the overall incidence of ovarian tumors in pregnancy is 2.4 - 5.7% ( 1 ) . of these tumors ,
currently , an ultrasound is routinely used early in pregnancy , and this has led to an early diagnosis and management of asymptomatic ovarian tumors .
in contrast to previous guidelines for managing gynecological malignancies in pregnancy , today , most women with ovarian cancer complicating pregnancy hope to maintain the pregnancy and preserve fertility , which has been encouraged by late maternity and a low birthrate . in the absence of large prospective randomized trials and cohort studies , it is difficult to know how to manage patients best and make standard guidelines for management of these tumors during pregnancy . to establish standard a guideline for management of ovarian cancer complicating pregnancy , it is necessary to identify surgical strategies with or without adjuvant intrapartum chemotherapy that results in safe oncologic and fetal outcomes .
this study was undertaken to help establish a guideline for management of ovarian malignancy complicating pregnancy .
we retrospectively analyzed the medical records of patients ( n=27 ) with ovarian cancer complicating pregnancy who were treated at cheil general hospital and women 's healthcare center between january 1996 and november 2006 . in these patients ,
twenty - five of these patients were diagnosed in our institute , and two were transferred from other hospitals .
conservative surgical management was defined as cystectomy , or unilateral salpingo - oophorectomy ( uso ) , or uso with omentectomy and multiple biopsies .
specialized pathologists at our institution reported findings of intra - operative frozen biopsies and post - operatively confirmed pathology specimens for all 27 patients .
the 1988 figo staging system was retrospectively used for each case after reviewing the operative reports and pathologic findings .
follow - up information was recorded up to the date of last contact or death .
mean age of the patients was 29.1 yr ( range 23 - 40 ) . of 27 patients with
ovarian tumor complicating pregnancy , 25 were diagnosed during pregnancy and the others were incidentally diagnosed at cesarean section .
mean time of diagnosis of ovarian tumor was 12.5 weeks of gestational age ( ga ) ( range 5.0 - 41.0 weeks of ga ) . in the patients diagnosed during pregnancy , 6 had the presenting symptoms such as abnormally distended abdomen due to huge ovarian tumor .
most patients without symptoms ( n=21 ) were diagnosed incidentally at early ga by a routine ultrasound examination ( table 1 ) .
histopathologic characteristics included ovarian borderline malignancy ( n=15 ) , epithelial ovarian cancers ( eoc ) ( n=7 ) and malignant germ cell tumors ( gct ) ( n=5 ) .
the mean size of the ovarian tumors measured by ultrasound sonogram was 11.4 cm ( range , 4 - 22 cm ) and three of 27 patients had an ovarian tumor less than 6 cm in diameter .
the initial operation included a conservative operation ( n=26 ) and a cytoreductive operation with hysterectomy ( n=1 ) .
the conservative surgical management included cystectomy ( n=10 ) , uso ( n=13 ) and uso with omentectomy and multiple biopsy ( n=3 ) .
patients with ovarian borderline malignancies underwent cystectomy ( n=7 ) , uso ( n=6 ) or uso with omentectomy and multiple biopsy ( n=2 ) .
the patients with germ cell tumor underwent cystectomy ( n=2 ) , uso ( n=2 ) or uso with omentectomy and multiple biopsy ( n=1 ) , with no recurrence in any patient with malignant germ cell tumor . in the patients with eoc , the surgical approaches were cystectomy ( n=1 ) , uso ( n=5 ) or cytoreductive operation with hysterectomy ( n=1 ) . in this group ,
of the 22 patients who underwent surgical interventions during pregnancy , there were no definite feto - maternal complications after surgical management .
of these 22 patients , nineteen ( 86.4% ) received surgical intervention during second trimester and three ( 13.6% ) during the first trimester .
a total of 8 patients received adjuvant chemotherapy ; 3 patients received chemotherapy with fetus in utero , and 5 patients received chemotherapy just after delivery .
