9
Ovarian cancer in pregnancy

https://doi.org/10.1016/j.bpobgyn.2016.09.013Get rights and content

Highlights

  • Ovarian cancer in pregnancy is an uncommon event.

  • Diagnosis may be challenging due to the modifications induced by pregnancy.

  • Surgery can be performed after 16 weeks of gestation.

  • Chemotherapy can be administered in the second and third trimesters.

  • The treatment aims at adequately curing patients and achieving full-term delivery.

Although the occurrence of ovarian masses in pregnancy is relatively common, the majority of them is functional and resolve spontaneously; nevertheless, ovarian cancer is the fifth most common malignancy diagnosed in pregnancy. If malignancy is suspected, treatment should be decided on the basis of gestational age, stage of the disease and patient preferences. In early stage, ovarian cancer surgery may be planned preferably after 16 weeks of pregnancy, and chemotherapy can be administered from the second trimester if indicated as in non-pregnant patients. In advanced-stage disease, when complete cytoreduction is not achievable, neoadjuvant chemotherapy could be administered even in pregnancy. Chemotherapy should be a combination of carboplatin and paclitaxel in epithelial ovarian cancer patients and a combination of cisplatin, vinblastin and bleomycin in non-epithelial ovarian cancer. The outcome of patients with ovarian cancer diagnosed in pregnancy is similar to non-pregnant patients, and stage of the disease is the most important prognostic factor.

Introduction

A small proportion of pregnant women (∼0.2–2%) are diagnosed with adnexal masses, mostly in the first trimester by routine obstetrical ultrasound. The vast majority are benign, pregnancy-related masses and will resolve spontaneous within the first 16 weeks of pregnancy. However, malignancy rate of adnexal masses in pregnancy is 1–6%, which makes ovarian cancer the fifth most common tumour in pregnancy [1], [2], [3]. Awareness on the possibility of ovarian cancer in pregnancy is important and careful evaluation of (persisting) adnexal masses in pregnancy is required to avoid delay in diagnosis.

This chapter will give an overview of the diagnostic and therapeutic possibilities in pregnant patients with adnexal masses and ovarian cancer.

Section snippets

Diagnosis

Adnexal masses in premenopausal women are often found incidentally and are mostly of little clinical relevance. Because of the extensive use of obstetrical ultrasound, the number of masses diagnosed in pregnancy has increased over the past decades and it is therefore important to identify those who need further evaluation. Adnexal masses in pregnancy can be categorized into ovarian and non-ovarian as well as pregnancy-related and non-pregnancy-related. Non-pregnancy related masses can change

Surgical treatment

Surgery can be seen as the least controversial type of oncologic treatment in pregnancy because of the frequent application of surgery for non-oncological reasons with no reported adverse effects. Non-obstetrical surgery is performed in one to four of 200 pregnant patients. Surgery can be performed throughout pregnancy, provided specific measures are taken. If the expected delivery date is forthcoming, the general condition of the patient good and disease is not quickly progressive, and one

Chemotherapy for epithelial ovarian cancers

Chemotherapy should be offered after primary surgery in all cases of epithelial ovarian cancer. As in non-pregnant patients, only stage IA, grade 1 and 2 patients can avoid chemotherapy and be carefully monitored. When the diagnosis of advanced epithelial ovarian cancer is made preoperatively, neoadjuvant chemotherapy could be proposed as complete cytoreduction including hysterectomy, which cannot be achieved if pregnancy has to be preserved.

To avoid maternal hematopoietic nadir and neonatal

Oncological outcome

Stensheim et al. [67] compared the cause-specific survival for patients diagnosed with cancer in pregnancy or lactation with the outcome in non-pregnant cancer patients. For ovarian cancer, pregnant patients seemed to have a reduced risk of cause-specific death (RR 0.46, CI 0.17–1.23). Physical examination and ultrasound investigation in pregnancy might imply early diagnosis of an ovarian tumour, similarly to incidentally detected tumours in caesarean delivery. A higher proportion (60%) was

Obstetrical outcome after ovarian cancer in pregnancy

Pregnancies complicated by maternal cancer are considered as high-risk pregnancies and should be followed in a multidisciplinary high-risk obstetric unit.

Comparing the obstetrical outcome of patients diagnosed with cancer in pregnancy to the outcome of normal pregnancies, three complications occur more commonly: prematurity, foetal growth restriction and foetal loss *[55], [70], [71]. Foetal losses are associated with higher rates of pregnancy terminations as well as infectious complications,

Summary

Malignant ovarian cancer diagnosis in pregnancy is an uncommon event, but it requires adequate treatment in order to obtain a good obstetrical and oncological outcome. Diagnosis is usually made by ultrasound, and the differentiation of suspicious ovarian masses from pregnancy-related functional cysts might be challenging, also because tumour markers, such as CA 125, are not reliable in pregnancy. When ultrasound is not conclusive, MRI can add value in characterizing ovarian masses. With regard

Conflict of interest statement

None.

References (76)

  • P. Köpf-Maier et al.

    Lack of severe malformations versus occurrence of marked embryotoxic effects after treatment of pregnant mice with cis-platinum

    Toxicology

    (1985 Mar 29)
  • M.S. Hassan et al.

    Teratogenic effect of cisplatin in rats and the protective role of sodium selenate

    Exp Toxicol Pathol Off J Ges Für Toxikol Pathol

    (2016 May)
  • L. Elit et al.

    An endodermal sinus tumor diagnosed in pregnancy: case report and review of the literature

    Gynecol Oncol

    (1999 Jan)
  • M.P. Shieh et al.

