthesia, social work, having regular team meetings to update on the status and what's going on with the patient is very important to make sure everyone's on board. Accurate dating during pregnancy is very important because it determines what we can and can't do and when we can give chemotherapy, et cetera. In terms of genetic testing, I recommend standard screening for chromosomal and structural anomalies. And then whatever genetic testing would be recommended based on the cancer. So ovarian cancer, get your genetic testing, et cetera. But there's no special genetic testing that needs to be done just because they were pregnant and had a cancer at the same time. Nutrition counseling is very important. Like we said, having NICU involved and MFM involved because chemotherapy during pregnancy can be associated with intrauterine growth restriction, pre-prom and preterm delivery. And taxanes, like Taxol, can increase your risk of NICU admission. So making sure that the NICU is aware of what the patient received during pregnancy as well. So timing of delivery. You know, if possible, we really don't want to induce anybody before 37 weeks if we don't have to. So if the patient's doing well and responding to treatment and mom and baby are doing OK, then it's OK to wait until 37 weeks to be induced to really avoid neonatal morbidities. And we talk about cervical cancer specifically. And we talk about the mode of delivery, meaning vaginal delivery versus cesarean delivery. And so cesarean delivery is the preferred mode of delivery for cervical cancer during pregnancy because vaginal delivery theoretically can result in cervical lacerations, increased bleeding. There are case reports that there have been implantation of malignant cells at episiotomy sites and laceration sites. And so this decreases the risk of metastases as well. And theoretically, cervical cancer could obstruct the birth canal as well, which could cause problems during birth. It's important to note that patients with a past previously treated cervical cancer are OK for vaginal delivery. So if you have a patient who's pregnant but she had an early stage cervical cancer five years ago, was treated, and is fine, no active lesions, no recurrence, there's no reason that she cannot go on to have a vaginal delivery. Things to do postpartum. So always send the placenta to pathology to evaluate for metastatic disease, although very rare. Metastasis to the fetus is also very, very rare. Postpartum VTE prophylaxis, highly recommended. The ESMO guidelines say for at least one week postpartum. I would argue at least two. And breastfeeding is OK postpartum if the patient is not actively receiving chemotherapy during that time. In terms of overall prognosis for the mom, the prognosis of cervical cancer, particularly during pregnancy, is similar to the prognosis in a non-pregnant state. Pregnancy does not appear to negatively impact cervical cancer outcomes nor positively impact their outcomes either. So their overall survival and progression-free survival tends to be the same. In terms of the impact on the babies, there's no babies fetus, sorry. There's no studies that have specifically looked at the long-term toxic effects of children who have been exposed to GYN cancer in utero. So it's unclear if in utero chemotherapy exposure has similar toxic effects. But basically, they look at young kids who had a cancer when they were younger and received chemotherapy when they were infants or young children, which can lead to long-term cardiotoxic effects, hearing loss, neurocognitive problems, et cetera. And so they kind of extract those same risks for increased morbidities. And the pediatrician will watch those kids closely and look for those things as their development goes on. Mental health is a huge, huge component during pregnancy, during cancer, let alone you have a pregnancy and a cancer at the same time. And so involving psychologists and therapists is really highly recommended as part of the interdisciplinary care team. We do have evidence to show that stress and anxiety are linked to adverse birth outcomes. So minimizing that can really help the health of the mother and the health of the baby as well. Educating your patient is very, very important. So letting them know that outcomes are the same, letting them know what to expect, what the course is going to be, how this can affect the baby. All of that can reduce stress and really helps the patients. And support groups can be really helpful, too. This is a very rare thing to have a cancer during pregnancy. And no matter what we say to them, sometimes just talking to somebody else who has gone through it, too, can really be helpful. So overall conclusion, cervical cancer in pregnancy can be managed safely. And the prognosis of cervical cancer during pregnancy is favorable. Management of any gynecologic cancer in pregnancy requires a multidisciplinary approach. And pregnant cancer patients really deserve a careful, continuous assessment and support of their psychological and mental health on a routine basis. And follow-up in the postpartum period as well is very, very important, too. So that is all I have for you. And I'll take any questions. And thank you all so much.

gynecologic cancers

cervical cancer

pregnancy

treatment options

mental health support