Uterus neck cancer at pregnancy
Uterus neck cancer at pregnancy — a malignant new growth which comes from a transformational zone of an ekzotserviks, an endotserviksa and comes to light during pregnancy. More than in two thirds of cases proceeds asymptomatically. At a manifest current it is shown by contact bleeding, spontaneous vaginal bleedings, leykorey, pain in the bottom of a stomach, malfunction of pelvic bodies. It is diagnosed on the basis of the given gynecologic survey, PTsR, the cytologic analysis, a kolposkopiya, histology of a bioptat. For treatment use organ-preserving and radical surgical interventions, beam and chemotherapy.
Uterus neck cancer at pregnancy
The Uterus Neck Cancer (UNC) — the most widespread oncopathology revealed at pregnant women. 1-3% of frustration are diagnosed in the gestational period. Depending on the region prevalence of a disease makes from 1,2 to 10 cases on 10 000 pregnancies. Gestation comes at 3,1% of patients with earlier established diagnosis of RShM. The disease is revealed more often at sexually active smoking women who nachl intimate life up to 16 years, have more than 2-3 sexual partners a year, are infected with a virus of a papillomatoz of the person (VPCh, HPV), and often and other genital infections (clamidiosis, a trichomoniasis, syphilis, gonorrhea, ureaplasmosis).
The uterus neck cancer reasons at pregnancy
In most cases malignant regeneration mucous ekzo-and the endotserviksa begins long before a gestation. The neoplasia is associated with the viruses of a papillomatoz of the person transmitted at sexual contacts. The DNA-containing papillomatozny viruses decide at 95% of patients on the confirmed diagnosis of cancer of neck of a uterus. In 65-75% of cases virus agents of 16 and 18 serotypes are considered as a provocative factor, is more rare — HPV 31, 33, 35, other types of high and average risk. Contamination of VPCh in female population makes 5-20%. At most of patients a virus it is long persistirut without any clinical manifestations.
The factors promoting increase in its pathogenicity and the beginning of an onkoprotsess are not revealed yet. Despite a theoretical possibility of acceleration of carcinogenesis against the background of physiological decrease in immunity at pregnancy, convincing data on negative impact of a gestation on the course of malignant process in a neck to a uterus are absent today. Moreover, on observations of experts in the sphere of oncology, obstetrics and gynecology, at two thirds of pregnant women regress of precancer states is noted.
Detection of RShM in the period of a gestation is favored by a number of circumstances. First, many patients from risk group out of pregnancy extremely seldom visit medical institutions with the preventive purpose. Registration in antenatal clinic for the purpose of receiving medical care and social payments assumes regular observation of the expert and performance of screening inspections during which cancer can be found. Secondly, by 20th week of gestational term most of pregnant women has a shift of a knaruzha of a zone of transformation and a joint of a cylindrical cervical epithelium to flat vaginal. As a result the site of a mucous neck most often affected by cancer becomes well noticeable and available to carrying out cytologic screening, a kolposkopiya and other researches.
Though the probability of infection with a human papillomavirus infection reaches 75%, at 90% of women the immune system quickly eliminirut the activator. In 10% of cases virus particles persistirut in basal epitelialny cages and can regress. Only at some patients under the influence of unspecified factors of VPCh begins to progress. DNA of viruses is built in a genome of cages of an epithelium of a neck that leads to violation of mechanisms of apoptosis and malignant morphological transformation — from a slight and moderate dysplasia before the expressed displastichesky changes and a carcinoma of in situ. Virus genes of E5 and E6 render the blocking effect on antioncogenes of p53 Rb of normal cellular elements of a neck of a uterus.
Because of an inactivation of a tumoral supressor uncontrolled proliferation of tumor cells is started. Besides, under the influence of protein in which synthesis E6 gene participates the telomeraza is activated that promotes emergence of immortal cellular clones and development of tumors. At the same time due to blocking of a tsiklinzavisimy kinase r21 and r26 active division of the damaged cages begins the protein produced by E7 gene. In the subsequent cancer cells extend from a uterine neck, mucous on other fabrics, the tumor sprouts in adjacent bodies and spreads.
