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Case history

image A 31-year-old woman presented with bleeding at 27 weeks of pregnancy. This was her fourth pregnancy. She had a previously reported abnormal smear (cervical intraepithelial neoplasia), but no further follow-up had been offered. She had no other relevant medical history. On examination she was found to have a visible tumour at the cervix, and a biopsy was taken. Histopathology reported a poorly differentiated squamous cell carcinoma. An MRI scan of the pelvis revealed a 5 cm × 3 cm × 4 cm tumour in the anterior lip of the cervix extending into the left parametrium. A CT scan of the thorax reported no metastatic disease.

The patient had an elective caesarean section in a tertiary care centre at 32 weeks, 5 weeks after diagnosis, and gave birth to a healthy baby. The reassessment MRI and PET-CT scan showed the tumour had grown to 6.0 cm × 6.5 cm, with prolapse into the upper vagina and an abnormal pelvic node: International Federation of Gynecology and Obstetrics (FIGO) stage IIB node-positive squamous cell carcinoma of the cervix.

She was scheduled to have 48 Gy of radiotherapy in 28 fractions and five cycles of weekly concurrent cisplatin chemotherapy, followed by 21 Gy of intracavity brachytherapy in three fractions. It was not, however, possible to deliver the MRI-guided brachytherapy boost to the whole tumour, due to the location of the residual disease. She therefore had an external beam phase 2 boost to the residual tumour volume (18 Gy in 10 fractions and two further, concurrent cisplatin cycles). The potential increase in significant long-term toxicity was discussed with her.

She had a good partial response after 6 weeks of treatment. Routine follow-up at 3 months with post-treatment MRI and a PET-CT scan showed a complete response to treatment, and MRI at 12 months showed no residual or progressive disease.

At baseline, during treatment and in the year following treatment, as part of a clinical study of patient-reported outcomes the patient completed online questionnaires regarding her symptoms and routine clinical care. During treatment she reported expected short-term side effects of fatigue, diarrhoea, urinary frequency and dysuria. These settled but over the next 18 months of follow-up she developed late effects of peripheral neuropathy, urinary incontinence, intermittent haematuria and urgency, bowel urgency and abdominal cramps, hip stiffness and menopausal symptoms. Radiation cystitis was diagnosed following intermittent haematuria symptoms (Figure 14.1). Supportive treatments for those symptoms were given. She has had some benefit from hormone replacement therapy for hot flushes and joint aches; pelvic floor exercises for urinary incontinence; and bowel symptoms are managed with hyoscine butylbromide and loperamide as required. Her peripheral neuropathy symptoms have resolved.

What is the evidence base for postpartum treatment options?

How does the management of cervical cancer differ depending on tumour stage and trimester of pregnancy?

What is the role of PET-CT in staging and response assessment in cervical cancer?

What is the schedule and purpose of routine follow-up after ...

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