Research www. AJOG.

org

ONCOLOGY
Cervical cancer associated with pregnancy: Results of a
multicenter retrospective Korean study (KGOG-1006)
Jong-Min Lee, MD, PhD; Kwang-Beom Lee, MD; Young-Tak Kim, MD, PhD; Hee-Sug Ryu, MD, PhD;
Young-Tae Kim, MD, PhD; Chi-Heum Cho, MD, PhD; Sung-Eun Namkoong, MD, PhD;
Ki-Hun Lee, MD, PhD; Ho-Sun Choi, MD, PhD; Kyung-Tai Kim, MD, PhD

OBJECTIVE: The objective of the study was to analyze the characteris-
tics of cervical cancer associated with pregnancy.
STUDY DESIGN: Forty patients with cervical cancer associated with
pregnancy were retrospectively identified between 1995-2003. Three
controls for each case were matched on the basis of age, stage, histol-
ogy, and date of treatment.
RESULTS: Sampling of cervical cytology after the second trimester was
the most common cause of delayed diagnosis. Among 12 patients who
delayed treatment for fetal maturity, 2 died of disease. There was no
difference in overall survival between pregnant and nonpregnant pa-
tients with stage Ib tumors. In contrast to nonpregnant patients, the
depth of stromal invasion was not correlated with the incidence of
lymph vascular space involvement and lymph node metastasis in preg-
nant patients.
CONCLUSION: Thorough evaluation is warranted before deciding
whether to delay treatment until fetal maturity. Pregnancy does not ad-
versely affect the prognosis of early-stage cervical cancer significantly.
Key words: cervical cancer, pregnancy, prognosis

Cite this article as: Lee J-M, Lee K-B, Kim Y-T, et al. Cervical cancer associated with pregnancy: Results of a multicenter retrospective Korean study (KGOG-
1006). Am J Obstet Gynecol 2008;198:92.e1-92.e6.

U terine cervical cancer is the fourth

most common malignant disease
in Korean women, accounting for 9.8%
cern.2 Thus, cervical cancer associated
with pregnancy is a clinical challenge.
Although cervical cancer is the most
vical cancer.3-5 Because of the lack of suf-
ficient data about the effect of pregnancy
on tumor biology, the effects of cancer
of total malignancies in Korean women common gynecologic malignancy asso- on maternal and fetal outcomes, and the
in 2002.1 Because of the increased avail- ciated with pregnancy, it is relatively impact of adequate intervention timing
ability of screening tests, the incidence of rare, with an incidence ranging from 1 on maternal and fetal outcomes, the
cervical cancer has been decreasing in per 1200-10,000 pregnancies, depending management guidelines for these pa-
Korea. However, the incidence of early- on whether carcinoma in situ and post- tients remain unclear.3,4
stage cervical cancer has increased, espe- partum patients are included.3 Preg- To answer some of these questions, we
cially among women in their 20s and 30s nancy has been found not to adversely retrospectively evaluated the clinical
for whom child-bearing remains a con- affect the prognosis of patients with cer- outcomes of patients having cervical
cancer associated with pregnancy. We
also describe the results following delays
From the Departments of Obstetrics and Gynecology, East-West Neo Medical Center, in treatment until fetal maturity, and we
Kyung Hee University, Seoul, Korea (Dr J.-M. Lee); Gachon University, Gil Medical Center, assess the effects of pregnancy on the
Inchon (Dr K.-B. Lee); University of Ulsan College of Medicine, Asan Medical Center, Seoul prognosis of patients with cervical
(Dr Young-Tak Kim); Ajou University School of Medicine, Suwon (Dr Ryu); Yonsei
cancer.
University College of Medicine, Seoul (Dr Young-Tae Kim); Keimyung University, Dongsan
Medical Center, Daegu (Dr Cho); The Catholic University of Korea School of Medicine,
Seoul (Dr Namkoong); Cheil General Hospital and Women’s Health Care Center, M ATERIALS AND M ETHODS
Sungkyunkwan University School of Medicine, Seoul (Dr K.-H. Lee); Chonnam National Forty patients having cervical cancer as-
University College of Medicine, Gwangju (Dr Choi); and Hanyang University College of
sociated with pregnancy, including 1 pa-
Medicine, Seoul (Dr K.-T. Kim), Korea.
tient diagnosed 1 month after vaginal de-
Presented at the 11th Biennial Meeting of International Gynecologic Cancer Society, Oct. 14-18,
livery, were identified from tumor
2006, Santa Monica, CA.
registry databases at 13 tertiary medical
Received Feb. 5, 2007; revised April 3, 2007; accepted June 29, 2007.
centers in Korea from 1995-2003. Insti-
Reprints: Kyung-Tai Kim, Department of Obstetrics and Gynecology, College of Medicine,
Hanyang University, Seoul, 133-792, Korea; kimkt@hanyang.ac.kr.
tutional review board approval was ob-
tained from each of the participating
This work was supported in part by a grant from the Korea Health 21 R&D Project, Ministry of
Health and Welfare, Republic of Korea (0412-CR01-0704-0001). centers.
0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2007.06.077 We reviewed their medical records, in-
cluding medical charts, electronic

