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DOI 10.1007/s00404-009-0977-4
C A S E RE P O RT
Received: 10 July 2008 / Accepted: 30 January 2009 / Published online: 21 February 2009
Springer-Verlag 2009
Abstract Introduction
Background The management of ovarian cancer during
pregnancy represents a major challenge and requires close Ovarian cancer is the second most frequent gynecological
multidisciplinary team approach. cancer complicating pregnancy [1]. When a malignant
Case A 35-year-old pregnant woman with a yolk sac ovarian tumor is diagnosed during gestation, it is adenocar-
tumor underwent left salpingo-oophorectomy at 25 weeks cinoma in 35%, borderline malignant tumor in 30% and
of gestation. Chemotherapy was deferred to the end of the germ-cell/sex cord stromal tumor (mostly dysgerminomas)
pregnancy owing to concerns for potential fetal risks. in 35% of cases [2]. The yolk sac tumor is a malignant
Alpha-feto protein level was used to monitor the underlying germ-cell neoplasm arising from multipotential embryonal
disease activity. The patient underwent exploratory laparot- stem cells with diVerent ion toward yolk sac and vitelline
omy with cesarean section followed by total hysterectomy, structures [3]. Accounting for 1% of ovarian malignancies
omentectomy, right salpingooophorectomy, pelvic, and overall, it is rare but highly malignant tumor, occurring pri-
para-aortic lymphadenectomies at 32 weeks of gestation. marily in children and young women, whereas its incidence
She received four postoperative courses of chemotherapy in pregnancy is exceptionally low.
(cisplatin, etoposide, and peplomycin). Currently, mother The detection of malignancy during pregnancy often
and child are doing well 6 months after the last chemother- requires diYcult decision regarding maternal therapy and
apy cycle. the side eVects of the treatment to the unborn child. The
Conclusion In a case of yolk sac tumor in the second tri- optimal management of pregnant patients with ovarian can-
mester of pregnancy, radical surgery combined with elec- cer should aim to beneWt the mothers life and protect the
tive caesarian section followed by chemotherapy could fetus from the harmful eVects of cancer treatment [4, 5].
achieve remission and rescue of fetus. However, the treat- Surgical management during pregnancy is similar to non-
ment needs to be individualized as there is lack of evidence. pregnant patients and consists of unilateral salpingo-oopho-
rectomy in the initial stages of the disease. Prognosis seems
Keywords Yolk sac tumor Pregnancy AFP Cisplatin to be similar if appropriate treatment is conducted.
Etoposide Peplomycin Malignant germ-cell tumor of the ovary is extremely
sensitive to chemotherapy. Prognosis has markedly
improved with the concomitant use of bleomycin, etopo-
side, and cisplatin. However, the decision to start cytotoxic
therapy in a pregnant patient remains a dilemma. Almost all
chemotherapy agents can cross the placenta and cause tera-
I. PaWlis (&) D. Haidopoulos A. Rodolakis G. Vlachos togenesis. In addition, no comparable data are available to
Z. Voulgaris M. Sotiropoulou A. Antsaklis determine the long-term eVects on individuals who have
1st Department of Obstetrics and Gynecology,
been exposed to chemotherapy in uterus. Therefore, it is
Gynecologic Oncology Unit, Alexandra Hospital,
University of Athens, Athens, Greece imperative that such patients are under the care of a multi-
e-mail: johnpaWlis@hotmail.com disciplinary team that includes a high-risk obstetrician, a
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804 Arch Gynecol Obstet (2009) 280:803806
Case report
123
Arch Gynecol Obstet (2009) 280:803806 805
She then underwent four courses of platinum, etoposide, interpretation of tumor markers, including AFP, diYcult.
and bleomycin and her serum AFP monitored every month During normal pregnancy, Wrst the yolk sac then the fetal
afterwards rapidly declined to undetectable levels. The liver and gastrointestinal tract produces AFP. Maternal
mother and child are doing well 6 months after the last serum AFP levels are used to screen for certain fetal abnor-
cycle of chemotherapy. malities, particularly neural tube defects and trisomy 21.
Nonetheless, substantially elevated levels are associated
with endodermal sinus tumors. Outcome of many cases
Discussion support that a germ-cell tumor of either gonadal or extrago-
nadal origin should be considered as a diagnostic alterna-
Yolk sac tumors, unlike most ovarian malignancies, have tive in pregnant women with elevated serum AFP in
been known to be highly responsive to combined chemo- the absence of any fetal malformation or maternal disease
therapy agents. This is the rationale behind using chemo- [11, 14]. In our patient, tumor recurrence was presumed fol-
therapy after surgical resection in the initial stages of the lowed an elevated AFP to 500 ng/ml, since major fetal
disease or as Wrst line in more advanced cases. anomaly was excluded by detailed ultrasound scanning.
However, the use of such agents during pregnancy has Exploratory laparotomy with cesarean section followed
not been validated. Pregnancy aVects various physiological by total hysterectomy, omentectomy, right salpingo-oopho-
parameters and there is currently no available evidence on rectomy, pelvic and para-aortic lymphadenectomies were
the necessary therapeutic doses of chemotherapy during performed at 32 weeks of gestation. After termination of
this period [6]. Current experience has shown increased ter- pregnancy, the patient underwent four courses of chemo-
atogenicity during the Wrst trimester [79] but reports on therapy and routine follow-up procedures were started. Six
pregnancy outcomes during second and third trimester have months later, there was no evidence of recurrence clinically
been more uncertain [10]. Although normal pregnancy out- or radiologically and patients serum AFP levels remained
comes have been suggested from isolated reports [11], undetectable. The mother didnt breastfeed, since breast-
plethora of adverse fetal outcomes have been reported in feeding during cytotoxic chemotherapy has been discour-
the literature [10, 1214]. Furthermore, as yolk sac tumors aged in general [19].
are particularly rare during pregnancy there is limited In conclusion, our case suggests that unilateral salpingo-
expertise and certainly no consensus among clinicians on oophorectomy and surgical staging, without initial combi-
their optimal management. nation chemotherapy could be considered in a pregnant
In our case, we had to deal with a precious pregnancy. woman with a yolk sack tumor diagnosed during the second
Our advanced aged patient gets pregnant after years of trimester of pregnancy, although it may not be the standard
infertility and only after IVF treatment. The patient and her management in such patients. Chemotherapy during preg-
family strongly desired continuation of the pregnancy. In nancy requires consideration of the eVects on both the
view of the above, decision on further management was mother and fetus. A multidisciplinary team should be
taken after careful review of the available evidence and responsible for the management .The risks and beneWts
consideration of the patients wishes. have to be discussed with caution, considering the limited
In our initial assessment, the size of the ovarian mass as data on the short and long-term infant sequelae of chemo-
well as its suspicious radiological features made surgery therapy exposure in the uterus.
essential and, therefore, we performed salpingo-oophorec-
tomy and partial omentectomy at 25 weeks of gestation. ConXict of interest statement None.
Much eVort was taken in order to achieve a correct staging
and prognostic characterization and, more important, the
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