Obstetric dilemma in an ovarian cancer patient.

Abstract

Sir, Ovarian cancer is the most lethal female genital cancer worldwide. It is estimated that 3–17% of patients with ovarian cancer are younger than 40 years of age at the time of diagnosis and that 7–8% of all stage I epithelial ovarian cancers occur in women younger than 35 years (1). Many of these women will be interested in preserving their fertility despite the treatment of ovarian carcinoma. All the young ovarian cancer patients whatever their histologic type − epithelial, germ cell, or sex-cord stromal – are interested in “fertility sparing surgery” for the treatment of their disease. In the literature there are many new reports specifically on this topic describing successful fertility sparing surgical methods and related problems. We recently reported an epithelial ovarian cancer patient who gave birth to twins after fertility sparing surgery and chemotherapy (2). As this type of surgery is being increasingly preferred by gynecologic oncologists, interesting clinical queries and experiences are being reported. Here we report such a case. A 29-year-old nulligravida was diagnosed with an adnexial mass and fertility sparing surgery was carried out with a right salphingo-oopherectomy. Pathologic evaluation was reported as endodermal sinus tumor (EST) of the right ovary, which was FIGO stage Ia. Intraoperative findings were also characteristic of this stage. A full pelvic and paraaortic lymph node dissection was carried out in the operation and 62 lymph nodes were reported as negative for metastasis. Omentum and peritoneal cytology were also negative. After four cycles of a BEP (bleomycin, etoposide and cisplatin) chemotherapy regimen given as adjuvant chemotherapy, the patient was followed-up at 3-month intervals. All the ultrasonographic evaluations and alpha-fetoprotein (AFP) levels were in normal ranges during the first year. At the end of the first year of follow-up an alteration in AFP levels was indicated but there was no recurrent lesion by imaging techniques and AFP levels were stable at a plateau of 20–30 ng/mL. Twelve months after the completion of chemotherapy, the patient was admitted to our clinic with menstrual delay. Her serum B human chorionic gonadotropin (hCG) level was > 5000 IU/mL and transvaginal ultrasonography showed an intrauterine pregnancy of 6 weeks. She was under the surveillance of our perinatalogy department thereafter. Under normal conditions the maternal serum screening test for neural tube defects and trisomies applied between the 14th and 18th weeks of pregnancy is part of a routine antenatal surveillance of our clinic as accepted worldwide (3). Her AFP level was 861.3 ng/mL before the first operation and 150 ng/mL during her last routine oncology follow-up when she was diagnosed as pregnant. Her AFP level was 206 ng/mL at the 14th week of pregnancy. Her multiple of median (MOM) level was out of the normal range in the triple test because of the elevated AFP level (12,82 MOM, and risk for neural tube defect 1/14, Software by Robert Maciel Assoc., USA). This result was confusing with regard to many of the fetal problems that are found with elevated maternal serum AFP levels. We ignored this result because of her special condition and used detailed ultrasonographic evaluation for fetal anomalies that are known to cause abnormal AFP levels. The fetus was found to be anatomically normal by ultrasonographic evaluation. Although we point out this case as a very condition, it will take greater interest as fertility sparing surgery for ovarian cancer is preferred more for young patients. It must be another title in which maternal serum screening is of no value, and must be stated that ultrasonographic screening takes the first place in the follow-up of pregnancies of the patients who were treated by fertility sparing surgery for endodermal sinus tumors of ovary. In these patients maternal serum screening must be ignored because of possible alterations in marker levels. Cem Baykal Paris Cad. 37/9 Kavaklidere Ankara Turkey e-mail: cem.baykal@ttnet.net.tr