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TABLE 1 TABLE 2
Patient characteristics Causes of delayed diagnosis
Variables during or after the second
Mean age (range), y 33.5 (21-46)
trimester
..............................................................................................................................................................................................................................................
Number
Mean gravidity (range) 2.1 (0-7)
.............................................................................................................................................................................................................................................. Causes (n ⴝ 22)
Mean parity (range) 1.1 (0-3) No antenatal care 2
..............................................................................................................................................................................................................................................
...........................................................................................................
Stage Ia1 6 Delayed cervical cytology 13
..............................................................................................................................................................................................................................................
...........................................................................................................
Ib1 16 Cervical cytology not performed 3
..............................................................................................................................................................................................................................................
Ib2 9 until bleeding
.............................................................................................................................................................................................................................................. ...........................................................................................................

IIa 4 Cytologic underestimation of 3

..............................................................................................................................................................................................................................................
LSIL or less
IIb 3 ...........................................................................................................
..............................................................................................................................................................................................................................................
Inaccurate biopsy 1
IIIb 1 ...........................................................................................................
..............................................................................................................................................................................................................................................
LSIL, low-grade squamous intraepithelial lesion.
IVa 1 Lee. Cervical cancer associated with pregnancy.
..............................................................................................................................................................................................................................................
Gestational age at diagnosis First trimester 18 Am J Obstet Gynecol 2008.
..............................................................................................................................................................................................................................................
Second trimester 14
..............................................................................................................................................................................................................................................
Third trimester 7 and 1 was diagnosed at 1 month postpar-
..............................................................................................................................................................................................................................................
Postpartum 1 tum. Squamous cell carcinoma was the
..............................................................................................................................................................................................................................................
most frequent histologic subtype.
Histology Squamous cell carcinoma 30
.............................................................................................................................................................................................................................................. Twelve patients delayed treatment to
Adenocarcinoma 6 achieve fetal maturity; the mean delay
..............................................................................................................................................................................................................................................
Adenosquamous carcinoma 1 was 15.7 weeks (range, 3-34 weeks).
..............................................................................................................................................................................................................................................
Others a
3 Of the 22 patients diagnosed during or
..............................................................................................................................................................................................................................................
after the second trimester, 2 had no an-
Delay in treatment for fetal maturity No 28
.............................................................................................................................................................................................................................................. tenatal care, 13 had cervical cytology af-
Yes 12 ter the second trimester, 3 did not have
..............................................................................................................................................................................................................................................
a
Others: small cell neuroendocrine, clear cell, adenoma malignum. cervical cytology until vaginal bleeding
Lee. Cervical cancer associated with pregnancy. Am J Obstet Gynecol 2008. occurred, 3 had cytologic underestima-
tion of low-grade squamous intraepithe-
lial lesion (LSIL) or less, and 1 had an
records, and follow-up data. Among the Case-control differences were evalu- inaccurate colposcopically directed bi-
data collected were patient age, gesta- ated using Student t test or the Mann– opsy (Table 2).
tional age, date of diagnosis, histology, Whitney U test for continuous variables Table 3 shows the trend of primary
type and date of treatment, duration of and ␹2 test or Fisher’s exact test for cate- treatment according to FIGO stage at di-
treatment delay, and follow-up data. Tu- gorical variables. Overall survival was agnosis. Thirty-six patients, including 2
mor stages were assigned according to evaluated using the Kaplan-Meier with stage IIb and 1 with stage IVa tu-
the International Federation of Gynecol- method and log-rank tests. The signifi- mors, underwent primary surgery. De-
ogy and Obstetrics (FIGO) staging cance level for all analyses was set at 0.05. finitive surgery for patients with early-
system. All analyses were performed using SPSS stage disease except stage Ia1 consisted of
To evaluate the effects of pregnancy on 11 software (v 11; SPSS, Chicago, IL). radical hysterectomy with pelvic
cervical cancer, we identified, for each lymphadenectomy.
pregnant patient, 3 nonpregnant women R ESULTS Twenty-eight patients underwent im-
with FIGO stage Ib tumors, matched on Patient characteristics are shown in Ta- mediate treatment; 17 with gestation of
the basis of age (⫾ 5 years), FIGO stage ble 1. The mean age at diagnosis of the 40 21 weeks or less underwent radical sur-
(Ib1 and Ib2), histology (squamous cell pregnant patients was 33.5 years (range, gery with fetus in situ, 6 with gestation of
carcinoma vs adenocarcinoma vs adeno- 21-46 years); their mean gravidity was 20 weeks or longer underwent radical
squamous carcinoma vs others), and 2.1 (range, 0-7) and their mean parity surgery after cesarean delivery, 2 with
date of treatment (⫾ 2 years) in this or- was 1.1 (range, 0-3). Thirty-five patients gestation in the first trimester underwent
der of priority. For the purposes of the had FIGO stage I-IIa tumors, including radiation or chemoradiation with fetus
study, the referral date was designated as 16 with stage Ib1 and 5 patients with in situ, 1 with gestation of 32 weeks un-
the date of diagnosis. The date of treat- stage IIb or higher. At diagnosis, 18 were derwent radiation after cesarean deliv-
ment was calculated from the first date of in their first trimester, 14 in their second ery, 1 with gestation of 4 weeks under-
definitive treatment. trimester, and 7 in their third trimester, went conization after artificial abortion,

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Two patients in the latter group died; 1

