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Abstract

Introduction

This study aims to evaluate diagnosis, treatment and clinical outcomes for patients with cervical cancer in pregnancy (CCIP) and their fetuses over a 10-year period, providing clinical evidence for the management of CCIP.

Methods

Clinical data of 28 patients diagnosed with CCIP at our center between January 1st, 2013 and June 30th, 2023 were retrospectively analyzed, focusing on gestational age at diagnosis, treatment, and maternal-fetal outcomes.

Results

A total of 28 patients with CCIP were identified, accounting for 0.42% (28/6678) of patients with cervical cancer during the study period. The majority of patients (86%, 24/28) had squamous cell carcinoma diagnosed by colposcopic biopsy, and 21 patients presented with recurrent vaginal bleeding. Cervical cancer was diagnosed during pregnancy in 19 cases and in the postpartum period in 9 cases. The mean tumor diameter was 5.4 (2-12) cm. Among 19 patients diagnosed during pregnancy, 13 patients chose pregnancy preservation, resulting in an average delay of treatment by 16.4 (0-33) weeks without observed disease progression. Fetuses were delivered via cesarean section at an average gestational age of 36.3 weeks; eight of these patients received neoadjuvant chemotherapy. At a median follow-up duration of 40.1 (12-103) months, 25 patients survived. Disease-free survival was observed in 20 patients, whereas two patients experienced local progression, and six developed distant metastases.

Conclusion

Clinical outcomes for patients with CCIP appear comparable to those observed in non-pregnant patients in the general population. Pregnant patients presenting with abnormal vaginal bleeding should undergo prompt cervical cancer screening to enable early diagnosis and tailored management strategies. For patients with a strong desire to maintain their pregnancy, careful consideration should be given to postponing delivery until fetal maturity, thereby minimizing maternal and fetal complications and improving maternal and fetal outcomes.

Keywords

cervical cancer in pregnancy clinical outcome treatment cervical cancer pregnancy

Introduction

Cervical cancer in pregnancy (CCIP) refers to cervical cancer diagnosed either during pregnancy or within 6 to 12 months postpartum, with an incidence ranging from 1.5 to 12 cases per 100 000 pregnancies, accounting for approximately 10% of all malignancies in pregnancy.¹ In the past decade, the incidence of CCIP has risen in China, primarily due to a rising trend in advanced maternal age.² Pregnancy provides a valuable opportunity for cervical cancer screening, facilitating early detection in the majority of cases.³ However, balancing maternal health and fetal implications necessitates a multidisciplinary team approach to the diagnosis and management of CCIP, involving expertise in gynecologic oncology, pathology, neonatology, radiology, anesthesiology, maternal-fetal medicine, and social work. Therefore, the clinical management of CCIP remains a significant clinical challenge.⁴

The clinical management principles for CCIP are generally consistent with those for cervical cancer in non-pregnant patients.^5,6 Radiotherapy is an essential treatment for cervical cancer⁷; however, pregnancy-related physiological changes complicate clinical decision-making for radiation oncologists, posing substantial challenges. Regarding surgical interventions, a systematic review⁸ has shown that surgical treatment of the cervical intraepithelial neoplasia (CIN) is associated with an increased risk of fetal implications before 37 pregnancy weeks compared to untreated women, making treatment decisions more difficult. Due to the rarity of CCIP and the ethical complexities involved, large-scale randomized controlled trials are difficult to conduct, resulting in limited high-quality evidence to inform clinical guidelines. As research on malignancies in pregnancy expands, there is an increasing focus on multidisciplinary collaboration, risk-benefit assessment, and personalized clinical guidance. For patients with a strong desire to maintain their pregnancy, clinical efforts should aim to preserve fetal viability while optimizing maternal outcomes.

This study conducted a retrospective analysis of patients with CCIP at our center over the past decade, with a focus on clinical manifestation, clinical management, diagnosis, and treatment strategies. We aimed to summarize current researches on the diagnosis, treatment, and management of CCIP, offering clinicians valuable insights and clinical evidence to inform future diagnosis, pregnancy-preserving and treatment strategies.

