1
|
Folkins S, Miller A, Nash CM. Risk of venous thromboembolism in pregnant patients with active malignancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:645-652. [PMID: 37968882 PMCID: PMC10993334 DOI: 10.1111/aogs.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Cancer currently occurs in about 1 in 1000 pregnancies. Both active malignancy and pregnancy are individual risk factors for venous thromboembolism (VTE). The purpose of this systematic review/meta-analysis was to evaluate the rate of VTE in pregnant patients with active malignancy compared with pregnant patients without malignancy. MATERIAL AND METHODS Embase, Medline/PubMed, Cochrane Database, and clinicaltrial.gov were search by a trained librarian from inception until June 2021, and limited to English and French language human studies using keywords related to pregnancy, neoplasm, and thrombosis. This study was prospectively registered with PROSPERO (CRD42021245886). Title, abstract, and full-text review was performed using the Covidence data management system. Two authors reviewed the studies independently. Of the 3821 articles screened, seven cohort studies were included that reported VTE rate in patients with active malignancy in pregnancy. RESULTS A total of 5928 individuals had active malignancy and pregnancy. Active malignancy in pregnancy significantly increased the odds of a VTE (odds ratio [OR] 6.8, 95% confidence interval [CI] 3.8-12.1). Specifically, patients with thyroid (OR 2.7, 95% CI 1.3-6.3), cervix (OR 6.6, 95% CI 2.4-18.0), or other gynecological (OR 10.6, 95% CI 4.4-25.8) cancers; Hodgkin's lymphoma (OR 8.7, 95% CI 3.3-23.4); or acute leukemia (OR 17.1, 95% CI 10.9-26.8) all had increased odds, whereas those with brain cancer (OR 6.1, 95% CI 0.4-98.2), breast cancer (OR 2.5, 95% CI 0.3-17.4), malignant melanoma (OR 5.5, 95% CI 0.3-88.1), or non-Hodgkin's lymphoma (OR 3.2, 95% CI 0.8-12.9) malignancies did not have statistically significant increased odds for VTE. No studies reported whether prophylactic anticoagulation was used during pregnancy in this population; nor did they report timing in pregnancy of the VTE. The absolute risk for VTE in those with active malignancy was 0.9% compared with 0.2% in those without active malignancy in pregnancy. CONCLUSIONS Pregnancy with active malignancy confers a significant increased risk for VTE compared with pregnancy alone. Given this finding, prophylactic anticoagulation during pregnancy and postpartum could be considered in this patient population. Data are underpowered to make firm recommendations per cancer type.
Collapse
Affiliation(s)
- Sara Folkins
- Dalhousie University Medical SchoolHalifaxNova ScotiaCanada
| | - Ashley Miller
- Division of General Internal Medicine, Department of MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Christopher M. Nash
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynaecologyDalhousie UniversityHalifaxNova ScotiaCanada
| |
Collapse
|
2
|
Koo ZP, Chainchel Singh MK, Mohamad Noor MHB, Omar NB, Siew SF. Fatal anterior mediastinal mass in a pregnant lady. Forensic Sci Med Pathol 2024; 20:226-232. [PMID: 37436679 DOI: 10.1007/s12024-023-00669-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/13/2023]
Abstract
We report a fatal case of a 26-year-old nulliparous woman who presented with an anterior mediastinal mass in her late pregnancy. She had complained of a progressively increasing neck swelling and occasional dry cough in the early second trimester, which was associated with worsening dyspnoea, reduced effort tolerance and orthopnoea. Ultrasound of the neck showed an enlarged lymph node, and chest X-ray revealed mediastinal widening. At 35 weeks' gestation, the patient was referred to a tertiary centre for a computed tomography (CT) scan of the neck and thorax under elective intubation via awake fibreoptic nasal intubation as she was unable to lie flat. However, she developed sudden bradycardia, hypotension and desaturation soon after being positioned supine, which required resuscitation. She succumbed after 3 days in the intensive care unit. An autopsy revealed a large anterior mediastinal mass extending to the right supraclavicular region, displacing the heart and lungs, encircling the superior vena cava and right internal jugular vein with tumour thrombus extending into the right atrium. Histopathology examination of the mediastinal mass confirmed the diagnosis of a primary mediastinal large B-cell lymphoma. This report emphasizes the severe and fatal outcome resulting from the delay and misinterpretation of symptoms related to a mediastinal mass.
Collapse
Affiliation(s)
- Zhao Peng Koo
- Department of Forensic Pathology, University of Malaya Medical Centre, Jln Profesor Diraja Ungku Aziz, 59100, Kuala Lumpur, Malaysia.
| | - Mansharan Kaur Chainchel Singh
- National Institute of Forensic Medicine, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia
- Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi Mara (UiTM), Sg Buloh, Selangor, Malaysia
- Faculty of Medicine, Universiti Teknologi Mara (UiTM), Sg Buloh, Selangor, Malaysia
| | | | - Norhayati Binti Omar
- Department of Pathology, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia
| | - Sheue Feng Siew
- National Institute of Forensic Medicine, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia
| |
Collapse
|
3
|
Tadmor T, Melamed G, Alapi H, Gazit S, Patalon T, Rokach L. Pregnancy Course of 10 Women Diagnosed with Chronic Lymphocytic Leukemia. Acta Haematol 2023; 146:379-383. [PMID: 37276848 PMCID: PMC10614226 DOI: 10.1159/000531400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
Pregnancies following diagnosis of chronic lymphocytic leukemia (CLL) are rare events, mainly because the disease is typically diagnosed in the elderly. Literature on the topic is based only on case reports, and limited data are available on the influence of pregnancy on CLL course. In this retrospective study, we aimed to summarize the clinical and laboratory course of 10 women with CLL who became pregnant. None of the patients had significant changes in blood count during or after pregnancy or had complications such as infection, autoimmune phenomenon, or preeclampsia. Four out of 10 pregnancies were terminated with an early miscarriage. Following labor, 1 patient started anti-CLL treatment due to preexisting anemia, but none of the women required therapy during CLL progression during the first 2 years of follow-up. We conclude that based on our serial, pregnancy does not negatively impact on CLL course.
Collapse
Affiliation(s)
- Tamar Tadmor
- Hematology Unit, Bnai Zion Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Guy Melamed
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Hillel Alapi
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Sivan Gazit
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Tal Patalon
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Lior Rokach
- Department of Software and Information Systems Engineering, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
4
|
Mills GS, Chadwick V, Tang C, Perram J, Anderson MA, Anazodo A, Kidson-Gerber G, Shand A, Lavee O, Withers B, Milliken S, Di Ciaccio PR, Hamad N. Immunochemotherapy for life-threatening haematological malignancies in pregnancy: a systematic review of the literature and cross-sectional analysis of clinical trial eligibility. Lancet Haematol 2023; 10:e458-e467. [PMID: 37263722 DOI: 10.1016/s2352-3026(23)00059-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 06/03/2023]
Abstract
The management of potentially life-threatening malignancies in pregnancy is complicated by a lack of robust safety and efficacy evidence. This data shortage stems from a historical exclusion of women of childbearing potential from prospective clinical trials due to concerns around potential teratogenicity and toxicity of investigational agents. We conducted a systematic review of published data on immunochemotherapeutic treatment of life-threatening haematological malignancies in pregnancy between 2010 and 2022, and the maternal and neonatal outcomes. We then performed a cross-sectional observational study of clinical trial protocols on ClinicalTrials.gov, between 2016 and 2022, recruiting women of childbearing potential with potentially life-threatening haematological malignancies, collecting trial demographic data, and documenting whether pregnant or lactating women were explicitly excluded, along with the type and duration of contraception required for women of childbearing potential. We included 17 studies for analysis in our systematic review. A total of 595 women were treated with immunochemotherapy during pregnancy, with a median age of 29 years (range 14-48). Of these, 81 women (14%) were treated in the first trimester, and 514 (86%) were treated in the second and third trimesters collectively. In total, 68 trials for acute myeloid leukaemia, acute lymphocytic leukaemia, high-grade non-Hodgkin lymphoma, and Hodgkin lymphoma (40%, 26%, 21%, and 13%, respectively) were included in our ClinicalTrials.gov analysis. Most protocols (66 [97%]) explicitly excluded pregnant women, with 40 (69%) not providing a rationale for exclusion. The potential harm to the fetus from anti-cancer therapy has historically been given greater moral precedence than a pregnant woman's autonomy. This pattern is reflected in the lack of rigorous evidence for immunochemotherapy in pregnancy and a universal exclusion of pregnant and lactating women from clinical trial protocols in this study. Nonetheless, the administration of systemic chemotherapy in the second and third trimesters was not associated with an increased rate of congenital malformations or perinatal mortality in our systematic review cohort, with maternal outcomes broadly comparable to those of the non-pregnant population.
Collapse
Affiliation(s)
- Georgia S Mills
- Department of Haematology, Northern Beaches Hospital, Frenchs Forest, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine, Macquarie University, North Ryde, NSW, Australia.
| | - Verity Chadwick
- Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Catherine Tang
- Department of Haematology, Gosford Hospital, Gosford, NSW, Australia
| | - Jacinta Perram
- Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia; Department of Haematology and Bone Marrow Transplant, Westmead Hospital, Westmead, NSW, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Parkville, VIC, Australia
| | - Antoinette Anazodo
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Giselle Kidson-Gerber
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia; Department of Haematology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Antonia Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia; Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Orly Lavee
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Barbara Withers
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Sam Milliken
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Pietro R Di Ciaccio
- Department of Haematology, Sydney Adventist Hospital, Sydney, NSW, Australia; College of Health and Medicine, Australian National University, Canberra, ACT, Australia
| | - Nada Hamad
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Haematology and Bone Marrow Transplant, St Vincent's Hospital, Darlinghurst, NSW, Australia; Faculty of Medicine, University of Notre Dame, Sydney, NSW, Australia
| |
Collapse
|
5
|
Sorouri K, Loren AW, Amant F, Partridge AH. Patient-Centered Care in the Management of Cancer During Pregnancy. Am Soc Clin Oncol Educ Book 2023; 43:e100037. [PMID: 37220323 DOI: 10.1200/edbk_100037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.