TABLE 3 (case 9) had a stage Ib1 tumor and de-
Trend of primary treatment according to FIGO stage layed treatment for 6 weeks. She had
Stage Conization Type I H Type II H Type III H RT alone CCRT pathologic tumor size of 2 cm, deep stro-
Ia1 4 2 mal invasion, and lymph vascular space
..............................................................................................................................................................................................................................................
Ib1 2 14 involvement and did not receive adju-
..............................................................................................................................................................................................................................................
vant treatment. She had disease recur-
Ib2 9
.............................................................................................................................................................................................................................................. rence at paraaortic lymph nodes 10
IIa 2 2 months later and died of her disease at 34
..............................................................................................................................................................................................................................................
IIb 2 1
..............................................................................................................................................................................................................................................
months. The other (case 10) had a stage
IIIb 1 Ib2 tumor and delayed treatment for 4
..............................................................................................................................................................................................................................................
weeks. She had pathologic tumor size of
IVa 1
.............................................................................................................................................................................................................................................. 4.5cm, lymph vascular space involve-
Total 4 2 2 28 2 2 ment, and multiple pelvic/paraaortic
..............................................................................................................................................................................................................................................
CCRT, concurrent chemoradiation; H, hysterectomy; RT, radiation. lymph nodes metastases. She received
Lee. Cervical cancer associated with pregnancy. Am J Obstet Gynecol 2008. adjuvant chemoradiation, but she died
of her disease at 34 months because of
and 1 who was diagnosed 1 month after FIGO stage Ia1 tumors, 5 had stage Ib1, disease progression. The remaining 10
vaginal delivery underwent radical sur- and 1 each had stages Ib2, IIa, and IIIb. patients are alive after a median fol-
gery. The patient with stage IVa had no Histologically, 7 patients had squa- low-up of 40 months.
antenatal care and had visited the emer- mous cell carcinoma, 1 had adenocar- Comparison of the pregnant patients
gency department because of labor cinoma, 1 had adenosquamous carci- with the 3 nonpregnant patients
pains; she underwent an emergency ce- noma, and 3 had other tumor types. Six matched for age, FIGO stage Ib, histol-
sarean delivery, inadvertent radical hys- patients with a gestation of less than 20 ogy, and date of treatment revealed no
terectomy, and pelvic lymphadenectomy weeks and stage Ia1/Ib1 tumors de- significant differences in the status of re-
with low anterior resection of rectum be- layed treatment for 9-34 weeks to in- section margin (P ⫽ .08), parametrial
cause of erroneous estimation for rectal crease fetal maturity, and 6 patients extension (P ⫽ .68), lymph vascular
invasion on preoperative physical with a gestation of 20 weeks or longer space involvement (P ⫽ .45), lymph
examination. and stage Ib1/Ib2/IIa/IIIb tumors de- node metastasis (P ⫽ .48), and treatment
Table 4 shows the characteristics of layed treatment for 3-17 weeks to in- modality (P ⫽ .15; Table 5). The esti-
patients in whom treatment was de- crease fetal maturity. Fetal outcome in mated 5 year survival rates of pregnant
layed for fetal maturity. Four had both groups was excellent. and nonpregnant patients with stage Ib

TABLE 4
Clinical characteristics of patients managed with planned delay for fetal maturity
GA at dx Delay in Patient status
Cases Age Stage Hx (wks) tx (wks) Tx (mo) Infant (g)
1 33 Ia1 S 11 27 Conization Alive (9) 3610
................................................................................................................................................................................................................................................................................................................................................................................
