(2)周産期科サイドよりみた浸潤子宮頸癌に対する妊孕性温存療法の現状と課題(<特集>第62回学術講演会 シンポジウム1 婦人科癌における妊孕性温存治療(手術および薬物療法))

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  • A Study of Pregnancy-related Complications after Fertility Preserving Treatments for Invasive Uterine Cervical Cancer

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Radical trachelectomy (RT) with pelvic lymphadenectomy has become a feasible treatment modality for patients with early-stage invasive uterine cervical cancer in women who would like to preserve their fertility. Our department started performing vaginal RT with pelvic lymphadenectomy in 2003 and we have already performed twenty vaginal RTs. Among them, we experienced four successful deliveries so far. In this study, we compared pregnancy courses after vaginal RT in four patients with the pregnancy courses after laser conization that was performed during the same period in twenty patients, with respect to symptoms, cervical length, and infectious signs. And we also studied the significance of planned delay in treatment until maturation of the fetus as a treatment modality for pregnant patients with invasive gynecologic cancers. New strategy to reduce pregnancy-related complications in those patients was also studied. Our operative procedure for vaginal RT was based on that of Dargent et al. In vaginal RT, we usually amputated the cervix at the level of uterine artery, which corresponded to approximately 10mm below the isthmus. As the removal of parametrium, we cut them at the level of Type II hysterectomy. For pregnancy, premature labor and the following occurrence of preterm premature rupture of the membrane (pPROM) appeared to be a significant risk in patients who underwent vaginal RT. Various factors such as lack of a protective effect against vaginal infection or the lack of mechanical support of the residual cervix might induce such complications. Originally, we started anti-infectious treatments after the detection of infectious signs such as the elevation of granulocyte elastase level and oncofetal fibronectin level, or the positive vaginal flora. However, earlier two patients suffered from sudden pPROM at 32 and 23 weeks of gestation without any symptoms, respectively. Especially placenta from the second patient, who suffered f rom pPROM at 23 weeks of gestation, showed severe choriamnionitis (CAM). This might indicate the existence of chronic intrauterine inflamation without any clinical symptoms from the earlier pregnancy period. The outcome of pregnancy after conization was also influenced by cone size and height. Larger dissection of the uterine cervix tended to result in earlier delivery. Among them, two patients experienced pPROM before 32 weeks of gestation. One repeated vaginal infection during pregnancy in spite of repeated anti-infectious treatments. Another patient underwent conization twice, and originally she had shorter uterine cervical length. These results indicate the necessity of prophylactic approach to them. From these results, we proposed a new strategy for patients who underwent VRT to prevent pPROM. We recommended patients to admit our hospital early in their second trimester, and we started prophylactic daily vaginal administration of popidone-iodine and a ulinastatin vaginal suppository for those patients. Furthermore we carefully checked vaginal flora, the granulocyte elastase level, and the oncofetal fibronectin level in vaginal secretion, as well as the cervical length and abdominal tension of patients in shorter interval than usual patients with preterm labor. Thanks to this treatment modality, recent two patients did not suffered from pPROM and we could perform scheduled cesarean section in their late third trimester. However, this treatment modality needs hospital stay and bed rest for a long period. As to planned delay in treatment, five patients, (four with invasive uterine cervical cancer and one with ovarian cancer) chose this treatment modality for 2～19 weeks. Only one patient with advanced ovarian cancer died of the primary disease after the delivery, however the remaining four patients completed the treatment after the delivery. And they do not show recurrence so far. All the babies are growing well, and no fetal deaths or neonatal deaths occurred. Pl anned delay in treatment to allow for fetal maturity seemed to be acceptable in pregnant patients with certain types of invasive gynecologic cancers. Pregnancy after RT is very high risk one, and we need careful following-up for them. We believe early detection and thorough prevention of vaginal infection during pregnancy will have an impact to prevent preterm labor and pPROM in patients who underwent RT. Furthemore, it might be possible to perform more conservative operations for patients with stage I a2 disease. Such operation as s large conization with pelvic lymphadenectomy for selected women with stage I a2 disease might be taken into consideration.

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