Systematization of forms of cancer of neck of a uterus at pregnancy is based on the same criteria, as at not pregnant patients. Taking into account type of the struck epithelium of a tumor can be ekzofitny planocellular, coming from an ekzotserviks (come to light at 53,6% of pregnant women), endofitny adenokartsinomatozny, educated cages of an endotserviks (are diagnosed for 25,7% of patients). In 20,7% of cases the neck neoplasia at a gestation is mixed. For development of optimum tactics of conducting pregnancy it is important to consider cancer stage:
- Stage 0. At a prekartsinoma (in situ tumor) process is localized in an epitelialny layer, the atipiya of cages corresponds to borderline between a dysplasia of the III degree and a true malignant neoplasia. The forecast is optimum for incubation of pregnancy, low-invasive operations are after the delivery possible.
- Stage of I. Cancer does not go beyond a neck. The tumoral center is defined microscopically (IA, microinvasive cancer) or is macroscopic (IB). Continuation of a gestation and a natural rodorazresheniye in the consent of the patient with performance of conservative or radical interventions in the postnatal period is possible.
- Stage of II. The carcinoma extended to a uterus body, the top part of a vagina (IIA) and parametry (IIB). Walls of a basin and the lower third of a vagina are not involved in process. At gestational term pregnancy it is possible to prolong over 20 weeks no more than for 8 weeks before achievement by a fruit of viability and to finish Caesarian section.
- Stage of III. Cancer extended to the lower third of a vagina (IIIA), reaches basin walls, blocking of a kidney and emergence of a gidronefroz (IIIB) is possible. Treatment is recommended to be begun as soon as possible. In 1 trimester pregnancy is interrupted, in 2-3 — carry out Cesarean section with an expanded extirpation of a uterus.
- Stage of IV. In it is involved mucous a rectum and a bladder or the tumor went beyond a basin (IVA), there are remote metastasises (IVB). At pregnancy meets seldom. Detection of an inoperable tumor is the basis for performing Cesarean section at a viable fruit with the subsequent beam and chemotherapy.
Uterus neck cancer symptoms at pregnancy
The Preinvazivny and low-invasive forms of a neoplasia revealed at 70% of pregnant women proceed asymptomatically. At women with initial stages of invasive cancer (IB, IIA) contact bloody allocations after vaginal survey, sexual intercourse are noted. Bleedings from the damaged neoplasia vessels in the I trimester often mistakenly are regarded as the menacing spontaneous abortion, in II-III — as a premature otsloyka or prelying of a placenta. Emergence transparent is possible is more white. At tumors with disintegration of allocation become fetid. Pain in the lower part of a stomach taken for threat of termination of pregnancy arises seldom. Emergence of morbidity in lumbar and sacral area, a buttock, the back surface of a hip usually demonstrates infiltration of pelvic cellulose. When squeezing the tumor of mochetochnik breaks urine outflow, at germination of a bladder, a rectum are observed emergence of impurity of blood in urine and Calais, their otkhozhdeniye through a vagina.
At invasive types of cancer the probability of spontaneous interruption of a gestation an abortion or premature birth increases. Considerable deformation of body a tumor can provoke development of istmiko-tservikalny insufficiency. At the patients having bleeding a neoplasia anemia of pregnant women is stronger expressed. Level of perinatal mortality increases to 11,5%. Completion of pregnancy by natural childbirth in the presence of a large volume new growth significantly increases probability of ruptures of a uterine neck, massive postnatal bleedings, hematogenic metastasis of cancer. Therefore in such cases Cesarean section is recommended.
The main objectives of diagnostic search — an exception or confirmation of a zlokachestvennost of pathological process and exact definition of a stage of cancer. In the period of a gestation it is recommended to use the inspection methods which are not posing threats for a fruit that complicates statement of the correct diagnosis. The most informative are:
- Survey on a chair. The research in mirrors allows to find macroscopically visible changes of an ekzotserviks, transformational zone, to find the new growths acting in a vagina cavity from the tservikalny channel. Identification of contact bleeding of a neoplasia is possible.
- PTsR screening on VPCh. Though contamination a virus of papilloma does not testify to a neck tumor, obtaining the positive analysis raises an onkonastorozhennost. PTsR-diagnostics gives the chance to define a range of serotypes of the activator, to carry out their typing.
- Cytology of scrape of a neck of a uterus. At pregnancy the intake of material is carried out with care to warn bleeding, to keep a cervical stopper, to exclude damage of fetal covers. The research is directed to definition of a dysplasia, an atipiya, malignization.
- Expanded kolposkopiya. Supplements results of the cytologic test. It is made in the presence of laboratory signs of a precancer or cancer state for detection in a mucous membrane of a neck of the pathological center before performance of an aim biopsy and control over a material intake.