one patient with eoc complicating ectopic pregnancy received postoperative chemotherapy . of five patients with germ cell tumor ,
3 patients received it with the fetus in utero ( range , 22.8 - 30.6 weeks of ga ) and two patients at 2 weeks after cesarean delivery with 4 courses of bleomycin , etoposide and cisplatin ( bep ) .
three patients with eoc received 6 courses of paclitaxel plus carboplatin at 2 weeks after cesarean delivery .
all 26 patients with ovarian cancer complicating pregnancy were successful in having a full term delivery .
of the 26 healthy full - term infants , 15 were delivered by normal vaginal delivery and eleven were by cesarean section .
an ultrasound sonogram is a routine method for evaluating fetal status in women with pregnancy and it can also be used for early detection of an incidental ovarian tumor . with the wide use of routine prenatal ultrasound , finding of an adnexal mass in pregnancy is increasing ( 4 ) .
in contrast to past delivery modes , cesarean delivery is now more frequent , and this can also contribute to the early incidental diagnosis of ovarian tumor complicating pregnancy .
the incidence of ovarian tumor detected during pregnancy is 1/300 to 1/556 pregnancies ( 5 - 7 ) . of the ovarian tumors detected during pregnancy ,
the incidence of ovarian malignancy is 1/15,000 to 1/32,000 in the most reports ( 4 , 8) . in our series ,
ovarian cancer during pregnancy occurred in 0.29/1,000 deliveries ( from 1996 to 2006 , from 92,370 deliveries at cheil general hospital and women 's healthcare center ) .
this high incidence could be explained by recent wide use of ultrasound examination as a routine antenatal evaluation in our hospital .
several studies have reported that the histologic types of ovarian cancers during pregnancy are similar to those for nonpregnant women in the corresponding reproductive - age group ( 4 , 9 - 11 ) . in our series ,
borderline malignancy and invasive epithelial ovarian cancer were more dominant than other types of malignancies ( table 4 ) .
in white women , dysgerminoma is the most common ovarian germ cell tumor coexisting with pregnancy , and constitutes 25 - 35% of all reported ovarian cancers ( 9 , 12 , 13 ) .
however , the most common subtype of germ cell tumor in our study was immature teratoma .
surgical management of an adnexal mass , diagnosed during pregnancy , creates a dilemma to gynecologists .
if an adnexal mass , larger than 6 cm , has a complex structure , or ascites or persists for 16 gestational weeks , surgical management is critical for obtaining a final histologic diagnosis and ruling out malignancy ( 14 ) .
when any surgical intervention is needed for an adnexal mass during pregnancy , the surgery should be performed during the safest period of pregnancy .
elective surgery for tumors with low suspicion of malignancy should be delayed until the second trimester ( 16 - 18 weeks of gestation ) , when risk for spontaneous abortion , hormonal dependence of the corpus luteum of pregnancy is reduced , and when functional cysts are resolved in the vast majority of cases ( 15 ) . in the first trimester ,
spontaneous abortion rate after surgery has been documented to be 10% , while 76.3% patients progress to full - term delivery ( 16 ) . a mass , first noticed in the third trimester ,
is best managed by awaiting fetal maturity as long as the clinical suspicion of malignancy is low .
premature labor is more likely to occur and pregnancy outcome is poor if surgical exploration is attempted during the third trimester ( 17 , 18 ) .
the principles of management in ovarian cancer complicating pregnancy include surgery with adequate staging . for advanced disease ,
the principles of adequate staging and debulking surgery should be similar to those used for the treatment of nonpregnant women .
for most early - stage ovarian cancers , the surgical principles should be unilateral oophorectomy or adnexectomy with appropriate staging .
especially , in borderline ovarian malignancies and germ cell tumors , it is imperative to use conservative surgical strategies to maintain pregnancy . in our series , of 20 patients with borderline malignancies ( n=15 ) and germ cell tumors ( n=5 ) ,
9 patients received cystectomy , 8 patients received uso and 3 patients received uso with omentectomy and multiple biopsy as the initial surgical management . and all 5 patients with germ cell tumor received bep ( cisplatin , bleomycin , and etoposide ) chemotherapy without any feto - maternal complications .