2 26 Ia1 S 6 9 Conization Alive (29) 3255
................................................................................................................................................................................................................................................................................................................................................................................
3 21 Ia1 A 6 34 Conization Alive (40) 3610
................................................................................................................................................................................................................................................................................................................................................................................
4 27 Ia1 O 18 18 Type I H Alive (40) 2575
................................................................................................................................................................................................................................................................................................................................................................................
5 29 Ib1 S 11 25 Type III H Alive (58) 2500
................................................................................................................................................................................................................................................................................................................................................................................
6 37 Ib1 O 14 18 Type III H Alive (15) 2200
................................................................................................................................................................................................................................................................................................................................................................................
7 27 Ib1 O 23 13 Type III H Alive (22) 2575
................................................................................................................................................................................................................................................................................................................................................................................
8 28 Ib1 S 23 14 Type III H Alive (12) 2600
................................................................................................................................................................................................................................................................................................................................................................................
9 31 Ib1 AS 25 6 Type III H Death (34) 2030
................................................................................................................................................................................................................................................................................................................................................................................
10 29 Ib2 S 31 4 Type III H Death (34) 2100
................................................................................................................................................................................................................................................................................................................................................................................
11 35 IIa S 20 17 Type III H Alive (75) 2900
................................................................................................................................................................................................................................................................................................................................................................................
12 36 IIIb S 32 3 CCRT Alive (104) 1880
................................................................................................................................................................................................................................................................................................................................................................................
A, adenocarcinoma; AS, adenosquamous carcinoma; CCRT, concurrent chemoradiation; Dx, diagnosis; GA, gestational age; H, hysterectomy; Hx, histology; S, squamous cell carcinoma; O (case
4), adenoma malignum; O (case 6), clear cell carcinoma; O (case 7), small cell neuroendocrine carcinoma; Tx, treatment.
Lee. Cervical cancer associated with pregnancy. Am J Obstet Gynecol 2008.