Materials and Methods

Patients

Utilizing the cervical cancer patient database of the Department of Radiation Oncology at Peking Union Medical College Hospital, China, we retrieved clinical data from 28 patients diagnosed with CCIP during pregnancy or within 6 to 12 months postpartum, who underwent treatment at our center between January 1st, 2013, and June 30th, 2023. The collected data encompassed clinical staging, pathological classifications, treatment regimens, pregnancy outcomes, and follow-up status. A retrospective analysis was performed to evaluate clinical decision-making, treatment strategies, and maternal-fetal outcomes.

All enrolled patients underwent cervical biopsy, with pathological confirmation of cervical cancer. A comprehensive physical examination was performed by two experienced gynecologic oncology specialists. Additionally, ultrasound or magnetic resonance imaging (MRI) was utilized to assess the tumor size, its relationship with adjacent organs, and the metastasis status of pelvic and retroperitoneal lymph nodes. Clinical staging was performed following the International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging system. Gestational age and fetal development were evaluated through medical history review, physical examination, serum β human chorionic gonadotropin (β-hCG) levels, and ultrasound examination, followed by systematic prenatal assessments at the obstetric outpatient clinic.

The report of this study conforms to the STROBE guidelines.⁹ The study protocol was approved by the Ethics Committee of Peking Union Medical College Hospital (No. I-24PJ2180). The requirement for obtaining patient consent was waved by the IRB. And we have de-identified all patient details.

Treatment

An individualized treatment strategy was formulated through multidisciplinary tumor board meetings based on the patient's FIGO staging, gestational age, and the patient's and family's preferences regarding pregnancy continuation and tumor treatment. The multidisciplinary tumor board comprised expertise from gynecologic oncology, pathology, neonatology, radiology, anesthesiology, maternal-fetal medicine, and social work. This approach was implemented with full patient awareness, voluntary treatment selection, and informed consent. For patients who opted not to continue the pregnancy, termination was promptly performed, followed by cervical cancer treatment in accordance with clinical guidelines. For patients determined to continue the pregnancy, tumor progression and fetal status were closely monitored, with cervical cancer treatment deferred until fetal maturation and delivery. All viable fetuses were delivered via cesarean section. Following delivery, cervical cancer treatment was administered in accordance with clinical guidelines.

Outcomes and Follow-up

The therapeutic efficacy of cervical cancer treatment was evaluated during pregnancy and post-treatment based on the Response Evaluation Criteria in Solid Tumors (RECIST). Recurrence was defined as the reappearance of the same tumor lesion more than six months after completion of cancer treatment. A tumor was considered uncontrolled if the same lesion reappeared during treatment or within six months after completion of cancer treatment, or if the original lesion increased in size by more than 50%.

All patients received outpatient follow-up after childbirth and completion of cervical cancer treatment. Follow-up assessments comprised evaluation of uterine involution and lochia, cervical cytology screening, and, when indicated, colposcopy and cervical biopsy. Following cervical cancer treatment, follow-up visits adhered to oncology surveillance protocols: every three months for the first two years, every six months from years two to five, and annually thereafter. The study endpoints encompassed overall survival (OS), locally recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS).

Statistical Analysis

Statistical analysis of the research data was performed using IBM SPSS 29.0 and R software 4.4.1 (https://www.r-project.org). Numeric variables were represented using medians and quartiles, while categorical variables were represented using frequencies and percentages.

Results

Patient Characteristics

Between January 1st, 2013, and June 30th, 2023, a total of 6678 cervical cancer patients were treated at our center, of whom 28 patients were diagnosed with CCIP. Within this study cohort, CCIP accounted for 0.42% (28/6678) of all cases. The 28 patients ranged in age from 21 to 43 years, with a mean age of 27.3 years. The mean parity was 0.3 (0-1). The mean gestational age at diagnosis was 16 weeks, with nine patients diagnosed in early pregnancy, four in mid-pregnancy, seven in late pregnancy, and eight postpartum. Abnormal vaginal bleeding was the initial symptom in 21 of 28 patients, while 10 of 28 patients also experienced lower back discomfort.

