A woman treated for undifferentiated vulvar sarcoma at age 15 successfully delivered two children despite a complex reproductive history involving chemotherapy and pelvic radiation.
The case, reported in Cureus, provides rare clinical evidence regarding perinatal outcomes for childhood, adolescent, and young adult (C-AYA) cancer survivors who received both alkylating agents and pelvic radiotherapy.
The patient underwent tumor excision and lymphadenectomy at age 15, followed by a total dose of 45 Gy of radiation to the pelvic cavity and nine cycles of chemotherapy, including cyclophosphamide.
Her cumulative cyclophosphamide dose reached 17.6 g/m², placing her in a high-risk category for fertility impairment according to a European case-control study cited by the authors. While she experienced transient menstrual irregularities at age 19, she later conceived naturally at age 25.
The patient experienced several complications, including preterm birth and multiple pregnancy losses. During her first pregnancy, she experienced postpartum hemorrhage caused by uterine atony. Her third pregnancy ended in a mid-trimester miscarriage at 19 weeks and two days, complicated by chorioamnionitis and retained placental tissue that required uterine artery embolization.
For her fourth pregnancy at age 30, clinicians implemented a proactive management strategy. Due to the history of cervical changes, she underwent an elective prophylactic cervical cerclage at 12 weeks and five days of gestation. This intervention allowed the pregnancy to progress, resulting in the delivery of a healthy infant at 37 weeks and two days via vacuum extraction.
The 15 Gy dose of radiation estimated to have reached the uterus is a primary factor in the patient’s obstetric risks. Research suggests that uterine radiation doses exceeding 20 Gy are associated with higher rates of miscarriage and ectopic pregnancy compared to the general population. While the patient’s specific uterine dose distribution could not be verified, the authors said that the proximity of the cervix to the radiation field likely contributed to the cervical insufficiency observed in later pregnancies.
“This case contributes to the limited body of evidence on reproductive and perinatal outcomes among C-AYA cancer survivors treated with both alkylating agent-based chemotherapy and pelvic radiation therapy,” the report said. The patient remains under annual oncologic surveillance with no evidence of disease recurrence.
How did the patient’s prior chemotherapy affect her fertility? The patient received a cumulative cyclophosphamide dose of 17.6 g/m². While this level of exposure is statistically linked to a 2.7 odds ratio for fertility impairment, the patient recovered from transient menstrual irregularities after a course of hormone therapy and achieved four natural pregnancies.
Following the loss of her third pregnancy due to cervical dilation and subsequent shortening, clinicians identified a high risk for cervical insufficiency. Placing a prophylactic Shirodkar cerclage at 12 weeks helped maintain the pregnancy until 37 weeks.
The patient continues to undergo annual oncologic surveillance using imaging to monitor for potential recurrence of the undifferentiated vulvar sarcoma. As of the latest report, she has remained free of disease since completing her initial treatment at age 16.
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