Approach to Radical Hysterectomy for Cervical Cancer in Pregnancy: Surgical Pathway and Ethical Considerations

Rocco Guerrisi; Sarah Louise Smyth; Lamiese Ismail; Amanda Horne; Federico Ferrari; Hooman Soleymani Majd

doi:10.3390/jcm11247352

Approach to Radical Hysterectomy for Cervical Cancer in Pregnancy: Surgical Pathway and Ethical Considerations

J Clin Med. 2022 Dec 10;11(24):7352. doi: 10.3390/jcm11247352.

Authors

Rocco Guerrisi¹, Sarah Louise Smyth², Lamiese Ismail², Amanda Horne³, Federico Ferrari⁴, Hooman Soleymani Majd^{5

6}

Affiliations

¹ Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, 21100 Varese, Italy.
² Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford University Hospital, NHS Foundation Trust, Oxford OX3 9DU, UK.
³ Department of Clinical Oncology, Churchill Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford OX3 7LE, UK.
⁴ Department of Obstetrics and Gynecology, "Spedali Civili" Hospital, University of Brescia, 25121 Brescia, Italy.
⁵ Nuffield Department of Women's Reproductive Health, Medical Sciences Division, Oxford University, Oxford OX3 9DU, UK.
⁶ Department of Gynaecological Oncology, Churchill Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford OX3 7LE, UK.

Abstract

Introduction: Cervical cancer is currently the fourth most common cancer in women and in the poorest countries this neoplasia still represents a widespread and potentially lethal disease. We present a rare case of cervical cancer in pregnancy, analyzing the historical changes behind the procedure of radical hysterectomy for cervical cancer and discussing variations in surgical techniques and anatomical definitions that have since been proposed.

Results: We present the case of a 33-year-old patient who attended with vaginal bleeding in the second trimester of pregnancy. Examination revealed an abnormal looking cervix, with investigations concluding stage IIb squamous cell carcinoma. Following extensive discussion regarding management options, the patient went on to have a peripartum foetocidal type III nerve sparing radical Wertheim hysterectomy at 18 weeks gestation with conservation and transposition of the ovaries above the level of the pelvic brim. The patient recovered well without significant morbidity and received further input from fertility and psychological medical teams in addition to adjuvant treatment within the department of clinical oncology.

Discussion: This case represents several elements of great interest and learning. Notably, we highlight this both due to the surgical challenges that a gravid uterus presents in the execution of a radical hysterectomy; and regarding the compassionate care demonstrated by the team - not only in supporting the patient and her partner in a period of profound turmoil in terms of the management of their cancer diagnosis and unborn child, but also regarding the uncertainty in consideration of the oncological and fertility related outcomes.

Conclusion: This manuscript adds to the growing literature on the appropriate use of radical surgery for cervical cancer, more specifically during pregnancy and in consideration of such ethical dilemma, where management guidelines do not exist to aid clinicians further in their provision of treatment.

Keywords: case report; cervical cancer; pregnancy; radical hysterectomy.

Grants and funding

This research received no external funding.