All 28 patients were pathologically confirmed cervical cancer, with squamous cell carcinoma as the predominant histological subtype. Histological subtypes included squamous cell carcinoma 85.7% (24/28), adenosquamous carcinoma 3.6% (1/28), adenocarcinoma 3.6% (1/28), and small cell neuroendocrine carcinoma 7.1% (2/28). Based on the FIGO staging system, the clinical stage distribution among these patients was as follows: 5 (17.9%) in stage I, 4 (14.3%) in stage II, 17 (60.7%) in stage III, and 2 (7.1%) in stage IV.

A total of eleven patients had concurrent human papillomavirus (HPV) infection, including six with HPV 16, two with HPV 18, and three with other HPV types. Sixteen patients were not tested for HPV, and one tested negative. Additionally, 11 patients underwent ThinPrep cytologic test (TCT) screening, with abnormal results in all cases: CIN grade 3 (CIN3) 27.3% (3/11), carcinoma in situ (CIS) 18.2% (2/11) and squamous cell carcinoma 54.5% (6/11). The remaining 17 patients did not undergo TCT screening. All patients underwent ultrasound or MRI examinations. The mean tumor diameter was 5.4 (2-12) cm. Vaginal involvement was identified in 14 cases, parametrial involvement in 10 cases, pelvic lymph node metastasis in 18 cases, and retroperitoneal lymph node metastasis in 9 cases. Squamous cell carcinoma antigen (SCCAg) levels elevated in 15 patients, with a mean level of 9.5 ng/mL (range: 0-96.3 ng/mL), while cancer antigen 125 (CA125) levels elevated in 4 patients, with a mean level of 40.4 U/mL (range: 0-93.4 U/mL).

Pregnancy Outcomes

Of the 28 patients with CCIP, 19 patients were diagnosed during pregnancy. Among these, 13 patients were strongly determined to continue their pregnancy. Of these 13 patients, one was in stage I (gestational ages: 12 weeks), two were in stage II (gestational ages: 5 and 20 weeks), nine were in stage III (gestational ages: 7-39 weeks), and one was in stage IV (gestational ages: 39 weeks). All 13 patients underwent cesarean section for pregnancy termination at a mean gestational age of 36.3 weeks. Among these, eight patients received neoadjuvant chemotherapy before pregnancy termination, with regimens including paclitaxel plus cisplatin or paclitaxel plus carboplatin. Six patients opted for pregnancy termination, including two in stage Ib (gestational age: 6 and 7 weeks) and four in stage III. Among the four patients in stage III, three were in early pregnancy (gestational ages: 6-11 weeks), and one was in mid-pregnancy (gestational age: 20 weeks). Additionally, 9 patients were diagnosed with CCIP postpartum. The details are shown in Table 1.

Table 1.

Modes of Pregnancy Termination in 28 Patients with Cervical Cancer in Pregnancy, Stratified by FIGO Stage. The Modes of Pregnancy Termination Include Induced Abortion, Radical Surgery and Cesarean Section.

FIGO stage, n	Number of cases, n	Induced abortion, n	Radical surgery, n	Cesarean section, n
Stage I	5	0	4	1
Ib1	1	0	1	0
Ib2	3	0	3	0
Ib3	1	0	0	1
Stage II	4	0	0	4
IIa	3	0	0	3
IIb	1	0	0	1
Stage III	17	2	2	13
IIIc1	14	2	2	10
IIIc2	3	0	0	3
Stage IV	2	1	0	1

FIGO: International Federation of Gynecology and Obstetrics staging system.

Treatment

Of the 28 patients with CCIP, 21 patients received radical radiotherapy, while 7 patients underwent postoperative radiotherapy. The radical radiotherapy, intensity-modulated radiotherapy (IMRT), was delivered using 6 MV X-rays, targeting the cervix, uterus, partial vagina, pelvic lymphatic drainage regions (including the common iliac, internal iliac, obturator, partial presacral, and external iliac nodes), and/or the retroperitoneal lymphatic drainage area. A total dose of 50.4 Gy was delivered in 28 fractions (1.8 Gy per fraction, 5 fractions per week), with three-channel intracavitary brachytherapy interspersed, providing a total dose of 30 Gy in 5 fractions. Concurrent cisplatin (DDP) sensitizing chemotherapy was given for 4 to 6 cycles. Postoperative radiotherapy, IMRT, was also delivered using 6 MV X-rays, targeting the vaginal stump and pelvic lymphatic drainage regions (including the common iliac, internal iliac, obturator, partial presacral, and external iliac nodes). A total dose ranging from 45 to 50.4 Gy was administered in 25-28 fractions (1.8 Gy per fraction, 5 fractions per week), supplemented with single-channel intracavitary brachytherapy delivering an additional 10 Gy in 2 fractions. Concurrent DDP sensitizing chemotherapy was given for 4 to 6 cycles. In terms of chemotherapy, platinum use was strictly avoided during the first trimester (≤12 weeks) due to teratogenic risks, according to the multidisciplinary tumor board meetings. In mid-to-late pregnancy, chemotherapy was deemed relatively safe after comprehensive fetal anomaly screening and maternal counseling.