Collapse
Affiliation(s)
- Kimia Sorouri
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alison W Loren
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Frédéric Amant
- Netherlands Cancer Institute, Amsterdam, the Netherlands
- KU Leuven, Leuven, Belgium
- University of Amsterdam, Amsterdam, the Netherlands
| | - Ann H Partridge
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| |
Collapse
|
6
|
Kobayashi S, Biyajima K, Matsuzawa S, Sakai K, Kawakami F, Kawakami T, Nishina S, Sakai H, Fuseya C, Nakazawa H. Acute leukemias in pregnant women: Results of a retrospective study at a local tertiary-care hospital in Japan. EJHAEM 2023; 4:393-400. [PMID: 37206296 PMCID: PMC10188455 DOI: 10.1002/jha2.682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 05/21/2023]
Abstract
Leukemia may rarely develop in a woman during pregnancy, posing clinical challenges to the patient, fetus, family, and medical staff managing malignancy and pregnancy. We retrospectively analyzed cases of pregnancy-associated leukemia consecutively diagnosed and treated at a local tertiary-care hospital in Nagano, Japan, over the past 20 years. Five cases were identified among 377,000 pregnancies in the area (one in every 75,000 pregnancies), all involving acute leukemia (three acute myelogenous leukemia [AML] and two acute lymphoblastic leukemia [ALL]). The cases were diagnosed in the first trimester (n = 1), second trimester (n = 3), or third trimester (n = 1). There were no apparent pregnancy-associated delays in diagnosing and treating the cases. Three patients underwent induction chemotherapy during pregnancy, two of whom eventually delivered healthy babies. One of the five patients chose abortion before chemotherapy initiation. Two cases showing high-risk features at the diagnosis (AML with an FLT3-ITD mutation [n = 1] and relapsed ALL [n = 1]) eventually died despite consolidative allogeneic hematopoietic stem cell transplantation. Our results suggested that patients with pregnancy-associated acute leukemia can be treated similarly to nonpregnant patients, although pregnancy imposes particular clinical challenges that should be resolved with multidisciplinary care.
Collapse
Affiliation(s)
- Shuhei Kobayashi
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Kyoko Biyajima
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Shuji Matsuzawa
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Kaoko Sakai
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Fumihiro Kawakami
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Toru Kawakami
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Sayaka Nishina
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Hitoshi Sakai
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| | - Chiho Fuseya
- Department of Obstetrics and GynecologyShinshu University School of MedicineMatsumotoJapan
| | - Hideyuki Nakazawa
- Department of Hematology and Medical OncologyShinshu University School of MedicineMatsumotoJapan
| |
Collapse
|
7
|
Di Ciaccio PR, Mills G, Shipton MJ, Campbell B, Gregory G, Langfield J, Greenwood M, McKeague S, Shanavas M, Eslick R, Kidson-Gerber G, Smallbone P, Tang C, Morris K, Bilmon I, Yannakou C, Badoux X, Berkahn L, Farina S, Mason KD, Motum P, Goss K, Hamad N. The clinical features, management and outcomes of lymphoma in pregnancy: A multicentre study by the Australasian Lymphoma Alliance. Br J Haematol 2023; 201:887-896. [PMID: 36880558 DOI: 10.1111/bjh.18727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/18/2023] [Accepted: 02/18/2023] [Indexed: 03/08/2023]
Abstract
Lymphoma in pregnancy (LIP) presents unique clinical, social and ethical challenges; however, the evidence regarding this clinical scenario is limited. We conducted a multicentre retrospective observational study reporting on the features, management, and outcomes of LIP in patients diagnosed between January 2009 and December 2020 at 16 sites in Australia and New Zealand for the first time. We included diagnoses occurring either during pregnancy or within the first 12 months following delivery. A total of 73 patients were included, 41 diagnosed antenatally (AN cohort) and 32 postnatally (PN cohort). The most common diagnoses were Hodgkin lymphoma (HL; 40 patients), diffuse large B-cell lymphoma (DLBCL; 11) and primary mediastinal B-cell lymphoma (PMBCL; six). At a median follow up of 2.37 years, the 2- and 5-year overall survival (OS) for patients with HL were 91% and 82%. For the combined DLBCL and PMBCL group, the 2-year OS was 92%. Standard curative chemotherapy regimens were successfully delivered to 64% of women in the AN cohort; however, counselling regarding future fertility and termination of pregnancy were suboptimal, and a standardised approach to staging lacking. Neonatal outcomes were generally favourable. We present a large multicentre cohort of LIP reflecting contemporary practice and identify areas in need of ongoing research.
Collapse
Affiliation(s)
- Pietro R Di Ciaccio
- Sydney Adventist Hospital, Wahroonga, New South Wales, Australia.,College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.,School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Georgia Mills
- Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia.,Faculty of Medicine, Macquarie University, Ryde, New South Wales, Australia
| | - Michael J Shipton
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Belinda Campbell
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Department of Clinical Pathology, University of Melbourne, Parkville, Victoria, Australia
| | | | - Jenna Langfield
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Matthew Greenwood
- Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Sean McKeague
- Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Mohammad Shanavas
- Mater Hospital Brisbane, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Renee Eslick
- The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Giselle Kidson-Gerber
- Prince of Wales Hospital and The Royal Hospital for Women, Randwick, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
| | | | - Catherine Tang
- Gosford Hospital, Gosford, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Kirk Morris
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Ian Bilmon
- Sydney Adventist Hospital, Wahroonga, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Westmead Hospital, Westmead, New South Wales, Australia
| | - Costas Yannakou
- Epworth Freemasons, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Xavier Badoux
- St George Hospital, Kogarah, New South Wales, Australia
| | | | | | - Kylie D Mason
- Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Penelope Motum
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | - Nada Hamad
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Medicine, Sydney, University of Notre, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Mills GS, Di Ciaccio PR, Tang C, Chadwick V, Mason KD, Campbell BA, Shipton MJ, Shanavas M, Morris KL, Greenwood M, Langfield J, Kidson-Gerber G, Eslick R, Badoux X, Yannakou CK, Gangatharan SA, Bilmon I, Hamad N. Capturing the lived experiences of women with lymphoma in pregnancy: a qualitative study. Leuk Lymphoma 2023; 64:319-328. [PMID: 36423348 DOI: 10.1080/10428194.2022.2148376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Lymphoma in pregnancy is a rare and challenging diagnosis that complicates ∼1:6000 pregnancies; posing a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. These difficulties are compounded by the paucity of real-world data on the management of LIP, and a lack of relevant support systems for women in this setting. We conducted a retrospective multicenter qualitative study, interviewing women aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020 from 13 Australasian sites. Semi-structured telephone interviews were conducted, recorded, and analyzed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. Of the 32 women interviewed, 20 (63%) were diagnosed during pregnancy (16, 34, and 13% in the 1st, 2nd, and 3rd trimesters, respectively), while 12 (37%) were diagnosed post-partum. Women recalled that their chief concerns at diagnosis were the welfare of their child (n = 13, 41%) and a fear of dying (n = 9, 28%). Perceived diagnostic delay attributed to pregnancy was reported by 41% of participants. Other key themes were communication, educational materials, psychosocial supports, and oncofertility issues. To our knowledge this is the first report capturing the lived experiences of survivors of lymphoma during pregnancy, affording a unique opportunity to consider the management, psychosocial supports, and delivery of care to meet the needs of these women.What is the NEW aspect of your work? To our knowledge, this is the first report capturing and analyzing the healthcare experiences of survivors of Lymphoma in Pregnancy (LIP).What is the CENTRAL finding of your work? Women valued clear and empathic communication, provision of tailored educational materials, access to psychosocial supports (particularly childcare and financial supports), and timely oncofertility management in their healthcare journey.What is (or could be) the SPECIFIC clinical relevance of your work? Women's personal accounts of positive and negative experiences of LIP care provide insights into their specific concerns and needs which can shape healthcare policy and development of a specific framework for managing and supporting patients with LIP (and other cancers).
Collapse
Affiliation(s)
- Georgia S Mills
- Department of Hematology, Northern Beaches Hospital, Frenchs Forest, Australia.,Northern Beaches Clinical School, Macquarie University, Sydney, Australia.,Department of Hematology and Bone Marrow Transplant, St. Vincent's Hospital, Darlinghurst, Australia
| | - Pietro R Di Ciaccio
- Department of Hematology, Sydney Adventist Hospital, Sydney, Australia.,School of Medicine, University of New South Wales, Sydney, Australia
| | - Catherine Tang
- Department of Hematology, Gosford Hospital, Gosford, Australia.,Department of Haematology, Wellington Hospital, Wellington, New Zealand
| | - Verity Chadwick
- Department of Hematology and Bone Marrow Transplant, St. Vincent's Hospital, Darlinghurst, Australia
| | - Kylie D Mason
- Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Clinical Pathology, The University of Melbourne, Parkville, Australia
| | - Belinda A Campbell
- Department of Clinical Pathology, The University of Melbourne, Parkville, Australia.,Department of Radiation Oncology, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Michael J Shipton
- Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Mohamed Shanavas
- Department of Haematology, Mater Hospital, Brisbane, Australia.,Department of Medicine, University of Queensland, Brisbane, Australia
| | - Kirk L Morris
- Department of Haematology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Matthew Greenwood
- Department of Haematology, Royal North Shore Hospital, Sydney, Australia.,School of Medicine, University of Sydney, Sydney, Australia
| | - Jenna Langfield
- Department of Haematology, Royal North Shore Hospital, Sydney, Australia.,School of Medicine, University of Sydney, Sydney, Australia
| | - Giselle Kidson-Gerber
- School of Medicine, University of New South Wales, Sydney, Australia.,Department of Haematology, Prince of Wales Hospital and The Royal Hospital for Women, Randwick, Australia
| | - Renee Eslick
- Department of Haematology, The Canberra Hospital, Canberra, Australia
| | - Xavier Badoux
- Department of Haematology, St. George Hospital, Sydney, Australia
| | - Costas K Yannakou
- Department of Molecular Oncology and Cancer Immunology, Epworth HealthCare, Melbourne, Australia
| | - Shane A Gangatharan
- Fiona Stanley Hospital, Murdoch, Australia.,School of Medicine, University of Western Australia, Nedlands, Australia
| | - Ian Bilmon
- Department of Hematology and Bone Marrow Transplant, Westmead Hospital, Westmead, Australia
| | - Nada Hamad
- Department of Hematology and Bone Marrow Transplant, St. Vincent's Hospital, Darlinghurst, Australia.,School of Medicine, University of New South Wales, Sydney, Australia.,School of Medicine, University of Notre Dame, Sydney, Australia
| |
Collapse
|
9
|
Krayem B, Brenner B, Horowitz NA. Thrombosis in Pregnant Women with Hematological Malignancies: A Case-Based Review. Semin Thromb Hemost 2022; 49:348-354. [PMID: 36535649 DOI: 10.1055/s-0042-1759683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractCancer and pregnancy induce a procoagulant environment which may lead to maternal and fetal complications, such as venous thromboembolism, fetal growth restriction, and fetal loss. The incidence of hematological malignancies diagnosed during pregnancy is rising, and thrombotic events in such malignancies are not rare. Management of thrombosis during pregnancy poses a therapeutic challenge, that is further exacerbated by the impact of cancer. The available data on managing pregnant women with hematological malignancies are limited to those with myeloproliferative neoplasms, mainly essential thrombocythemia, and, to a lesser extent, polycythemia vera. Low-dose aspirin is recommended throughout pregnancy, and considering treatment with low-molecular-weight heparin and interferon formulations is advised for high-risk patients. Currently, guidelines for handling thrombotic events in pregnant women with lymphoma or leukemia are lacking, and their management is based on data extrapolated from retrospective studies, and guidelines for prevention and treatment of cancer-associated thrombosis. The present case-based review will focus on the complex issue of thrombotic risk in pregnant women with hematological malignancies, specifically myeloproliferative neoplasms, lymphomas, and leukemias.
