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CASE HISTORY

Case History

image A 33-year-old woman attended for routine cervical screening. Her past history included an elective caesarean section for breech presentation and a BMI > 50.Her cervical cytology sample detected low-grade dyskaryosis with high-risk human papilloma virus detected. A colposcopic examination took place with a cervical biopsy and revealed Cervical Intraepithelial Neoplasia (CIN) 2. She underwent a Large Loop Excision of the Transformation Zone (LLETZ) which showed a FIGO Stage 1B1 Squamous cell carcinoma of the cervix, incompletely excised at the deepest margin. Staging investigations included Magnetic Resonance imaging (MRI) of the pelvis which showed possible involvement of a left external iliac lymph node. A subsequent PET-CT scan did not show uptake in the cervix or nodes. Treatment options were discussed, and she opted for fertility sparing treatment with a laparoscopic radical trachelectomy and bilateral lymphadenectomy. The final histology did not show any evidence of metastasis in the lymph nodes and there was no evidence of residual neoplasia in the cervix or paracervical tissues. She was subsequently followed up with an MRI scan and 6-monthly cervical cytology, which were all normal. Two years later she went on to conceive a singleton pregnancy which was managed using serial scans in early pregnancy, and growth scans in the third trimester. She developed gestational diabetes, which was treated with metformin, and suffered preterm prelabour rupture of membranes at 34+4 weeks gestation, following which she was transferred to a tertiary centre. A healthy baby was delivered by semi-elective caesarean section two days later after steroid cover had been administered for fetal lung maturation.

How did staging affect the options for fertility preservation in this case?

What treatment options were available for this woman?

Are there fertility sparing options for treatment if her cancer had been more advanced?

How are this woman’s fertility and obstetric outcomes affected by treatment for cervical cancer?

How should she be counselled about management in any future pregnancies?

How should we counsel her about the effects of future fertility and contraception?

How did staging affect the options for fertility preservation in this case?

Early stage cancers (< FIGO Stage 1B2) are usually treated surgically. For Stage 1A1 cancers a LLETZ can be sufficient, but for more advanced cancers lymph node assessment would need to be performed due to the risk of metastases, whether this is combined with a local procedure, such as a LLETZ or knife cone biopsy, or a radical trachelectomy1. Radical trachelectomy involves the surgical removal of the majority of the cervix and parametrial tissue and the insertion of a permanent cervical suture to help mitigate against cervical insufficiency in any subsequent pregnancy. In view of the slightly enlarged lymph node on MRI scan, this patient had further pre-operative assessment with a PET-CT scan, and intra-operative assessment with a frozen section enabling immediate histopathological review.

What cancer treatment options were available for this woman?

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