Clinical Outcomes and Follow-up

The median follow-up duration for the 28 patients was 40.1 (12-103) months. Among these, 25 patients survived, while 3 succumbed to the disease. One patient with stage IIa2 cervical cancer developed liver metastasis 41.2 months post-diagnosis and succumbed 53.7 months post-diagnosis. Another patient with stage IIIc2 cervical cancer developed liver and lung metastases 7.63 months post-diagnosis and succumbed 12.03 months post-diagnosis. Additionally, one patient with stage IV cervical cancer developed liver and lung metastases 4.4 months post-diagnosis and succumbed 15.23 months post-diagnosis. Among the surviving patients, 20 patients remained free of disease. Two patients experienced local disease progression, both classified as stage IIIc1. One developed local cervical recurrence 51 months post-diagnosis and achieved disease control following surgical treatment, while the other had persistent pelvic lymph node involvement detected one-month post-diagnosis, which was controlled with an additional course of radiotherapy. Six patients developed distant metastases, including two with cervical lymph node metastases, two with mediastinal lymph node metastases, three with liver metastases, two with lung metastases, and two with retroperitoneal lymph node metastases. The details are shown in Table 2.

Table 2.

Clinical Outcomes of 28 Patients with Cervical Cancer in Pregnancy, Stratified by FIGO Stage. Outcomes Were Assessed at a Median Follow-up of 40.1 Months.

FIGO stage, n	Survival, n	DFS, n	LRFS, n	DMFS, n
Stage I (n = 5)	5	5	5	5
Ib1	1	1	1	1
Ib2	3	3	3	3
Ib3	1	1	1	1
Stage II (n = 4)	3	3	3	3
IIa	2	2	2	2
IIb	1	1	1	1
Stage III (n = 17)	16	11	14	13
IIIc1	14	10	12	12
IIIc2	2	1	2	1
Stage IV (n = 2)	1	1	1	1

DFS: disease-free survival; DMFS: distant metastasis-free survival; FIGO: International Federation of Gynecology and Obstetrics staging system; LRFS: locally recurrence-free survival.

Among 21 patients receiving radical radiotherapy (Stage I: n = 1; Stage II: n = 2; Stage III: n = 16; Stage IV: n = 2), 19 patients survived at the end of follow-up and two cases died. One experienced local recurrence, and one developed distant metastasis. 7 patients undergoing surgery followed by postoperative radiotherapy comprised earlier-stage cases (Stage I: n = 4; Stage II: n = 2; Stage III: n = 1). During the follow-up period, 6 patients survived, one died and one developed distant metastasis.

Among the 28 patients, 13 patients opted for pregnancy preservation with intentional treatment delay (median delay: 16.4 (0-33) weeks) to prioritize fetal maturity. These patients were predominantly diagnosed in mid-to-late pregnancy and managed under strict multidisciplinary tumor board surveillance, including weekly tumor assessments and fetal monitoring. At a median follow-up of 40.1 months, delayed-treatment patients exhibited comparable survival outcomes to non-delayed patients in OS, DFS and distant metastasis rates. Notably, none of the delayed-treatment patients experienced disease progression during pregnancy, and all fetuses were delivered via cesarean section at a mean gestational age of 36.3 weeks. These outcomes align with those reported in non-pregnant cervical cancer cohorts, suggesting that multidisciplinary-guided deferral does not adversely affect maternal prognosis when fetal maturity is prioritized.

