姙娠에 合倂된 子宮頸癌에 關한 臨床的考察

Abstract

[한글]

[영문]

The recent emphasis upon the early diagnosis of malignant neoplasms has been mroe rewarding in the case of carcinoma of the cervix than perhaps with any other cancer, because of the widespread publicity given this lesion, and due to the increasing awareness of the value of the Papanicolaou smear in the diagnosis of the eariest stages of the disease.

Theoretically, carcinoma of the cervix might be completely eradicated by mass screening methods, routine Papanicolaou smears, and regular pevic examination beginning at an early age.

From the practical viewpoint, however, this is yet difficult in Korea for reasons of economy and because of the reticence of large segmant of our population to visit physicians unless something is wrong.

Failure to examine pregnant patients completely and to take smears during pregnancy has been based upon the reasoning that smears are of value during presgnancy, and that biopsy during pregnancy may precipitate abortion, bleeding, infection, and dystocia due to cervical structure.

Recently, it has come to be known that there is no contraindication for cervical biopsy during pregnancy when necessary; further pathologists are now generally in accord with the fact that smears are accurate during pregnancy, and that changes in the vaginal and cervical cells during pregnancy are easily distinguishable from those brought about by malignant change.

According to the literature, cervical cancer associated with pregnancy is relatively rare. But we have seen 19 cases in situ and invasive cervical cancer between Feb. 1959 and Aug. 1964 and clinically analized them, and reviowed literstomes.

Carcinoma of cervix in the First trimester of pregnancy, particularly in the situ stages, is undoubtedly present much more frequently than has previously been suspected.

Routine smear examination at the First prenatal visit will aid tremendously in discovering these lesions before invasion begins.

In general, treatment of the cervix in the Fiurst trimester follows the same treatment methods omployed in nonpregnant patient.

Cone biopsy and punch biopsy essential to rule out not only malignant changes but also invasive cancer in those patients whose smears have been reported as suspicious and who have suspicious local lesions.

When associated invasive cancer continuation of pregnancy should not be considered, however, if lesion is proved by cone to be in-situ, the pregnancy may continue in normal fashion.

In 2nd or 3rd trimester, obstetrics is the only branch of medicine in which two lives have to be considered directly in making therapeutic decisions. It is sometimes necessary, albeit distressing, to have to favor one of the two. Selection of the est therapy in carcinoma of the cervix associated with pregnancy is most difficult in 2nd and 3rd trimester because of the need to give optimal chances to both the maternal and fetal lives.

Those who have struggled with this problem generally agree that before the third trimester the carcinoma should be treated promptly and fully without regard to the fetus and that, for some reason, the maternal prognosis for carcinoma of the cervix worsens materially in 2nd and 3rd trimester.

So that 1) The pregnancy should be terminated by classic cesarean section or hysterotomy as soon as the diagnosis is made, except in rare situations such as primigravidity or strong religious considerations.

Three reasons support this approach First, full and immediate therapy can be applied and is in the best maternal interest. 2nd can occasionally result in a premature infant who can survive and be normal.

2) After evacuation of the uterus, conventional radiation therapy should be employ for all patients with favourable or unfavourable stage. Or raidcal hysterectomy with dissection of lymph nodes for patients of operable carcinoma of the cervix.

Summary and Conclusion

1) We have observed the clinical aspects in 10 cases (Ca. in situ -4 cases, invasive Ca -15 cases) of cancer of the uterine amrvix associated with pregnancy. As to the trimester of pregnancy 11 cases in the first trimester, 3 cases in the second trimester, 4 cases in the third trimester, and 1 case was found at post-partum examination.

2) The incidence was 0.63% of the total number of hospitalised pregnant women. This is higher than what has been reported by others. The increase incidence might be due to the rather small number of deliveries at our hospital. In addition, the peak incidence of uterine cervical cancer in pregnant and non-pregnant patients at our hospital starts from the time of the reproductive period, as 36-40 years old, and we found an abruptly increasing curve in which the younger group forms notably big proportion. this is about 10 years younger than the peak incidence reported in the literatures.

3) The average age was 34.5 in pre-invasive, 36.2 in invasives, respectively. These ages are 10 years younger than what has been reported for non-pregnant patients.

4) Symptoms are similar to those found in non-pregnant patients except for the additional signs of pregnancy.

5) There were no complications such as abortion or massive bleeding during the punch biopsy and conization for diagnosis.

6) We have not as yet observed the 5 year survival rate, but 10 cases (66.7%) are still living without any symptom of cancer after treatment.

7) More cases and further studies are necessary before we can report the 5 year result of treatment of uterine cervical cancer associated with pregnancy.