Collapse
Affiliation(s)
- Baher Krayem
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Netanel A. Horowitz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
10
|
Delzotto J, Naqvi TS, Opara NU, Delzotto A, Morgan A. Unusual Presentation of Hodgkin's Lymphoma in Pregnancy: A Case Report and Systematic Review of Literature. Hematol Rep 2022; 14:322-334. [PMID: 36412626 PMCID: PMC9680227 DOI: 10.3390/hematolrep14040046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/30/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Diseases occurring during pregnancy create a dilemma of managing the patient without causing harm to the unborn child. Three percent of the peak incidence of Hodgkin lymphoma (HL) is congruent with the reproductive period, particularly with pregnancy. Pregnant patients with HL always require a team of medical experts ranging from a medical oncologist, high-risk obstetrician, and neonatologist. Effective communication with both the patient and family is also necessary. The treatment goal for these patients should focus on achieving complete remission for the mother while permitting the delivery of a healthy child. Pregnant patients diagnosed with HL should undergo similar clinical investigations as other non-pregnant patients with accurate disease staging and appropriate non-radiation imaging such as ultrasound while avoiding invasive procedures.
Collapse
Affiliation(s)
- Joseph Delzotto
- Department of Emergency Medicine, Charleston Area Medical Center, Charleston, WV 25304, USA
| | - Tahira. S. Naqvi
- Department of Internal Medicine, Charleston Area Medical Center, Charleston, WV 25304, USA
| | - Nnennaya. U. Opara
- Department of Emergency Medicine, Charleston Area Medical Center Institute for Academic Medicine, Charleston, WV 25304, USA
- Correspondence:
| | - Anthony Delzotto
- Department of Emergency Medicine, Charleston Area Medical Center, Charleston, WV 25304, USA
| | - Andrew Morgan
- Department of Emergency Medicine, Charleston Area Medical Center, Charleston, WV 25304, USA
| |
Collapse
|
11
|
Zhang L, Wang Y, Lu M, Shen M, Duan Z. Patients with blastic plasmacytoid dendritic cell neoplasm in pregnancy: A rare case report. Medicine (Baltimore) 2022; 101:e30622. [PMID: 36197206 PMCID: PMC9509190 DOI: 10.1097/md.0000000000030622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
RATIONALE Previous clinical reports of patients with blastic plasmacytoid dendritic cell neoplasm (BPDCN) in pregnancy are rare. PATIENT CONCERNS The present study presents the case of 37-year-old women exhibiting third trimester with progressive painless, abdominal skin nodules. INTERVENTIONS AND OUTCOMES A 37-year-old pregnant woman with BPDCN and partial placenta previa and racket-shaped placenta. After comprehensive evaluation, the pregnancy status ends at 37 weeks and 6 days by cesarean section of lower uterus and no abnormality in the newborn. LESSONS Pregnant women diagnosed with BPDCN in the third trimester should terminate the pregnancy promptly for further treatment.
Collapse
Affiliation(s)
- Li Zhang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yidong Wang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Mingming Lu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Mengdan Shen
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zhao Duan
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- * Correspondence: Zhao Duan, MD, Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Xi’an Jiaotong University, No.157 Xiwu Road, Xi’an 710004, China (e-mail: )
| |
Collapse
|
12
|
Parpinel G, Laudani ME, Giunta FP, Germano C, Zola P, Masturzo B. Use of Positron Emission Tomography for Pregnancy-Associated Cancer Assessment: A Review. J Clin Med 2022; 11:jcm11133820. [PMID: 35807104 PMCID: PMC9267808 DOI: 10.3390/jcm11133820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 12/10/2022] Open
Abstract
Background. Positron emission tomography (PET) has proven clinical utility both in the initial and relapse staging phase, but this technique is controversial during pregnancy. The objective of this review is to provide a compendium of available information on the use of PET during pregnancy. Materials and methods. A systematic literature review was conducted from 1 January 2004 until 20 May 2021. A total of 4 small series and 9 case reports consisting of 25 cases were selected. Results. During the first trimester, the fetus is most sensitive to ionization damage, so lower doses are recommended (2.6E-02 mGy/MBq). Fetal-effective doses are higher in this period and the average fetal dose (4.06 ± 3.22 mGy) remains significantly below the threshold for deterministic effects. During the second and third trimesters, recommended doses are higher (1.4E-02 mGy/MBq at 6 months, and 6.9E-03 mGy/MBq at 9 months of gestation). 18F-FDG activity was distributed to the whole fetus with a prevalence of myocardial tissue in seven cases. The use of special precautions, such as PET-magnetic resonance (MR) and urinary bladder catheterization, reduces the amount of radioactive tracer. Breastfeeding interruption is not recommended. Conclusions. 18F-FDG PET is not contraindicated in pregnancy, but multidisciplinary discussion is necessary and strict precautions are recommended.
Collapse
Affiliation(s)
- Giulia Parpinel
- Unit of Gynecology and Obstetrics 2U, Sant’Anna Hospital, Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy; (G.P.); (M.E.L.); (P.Z.)
| | - Maria Elena Laudani
- Unit of Gynecology and Obstetrics 2U, Sant’Anna Hospital, Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy; (G.P.); (M.E.L.); (P.Z.)
| | - Francesca Paola Giunta
- Unit of Nuclear Medicine, Department of Medical Sciences, Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Chiara Germano
- Department of Obstetrics and Gynecology, Ospedale degli Infermi, 13875 Ponderano, Italy;
- Correspondence:
| | - Paolo Zola
- Unit of Gynecology and Obstetrics 2U, Sant’Anna Hospital, Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy; (G.P.); (M.E.L.); (P.Z.)
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology, Ospedale degli Infermi, 13875 Ponderano, Italy;
| |
Collapse
|
13
|
Heesterbeek CJ, Aukema SM, Galjaard RJH, Boon EMJ, Srebniak MI, Bouman K, Faas BHW, Govaerts LCP, Hoffer MJV, den Hollander NS, Lichtenbelt KD, van Maarle MC, van Prooyen Schuurman L, van Rij MC, Schuring-Blom GH, Stevens SJC, Tan-Sindhunata G, Zamani Esteki M, de Die-Smulders CEM, Tjan-Heijnen VCG, Henneman L, Sistermans EA, Macville MVE. Noninvasive Prenatal Test Results Indicative of Maternal Malignancies: A Nationwide Genetic and Clinical Follow-Up Study. J Clin Oncol 2022; 40:2426-2435. [PMID: 35394817 DOI: 10.1200/jco.21.02260] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Noninvasive prenatal testing (NIPT) for fetal aneuploidy screening using cell-free DNA derived from maternal plasma can incidentally raise suspicion for cancer. Diagnostic routing after malignancy suspicious-NIPT faces many challenges. Here, we detail malignancy suspicious-NIPT cases, and describe the clinical characteristics, chromosomal aberrations, and diagnostic routing of the patients with a confirmed malignancy. Clinical lessons can be learned from our experience. METHODS Patients with NIPT results indicative of a malignancy referred for tumor screening between April 2017 and April 2020 were retrospectively included from a Dutch nationwide NIPT implementation study, TRIDENT-2. NIPT profiles from patients with confirmed malignancies were reviewed, and the pattern of chromosomal aberrations related to tumor type was analyzed. We evaluated the diagnostic contribution of clinical and genetic examinations. RESULTS Malignancy suspicious-NIPT results were reported in 0.03% after genome-wide NIPT, and malignancies confirmed in 16 patients (16/48, 33.3%). Multiple chromosomal aberrations were seen in 23 of 48 patients with genome-wide NIPT, and a malignancy was confirmed in 16 patients (16/23, 69.6%). After targeted NIPT, 0.005% malignancy suspicious-NIPT results were reported, in 2/3 patients a malignancy was confirmed. Different tumor types and stages were diagnosed, predominantly hematologic malignancies (12/18). NIPT data showed recurrent gains and losses in primary mediastinal B-cell lymphomas and classic Hodgkin lymphomas. Magnetic resonance imaging and computed tomography were most informative in diagnosing the malignancy. CONCLUSION In 231,896 pregnant women, a low percentage (0.02%) of NIPT results were assessed as indicative of a maternal malignancy. However, when multiple chromosomal aberrations were found, the risk of a confirmed malignancy was considerably high. Referral for extensive oncologic examination is recommended, and may be guided by tumor-specific hallmarks in the NIPT profile.