Discussion

CCIP is among the most frequently diagnosed malignant tumors during pregnancy. In this study cohort, CCIP accounted for 0.42% (28/6678) of all cases. The most common clinical manifestation of CCIP is irregular vaginal bleeding. In this study, 21 of 28 patients had abnormal vaginal bleeding as their initial symptom. Therefore, in cases of abnormal vaginal bleeding during pregnancy, a comprehensive gynecological evaluation should be performed, including cytology screening and HPV testing. If clinically indicated, colposcopy with biopsy is permissible and is generally considered safe during pregnancy.¹⁰ Staging of CCIP follows the same FIGO staging criteria used for non-pregnant patients.^11,12 Ultrasound is recommended for fetal monitoring in patients undergoing delayed treatment, particularly those receiving neoadjuvant chemotherapy, with evaluations conducted biweekly. For patients with stage IB or higher who undergo delayed treatment, chest X-ray with abdominal shielding is considered acceptable after mid-pregnancy. MRI without contrast is recommended as the imaging modality for tumor assessment, while positron emission tomography/magnetic resonance imaging (PET/MRI) may be considered when available.^13–15 In this study, all patients with CCIP were pathologically confirmed and underwent MRI evaluation, with FIGO staging as the standard staging system.

Due to its low incidence and associated ethical considerations, CCIP is characterized by a paucity of high-level evidence and lacks a standardized treatment protocol. Current treatment recommendations are largely derived from retrospective studies. Management decisions should be guided by international guidelines and expert consensus from the FIGO, the National Comprehensive Cancer Network (NCCN), the International Gynecologic Cancer Society (IGCS), the European Society of Gynecological Oncology (ESGO), and other national guidelines, comprehensively considering clinical stage, gestational age, and fetal development. For patients with CCIP who choose not to continue the pregnancy, treatment should follow standard protocols for non-pregnant patients, irrespective of clinical stage. However, for those opting to continue their pregnancy, treatment must prioritize maternal prognosis while also ensuring eligibility for pregnancy continuation. For patients diagnosed in late pregnancy (≥28 weeks), when the fetus is considered mature with a high survival rate, management options include immediate cesarean section followed by cancer treatment, or administration of neoadjuvant chemotherapy to prolong pregnancy until fetal maturation before initiating definitive oncologic therapy. For patients diagnosed in early to mid-pregnancy (<28 weeks), the decision to continue pregnancy should be based on clinical stage, gestational age, and fetal development. In early-stage CCIP, a comprehensive approach incorporating fetal lung maturation and delivery planning may enable safe pregnancy continuation until full term. Multiple case reports and series have documented favorable outcomes in patients with stage IA–IIB cervical cancer who delayed treatment until after 32 weeks of gestation.^1,16,17 In this study, 13 patients chose to continue their pregnancy, including two diagnosed in early pregnancy (5-7 weeks), seven in mid-pregnancy (12-20 weeks), and four in late pregnancy (28-39 weeks). Among these, eight patients received neoadjuvant chemotherapy before pregnancy termination, with regimens comprising paclitaxel plus cisplatin or paclitaxel plus carboplatin. The mean duration of treatment delay was 16.4 (0-33) weeks. None of the patients who underwent treatment delay experienced disease progression.

Regarding fetal maturation, guidelines on the timing of pregnancy termination differ among regions and lack standardization. Decisions should be based on a comprehensive evaluation of factors, including fetal maturity, tumor stage, disease progression, treatment regimen, and the capacity of local neonatal intensive care units.¹⁸ FIGO recommends that expectant management should be limited to a maximum of 34 weeks of gestation. IGCS and ESGO guidelines suggest that pregnancy may be safely prolonged up to 37 weeks if maternal and fetal conditions are stable, in order to reduce neonatal mortality and complications associated with prematurity. In our cohort, multidisciplinary tumor board integrated these guidelines with real-time fetal and tumor monitoring through weekly ultrasound and MRI. All fetuses were delivered via cesarean section at a mean gestational age of 36.3 weeks, aligning with IGCS/ESGO recommendations while mitigating maternal risk.

