妊娠合并妇科恶性肿瘤的发生率约千分之一。对于这些患者的处理应由妇科肿瘤、病理学、新生儿学、放射学、麻醉学、母胎医学、社会工作等多学科共同讨论决定。

      怀孕为宫颈癌筛查提供了一个机会，对早期宫颈癌的治疗可有意延迟处理，以延长孕期。若子宫颈癌病灶明显，不宜采用阴道分娩，应建议剖宫产并同时行根治性子宫切除加淋巴结清扫术。患者如果是局部晚期和转移/复发性宫颈癌，应在诊断的同时立即进行放化疗和全身治疗;对于合适的病例，可采用新辅助化疗来控制病情，延长妊娠时间。

       妊娠期大多数附件肿块是生理性的或良性的，前者多在妊娠中期消失。持续存在，无症状的良性的肿块可以保守处理;如果需要手术，手术时机最好选择在妊娠15-20周，在可能的情况下应尽量选择腹腔镜手术。

       良性和恶性生殖细胞肿瘤和交界性肿瘤偶尔也会在妊娠期遇到，恶性生殖细胞肿瘤及交界性肿瘤的处理原则是以侧附件切除，保留子宫和对侧卵巢。

      上皮性卵巢癌极为罕见。超声和磁共振成像没有电离辐射，可以用来评估疾病的程度。肿瘤标记物,包括ca - 125,AFP,LDH, inhibin-B,甚至CEA和ßhCG可能能够提供有用的信息。如果需要，化疗可以在妊娠中晚期，胎儿器官发育完成后进行。因为铂和其他抗肿瘤药物可以穿过胎盘，所以在34周后应停止化疗，以避免新生儿骨髓抑制。贝伐珠单抗、免疫检查点抑制剂和PARP抑制剂应在整个妊娠期间避免使用。

       尽管可以考虑使用糖皮质激素促进胎儿肺成熟和进行羊水指数评估，但没有证据表明抗宫缩药、产前胎儿心率监测和/或羊膜穿刺术对患者有益。

       尽管平滑肌肉瘤和一胎正常/一胎为葡萄胎的妊娠有文献报道，但是妊娠期子宫内膜癌、外阴癌和阴道癌极为罕见。

        对于妇科恶性肿瘤，妊娠并不会加重其临床恶性行为/或带来更差的预后。

Gynecologic cancer in pregnancy.

KorenagaTK¹, Tewari KS².Gynecol Oncol. 2020Apr 5

Cancercomplicates 1 in 1000 pregnancies. Multidisciplinary consensus comprised ofGynecologic Oncology, Pathology, Neonatology, Radiology, Anesthesiology,Maternal Fetal Medicine, and Social Work should be convened.

Pregnancyprovides an opportunity for cervical cancer screening, with deliberate delaysin treatment permissible for early stage carcinoma.Vaginal delivery iscontraindicated in the presence of gross lesion(s) and radical hysterectomywith lymphadenectomy at cesarean delivery is recommended. Women with locallyadvanced and metastatic/recurrent disease should commence treatment atdiagnosis with chemoradiation and systemic therapy, respectively ;neoadjuvantchemotherapy to permit gestational advancement may be considered in selectcases.

Mostadnexal masses are benign and resolve by the second trimester. Persistent,asymptomatic, benign-appearinhg masses can be managed conservatively; surgery,if indicated, is best deferred to 15-20 weeks, with laparoscopy preferable overlaparotomy whenever possible.

Benignand malignant germ cell tumors and borderline tumors are occasionallyencountered, with unilateral adnexectomy and preservation of the uterus andcontralateral ovary being the rule. Epithelial ovarian cancer is exceedinglyrare. Ultrasonography and magnetic resonance imaging lack ionizing radiationand can be employed to evaluate disease extent. Tumor markers, includingCA-125, AFP, LDH, inhibin-B, and even CEA and ßhCG may be informative. Ifrequired, chemotherapy can be administered following organogenesis during thesecond and third trimesters. Because platinum and other anti-neoplastic agentscrosses the placenta, chemotherapy should be withheld after 34 weeks to avoidneonatal myelosuppression. Bevacizumab, immune checkpoint inhibitors, and PARPinhibitors should be avoided throughout pregnancy.

Althoughantenatal glucocorticoids to facilitate fetal pulmonary maturation and amnioticfluid index assessment can be considered, there is no demonstrable benefit oftocolytics, antepartum fetal heart rate monitoring, and/or amniocentesis.

Endometrial,vulvar, and vaginal cancer in pregnancy are curiosities, althoughleiomyosarcoma and the dreaded twin fetus/hydatidiform mole have been reported.

Forgynecologic malignancies, pregnancy does not impart aggressive clinicalbehavior and/or worse prognosis.

王静教授：卵巢癌的维持治疗