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TABLE 5 FIGURE 1
Clinicopathologic variables in pregnant and nonpregnant patients with Overall survival of pregnant
FIGO stage Ib tumors and nonpregnant patients with
Cases Controls
FIGO stage Ib tumors
Variable (n ⴝ 21) (n ⴝ 63) P
Age (median, range), y 33 (21-46) 38 (22-50)
..............................................................................................................................................................................................................................................
Stage (%)
..............................................................................................................................................................................................................................................
Ib1 12 (57.1) 36 (57.1) 1.00
.....................................................................................................................................................................................................................................
Ib2 9 (42.9) 27 (42.9)
..............................................................................................................................................................................................................................................
Histology (%)
.....................................................................................................................................................................................................................................
SCC 13 (61.9) 39 (61.9) 1.00
.....................................................................................................................................................................................................................................
Adenocarcinoma 5 (23.8) 15 (23.8)
.....................................................................................................................................................................................................................................
Adenosquamous 1 (4.8) 3 (4.8)
.....................................................................................................................................................................................................................................
Others 2 (9.5) 6 (9.5)
..............................................................................................................................................................................................................................................
Lee. Cervical cancer associated with pregnancy. Am J Obstet
RM (%) Gynecol 2008.
.....................................................................................................................................................................................................................................
Negative 20 (95.2) 63 (100) .08
.....................................................................................................................................................................................................................................
Positive 1 (4.8) 0 (0) age at diagnosis of 30-35 years.4,6,7
..............................................................................................................................................................................................................................................
PM (%) Generally, cervical cancer diagnosed
.....................................................................................................................................................................................................................................
within 6-12 months of an antecedent
Negative 18 (85.7) 57 (90.5) .68
..................................................................................................................................................................................................................................... pregnancy is considered to have been
Positive 3 (14.3) 6 (9.5)
..............................................................................................................................................................................................................................................
present during pregnancy.8 Because of
DOI (%) the current trend of delaying preg-
.....................................................................................................................................................................................................................................
Inner 2/3 16 (76.2) 30 (47.6) .02 nancy into the later reproductive years
.....................................................................................................................................................................................................................................
and the increased availability of
Outer 1/3 5 (23.8) 33 (52.4)
.............................................................................................................................................................................................................................................. screening tests for cervical cancer, phy-
LVSI (%) sicians caring for pregnant women
.....................................................................................................................................................................................................................................
Negative 9 (42.9) 33 (52.4) .45 may encounter early-stage cervical
.....................................................................................................................................................................................................................................
Positive 12 (57.1) 30 (47.6) cancer more frequently.3
..............................................................................................................................................................................................................................................
In analyzing the causes of delayed di-
Positive LN (%)
..................................................................................................................................................................................................................................... agnosis made during or after the second
Negative 14 (66.7) 47 (74.6) .48
.....................................................................................................................................................................................................................................
Positive 7 (33.3) 16 (25.4) FIGURE 2
..............................................................................................................................................................................................................................................
Tx modality (%)
Incidence of lymph vascular
..................................................................................................................................................................................................................................... space involvement (LVSI) and
NACT plus surgery 4 (19.0) 6 (9.5) .15 lymph node metastasis (LNM)
.....................................................................................................................................................................................................................................
Surgery 7 (33.3) 36 (57.1)
.....................................................................................................................................................................................................................................
relative to depth of stromal
Surgery plus adjuvant Tx 10 (47.6) 21 (33.3) invasion in nonpregnant
..............................................................................................................................................................................................................................................
DOI, depth of stromal invasion; LN, lymph node; LVSI, lymph vascular space involvement; NACT, neoadjuvant chemotherapy;
patients
PM, parametrial invasion; RM, resection margin; SCC, squamous cell carcinoma; Tx, treatment.
Lee. Cervical cancer associated with pregnancy. Am J Obstet Gynecol 2008.