Regarding treatment, the indications for postoperative adjuvant radiotherapy in patients with CCIP are identical to those in non-pregnant patients. In this study, seven patients underwent postoperative radiotherapy following radical surgery, including three who received adjuvant chemotherapy during pregnancy. One patient achieved successful tumor downstaging, thereby enabling surgical intervention. Previous studies have also demonstrated the safety of chemotherapy, suggesting that treatment deferral may be safe to allow for fetal lung maturation prior to delivery. For patients with locally advanced CCIP, the recommended treatment regimen consists of external beam radiotherapy (EBRT) followed by high-dose-rate (HDR) intracavitary brachytherapy, with concurrent weekly platinum-based sensitizing chemotherapy.^19,20 In our study, 21 patients received radical treatment for cervical cancer, comprising EBRT combined with HDR brachytherapy. The mean interval between pregnancy termination and EBRT initiation was 55 (16-107) days. This interval was determined by individualized clinical adjustments, including uterine involution and postoperative recovery. Among these patients, 16 patients continued their pregnancies, whereas five elected to terminate their pregnancies.

According to the literature, the treatment outcomes of CCIP are generally comparable to those of non-pregnant patients. In our study, none of the five patients with stage I CCIP exhibited disease progression at follow-up. Among the four patients with stage II CCIP, one underwent surgery followed by adjuvant radiotherapy and subsequently experienced liver metastasis 41.2 months after diagnosis. Despite receiving subsequent chemotherapy, the patient ultimately succumbed to the progressed disease. Among the 17 patients with stage III CCIP, two exhibited locally progression. One patient developed local cervical recurrence 51 months after diagnosis and achieved disease control following surgical intervention, while another had persistent pelvic lymph node involvement one-month post-diagnosis, which was managed with additional radiotherapy. Four patients developed distant metastases, including one with cervical lymph node metastasis, one with mediastinal and supraclavicular lymph node metastases, one with liver, lung, and abdominal metastases, and one with retroperitoneal lymph node metastasis. Among the two patients with stage IV CCIP, one achieved stable disease control following radical chemoradiotherapy and remained progression-free at the final follow-up (27.6 months). The other patient developed liver and lung metastases 4.4 months post-diagnosis and, despite receiving chemotherapy and targeted therapy, experienced disease progression and ultimately succumbed to the disease. Within this study cohort, the clinical outcomes of patients with CCIP aligned with those observed in non-pregnant patients with cervical cancer.

The diagnosis, treatment, and management of CCIP require careful consideration of both maternal and fetal health. The core dilemmas center around balancing maternal risk and fetal benefit, as well as ensuring patient autonomy and informed consent. Multidisciplinary collaboration, meticulous risk-benefit assessment, and individualized treatment strategies will be essential in addressing this complex clinical challenge in the future. As a retrospective study, treatment strategies for all cases in this cohort were guided and determined by the multidisciplinary tumor board. Although our study spanned a prolonged period, its single-center design presented inherent limitations. Nevertheless, the findings may still serve as a valuable reference for the diagnosis and management of CCIP. With the accumulation of larger-scale studies and further clinical experience, more effective treatment strategies and refined clinical guidance are expected to become available for patients with CCIP.

Conclusion

Footnotes

ORCID iD

Zhikai Liu

Ethical Considerations and Consent to Participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Peking Union Medical College Hospital (PUMCH), China, with the approval number I-24PJ2180. The requirement for obtaining patient consent was waved by the IRB.

Author Contributions

All authors contributed to the conceptualization of the study. Y.S. and W.C. were responsible for methodology, investigation, formal analysis, writing-original draft and writing-review and editing. J.S. was responsible for methodology, investigation, resources and writing-review and editing. H.Z., H.G. and L.H. were responsible for investigation and resources. K.H. and F.Z. were responsible for investigation, resources and supervision. Z.L. contributed to supervision, project administration and funding acquisition. All authors read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Key R&D Program of China, Ministry of Science and Technology of the People's Republic of China (Grant No. 2022YFC2407100, 2022YFC2407102).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Cervical Cancer in Pregnancy: A 10-Year Retrospective Analysis of Clinical Management and Future Perspectives

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Materials and Methods

Patients

Treatment

Outcomes and Follow-up

Statistical Analysis

Results

Patient Characteristics

Pregnancy Outcomes

Treatment

Clinical Outcomes and Follow-up

Discussion

Conclusion

Footnotes

ORCID iD

Ethical Considerations and Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References