Collapse
Affiliation(s)
- Catharina J Heesterbeek
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sietse M Aukema
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Elles M J Boon
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Katelijne Bouman
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Brigitte H W Faas
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Mariëtte J V Hoffer
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Klaske D Lichtenbelt
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Merel C van Maarle
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lisanne van Prooyen Schuurman
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maartje C van Rij
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Servi J C Stevens
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Gita Tan-Sindhunata
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Masoud Zamani Esteki
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Christine E M de Die-Smulders
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Lidewij Henneman
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Erik A Sistermans
- Department of Human Genetics, and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Merryn V E Macville
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, the Netherlands
| | | |
Collapse
|
14
|
Zanotti-Fregonara P. Radiation Absorbed Dose to the Embryo and Fetus from Radiopharmaceuticals. Semin Nucl Med 2022; 52:140-148. [PMID: 35067360 PMCID: PMC8923960 DOI: 10.1053/j.semnuclmed.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nuclear medicine procedures are generally avoided during pregnancy out of concern for the radiation dose to the fetus. However, for clinical reasons, radiopharmaceuticals must occasionally be administered to pregnant women. The procedures most likely to be performed voluntarily during pregnancy are lung scans to diagnose pulmonary embolism and 18F-fluoro-2-deoxyglucose (18F-FDG) scans for the staging of cancers. This article focuses on the challenges of fetal dose calculation after administering radiopharmaceuticals to pregnant women. In particular, estimation of the fetal dose is hampered by the lack of fetal biokinetic data of good quality and is subject to the variability associated with methodological choices in dose calculations, such as the use of various anthropomorphic phantoms and modeling of the maternal bladder. Despite these sources of uncertainty, the fetal dose can be reasonably calculated within a range that is able to inform clinical decisions. Current dose estimates suggest that clinically justified nuclear medicine procedures should be performed even during pregnancy because the clinical benefits for the mother and the fetus outweigh the small and purely hypothetical radiation risk to the fetus. In addition, the fetal radiation dose should be minimized without compromising image quality, such as by encouraging bladder voiding and by using positron emission tomography (PET)/magnetic resonance imaging (MRI) devices or high-sensitivity PET scanners that generate images of good quality with a lower injected activity.
Collapse
|
15
|
Northgraves M, Allsup D, Cohen J, Huang C, Turgoose J, Ali S. A prospective registry-based cohort study of the diagnosis and management of acute leukaemia in pregnancy: Study protocol. PLoS One 2022; 17:e0263195. [PMID: 35130292 PMCID: PMC8820608 DOI: 10.1371/journal.pone.0263195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background Acute leukaemias (AL) are aggressive but potentially curable blood cancers that can potentially affect women of childbearing age. When a pregnancy is complicated by a diagnosis of AL, clinicians face a complex dilemma: to balance risking the mother’s survival through delayed AL treatment, against the potential harm to the foetus through exposure to anti-cancer drugs. Up until now, all guidance and advice regarding the management of AL in pregnancy, have been based on expert opinion and small case studies. There is a pressing need for more studies in the subject to address this evidence gap. Methods and analysis This study is a registry-based observational cohort study which aims to monitor and record the treatment outcomes of patients diagnosed with AL during pregnancy. Additionally, the study aims to assess pregnancy outcomes in patients who become pregnant following successful treatment. Prospective and historical cases from August 2009 onwards will be identified from AL treating haematology units within the UK. Details of diagnosis, AL treatment delivered, antenatal and postnatal outcomes for mother and neonate will be collected. This study will establish a new research database for Leukaemia in Pregnancy. Trial registration The study was registered on Clinicaltrials.gov (NCT04182074) on the 2nd December 2019.
Collapse
Affiliation(s)
| | - David Allsup
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, Hull, United Kingdom
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull, United Kingdom
- Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, United Kingdom
| | - Chao Huang
- Hull Health Trials Unit, University of Hull, Hull, United Kingdom
- Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, United Kingdom
| | - John Turgoose
- Hull Health Trials Unit, University of Hull, Hull, United Kingdom
| | - Sahra Ali
- King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
| |
Collapse
|
16
|
Lymphoma during pregnancy in Japan: a multicenter retrospective cohort study. Int J Hematol 2022; 115:382-390. [PMID: 34981434 DOI: 10.1007/s12185-021-03281-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study was conducted to characterize lymphoma occurring during pregnancy and to investigate the outcomes of the patients and the fetuses. METHODS Clinical data were gathered retrospectively from 29 patients at 13 participating institutions, and data from 28 eligible patients were analyzed. RESULTS Six (21%) patients had Hodgkin lymphoma (HL) and 22 (79%) patients had non-Hodgkin lymphoma (NHL). All patients with HL presented with lymphadenopathy, but 15 (68%) of the 22 patients with NHL presented with extranodal sites only. At the median follow-up period of 1325 (range 6-4461) days, the 5-year overall survival rate was 63% for patients with NHL and 100% for patients with HL. Three of the 13 patients who received chemotherapy during pregnancy (23%) developed Pneumocystis jiroveci pneumonia (PCP). There was 1 intrauterine fetal death, 1 spontaneous abortion in the first trimester, and 15 (54%) preterm births. CONCLUSION This study showed a higher proportion of NHL than HL during pregnancy in Japan, which was inconsistent with the proportions observed in Western countries. The high incidence of maternal PCP and preterm birth suggested the need for improvements in our management of lymphoma during pregnancy.
Collapse
|
17
|
Wang P, Yang Z, Shan M, Lu S, Zhang L, Li S, Hu S, Tian H, Xu Y, Wu D. Maternal and Fetal Outcomes of Acute Leukemia in Pregnancy: A Retrospective Study of 52 Patients. Front Oncol 2022; 11:803994. [PMID: 34970499 PMCID: PMC8712699 DOI: 10.3389/fonc.2021.803994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/26/2021] [Indexed: 12/02/2022] Open
Abstract
Acute leukemia during pregnancy (P-AL) is a rare disease with limited data regarding the management and outcomes of mothers and fetuses. We retrospectively analyzed the characteristics, pregnancy outcomes and maternal and neonatal prognoses of 52 patients with P-AL collected from January 2013 to December 2020 in our center. Seventeen (32.7%) patients received chemotherapy during pregnancy (exposed cohort), while 35 (67.3%) received chemotherapy after abortion/delivery (nonexposed cohort). Twenty-six (50.0%) pregnancies ended with abortion, and 26 (50.0%) babies were born through spontaneous delivery or cesarean section. Seven infants (26.9%) were born in the exposed cohort, while 19 infants (73.1%) were born in the nonexposed cohort. Fetuses in the exposed cohort had lower gestational ages (P=0.030) and birth weights (P=0.049). Considering the safety of the fetus, seven patients in the exposed cohort received low-dose chemotherapy, one patient received all-trans retinoic acid (ATRA) and one patient only received corticosteroids as induction therapy. Patients received low-dose chemotherapy as induction therapy had a lower complete remission (CR) rate (P=0.041), and more patients in this group received HSCT (P=0.010) than patients received intensive chemotherapy. Patients who delayed chemotherapy in the nonexposed cohort experienced a trend toward a higher mortality rate than patients who received timely chemotherapy (P=0.191). The CR (P = 0.488), OS (P=0.655), and DFS (P=0.453) were similar between the exposed and nonexposed cohorts. Overall, the 4-year overall survival (OS) and disease-free survival (DFS) rates were estimated at 49.1% and 57.8%, respectively. All newborns were living, without deformities, or developmental and intellectual disabilities. Our study indicated that P-AL patients in the first trimester might tend to receive chemotherapy after abortion. Both the status of disease and patients’ willingness should be taken into consideration when clinicians were planning treatment strategies in the second or third trimester. Low-dose or delayed chemotherapy might decrease the efficacy of induction therapy and survival rate of patients, but HSCT could improve the prognosis.
Collapse
Affiliation(s)
- Peng Wang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhen Yang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Meng Shan
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shenqi Lu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Luwei Zhang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shijia Li
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuhong Hu
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Hong Tian
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yang Xu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| |
Collapse
|
18
|
[Diagnosis and treatment of acute leukemia during pregnancy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:82-86. [PMID: 35232003 PMCID: PMC8980671 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
19
|
Wu P, Jordan KP, Chew-Graham CA, Mohamed MO, Barac A, Lundberg GP, Chappell LC, Michos ED, Maas AHEM, Mamas MA. In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses. Mayo Clin Proc 2021; 96:2779-2792. [PMID: 34272068 DOI: 10.1016/j.mayocp.2021.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/12/2021] [Accepted: 03/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery. METHODS We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database. RESULTS We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth. CONCLUSION Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.