cervical cancer were 75.0% and 89.4%, node metastasis (P ⫽ .046; Figure 2). In
respectively; this difference was not sig- pregnant patients, however, the depth of
nificant (P ⫽ .41; Figure 1). stromal invasion did not affect the inci-
We also evaluated whether the depth dence of lymph vascular space involve-
of stromal invasion correlated with the ment (P ⫽ .34) or lymph node metastasis
incidence of lymph vascular space in- (P ⫽ .62; Figure 3).
volvement or lymph node metastasis. In
nonpregnant patients, the depth of stro-
mal invasion was significantly correlated C OMMENT Lee. Cervical cancer associated with pregnancy. Am J Obstet
with the incidence of lymph vascular Cervical cancer associated with preg- Gynecol 2008.
space involvement (P ⫽ .00) and lymph nancy is a rare disease, with a median

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cal cancer.9 In addition, only 69% of should be considered for pregnant pa-
FIGURE 3
pregnant patients with stage Ib cervical tients with abnormal cytology and/or
Incidence of lymph vascular
cancer were reported to have had posi- suspicious clinical findings.
space involvement (LVSI) and
tive cytology leading to their diagnosis.10 The surgical treatment guidelines for
lymph node metastasis (LNM)
Not surprisingly, therefore, carcinoma pregnant women with cervical cancer are
relative to depth of stromal
was suspected on cervical cytology in similar to those for nonpregnant wom-
invasion in pregnant patients
only 19 of our 40 patients. en.17 Of our 35 patients with stage I-IIa
During pregnancy, both cervical tumors, 33 underwent surgical manage-
glands and stroma undergo physiologic ment without significant complications.
changes. Decidual cells, endocervical Three of the 5 women with locally ad-
gland hyperplasia, or glandular cells ex- vanced cervical cancer, including stages
hibiting an Arias-Stella reaction may ap- IIb-IVa, however, also underwent radi-
pear worrisome on cytologic interpreta- cal surgery, suggesting the difficulty of
tion.11 However, cytology may be falsely preoperative evaluation in pregnant pa-
negative because it may pick up only the tients with cervical cancer and the sur-
inflammatory and/or the nonneoplastic geon’s inclination to perform surgery at
cells because of the focal neoplastic the time of abdominal delivery.
lesion. Because of a lack of prospective clini-
Lee. Cervical cancer associated with pregnancy. Am J Obstet
The use of an endocervical brush and cal trials, the management of cervical
Gynecol 2008. spatula to obtain a cytologic specimen, as cancer during pregnancy remains un-
compared with a cotton applicator and clear and varies according to stage of dis-
spatula, is safe in pregnancy and reduces ease, gestational age at diagnosis, and
trimester in 22 women, we found that 2 the number of suboptimal smears.12,13 ethical or religious background. Delay-
had never received antenatal care and 16 This is significant because the fraction of ing definitive treatment to improve fetal
had not had or had delayed cervical cy- suboptimal smears in pregnant women outcomes, although beneficial to the fe-
tology. Interestingly, delayed diagnosis is as high as 58% when using the conven- tus, may carry an additional risk of tu-
in 3 patients was because of cytologic un- tional cotton swab vs 29% when using mor progression. A delay in definitive
derestimation of LSIL or less. The lack of the cytobrush.14 Several well-done series treatment is regarded as feasible and safe
access to health care and noncompliance have confirmed the safety and accuracy in patients with small-sized early-stage
with recommended cervical cytological of colposcopy and directed biopsy in disease if there is no evidence of disease
screening has been regarded as signifi- pregnancy.15,16 Therefore, colposcopy progression. However, no firm data are
cant factors in the development of cervi- and directed biopsies, when indicated, available in patients with advanced dis-

