When Cancer and Pregnancy Intersect

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12/08/2015

Published in Summer 2016 and Gynecology and Obstetrics - Winter 2016

For Ashley Kulp, a 29-year-old new patient of Amanda Nickles Fader, the diagnosis alone was harrowing. Kulp had presented with abdominal pain and bleeding, and examination revealed a 3-centimeter fungating mass on her cervix. A biopsy showed that it was neuroendocrine carcinoma, a rare cervical cancer subtype with a typically poor prognosis. An MRI provided further bad news: There was a second mass growing on Kulp’s right ovary, a possible sign of metastatic disease.

But complicating the case even further was that Kulp was 29 weeks’ pregnant with her first child.

“In the rare instance when cancer and pregnancy intersect, it creates a very difficult dilemma for patients and those of us who treat them,” says Fader, director of the Johns Hopkins Kelly Gynecologic Oncology Service. “We and they have to make some tough decisions about the best treatment options and how to optimize outcomes for both mother and fetus.”

Options for Kulp included allowing the pregnancy to proceed without intervention, delivering a course of chemotherapy during pregnancy, or delivering the baby through cesarean section to avoid the fungating mass and performing a concurrent radical hysterectomy. The last option provided the most positive prognosis for Kulp but would increase risk to the baby.

Fader worked with maternal-fetal medicine colleague Linda Szymanski, medical director of labor and delivery and inpatient obstetric services at The Johns Hopkins Hospital, as well as others in neonatology and anesthesiology to ensure that Kulp received extensive counseling to help her make the most informed decision.

Kulp elected early delivery and radical hysterectomy. After she received steroids to speed fetal lung maturity, her baby boy, Kayden, was delivered without complication at 30 weeks’ gestation, and Fader performed a radical hysterectomy and surgical debulking procedure that included staging biopsy of the lymph nodes and removal of large tumor masses in the ovary and bowel mesentery.

Although each member of the care team agreed that early delivery wasn’t ideal, Kayden had an uncomplicated hospital stay, leaving after just four weeks. After surgery, Kulp received an innovative combination of chemotherapy and radiation and also remains healthy, with no evidence of disease recurrence.

“Having the privilege of collaborating with an exceptional treatment team to help women like Ashley Kulp live the best, most meaningful life possible—it doesn’t get any better than that,” says Fader.

Center for Rare Gynecological Cancer

Caring for patients like Ashley Kulp is par for the course for Johns Hopkins’ Center for Rare Gynecologic Cancers, where patients with uncommon tumor types, including low-grade serous, clear cell and mucinous carcinoma of the ovary, leiomyosarcoma of the uterus, neuroendocrine carcinoma of the cervix and other rare malignancies, are seen by center director Amanda Nickles Fader and colleagues. These tumors represent less than 15 percent of all gynecological cancers but are among the most lethal. Besides providing state-of-the-art treatments and innovative clinical trials in the center, Fader has focused her research on elucidating the molecular make-up of these rare tumors and defining best practices. For more information or to refer a patient: 410-955-8240 or 1-844-H-GYNONC (1-844-449-6662).