Collapse
Affiliation(s)
- Pensée Wu
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Staffordshire, United Kingdom; Academic Unit of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom.
| | - Kelvin P Jordan
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Carolyn A Chew-Graham
- School of Medicine, Keele University, Staffordshire, United Kingdom; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele University, Staffordshire, United Kingdom
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Staffordshire, United Kingdom; The Heart Centre, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| | - Ana Barac
- Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Gina P Lundberg
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA; Emory Women's Heart Center, Atlanta, GA
| | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, London, United Kingdom
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angela H E M Maas
- Department of Cardiology, Women's Cardiac Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Staffordshire, United Kingdom; The Heart Centre, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| |
Collapse
|
20
|
Mellemkjær L, Eibye S, Albieri V, Kjær SK, Boice JD. Pregnancy-associated cancer and the risk of second primary cancer. Cancer Causes Control 2021; 33:63-71. [PMID: 34643832 DOI: 10.1007/s10552-021-01500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Hormonal changes related to pregnancy and lactation among women treated for cancer might influence the risk of second primary cancer. We investigated whether pregnancy near the time of breast cancer, Hodgkin lymphoma or other cancer diagnoses is associated with increased risk of developing a new primary cancer. METHODS Women born after 1 April 1935 diagnosed with cancer at ages 15-44 years during 1968-2006 were identified in the Danish Cancer Registry. Information about pregnancies from various nationwide registers was used to identify women with a pregnancy-associated cancer defined as a cancer diagnosed 6 or fewer months before the pregnancy, during the pregnancy or up to 1 year after the pregnancy. Second primary cancers were ascertained through 2013, and hazard ratios (HRs) were calculated using Cox regression models adjusted for age, calendar-period and number of pregnancies with the reference defined as cancer not associated with a pregnancy. RESULTS We identified 2,974 women with pregnancy-associated cancer and 31,970 women who were not pregnant near the time of their cancer diagnosis. There was no association between pregnancy-associated cancer and a second cancer (HR 0.91; 95% CI 0.79-1.05). Among 680 women with either breast cancer or Hodgkin lymphoma associated with pregnancy, a HR of 1.16 (95% CI 0.87-1.56) for second breast cancer was observed based on 48 cases. CONCLUSION While hormonal changes might stimulate development of specific cancers, in particular breast cancer, it is reassuring that risk of breast and other second cancers was not related to pregnancy near the time of a first primary cancer diagnosis.
Collapse
Affiliation(s)
- Lene Mellemkjær
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Strandboulevarden 49, 2100, Copenhagen, Denmark.
| | - Simone Eibye
- Department of Oncology and Radiation Biology, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Vanna Albieri
- Unit of Statistics and Data Analyses, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne K Kjær
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Strandboulevarden 49, 2100, Copenhagen, Denmark.,Department of Gynecology, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John D Boice
- National Council on Radiation Protection and Measurements, Bethesda, MD, USA.,Division of Epidemiology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| |
Collapse
|
21
|
Kalampokas E, Vlahos N, Kalampokas T, Gurumurthy M. Common Malignancies During Pregnancy: A Comprehensive Review. CANCER DIAGNOSIS & PROGNOSIS 2021; 1:103-109. [PMID: 35399318 DOI: 10.21873/cdp.10015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 01/31/2023]
Abstract
Malignant disease complicates pregnancy in up to 1 per 1,000-2,000 cases. Pregnancy itself does not constitute a predisposing factor for malignancy. Management and treatment of patients suffering from a malignancy during pregnancy still represents a challenge in everyday clinical practice. Recent advances in imaging, diagnostic and overall treatment modalities have tailored the management of patients, specifically those who wish to maintain the pregnancy. The aim of this review was to provide clinicians with concise information on the management of the most common malignancies during pregnancy. We performed a review of the current literature including review articles, original research articles and guidelines, which are used for the management of the most common malignancies during pregnancy. Breast, cervical and ovarian malignant tumours are the most common during pregnancy. However, the overall outcome and survival per stage for these cancers do not appear to be influenced by pregnancy. Ethical, emotional and treatment dilemmas may be encountered during treatment planning. Individualization of treatment planning should be made by a multidisciplinary team but the final decision rests with the parents.
Collapse
Affiliation(s)
| | - Nikolaos Vlahos
- Department of Obstetrics and Gynaecology, Aretaieio Hospital, Athens, Greece
| | | | | |
Collapse
|
22
|
Tafesse TB, Bule MH, Khan F, Abdollahi M, Amini M. Developing Novel Anticancer Drugs for Targeted Populations: An Update. Curr Pharm Des 2021; 27:250-262. [PMID: 33234093 DOI: 10.2174/1381612826666201124111748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Due to higher failure rates, lengthy time and high cost of the traditional de novo drug discovery and development process, the rate of opportunity to get new, safe and efficacious drugs for the targeted population, including pediatric patients with cancer, becomes sluggish. OBJECTIVES This paper discusses the development of novel anticancer drugs focusing on the identification and selection of targeted anticancer drug development for the targeted population. METHODS Information presented in this review was obtained from different databases, including PUBMED, SCOPUS, Web of Science, and EMBASE. Various keywords were used as search terms. RESULTS The pharmaceutical companies currently are executing drug repurposing as an alternative means to accelerate the drug development process that reduces the risk of failure, time and cost, which take 3-12 years with almost 25% overall probability of success as compared to de novo drug discovery and development process (10- 17 years) which has less than 10% probability of success. An alternative strategy to the traditional de novo drug discovery and development process, called drug repurposing, is also presented. CONCLUSION Therefore, to continue with the progress of developing novel anticancer drugs for the targeted population, identification and selection of target to specific disease type is important. Considering the aspects of the age of the patient and the disease stages such as each cancer types are different when we study the disease at a molecular level. Drug repurposing technique becomes an influential alternative strategy to discover and develop novel anticancer drug candidates.
Collapse
Affiliation(s)
- Tadesse B Tafesse
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammed H Bule
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Fazlullah Khan
- Department of Allied Health Sciences, Bashir Institute of Health Sciences, Bhara Kahu Islamabad, Iran
| | - Mohammad Abdollahi
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), and Department of Toxicology and Pharmacology, School of Pharmacy, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mohsen Amini
- Department of Medicinal Chemistry, School of Pharmacy, Drug Design and Development Research Center and The Institute of Pharmaceutical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
23
|
van Gerwen M, Huis In 't Veld E, van Grotel M, van den Heuvel-Eibrink MM, Van Calsteren K, Maggen C, Drochytek V, Scarfone G, Fontana C, Fruscio R, Cardonick E, van Dijk-Lokkart EM, Amant F. [Formula: see text]Long-term neurodevelopmental outcome after prenatal exposure to maternal hematological malignancies with or without cytotoxic treatment. Child Neuropsychol 2021; 27:822-833. [PMID: 33876721 DOI: 10.1080/09297049.2021.1902489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Data on the long-term neurodevelopmental outcomes of children exposed to hematological maternal cancer with or without treatment during pregnancy are lacking. A total of 57 children, of whom 33 males and 24 females, prenatally exposed to hematological malignancies and its treatment, were invited for neuropsychological and physical examinations at 18 months, 36 months, 6, 9, 12, 15 and 18 years of age. Oncological, obstetrical, neonatal and follow-up data of these children were collected. Parents were asked to complete questionnaires on their child's general health, school performances, social situation, behavioral development, executive functioning, and if their child receives supportive care. Non-Hodgkin lymphoma was diagnosed in 35.1%, Hodgkin lymphoma in 28.1%, acute myeloid leukemia in 15.8%, chronic myeloid leukemia in 12.3%, and acute lymphoblastic leukemia in 8.8%. Cognitive development at a median age of 10.7 years was within the normal range. In subgroup analyses of children in early childhood, the gestational age at birth was correlated with the cognitive outcome at a median age of 1.7 years. Scores for language development, intelligence, attention, memory and behavior, as well as clinical neurological and general pediatric examinations were within normal ranges. In subgroup analyses, the need for supportive care in the child was associated with the loss of the mother. Prenatal exposure to hematological maternal malignancies with or without treatment did not affect the neurodevelopment of the child in the long term. Yet, caution is indicated and surveillance of the emotional development of the child is needed, especially when the mother is deceased to cancer.
Collapse
Affiliation(s)
- Mathilde van Gerwen
- Center for Gynecologic Oncology Amsterdam, the Netherlands Cancer Institute, Amsterdam, The Netherlands.,Pediatric Oncology , Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Evangeline Huis In 't Veld
- Center for Gynecologic Oncology Amsterdam, the Netherlands Cancer Institute, Amsterdam, The Netherlands.,Pediatric Oncology , Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Martine van Grotel
- Pediatric Oncology , Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Kristel Van Calsteren
- Department of Obstetrics, University Hospitals Leuven, Leuven and Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Vit Drochytek
- Department of Obstetrics and Gynecology, 3rd Medical Faculty Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Giovanna Scarfone
- Gynecological Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla Fontana
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Robert Fruscio
- Clinic of Obstetrics and Gynecology, University of Milan-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Elyce Cardonick
- Department of Obstetrics and Gynecology, Cooper University Health Care, Camden, NJ, USA
| | - Elisabeth M van Dijk-Lokkart
- Department of Child & Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frédéric Amant
- Center for Gynecologic Oncology Amsterdam, the Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oncology, KU Leuven, Leuven, Belgium.,Center for Gynecologic Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| |
Collapse
|
24
|
Luttwak E, Gurevich-Shapiro A, Azem F, Lishner M, Klieger C, Herishanu Y, Perry C, Avivi I. Novel agents for the treatment of lymphomas during pregnancy: A comprehensive literature review. Blood Rev 2021; 49:100831. [PMID: 33931297 DOI: 10.1016/j.blre.2021.100831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/12/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
Lymphoproliferative diseases occurring during pregnancy present unique diagnostic and therapeutic challenges aiming to achieve maternal cure without impairing fetal health, growth, and survival. These goals are further complicated by the fast-paced emergence of novel therapies and their introduction as standard of care, even in newly diagnosed patients. Due to the rarity of hematological malignancies in pregnancy and the exclusion of pregnancy in almost all clinical trials, available data on the fetal effects of novel drugs are limited to animal models and case reports. The current review addresses the entire multidisciplinary team involved in treating pregnant patients with lymphoproliferative diseases. We describe novel agents according to their mechanism of action, and summarize our knowledge of their effects during the gestational period, particularly those associated with fetotoxicity. Therapeutic dilemmas associated with the employment of these new agents are also discussed.
