Neoadjuvant Chemotherapy of Cervical Squamous Cell Carcinoma during Pregnancy: A Case Report

Background and aim: Cervical malignancy is one of the three most prevalent cancers during pregnancy with an incidence rate of 4 in every 10 pregnant woman. Squamous cell carcinoma (SCC) is one of the common primary malignancies of the genital system. This malignancy comprises 80%-90% of vaginal cancers, and its incidence rate is increasing rapidly among the female population worldwide. The related literature suggest factors that may cause SCC, which include human papillomavirus (HPV) viral infection (especially in young women), smoking, and certain infections such as Chlamydia trachomatis and Neisseria gonorrhea. Cancer management in pregnant women is challenging and treatment can differ depending on the case. The occurrence of genital cancers during pregnancy is rare and clinically challenging. The incidence rate of this type of malignancy is a growing trend in women of child-bearing age. Primary diagnosis during the early stages of disease may prevent surgical intervention, while delayed diagnosis may lead to tumor progression. The type of treatment depends on gestational age, histology report, lymph node involvement, and disease stage. There is a scarcity of studies as to clinical management of cervical cancer in pregnant patients, and the effects of SCC on pregnancy sequelae have not been studied. Here, we present the case of a pregnant women with SCC and the performed medical procedures. Case presentation: A 35-year-old female (gravida: 2, abortion: 1) was a candidate for cerclage surgery based on an ultrasound report in the 12th week of pregnancy, which determined the cervical canal length to be 30 mm. During the cerclage procedure, the gynecological surgeon observed a suspicious lesion. Accordingly, cervical biopsy was performed for the patient in the 16th week of pregnancy. The diagnostic pathology of the first biopsy was SCC in situ, keratinizing type based on World Health Organization classification without vascular invasion. Cervical examination revealed a small ulcer in the anterior side of the cervix (labeled at 12-2 o clock). Due to presence of this lesion in the cervical canal, another conization was conducted within the following two weeks. The macroscopic report revealed an irregular, brownish surface of ectocervix and conization of the uterine cervix that measured 3.5×1.2 cm from the 3 o clock position of the mucosal canal. The diagnostic pathology report of conization indicated invasive SCC of a large cell non-keratinizing type, with undetermined margins, along with stromal and angiolymphatic invasion. The cells were moderately differentiated and involved all quadrants. There was exo- and endocervical canal involvement. Neoadjuvant chemotherapy with taxol (infusion of 135 mg/m2 in 24 h) and cisplatin (75 mg/m2 in 24 h) as the T-C regimen was initially administered to the patient in the 25th week of pregnancy. The second cycle was administered 21 days later and the third cycle was given 42 days later. All injections were performed by the rapid intravenous injection method. Due to a negative pathology report, chemotherapy was discontinued post-surgery. Finally, the patient underwent a caesarean section, type II radical hysterectomy, and bilateral pelvic lymphadenectomy in the 36th week of pregnancy. The neonatal Apgar score was 10-10 (for 1 and 5 min). The ovaries were saved during surgery. Frozen section diagnosis of the uterus showed severe dysplasia in the cervix (CIN3) with free vaginal margins and other pathologic pregnancy related changes. The same reports for the right and left pelvic lymph nodes showed reactive and ectopic decidual reactive changes, respectively. Pathology reports of the left ovarian cyst and placenta exhibited simple serous cyst and congestion, respectively. The permanent pathology for all of the tissues was negative after surgery. The patient is currently free of tumor and she is following in 3 months interval. Conclusion: Appropriate intervention during pregnancy may eliminate malignancy, and radical hysterectomy does not lead to infertility.