TABLE 6
Review of literature published since 1995 for planned treatment delay in cervical cancer associated with
pregnancy
FIGO stage (number of cases)
Period Delay Outcome
Authors accrued Ia1 Ia2 Ib1 Ib2 IIa IIIb (wks) (months)
Sood et al17 1960-1994 4 4 3 3-32 NED; 12-360
................................................................................................................................................................................................................................................................................................................................................................................
18
Sorosky et al 1989-1994 1 7 3-40 NED; 13-68
................................................................................................................................................................................................................................................................................................................................................................................
19
Zanetta et al 1992-1995 3 1 5-18 NED; 40-55
................................................................................................................................................................................................................................................................................................................................................................................
20 a
van Vliet et al 1977-1996 3 2 1 2-10 NED; 16-142
................................................................................................................................................................................................................................................................................................................................................................................
21
Takushi et al 1978-1997 8 1 2 1 6-25 NED; 52-156
................................................................................................................................................................................................................................................................................................................................................................................
5
Germann et al 1985-2000 9 4-24 5-YS; 100%
................................................................................................................................................................................................................................................................................................................................................................................
b c
Current study 1995-2003 4 5 1 1 1 3-34 NED; 9-104
................................................................................................................................................................................................................................................................................................................................................................................
Total cases 17 5 32 5 2 1 2-40
................................................................................................................................................................................................................................................................................................................................................................................
Cases of DOD 0 0 2 1 0 0
................................................................................................................................................................................................................................................................................................................................................................................
DOD, died of disease; NED, no evidence of disease; 5-YS, 5-year survival.
a
Includes 1 patient who died of disease at 14 months.
b
Includes 1 patient who died of disease at 34 months.
c
Includes 1 patient who died of disease at 34 months.
Lee. Cervical cancer associated with pregnancy. Am J Obstet Gynecol 2008.

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ease because of the low number reported
in the literature (Table 6).5,17-21
It has been recommended that a maxi-
mum delay of up to 12 weeks be allowed
for stage Ib1 tumors and 6 weeks for stage
Ib2 tumors, prior to the start of definitive
treatment.3 In addition, recent advances in
neonatal intensive care can dramatically
decrease the duration of a treatment delay.
However, the acceptable duration of treat-
ment delay has not been determined
clearly for pregnant patients with stage Ia2
or more advanced tumors because of an
absence of substantial objective data.21 In
this study, 12 patients delayed definitive
treatments for fetal maturity, and 2 with
stage Ib tumors died of their disease. Al-
though the current study population was
small and heterogeneous for stage and
length of treatment delay, the 2 patients
who died delayed treatment for only 4 and
6 weeks, respectively. Therefore, thorough
evaluation of clinical characteristics prior
to deciding on a treatment plan is
necessary.
Although most studies have found
that pregnancy did not adversely affect
maternal outcome or tumor biology,
most of these studies evaluated a small
number of patients, were retrospective in
design, and did not match prognostic
factors in cases and controls.10,22-24 Al-
though 1 study matched cases and con-
trols for age, year of diagnosis, stage, and
tumor type,25 pregnancy-dependent
pathologic characteristics were not in-
cluded. When we matched the pregnant
and nonpregnant patients with stage Ib
disease, we observed no significant dif-
ferences in pathologic risk factors and
overall survival. However, the depth of
stromal invasion was not correlated with
the incidence of lymph vascular space in-
volvement and lymph node metastasis in
pregnant patients, whereas they were
correlated in nonpregnant patients.
These findings may suggest that the
enlargement of the uterine cervix in-
duced by pregnancy may relatively lessen
the depth of stromal invasion in preg-
nant patients rather than that lymph vas-
cular space involvement and lymph
node metastasis may occur early in the
progression of disease in pregnant pa-
tients. Thus, clinical significance of the
depth of stromal invasion in pregnant
patients should be evaluated with more
information from a larger number of pa-
tients in the future.
Because of the limited number of pa-
tients and the characteristics inherent to
a retrospective design, our results cannot
provide definitive guidelines for treating
women with cervical cancer associated
with pregnancy. Our experiences, how-
ever, may contribute to the foundation
of knowledge with regard to cervical can-
cer associated with pregnancy. f cytobrush during pregnancy. Gynecol Oncol
ACKNOWLEDGMENTS
The following members of Korean Gynecologic
Oncology Group also participated in this study:
Asan Medical Center Seoul (Jung E. Mok, Joo
H. Nam, Yong M. Kim, Jong H. Kim); Donga
University Hospital (Goo H. Je); National Cancer
Center (Sang Y. Park, Byung H. Nam); and
Seoul National University Hospital (Soon B.
Kang, Jae W. Kim).
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