Collapse
Affiliation(s)
- E Luttwak
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - A Gurevich-Shapiro
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Immunology, Weizmann Institute of Science, Rehovot, Israel.
| | - F Azem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; IVF Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical, Tel Aviv, Israel
| | - M Lishner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Research Institue, Meir Medical Center, Kfar Saba, Israel
| | - C Klieger
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; IVF Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical, Tel Aviv, Israel
| | - Y Herishanu
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Perry
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I Avivi
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
25
|
Wang HF, Liang MY, Jiang Q. [Management of patients with lymphoma in pregnancy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:1053-1056. [PMID: 33445860 PMCID: PMC7840544 DOI: 10.3760/cma.j.issn.0253-2727.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- H F Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - M Y Liang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Q Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| |
Collapse
|
26
|
Arora A, Prakash G, Bagga R, Srinivasan R, Jain A. Managing Life-Threatening Malignant Superior Mediastinal Syndrome in Pregnancy: When Benefits of Radiation and Chemotherapy Outweigh the Risks—A Case Report and Review of Literature. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1732819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractThere is scarce literature on managing superior mediastinal syndrome during pregnancy. We report a case of 26-year-old primigravida who presented with life-threatening superior mediastinal syndrome at 32 weeks of gestation. The diagnosis was significantly delayed and, as a result, she reached the emergency with stridor and impending respiratory failure. She was diagnosed with primary mediastinal B cell lymphoma Lugano Stage II with a bulky mediastinal mass. She was treated with chemoimmunotherapy and underwent a preterm vaginal delivery after a week. She delivered a 1.6 kg healthy child with no malformations. Later, she completed three cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisolone and five cycles of dose-adjusted etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin, rituximab, followed by radiotherapy. She continues to be in remission at 18 months of follow-up. Delaying diagnostic imaging that involves ionizing radiation exposure and chemotherapy to avoid teratogenic and obstetric complications during pregnancy can adversely affect the prognosis in certain patients with high-grade malignancies. On the contrary, prompt multidisciplinary management can lead to a gratifying outcome.
Collapse
Affiliation(s)
- Aashima Arora
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Gaurav Prakash
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Rashmi Bagga
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| |
Collapse
|
27
|
Abstract
Lymphomas afflict all age groups of people, with certain types demonstrating a female predilection in adolescents and young adults. A proportion of lymphomas that are diagnosed in this population demographic occur in the setting of pregnancy. Most of these behave aggressively at presentation and require immediate or urgent therapy. Treatment must consider both maternal and fetal health, and management approaches are therefore influenced by gestational age at diagnosis and treatment and timing of delivery. Although there is a paucity of literature on how to treat these patients, limited retrospective reports demonstrate generally good outcomes and highlight the necessity of an experienced multidisciplinary team approach to management.
Collapse
|
28
|
Greiber IK, Mikkelsen AP, Karlsen MA, Storgaard L, Viuff JH, Mellemkjaer L, Hjortshøj CS, Lidegaard Ø. Cancer in pregnancy increases the risk of venous thromboembolism: a nationwide cohort study. BJOG 2021; 128:1151-1159. [PMID: 33314607 DOI: 10.1111/1471-0528.16627] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate if cancer in pregnancy causes a higher risk of venous thromboembolism (VTE) during pregnancy and postpartum compared with pregnant women without cancer. DESIGN A historical prospective cohort study using data from nationwide registries. SETTING AND POPULATION We assessed all pregnancies in Denmark between 1 January 1977 and 31 December 2017. METHODS We linked information concerning cancer diagnosis, pregnancy and VTE diagnosis and potential confounders. Event rates of VTE for women with pre-pregnancy cancer, cancer in pregnancy and without cancer were calculated per 10 000 pregnancies and compared using logistic regression analysis. MAIN OUTCOME MEASURES Occurrence of VTE during pregnancy or the postpartum period. RESULTS A total of 3 581 214 pregnancies were included in the study and we found 1330 women with cancer in pregnancy. In pregnant women with cancer, the event rate of VTE was 75.2 per 10 000 pregnancies compared with 10.7 per 10 000 pregnancies in the no cancer group. The findings correspond to an increased adjusted odds ratio of 6.50 (95% CI3.5-12.1) in the cancer in pregnancy group in comparison with the no cancer group. CONCLUSIONS Women with cancer in pregnancy have a markedly higher risk of pregnancy-associated VTE compared with women without cancer. In pregnancy-related VTE risk assessment, the presence of cancer alone may be sufficient to indicate thromboprophylaxis. TWEETABLE ABSTRACT Cancer in pregnancy increases the risk of VTE during pregnancy and the postpartum period.
Collapse
Affiliation(s)
- I K Greiber
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - A P Mikkelsen
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - M A Karlsen
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - L Storgaard
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - J H Viuff
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen O, Denmark
| | - L Mellemkjaer
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen O, Denmark
| | - C S Hjortshøj
- Department of Paediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ø Lidegaard
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Pregnancy-associated lymphoma (PAL) is an uncommon entity that lacks detailed prospective data. It poses significant management challenges that incorporate maternal and fetal risks associated with treatment or delayed intervention. Herein, we review the current literature for the diagnosis, management, and supportive care strategies for PAL. RECENT FINDINGS Establishment of a multidisciplinary team, including hematology-oncology, maternal-fetal medicine, and neonatology, is critical in the management of PAL. For staging, ultrasound and MRI are preferred modalities with use of computerized tomography in select situations. Data for the safety and effectiveness of therapy for PAL is largely based on retrospective studies. The timing of lymphoma-directed antenatal systemic therapy depends on the trimester, gestational age, lymphoma subtype and aggressiveness, and patient wishes. Therapy in the first trimester is usually not advocated, while treatment in the second and third trimesters appears to result in similar outcomes for PAL compared with non-pregnant patients with lymphoma. An overarching goal in most PAL cases should be to plan for delivery at term (i.e., gestational age > 37 weeks). For supportive care, most antiemetics, including agents such as neurokinin-1 receptor antagonists, have been used safely during pregnancy. For prevention or treatment of infections, particular antibiotics (i.e., macrolides, cephalosporins, penicillins, metronidazole), antivirals (i.e., acyclovir, valacyclovir, famciclovir), and antifungals (amphotericin B) have demonstrated safety and with use of growth factors reserved for treatment of neutropenia (vs. primary prophylaxis). Therapy for PAL should be individualized with goals of care that balance maternal and fetal well-being, which should include a multidisciplinary care team and overall intent for term delivery in most cases.
Collapse
|
30
|
Wang G, Peng X. A Review of Clinical Applications and Side Effects of Methotrexate in Ophthalmology. J Ophthalmol 2020; 2020:1537689. [PMID: 32850138 PMCID: PMC7439192 DOI: 10.1155/2020/1537689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 12/11/2022] Open
Abstract
Methotrexate (MTX) is a folate analog widely used against a range of diseases including malignancies and autoimmune disorders. Its high effectiveness-price ratio also won extensive application in ophthalmology. On the other hand, although MTX has an excellent pharmacological efficacy, MTX associated side effects in clinical use, which vary from patient to patient, are nonnegligible. There is no comparatively systematic review on MTX associated side effects and its risk factors. This review aimed to reveal novel clinical approaches of MTX and its adverse effects in order to provide a reference for ophthalmic scholars in clinical application of MTX.
Collapse
Affiliation(s)
- Ge Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Xiaoyan Peng
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| |
Collapse
|
31
|
Comes M, Batlle M, Ribera JM. Treatment adapted to pregnancy in a patient with Burkitt lymphoma. Med Clin (Barc) 2020; 154:470-471. [PMID: 31337491 DOI: 10.1016/j.medcli.2019.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 04/16/2019] [Accepted: 04/25/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Martina Comes
- Servicio de Hematología Clínica, ICO-Hospital Germans Trias i Pujol, Badalona, Barcelona; Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona.
| | - Montserrat Batlle
- Servicio de Hematología Clínica, ICO-Hospital Germans Trias i Pujol, Badalona, Barcelona; Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona
| | - Josep-Maria Ribera
- Servicio de Hematología Clínica, ICO-Hospital Germans Trias i Pujol, Badalona, Barcelona; Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona
| |
Collapse
|
32
|
Stang A, Schwärzler P, Schmidtke S, Tolosa E, Kobbe R. Successful Immunochemotherapy for Burkitt Lymphoma During Pregnancy as a Bridge to Postpartum High-Dose Methotrexate Therapy: A Case Report and Review of the Literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e284-e290. [DOI: 10.1016/j.clml.2019.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/09/2019] [Accepted: 12/14/2019] [Indexed: 01/10/2023]
|
33
|
Cotteret C, Pham YV, Marcais A, Driessen M, Cisternino S, Schlatter J. Maternal ABVD chemotherapy for Hodgkin lymphoma in a dichorionic diamniotic pregnancy: a case report. BMC Pregnancy Childbirth 2020; 20:231. [PMID: 32306909 PMCID: PMC7168968 DOI: 10.1186/s12884-020-02928-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/07/2020] [Indexed: 12/20/2022] Open
Abstract
Background Hodgkin lymphoma (HL) is the most common hematological malignancy during pregnancy. The first-line treatment for HL in pregnancy is the standard ABVD regimen without any drug and/or dose adjustment. However, data on chemotherapy during twin pregnancies are sparse, and a better understanding of the mechanisms involved in exposure to and the toxic effects of anticancer drugs in the fetuses is needed. Case presentation A 41-year-old dichorionic diamniotic pregnant patient was given ABVD treatment for HL at a gestational age of 28 weeks and 3 days. The patient received 2 cycles of chemotherapy with a 15-day therapeutic window including an actual 25 mg/m2 dose of doxorubicin per cycle. Unlike the female twin, the male twin presented four days after birth a left cardiac dysfunction. Doxorubicin cardiotoxicity in the male newborn was also supported by high blood levels of troponin. At one month of age, echocardiography findings were normal. We investigated literature data on physiological aspects of pregnancy that may influence doxorubicin pharmacokinetics, and pharmacodynamic and pharmacokinetic data on the use of doxorubicin in pregnancy. We detailed the role of the transporters in doxorubicin placenta distribution, and tried to understand why only one fetus was affected. Conclusions Fetal safety depends at least on maternal doxorubicin pharmacokinetics.Because of drug interactions (i.e. drug metabolism and drug transport), care should always be taken to avoid maternal pharmacokinetic variability. The toxic effects were discrepant between the dizygotic twins, suggesting additional fetus-specific pharmacokinetic/pharmacodynamic factors in doxorubicin toxicity.
