Letters to the Editors
org
baseline change, a change in short-term variability, or an arti-
fact by another, and the NICHD workshop guidelines do not
provide adequate information to settle this dispute.
For determining agreement among all 3 reviewers for the
other categorical variables, we found decreased short-term
variability to have a PA of 0.79 (95% CI 0.74 to 0.84) and
baseline FHR measured within 5 bpm increments to have a PA
of 0.38 (95% CI: 0.32 to 0.45).
Ernest M. Graham, MD
Division of Maternal-Fetal Medicine
Department of Gynecology and Obstetrics
Phipps 220
Johns Hopkins University School of Medicine
egrahaa@jhmi.edu
Richard E. Thompson, PhD
Department of Biostatistics
Bloomberg School of Public Health
Staging of cervical cancer complicating pregnancy
TO THE EDITORS: Palaia et al1 report a case of a patient
with locally advanced cervical carcinoma without lymph
node metastasis treated by neoadjuvant chemotherapy dur-
ing pregnancy followed by cesarean section and radical
surgery.
The pretherapeutic tumoral staging of this patient by cer-
vical biopsy and pelvic magnetic resonance imaging as lo-
cally advanced stage is insufficient to specify the prognosis
and to guide the therapeutics. Indeed, there was no lymph
node staging for this patient before the chemotherapy.
However, the knowledge of the pelvic lymph node status is a
major element of prognosis of cervical cancers.2
The lymph node staging could have been carried out by
laparoscopic lymphadenectomy during the pregnancy. In-
deed, certain teams showed the safety and feasibility of the
pelvic laparoscopic lymphadenectomy and its interest to
guide therapy during pregnancy.3,4 Only surgical staging be-
fore treatment gives complete information about tumor ex-
tension and status of the pelvic/paraaortic lymph nodes. In
the absence of lymph node involvement (as it is the case
presented), a radiotherapy could have been proposed to the
patient.
It has also been recently shown that radiotherapy during
the second and third trimester of pregnancy is relatively
harmless when patients are very keen to maintain their preg-
nancy.5 The chemotherapy could have been delayed after
the fetal extraction and would have probably been better
tolerated and thus more effective. Moreover, although trials
of neoadjuvant chemotherapy seem promising, we do not
have enough distance to conclude about its safety on the
fetus in the medium and long term. It will be necessary to
follow up this child during several years to conclude about
344 American Journal of Obstetrics & Gynecology MARCH 2008
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REFERENCES
1. Bernardes J, Costa-Pereira A, Ayres-de-Campos D, van Geijn HP,
Pereira-Leite L. Evaluation of interobserver agreement of cardiotoco-
f grams. Int J Gynaecol Obstet 1997;57:33-7.
2. Larma JD, Silva AM, Holcroft CJ, Thompson RE, Donohue PK, Graham
EM. Intrapartum electronic fetal heart rate monitoring and the identifica-
tion of metabolic acidosis and hypoxic-ischemic encephalopathy. Am J
Obstet Gynecol. 2007;197:301.e1-8.
3. National Institute of Child Health and Human Development Research
Planning Workshop. Electronic fetal heart rate monitoring: Research
guidelines for interpretation. Am J Obstet Gynecol 1997;177:1385-90.
4. Grant JM. The fetal heart rate trace is normal, isn’t it? Observer agree-
ment of categorical assessments. Lancet 1991;337:215-8.
© 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.11.038
the safety of the chemotherapy on her mental and physical
state.
The absence of lymph node involvement would be rather a
good prognosis; nevertheless, the lymph node staging after the
chemotherapy is not satisfactory because chemotherapy might
have sterilized lymph nodes that had been involved.
Finally, the follow-up of this patient is too short (only 10
months) to draw conclusions about the success of the treat-
ment. It would be necessary to have news from this patient in a
few years. f
Souhail Alouini, MD, PhD
Department of Gynecology and Obstetrics
Hôpital de Morlaix, France
alouini.s@wanadoo.fr
Patrice Mathevet, MD, PhD
Department of Gynecologic Surgery
Hôpital Edouard Herriot
Lyon, France
REFERENCES
1. Palaia I, Pernice M, Graziano M, Bellati F, Panici PB. Neoadjuvant
chemotherapy plus radical surgery in locally advanced cervical cancer
during pregnancy: a case report. Am J Obstet Gynecol. 2007;197:e5-6.
2. NCCN physician guidelines for cancer care. cervical cancer, practice
guidelines in oncology-v.1.2007. Available at: http://www.nccn.org/
professionals/physician_gls/PDF/cervical.pdf.
3. Hertel H. Laparoscopic lymph node staging of cervical cancer in the
19th week of pregnancy. A case report. Surg Endosc 2001;15:324.
4. Stan C, Megevand E, Irion O, Wang C, Bruchim I, Petignat P. Cervical
cancer in pregnant women: laparoscopic evaluation before delaying
treatment. Eur J Gynaecol Oncol 2005;26:649-50.
5. Kal HB, Struikmans H. Radiotherapy during pregnancy: fact and fic-
tion. Lancet Oncol 2005;6:328-33.
© 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.11.035