妊娠合并子宫颈癌13例诊治的临床分析

Management of invasive cervical cancer in pregnancy： clinical analysis of 13 cases

目的总结妊娠合并宫颈癌的临床特点及诊治经验，分析治疗效果及妊娠结局。方法回顾性分析2001年1月至2011年9月于北京协和医院就诊的13例孕期诊断为宫颈癌患者的临床资料，分析其诊断时的孕周、治疗方法的选择及母儿结局等。结果2001年1月至2011年9月北京协和医院共诊治宫颈癌2030例，其中妊娠合并宫颈癌者13例，占0．64％（13／2030）。13例患者诊断为宫颈癌时的平均孕周为21周”，其中早孕者2例、中孕者8例、晚孕者3例。主要症状为孕期阴道流血；13例患者均经病理检查诊断，主要病理类型为宫颈鳞癌（10例，10／13）；11例（11／13）为Ⅰ期。6例（6／13）患者，诊断后立即终止妊娠并积极治疗宫颈癌，诊断至开始治疗的平均时间为16d；7例（7／13）患者，因有强烈的生育要求、而行保胎观察并延迟宫颈癌的治疗，诊断至治疗宫颈癌的平均间期为65d，并均以剖宫产术终止妊娠，终止妊娠的平均孕周为34周”，其中2例在终止妊娠前分别进行了顺铂和氟尿嘧啶（PF）联合方案或单药顺铂先期化疗，使用PF方案化疗者新生儿死亡（1例）。7例中余6例新生儿均预后良好。11例Ⅰ期患者中有7例（7／11）进行了广泛性子宫切除及盆腔淋巴结切除术，1例Ib1期患者（1／11）进行了广泛性宫颈切除及盆腔淋巴结切除术；3例（3／11）患者于剖宫产术后行宫颈锥切术。2例Ⅱ期患者，均于终止妊娠后进行标准的同步放化疗。11例经手术治疗的Ⅰ期患者，2例复发，其中1例死亡，另1例复发后经放化疗治疗肿瘤得到控制。2例Ⅱ期患者，1例因放化疗后肿瘤未控死亡，另1例于根治性放疗后53个月复发，后失访。13例妊娠合并宫颈癌患者治疗后，共3例（3／13）复发，1例（1／13）肿瘤未控，2例（2／13）死亡。结论妊娠合并宫颈癌多为早期宫颈癌，治疗应个体化。对于中晚孕期发现的宫颈癌，如患者保胎要求强烈，根据病情酌情延迟宫颈癌治疗至胎儿成熟是一个合理的选择。孕期进行化疗有可能造成新生儿预后不良。

Objective To analyze the clinical characteristics and assess the outcome of treatment for cervical cancer during pregnancy. Methods A cohort of 13 patients with cervical cancer diagnosed during pregnancy from January 2001 to September 2011 in Peking Union Medical College Hospital （PUMCH） was retrospectively studied. Clinical information, gestational age at diagnosis, treatment options and maternal and child outcomes were collected and analyzed. Results Thirteen patients out of 2030 cases of invasive cervical cancer were diagnosed during pregnancy with an incidence of 0. 64% （13/2030）. The Mean gestational age at diagnosis of 13 patients is 21＋6 weeks. Two cases were diagnosed during the first trimester, 8 cases at second trimester and 3 cases at third trimester respectively. Vaginal bleeding during the pregnancy was main clinical manifestation presented in 8 patients and all thirteen cases were diagnosed by biopsy with pathological types of squamous cell carcinoma in 10 cases. The International Federation of Gynecology and Obstetrics （FIGO） stage was Ⅰ in eleven cases and stage Ⅱ in two cases. Six patients of them received treatment promptly after diagnosis. The other 7 patients had delayed treatment with mean diagnosis-treatment interval time of 65 days due to fertility reasons, who ended pregnancy by cesarean section at mean gestational age of 34＋6 weeks, two of them received chemotherapy with cisplatin ＋ fluorouracil （PF）or cisplatin respectively before the end of the pregnancy, while the one with PF chemotherapy experienced neonatal death. The rest 6 neonatal outcomes were good. As follow-up of 13 cases： 11 cases in stage Ⅰ received surgical treatment, and two of which had recurrence respectively, 15 months and 7 months post surgery, and one case had died. One case of StageⅡ patients died and one had recurrence afler 53 months af＇ter radiotherapy. The recmTence rate in 13 cases was 3/13 and the mortality rate was 2/13. Conclusions Most cases of cervical cancer diagnosed during pregnancy were in early FIGO stage. For those patients diagnosed in late pregnancy with strong fertility demand, considering delayed treatment according to FIGO stage of the disease and fetus matmity is appropriate. Chemotherapy during pregnancy may cause neonatal complications.