Collapse
Affiliation(s)
- Camille Cotteret
- Hôpital universitaire Necker - Enfants malades, Pharmacie, F-75015, Paris, France
| | - Yen-Vi Pham
- Hôpital universitaire Necker - Enfants malades, Pharmacie, F-75015, Paris, France
| | - Ambroise Marcais
- Hôpital universitaire Necker - Enfants malades, Hématologie adultes, F-75015, Paris, France
| | - Marine Driessen
- Hôpital universitaire Necker - Enfants malades, gynécologie-obstétrique, F-75015, Paris, France
| | - Salvatore Cisternino
- Hôpital universitaire Necker - Enfants malades, Pharmacie, F-75015, Paris, France.,Inserm UMR-S 1144, Team "Blood-brain barrier in brain pathophysiology and therapy", Université Paris Descartes, F-75006, Paris, France
| | - Joël Schlatter
- Hôpital universitaire Necker - Enfants malades, Pharmacie, F-75015, Paris, France.
| |
Collapse
|
34
|
Maggen C, Wolters VERA, Cardonick E, Fumagalli M, Halaska MJ, Lok CAR, de Haan J, Van Tornout K, Van Calsteren K, Amant F. Pregnancy and Cancer: the INCIP Project. Curr Oncol Rep 2020; 22:17. [PMID: 32025953 PMCID: PMC7002463 DOI: 10.1007/s11912-020-0862-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Cancer diagnosis in young pregnant women challenges oncological decision-making. The International Network on Cancer, Infertility and Pregnancy (INCIP) aims to build on clinical recommendations based on worldwide collaborative research. RECENT FINDINGS A pregnancy may complicate diagnostic and therapeutic oncological options, as the unborn child must be protected from potentially hazardous exposures. Pregnant patients should as much as possible be treated as non-pregnant patients, in order to preserve maternal prognosis. Some approaches need adaptations when compared with standard treatment for fetal reasons. Depending on the gestational age, surgery, radiotherapy, and chemotherapy are possible during pregnancy. A multidisciplinary approach is the best guarantee for experience-driven decisions. A setting with a high-risk obstetrical unit is strongly advised to safeguard fetal growth and health. Research wise, the INCIP invests in clinical follow-up of children, as cardiac function, neurodevelopment, cancer occurrence, and fertility theoretically may be affected. Furthermore, parental psychological coping strategies, (epi)genetic alterations, and pathophysiological placental changes secondary to cancer (treatment) are topics of ongoing research. Further international research is needed to provide patients diagnosed with cancer during pregnancy with the best individualized management plan to optimize obstetrical and oncological care.
Collapse
Affiliation(s)
- Charlotte Maggen
- Department of Oncology, KU Leuven, Leuven, Belgium
- Department of Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Vera E R A Wolters
- Department of Gynecology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Elyce Cardonick
- Department of Obstetrics and Gynecology, Cooper University Health Care, Camden, NJ, USA
| | - Monica Fumagalli
- Neonatal Intensive Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Michael J Halaska
- Faculty Hospital Kralovske Vinohrady and 3rd Medical, Faculty, Charles University, Prague, Czech Republic
| | - Christianne A R Lok
- Centre for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jorine de Haan
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Kristel Van Calsteren
- Department of Obstetrics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Frédéric Amant
- Department of Oncology, KU Leuven, Leuven, Belgium.
- Centre for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Centre for Gynecological Oncology Amsterdam (CGOA), Amsterdam University Medical Centers, Amsterdam, The Netherlands.
| |
Collapse
|
35
|
Maggen C, Dierickx D, Lugtenburg P, Laenen A, Cardonick E, Smakov RG, Bellido M, Cabrera-Garcia A, Gziri MM, Halaska MJ, Ottevanger PB, Van Calsteren K, O'Laughlin A, Polushkina E, Van Dam L, Avivi I, Vandenberghe P, Woei-A-Jin FJSH, Amant F. Obstetric and maternal outcomes in patients diagnosed with Hodgkin lymphoma during pregnancy: a multicentre, retrospective, cohort study. LANCET HAEMATOLOGY 2019; 6:e551-e561. [DOI: 10.1016/s2352-3026(19)30195-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 02/02/2023]
|
36
|
Farge D, Le Maignan C, Doucet L, Frere C. Women, thrombosis, and cancer. Thromb Res 2019; 181 Suppl 1:S47-S53. [DOI: 10.1016/s0049-3848(19)30367-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
|
37
|
Liu D, Yan J, Qiao J. Effects of malignancies on fertility preservation outcomes and relevant cryobiological advances. SCIENCE CHINA-LIFE SCIENCES 2019; 63:217-227. [DOI: 10.1007/s11427-019-9526-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/03/2019] [Indexed: 01/04/2023]
|
38
|
Bracewell-Milnes T, Marcus S, MacDonald R. An unusual cause of post-partum pyrexia. J OBSTET GYNAECOL 2019; 39:1017-1018. [PMID: 31023111 DOI: 10.1080/01443615.2019.1586857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Timothy Bracewell-Milnes
- Division of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus , London , UK
| | - Samuel Marcus
- Queen Elizabeth Hospital, Greenwich and Lewisham NHS Trust , London , UK
| | - Russell MacDonald
- Queen Elizabeth Hospital, Greenwich and Lewisham NHS Trust , London , UK
| |
Collapse
|
39
|
Nolan S, Czuzoj-Shulman N, Abenhaim HA. Obstetrical and newborn outcomes among women with acute leukemias in pregnancy: a population-based study. J Matern Fetal Neonatal Med 2019; 33:3514-3520. [PMID: 30773954 DOI: 10.1080/14767058.2019.1579188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: Acute leukemias (ALs) are rare but aggressive malignancies. The goal of our study was to determine the incidence, obstetrical, and newborn outcomes of ALs in pregnancy.Materials and methods: We performed a retrospective population-based cohort study on all births reported in the Health-Care Cost and Utilization Project-Nationwide Inpatient Sample between 1999 and 2014. We calculated the incidence of ALs in pregnancy and conducted multivariate logistic regression to obtain adjusted odds ratios for various maternal and newborn outcomes among this population compared to a nonaffected one.Results: We identified 291 maternal cases of ALs among 14,513,587 births, yielding an incidence of 2.01 per 100,000 births over the 15-year study period. There were approximately twice as many diagnoses of acute myeloid leukemia (AML) as compared to acute lymphoid leukemia (ALL). After adjusting for differing baseline characteristics and maternal and fetal deaths, we found that pregnant women with ALs were more likely to experience post-partum hemorrhage, to suffer from disseminated intravascular coagulation (DIC), to require transfusions, to have wound complications, and to experience venous thromboembolism (VTEs). Maternal death, preterm delivery, and intrauterine fetal death (IUFD) were more common in pregnant women with ALs.Conclusion: The incidence of ALs in pregnancy appears to be greater than what was previously believed. As it is associated with several adverse maternal and fetal outcomes, affected patients should be cared for in tertiary care institutions with access to high-risk obstetrical specialists, hematologists, and neonatologists.
Collapse
Affiliation(s)
- Sabrina Nolan
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Canada
| | - Haim Arie Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Canada
| |
Collapse
|
40
|
Farge D, Le Maignan C, Doucet L, Frere C. WITHDRAWN: Women, thrombosis, and cancer. Thromb Res 2019. [DOI: 10.1016/j.thromres.2019.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
41
|
Salama M, Isachenko E, Ludwig S, Einzmann T, Rahimi G, Mallmann P, Isachenko V. A successful multidisciplinary approach for treatment and for preserving the reproductive potential in a rare case of acute lymphocytic leukemia during pregnancy. Gynecol Endocrinol 2019; 35:115-118. [PMID: 30179055 DOI: 10.1080/09513590.2018.1498833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Leukemia in pregnancy is a rare condition with the prevalence of 1 in 75,000-100,000 pregnancies. In this case report, we present a successful multidisciplinary management strategy for treatment and for preserving the reproductive potential in a rare case of acute lymphocytic leukemia (ALL) during pregnancy. Several complex challenges existed and necessitated a multidisciplinary approach with strong coordination and collaboration between oncologists, gynecologists, reproductive cryobiologists, obstetricians, and neonatologists in order to improve the maternal and fetal outcome. Pregnancy in the second trimester is neither a contraindication for ALL treatment nor for emergency fertility preservation via ovarian tissue extraction and further cryopreservation.
Collapse
Affiliation(s)
- Mahmoud Salama
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
- b Oncofertility Consortium, Feinberg School of Medicine, Northwestern University , Chicago , IL , USA
| | - Evgenia Isachenko
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| | - Sebastian Ludwig
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| | - Thomas Einzmann
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| | - Gohar Rahimi
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| | - Peter Mallmann
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| | - Vladimir Isachenko
- a Department of Obstetrics and Gynecology Medical Faculty , University of Cologne , Cologne , Germany
| |
Collapse
|
42
|
Momen NC, Arendt LH, Ernst A, Olsen J, Li J, Gissler M, Ramlau-Hansen CH. Pregnancy-associated cancers and birth outcomes in children: a Danish and Swedish population-based register study. BMJ Open 2018; 8:e022946. [PMID: 30518582 PMCID: PMC6286483 DOI: 10.1136/bmjopen-2018-022946] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/20/2018] [Accepted: 10/05/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study aims to estimate the association between pregnancy-associated maternal cancers, diagnosed both prenatally and postnatally, and birth outcomes. DESIGN Population-based register study. SETTING National registers of Denmark and Sweden. PARTICIPANTS A total of 5 523 365 children born in Denmark (1977-2008) and Sweden (1973-2006).Primary and secondary outcome measures: gestational age, birth weight, size for gestational age, Apgar score, caesarean section and sex were the outcomes of interest. ORs and relative risk ratios (RRR) with 95% CIs were estimated using logistic regression and multinomial logistic regression, respectively. RESULTS In this study, 2% of children were born to mothers with a diagnosis of cancer. Children whose mothers received a prenatal cancer diagnosis had higher risk of being born preterm (RRR: 1.77, 95% CI 1.64 to 1.90); low birth weight (RRR 1.84, 95% CI 1.69 to 2.01); low Apgar score (OR 1.36, 95% CI 1.20 to 1.56); and by caesarean section (OR: 1.69, 95% CI 1.59 to 1.80). Associations moved towards the null for analyses using postnatal diagnoses, but preterm birth (RRR: 1.13, 95% CI 1.09 to 1.17) and low birth weight (RRR: 1.14, 95% CI 1.09 to 1.18) remained statistically significant, while risk of caesarean section became so (OR: 0.95, 95% CI 0.91 to 0.98). Additionally, statistical significance was reached for large for gestational age (RRR: 1.06, 95% CI 1.01 to 1.11), high birth weight (RRR: 1.04, 95% CI 1.01 to 1.06) and caesarean section (OR: 0.95, 95% CI 0.91 to 0.98). CONCLUSIONS Results suggest an association between pregnancy-associated cancers and adverse birth outcomes in the offspring. While this is strongest for prenatally diagnosed cancers, some smaller associations exist for postnatally diagnosed cancers, indicating that cancer itself could affect fetal development, or that cancer and adverse birth outcomes share risk factors. Future studies on maternal cancer during pregnancy should consider including some postnatal years in their exposure window.