most malignant ovarian germ cell tumors could be treated by conservative surgery without compromising survival since these tumors are very sensitive to standard combinational chemotherapy ( 19 ) . and
borderline malignancies differ from invasive epithelial ovarian cancer in their indolent behavior and good prognosis .
all six cases in gotlieb 's report ( 20 ) with immediate conservative surgery preserving pregnancy had satisfactory outcomes .
since there was no established benefit from postoperative therapy for ovarian borderline malignancy , even in late - stage diseases ( 21 ) , conservative surgery is safe for these tumors ( 20 , 22 ) .
conservative surgical management for most malignant ovarian germ cell tumors and borderline malignancies diagnosed during pregnancy should be considered as the proper initial treatment .
the standard management of eoc is based on the primary surgery , including hysterectomy and bilateral salpingo - oophorectomy with peritoneal sampling ( peritoneal washing , omentectomy , multiple peritoneal biopsies and the removal of peritoneal implants ) with lymph - node biopsy . recently , with the help of several developed diagnostic tools , and an increase in self - health monitoring among women , early detection of ovarian cancer has increased and with the widespread use of routine prenatal ultrasound , the finding of an adnexal mass during pregnancy is an increasingly common occurrence .
in contrast to past strategies for managing eoc , most young patients with malignancies desire to be managed focused on the quality of life after treatment , and to maintain the pregnancy if possible .
however , frequent relapse of eoc makes conservative treatment strictly limited to patients with early stage eoc and low risks . in our study ,
6 of 7 patients with eoc received comprehensive rather than complete staging operations ( 1 cystectomy and 5 uso ) .
our study demonstrates that in eoc complicating pregnancy , conservative management with adequate staging procedures should be considered for oncologic safety .
generally , chemotherapy is compatible with the second or third trimester , when the risk of congenital malformation for fetuses exposed to chemotherapy is no greater than in the general population ( 23 , 24 ) . in our study
, three patients with germ cell tumors received bep chemotherapy during pregnancy , all of which had healthy babies without congenital malformations .
the literature contains numerous reports of bep regimen and adjuvant cisplatin and cyclophosphamide used in pregnancy with no untoward effects ( 8 , 25 - 28 ) .
there were a few case reports describing the combined use of paclitaxel and carboplatin in human pregnancy , and there seems to be no significant fetal toxicity when these are administered during the second or third trimester ( 29 , 30 ) .
recently , no studies have evaluated the long - term consequences for children exposed to intrauterine chemotherapy . to establish standard guidelines for treatment and improve the quality of life in patients with pregnancy complicating ovarian cancer with an oncologic safety ,
 the aim of this study is to evaluate the clinical feature and pregnancy outcome in patients with ovarian cancer diagnosed during pregnancy . 
 we retrospectively analyzed the medical records of 27 patients diagnosed with ovarian cancer during pregnancy at cheil general hospital & women 's healthcare center from january 1996 to december 2006 . 
 mean age of the patients was 29.1 yr ( range 23 - 40 ) , and a mean follow - up period was 57 months ( range 7 - 112 months ) . 
 of 27 patients , 15 ( 55.5% ) had borderline malignancies , 7 ( 25.9% ) had epithelial malignancies and 5 ( 18.6% ) had germ cell tumors . 
 a total of 26 patients received a conservative surgery preserving pregnancy . 
 the mean time for surgical intervention during pregnancy was 20 weeks of gestational age . 
 of the 27 patients , 26 had full term delivery of a healthy baby without any congenital malformation . 
 only one patient with epithelial ovarian cancer had a relapse at 19 months after the first conservative operation with adjuvant chemotherapy . 
 there were few data for managing patients with ovarian cancer diagnosed during pregnancy . 
 this study results could help establish a guideline for management of ovarian malignancy complicating pregnancy . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION