Treatment of the pregnant mother with cancer: A systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part II: Hematological tumors

Leucine-rich diet supplementation modulates foetal muscle protein metabolism impaired by Walker-256 tumour

BACKGROUND

Cancer-cachexia induces a variety of metabolic disorders of protein turnover and is more pronounced when associated with pregnancy. Tumour-bearing pregnant rats have impaired protein balance, which decreases protein synthesis and increases muscle breakdown. Because branched-chain amino acids, especially leucine, stimulate protein synthesis, we investigated the effect of a leucine-rich diet on protein metabolism in the foetal gastrocnemius muscles of tumour-bearing pregnant rats.

METHODS

Foetuses of pregnant rats with or without Walker 256 tumours were divided into six groups. During the 20 days of the experiment, the pregnant groups were fed with either a control diet (C, control rats; W, tumour-bearing rats; Cp, rats pair-fed the same normoprotein-diet as the W group) or with a leucine-rich diet (L, leucine rats; LW, leucine tumour-bearing rats; and Lp, rats pair-fed the same leucine-rich diet as the LW group). After the mothers were sacrificed, the foetal gastrocnemius muscle samples were resected, and the protein synthesis and degradation and tissue chymotrypsin-like, cathepsin and calpain enzyme activities were assayed. The muscle oxidative enzymes (catalase, glutathione-S-transferase and superoxide dismutase), alkaline phosphatase enzyme activities and lipid peroxidation (malondialdehyde) were also measured.

RESULTS

Tumour growth led to a reduction in foetal weight associated with decreased serum protein, albumin and glucose levels and low haematocrit in the foetuses of the W group, whereas in the LW foetuses, these changes were less pronounced. Muscle protein synthesis (measured by L-[3H]-phenylalanine incorporation) was reduced in the W foetuses but was restored in the LW group. Protein breakdown (as assessed by tyrosine release) was enhanced in the L and W groups, but chymotrypsin-like activity increased only in group W and tended toward an increase in the LW foetuses. The activity of cathepsin H was significantly higher in the W group foetuses, but the proteolytic calcium-dependent pathway showed similar enzyme activity. In parallel, an intense oxidative stress process was observed only in the group W foetuses.

CONCLUSIONS

These data suggested that the proteasomal and lysosomal proteolytic pathways and oxidative stress are likely to participate in the process of foetal muscle catabolism of Walker's tumour-bearing pregnant rats. The present work shows that foetal muscle can be protected by supplementation with a leucine-rich diet.

Obstetrical, fetal and postnatal effects of gestational antiblastic chemotherapy: how to counsel cancer patients

At least one in a thousand pregnancies is complicated by cancer and, as the maternal age at pregnancy increases, numbers are growing. If chemotherapy cannot be postponed, both doctors and patients face complex medical and ethical issues. There is a conflict between optimal maternal therapy and fetal wellbeing. Treatment during the first trimester increases the risk of congenital malformations, spontaneous abortions and fetal death. Second and third trimester exposure is less risky, but it can cause intrauterine growth retardation and low birth weight. Other effects on pregnancy after the first trimester include premature birth, stillbirth, impaired functional development, myocardial toxicity and myelosuppression. Counseling and management of these cases are difficult, because literature is mostly represented by case reports or retrospective series while randomized prospective studies or guidelines are lacking. Moreover, personal experience is often scanty due to the rarity of the condition. This article reviews the available data regarding the different aspects of systemic treatment of cancer during pregnancy to help oncologist and obstetricians in counseling their patients and treat them accordingly.

Primary Mediastinal Large B-Cell Lymphoma during Pregnancy

Non-Hodgkin's Lymphoma (NHL) rarely presents during pregnancy and primary mediastinal large B-cell lymphoma (PMLBCL) accounts for approximately 2.5% of patients with NHL. The case of a 22-year-old woman who was diagnosed with Stage IIA PMLBCL during week 13 of her intrauterine pregnancy is described. The staging consisted in computed tomography (CT) of the chest and magnetic resonance imaging (MRI) of the abdomen and pelvis. She was managed with R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) for a total of six cycles and, because of the early presentation during the second trimester, she received the entire chemotherapy course during the pregnancy. She delivered a healthy baby at 34 weeks of pregnancy and a ¹⁸FDG-PET/CT scan demonstrated complete remission after delivery. After 20 months of follow up she remains with no evidence of disease and her 1-year-old son has shown no developmental delays or physical abnormalities. PMLBCL, although an uncommon subgroup of DLBCL, may present during pregnancy and R-CHOP should be considered as one suitable option in this complex scenario.

Hematological malignancies and pregnancy: treat or no treat during first trimester

Treatment of hematological malignancies (HM) during pregnancy remain unsolved, although the use of chemotherapy during second and third trimester has been accepted because of the low rate of toxicities, the use of cytotoxic drugs during first trimester is generally forbidden. Most of the concerns are related to congenital abnormalities and development, but long-term follow-up of these children are not available. From 1975 to 2008, we diagnosed and treated 15,750 cases of HM, and 143 female patients were pregnant during this time that were treated with combined chemotherapy. In our study, we present the long-term follow-up (the median follow-up was 22.4 years with a range of 3.8-32.0 years) of 54 newborns, whose mothers received chemotherapy during the first trimester of pregnancy with an intent-to-cure HM. Physical and neurological development were carefully assessed, and cardiac and chromosomal studies were performed until the age of 20 years to evaluate late toxicities. The obstetrical development of pregnancy was normal, chemotherapy was used at doses and schedules used in normal patients. Low-weight birth was the most frequent finding. No congenital abnormalities were detected. Physical, psychological and neurological developments were normal. Education and academic degree were according to the economical and social factors. Cardiac function and chromosomal examination were normal. No neoplasm or acute leukemia has been observed in these children. Forty-three mothers are alive and disease-free and can be considered cured. The use of cytotoxic drugs during the first trimester to treat HM seems to be beneficial to both the mother and fetus, and chemotherapy during the first trimester can be considered if the cure of the patient is the goal.

Haematological cancers in pregnancy

Haematological cancer in pregnancy, although rare, poses a substantial risk to both mother and fetus. Hodgkin's lymphoma is the most common, followed by non-Hodgkin lymphoma and acute leukaemia. Diagnosis of haematological cancers is challenged by an overlap of the disease and gestation-related symptoms and limitations of imaging studies in pregnancy. Data for safety and effectiveness of therapy are scarce and mostly retrospective. This report provides updated guidance for management, focusing on chemotherapy and biological agents. The primary goal of treatment is to preserve the mother's health; hence, pregnancy termination is often advisable at early stages, allowing delivery of adequate therapy. However, at later gestational stages treatment is often feasible. Pregnancy-related hypercoagulability, augmented by cancer, often necessitates thromboprophylaxis. The consequences and complex management of haematological cancer during pregnancy emphasise the need for collaborative research, focusing on basic mechanisms of disease and prospective epidemiological studies.

Management of haematological malignancy in pregnancy

The incidence of haematological malignancies in pregnancy ranges from 1 in 1000 to 1 in 10,000. International prospective epidemiology, management and outcome data are important to gain further knowledge of haematological malignancies in pregnancy. The management of haematological malignancies in pregnancy is complex and requires a multidisciplinary approach. The clinician and mother need to address both maternal and fetal well-being. The mother should be provided with the necessary information and support to make informed decisions regarding the pregnancy and disease management. The haematological malignancies are a diverse group with varied presenting features, pathophysiology, treatment options, levels of urgency to commence treatment in pregnancy, effect on maternal and fetal outcome and overall prognosis. We have reviewed the published research in this area, and provide concise up-to-date guidance on the management of haematological malignancies in pregnancy.

Cancer and pregnancy: a comprehensive review

BACKGROUND

Pregnancy complicated by cancer is relatively rare but, as women in western societies tend to delay childbearing to the third and fourth decade of life, this phenomenon is going to be encountered more often in the future.

MATERIAL AND METHODS

Review of the literature and description of the different diagnostic and therapeutic approaches which are required to diagnose and treat pregnant mothers with cancer.

RESULTS

As in non-pregnant patients, every effort should be made to provide the maximal benefit and best prognosis to the pregnant patient. In most cases, in order to avoid any harm to the fetus, different diagnostic approach should be incorporated and treatment should be tailored to each pregnant woman. Cooperation of multidisciplinary teams, incorporating medical and radiation oncologists, surgeons, obstetricians, neonatologists and experienced nursing staff, is required to provide optimal care for the patient. The benefits from use of surgery, chemotherapy and/or radiotherapy as well as the mother's wishes and beliefs need to be factored into recommendations and treatment planning.

CONCLUSIONS

With the experience gained, the developments in clinical and radiation oncology and the cooperation of multidisciplinary teams, treatment of cancer during pregnancy with normal fetal outcome is feasible.

Managing pregnant women with cancer: personal considerations and a review of the literature

Managing cancer during pregnancy is a very critical clinical situation. It is relatively rare but once encountered, it poses several clinical and sometimes social and ethical conflicts as well. Generalizing treatment decisions is very hard and in our opinion, each case should be discussed in a multidisciplinary manner acknowledging patients’ opinion as well to reach a proper decision. In this review we touch on the available evidence on managing cancer patients diagnosed during the course of pregnancy in an attempt to provide some guidance for clinicians dealing with such cases.