Collapse
Affiliation(s)
- Natalie C Momen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Andreas Ernst
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Jørn Olsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
- Department of Neurobiology, Karolinska Institute, Stockholm, Sweden
| | | |
Collapse
|
43
|
El-Messidi A, Alsarraj G, Czuzoj-Shulman N, Mishkin DS, Abenhaim HA. Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis. J Perinat Med 2018; 46:998-1003. [PMID: 29369817 DOI: 10.1515/jpm-2017-0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 11/07/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the management of pregnancies complicated by acute cholecystitis (AC) and determine whether pregnant women are more likely to have medical and surgical complications. METHODS We carried out a population-based matched cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. Pregnant women with AC were age matched to non-pregnant women with AC on a 1:5 ratio. Management and outcomes were compared using descriptive analysis and conditional logistic regression. RESULTS There were 11,835 pregnant women admitted with AC who were age matched to 59,175 non-pregnant women. As compared to non-pregnant women, women with AC were more commonly managed conservatively, odds ratio (OR) 6.1 (5.8-6.4). As compared to non-pregnant women, pregnant women with AC more commonly developed sepsis [OR 1.4 (1.0-1.9)], developed venous thromboembolism [OR 8.7 (4.3-17.8)] and had bowel obstruction [OR 1.3 (1.1-1.6)]. Among pregnant women with AC, surgical management was associated with a small but significant increased risk of septic shock and bile leak. CONCLUSION AC, in the context of pregnancy, is associated with an increased risk of adverse outcomes. Although the literature favors early surgical intervention, pregnancies with AC appear to be more commonly managed conservatively with overall comparable outcomes to surgically managed AC. Conservative management may have a role in select pregnant women with AC.
Collapse
Affiliation(s)
- Amira El-Messidi
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, Canada
| | - Ghazi Alsarraj
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada
| | | | - Daniel S Mishkin
- Division of Gastroenterology, Atrius Health, Harvard Medical School, Boston, USA
| | - Haim Arie Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada.,Center for Clinical Epidemiology, Jewish General Hospital, Montreal, Canada
| |
Collapse
|
44
|
Li H, Han C, Li K, Li J, Wang Y, Xue F. New onset acute promyelocytic Leukemia during pregnancy: report of 2 cases. Cancer Biol Ther 2018; 20:397-401. [PMID: 30453810 DOI: 10.1080/15384047.2018.1529122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is one of the most fatal hematological malignancies. APL during pregnancy is a rare comorbidity and can lead to adverse outcomes, such as maternal and/or fetal death, without timely and appropriate management. Medical management for APL during pregnancy remains challenging. We reported 2 patients with no regular prenatal visits who were diagnosed with APL during pregnancy. One presented with typical hematological abnormalities related to infection, while the other presented with intracranial hemorrhage, which is rare. Although supportive measures and chemotherapy were administered after APL was diagnosed, these two patients had completely different outcomes. The pregnancy outcomes of APL patients depend greatly on the timely diagnosis and appropriate management of the disease. Physicians should pay more attention to APL during pregnancy and thus may save more maternal and fetal lives. Further study of the management of APL during pregnancy is warranted. Abbreviations: AML: acute myeloid leukemia; APL: acute promyelocytic leukemia; WBC: white blood cell; RBC: red blood cell; Hb: hemoglobin; PT: prothrombin time; TT: thrombin time; APTT: activated partial thromboplastin time; TP: total protein; ALB: albumin; AST: aspartate transaminase; ALT: alanine aminotransferase; LDH: lactate dehydrogenase; ATRA: all-trans retinoic acid; ICH: intracranial hemorrhage; DIC: disseminated intravascular coagulation.
Collapse
Affiliation(s)
- Huiyang Li
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| | - Cha Han
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| | - Ke Li
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| | - Jie Li
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| | - Yingmei Wang
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| | - Fengxia Xue
- a Department of Gynecology and Obstetrics , Tianjin Medical University General Hospital , Tianjin China
| |
Collapse
|
45
|
Cottreau CM, Dashevsky I, Andrade SE, Li DK, Nekhlyudov L, Raebel MA, Ritzwoller DP, Partridge AH, Pawloski PA, Toh S. Pregnancy-Associated Cancer: A U.S. Population-Based Study. J Womens Health (Larchmt) 2018; 28:250-257. [PMID: 30307780 DOI: 10.1089/jwh.2018.6962] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The incidence of pregnancy-associated cancer (PAC) is expected to increase as more women delay childbearing until later ages. However, information on frequency and incidence of PAC is scarce in the United States. METHODS We identified pregnancies among women aged 10-54 years during 2001-2013 from five U.S. health plans participating in the Cancer Research Network (CRN) and the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). We extracted information from the health plans' administrative claims and electronic health record databases, tumor registries, and infants' birth certificate files to estimate the frequency and incidence of PAC, defined as cancer diagnosed during pregnancy and up to 1 year postpartum. RESULTS We identified 846 PAC events among 775,709 pregnancies from 2001 to 2013. The overall incidence estimate was 109.1 (95% confidence interval [CI] = 101.8-116.7) per 100,000 pregnancies. There was an increase in the incidence between 2002 and 2012 (the period during which complete data were available), from 75.0 (95% CI = 54.9-100.0) per 100,000 pregnancies in 2002 to 138.5 (95% CI = 109.1-173.3) per 100,000 pregnancies in 2012. The most common invasive cancers diagnosed were breast (n = 208, 24.6%), thyroid (n = 168, 19.9%), melanoma (n = 93, 11.0%), hematologic (n = 87, 10.3%), and cervix/uterus (n = 74, 8.7%). CONCLUSIONS Our study provides contemporary incidence estimates of PAC from a population-based cohort of U.S. women. These estimates provide the data needed to help develop clinical and public health policies aimed at diagnosing PAC at an early stage and initiating appropriate therapeutic interventions in a timely manner.
Collapse
Affiliation(s)
- Carrie M Cottreau
- 1 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | - Inna Dashevsky
- 1 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| | - Susan E Andrade
- 2 Meyers Primary Care Institute and University of Massachusetts Medical School , Worcester, Massachusetts
| | - De-Kun Li
- 3 Division of Research , Kaiser Permanente Northern California, Oakland, California
| | - Larissa Nekhlyudov
- 4 Brigham and Women's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Marsha A Raebel
- 5 Institute for Health Research , Kaiser Permanente Colorado, Denver, Colorado
| | - Debra P Ritzwoller
- 5 Institute for Health Research , Kaiser Permanente Colorado, Denver, Colorado
| | - Ann H Partridge
- 6 Dana-Farber Cancer Institute and Brigham and Women's Hospital , Harvard Medical School, Boston, Massachusetts
| | | | - Sengwee Toh
- 1 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, Massachusetts
| |
Collapse
|
46
|
Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Samuel Wann L, Januzzi JL, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness. Catheter Cardiovasc Interv 2018; 92:E35-E97. [DOI: 10.1002/ccd.27659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
47
|
Pregnancy associated acute leukemia: Single center experience. Cancer Treat Res Commun 2018; 16:53-58. [PMID: 31299003 DOI: 10.1016/j.ctarc.2018.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/21/2018] [Accepted: 06/11/2018] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Data regarding clinical characteristics, therapy, maternal and fetal outcomes of pregnancy-associated acute leukemia are limited. PATIENTS AND METHODS We herein, present the data of 27 pregnancy associated acute leukemia [18 acute myeloid leukemia (AML) and 9 acute lymphatic leukemia (ALL)]. Their data were compared to an age matched group of 75 non-pregnant acute leukemia patients admitted and treated during the same period [53 AML and 22 ALL]. RESULTS Complete remission rates, induction failure and induction deaths showed insignificant differences in pregnant versus non pregnant patients in both types of acute leukemia. Similarly, OS and DFS showed no significant difference between pregnant versus non pregnant patients in both types of acute leukemia. Cox regression analysis was conducted for prediction of OS and DFS in all the studied patients applying age, WBCs, BM blasts, LDH, cytogenetic abnormalities and pregnancy as covariates, Pregnancy was not considered as a risk factor for OS or PFS in univariate or multivariate analysis. CONCLUSION Our report to the best of our knowledge is the first to present direct evidence that pregnancy has no significant impact on outcome of acute leukemia compared to non-pregnant patients. These results are limited by the small number of cases and should be confirmed in a prospectively larger cohort of patients.
Collapse
|
48
|
Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Wann LS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018; 71:e283-e351. [PMID: 29729877 DOI: 10.1016/j.jacc.2018.02.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
49
|
Zanotti-Fregonara P, Hindie E. Performing nuclear medicine examinations in pregnant women. Phys Med 2017; 43:159-164. [DOI: 10.1016/j.ejmp.2017.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/28/2022] Open
|
50
|
Moshe Y, Bentur OS, Lishner M, Avivi I. The management of hodgkin lymphomas in pregnancies. Eur J Haematol 2017; 99:385-391. [DOI: 10.1111/ejh.12956] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Yakir Moshe
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Ohad Shimshon Bentur
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Michael Lishner
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Department of Medicine A; Meir Medical Center; Kfar Saba Israel
| | - Irit Avivi
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| |
Collapse
|