    Oligohydramnios associated with administration of weekly paclitaxel for triple-negative breast cancer during pregnancy

    Ann Oncol Off J Eur Soc Med Oncol ESMO

    (2011 Sep)
  • E. Cardonick et al.

    Maternal and fetal outcomes of taxane chemotherapy in breast and ovarian cancer during pregnancy: case series and review of the literature

    Ann Oncol Off J Eur Soc Med Oncol ESMO

    (2012 Dec)
  • A.M. Gonzalez-Angulo et al.

    Paclitaxel chemotherapy in a pregnant patient with bilateral breast cancer

    Clin Breast Cancer

    (2004 Oct)
  • J.-Y. Han et al.

    Pregnancy outcome after prenatal exposure to bleomycin, etoposide and cisplatin for malignant ovarian germ cell tumors: report of 2 cases

    Reprod Toxicol Elmsford N

    (2005 Apr)
  • F. Machado et al.

    Ovarian cancer during pregnancy: analysis of 15 cases

    Gynecol Oncol

    (2007 May)
  • E.A. Blake et al.

    Feto-maternal outcomes of pregnancy complicated by epithelial ovarian cancer: a systematic review of literature

    Eur J Obstet Gynecol Reprod Biol

    (2015 Mar)
  • E.A. Blake et al.

    Feto-maternal outcomes of pregnancy complicated by ovarian sex-cord stromal tumor: a systematic review of literature

    Eur J Obstet Gynecol Reprod Biol

    (2014)
  • S. Tamaru et al.

    Neurodevelopmental outcomes of very low birth weight and extremely low birth weight infants at 18 months of corrected age associated with prenatal risk factors

    Early Hum Dev

    (2011 Jan)
  • F. Amant et al.

    Long-term cognitive and cardiac outcomes after prenatal exposure to chemotherapy in children aged 18 months or older: an observational study

    Lancet Oncol

    (2012 Mar)
  • M. Kodama et al.

    Feto-maternal outcomes of pregnancy complicated by ovarian malignant germ cell tumor: a systematic review of literature

    Eur J Obstet Gynecol Reprod Biol

    (2014 Oct)
  • G.S. Leiserowitz

    Managing ovarian masses during pregnancy

    Obstet Gynecol Surv

    (2006 Jul)
  • N.A. Telischak et al.

    MRI of adnexal masses in pregnancy

    AJR Am J Roentgenol

    (2008 Aug)
  • G. Chiang et al.

    Imaging of adnexal masses in pregnancy

    J Ultrasound Med Off J Am Inst Ultrasound Med

    (2004 Jun)
  • P. Glanc et al.

    Adnexal masses in the pregnant patient: a diagnostic and management challenge

    Ultrasound Q

    (2008 Dec)
  • R. Usui et al.

    A retrospective survey of clinical, pathologic, and prognostic features of adnexal masses operated on during pregnancy

    J Obstet Gynaecol Res

    (2000 Apr)
  • D. Timmerman et al.

    Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group

    BMJ

    (2010)
  • M.D. Patel et al.

    Endometriomas: diagnostic performance of US

    Radiology

    (1999 Mar)
  • Expert Panel on MR Safety et al.

    ACR guidance document on MR safe practices: 2013

    J Magn Reson Imaging JMRI

    (2013 Mar)
  • ACOG Committee on Obstetric Practice

    ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy

    Obstet Gynecol

    (2004)
  • A.M. Takalkar et al.

    18F-FDG PET in pregnancy and fetal radiation dose estimates

    J Nucl Med

    (2011)
  • S.N. Han et al.

    Physiologic variations of serum tumor markers in gynecological malignancies during pregnancy: a systematic review

    BMC Med

    (2012)
  • J. Pearl et al.

    Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy

    Surg Endosc

    (2011 Nov)
  • F. Amant et al.

    Gynecologic cancers in pregnancy: guidelines of a second international consensus meeting

    Int J Gynecol Cancer Off J Int Gynecol Cancer Soc

    (2014 Mar)
  • S. Bunyavejchevin et al.

    Laparoscopic surgery for presumed benign ovarian tumor during pregnancy

    Cochrane Database Syst Rev

    (2013)
  • Shnider and Levinson

    Anesthesia for obstetrics

    (2012)
  • Cited by (43)

    • Rare association of the ovarian adenocarcinoma with pregnancy: A case report

      2022, Annals of Medicine and Surgery
      Citation Excerpt :

      Unfortunately, the diagnosis of cancer during pregnancy is often delayed due to the difficulty in differentiating certain symptoms from those of the pregnant state; notably nausea, vomiting, breast changes, abdominal pain, anemia and fatigue [8]. These ovarian cancers are more frequently reported in primigravida, and the majority are diagnosed at an early stage by routine ultrasound routine ultrasound examinations [13,14]. Because of its high sensitivity and specificity in characterizing the morphology of abdominal masses, ultrasound examination is the optimal diagnostic tool during pregnancy, and it can also differentiate benign from malignant masses [12,15].

    • Enlarging ovarian cysts mimicking malignant or borderline tumors during pregnancy

      2021, Gynecology and Obstetrics Clinical Medicine
      Citation Excerpt :

      In most cases, ovarian cysts present as benign or physiological cysts that generally regress spontaneously and seldomly cause severe symptoms. For persistent ovarian cysts during pregnancy, only about 1%–6% could finally be demonstrated as malignant 6, leading to an overall incidence of ovarian cancer being lower than 50 per million pregnancies.5,7 Among ovarian cancers during pregnancy, germ cell tumors were identified as the most common pathological type.8

    • Gynecological cancer during pregnancy—From a gyne-oncological perspective

      2024, Acta Obstetricia et Gynecologica Scandinavica
    View all citing articles on Scopus
    View full text