- Histologic research of a bioptat. It is applied to definition of a type of a tumor and degree of its differentiation. For decrease in a travmatization of a uterine neck and reduction of probability of bleeding to pregnant women carry usually out a wedge-shaped biopsy. According to many obstetricians-gynecologists, it is not necessary to carry out an intake of material 2 trimesters earlier.
For assessment of a condition of a rectum, pelvic cellulose, a bladder, regionarny lymph nodes the tsistoskopiya, a rektoromanoskopiya, MRT of separate bodies, MRT of lymph nodes can be recommended ultrasonography of a small pelvis. At suspicion on metastasises a preferable method of inspection is MRT of all body. Beam methods of diagnostics to pregnant women with suspicion of cancer of a uterine neck are appointed restrictedly because of the possible damaging impact on a fruit. The disease is differentiated with erosion, polyps, condylomas, cysts, tservitsity, an ektopiya, ektropiony, a dysplasia, vagina tumors, a spontaneous abortion, prelying of a placenta. Examines the patient , according to indications — the urologist, the proctologist.
Cancer therapy of a neck of a uterus at pregnancy
The choice of medical tactics depends on the gestational term, a stage of neoplastic process, reproductive plans of the patient. Preservation of a gestation regardless of the term of detection of cancer is possible only at new growths of 0 and IA stages (with a stromalny invasion to 3 mm). At a tumor of IA of a stage with a stroma invasion on depth from 3 to 5 mm, neoplaziya of IB and the II stage in the 1st trimester termination of pregnancy, from 13 to 20 week — performance of radical operation, after 20 weeks — pregnancy prolongation till 28-32 week term with monitoring of a state, an operational rodorazresheniye and a one-stage radical hysterectomy is shown. Accompanies the patients who decided to continue a gestation .
Cancer of the III-IV stage is the indication for interruption of a gestation on any term. Till 20th week the external radiation therapy provoking a spontaneous abortion at a dose 4000 is appointed. After 20 weeks term Cesarean section and a subtotal resection of a uterus irrespective of viability of a fruit is carried out. The main methods of treatment at cancer of a uterine neck at pregnant women same, as well as out of the gestational period:
- Organ-preserving operations. Are shown to young patients with a carcinoma of in situ and cancer of IA of a stage (at penetration in Strom 3 mm are not deeper), persons interested to keep fertility. Konization is carried out 4-8 weeks later after medical abortion or in 7-9 weeks after vaginal or abdominal childbirth.
- Simple hysterectomy. Removal of a uterus with preservation of appendages is recommended to women with preinvazivny and low-invasive cancer who have no reproductive plans. Operation is performed as independent intervention in the I trimester and is one-stage with Caesarian section at the decision to take out pregnancy.
- Radical hysterectomy with a podvzdoshny limfadenektomiya. Is operation of the choice at cancer of IB-II of stages. In the 1st trimester it is carried out, including, for termination of pregnancy, in the 2 and 3 it is made along with a surgical rodorazresheniye. 2-3 weeks later the woman adjyuvantny radiation therapy is recommended.
- Combined himioluchevy therapy. It is applied at a malignant new growth of a neck of a uterus of the III-IV stages. External radiation allows not only to influence tumoral process, but also to interrupt a gestation till 20th week. And radio methods do not use Himiopreparata at the decision of the woman to keep a fruit.
Forecast and prevention
At diagnostics at the pregnant woman of cancer of neck of a uterus the forecast always serious. The best results manage to be achieved at noninvasive forms of a neoplasia. Five-year survival of patients with cancer of the I stage revealed during pregnancy does not differ from a similar indicator for not pregnant women and reaches 88%. At a tumor of the II stage for 5 years about 54% of cancer patients (against 60-75% of women with the diagnosed cancer of a uterine neck out of pregnancy) survive, at the III stage — to 30-45%. At invasive tumors the treatment delay in connection with desire to keep pregnancy worsens the forecast of survival for 5% for every month of the prolonged gestation.
After organ-preserving operations cancer recurs at 3,9% of patients, and new pregnancy occurs at 20,0-48,4%. The remote consequences of a konization are istmiko-tservikalny insufficiency, infertility, formation rektovaginalny, uretro-and puzyrno-vaginal fistulas. Prevention provides observance of rules of sexual hygiene with use of methods of barrier contraception, refusal of chaotic sexual communications, regular dispensary observation VPCh-infitsirovannykh of patients, timely treatment of precancer states.