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Hagège J, Aguinaga L, Moatti H, Di Blasi R, Thieblemont C, Brice P, Renaud L. Management of Hodgkin Lymphoma during pregnancy, review of the literature and description of an homogenous expectative attitude associated with excellent outcome. Crit Rev Oncol Hematol 2024; 203:104482. [PMID: 39151837 DOI: 10.1016/j.critrevonc.2024.104482] [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: 10/24/2023] [Revised: 08/10/2024] [Accepted: 08/13/2024] [Indexed: 08/19/2024] Open
Abstract
Hodgkin lymphoma (HL) occuring during pregnancy is a rare condition, and management relies on sparse literature. The specificity of pregnancy requires the clinician to take into account the clinical emergency, the stage of the lymphoma, the trimester of pregnancy, and the patient's choices. The main objective is twofold: to limit the risk of toxicity and adverse events for both mother and fetus, without reducing the chances of a successful outcome. Current literature data suggest that the use of ABVD-type polychemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) is associated with obstetrical events and long-term fetal toxicity. We report here the results of a homogeneous management considering wait-and-see, vinblastine monotherapy and ABVD polychemotherapy options. The outcomes in terms of obstetrical complications, response rate, and overall survival (100 %) reinforce the idea that strategies that do not involve the use of multidrug therapy are possible and are associated with very good results.
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Affiliation(s)
- Joshua Hagège
- Hemato-oncologie, Hôpital Saint Louis, Paris, France
| | | | - Hannah Moatti
- Hemato-oncologie, Hôpital Saint Louis, Paris, France
| | | | | | - Pauline Brice
- Hemato-oncologie, Hôpital Saint Louis, Paris, France
| | - Loïc Renaud
- Hemato-oncologie, Hôpital Saint Louis, Paris, France.
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2
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Greiber IK, Viuff JH, Karlsen MA, Lidegaard Ø, Mikkelsen AP, Hjortshøj CS, Storgaard L, Mellemkjær L. School performance and educational achievement in children exposed to maternal cancer in utero. J Epidemiol Community Health 2024; 78:395-401. [PMID: 38589221 DOI: 10.1136/jech-2023-221753] [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: 12/05/2023] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND In utero exposure to maternal cancer and cancer treatment might influence the child's cognitive development. This study investigated if exposure to maternal cancer during fetal life impacted school performance and educational achievement as adults. METHODS This nationwide retrospective cohort study identified all live-born children in Denmark between January 1978 and December 2013. Exposure was defined as maternal cancer diagnosis during pregnancy. Four partly overlapping birth cohorts were constructed depending on the outcome of interest: (1) receiving special educational support for birth years 2001-2013; (2) grade point average (GPA) at the final exams after 10th grade for 1986-2003; (3) educational achievement at 20 years for 1978-1998; and (4) education at 30 years for 1978-1988. Logistic and linear models were adjusted for birth year, maternal age, maternal education and maternal death. RESULTS The estimated probability of receiving special educational support was similar in the exposed group and the reference (adjusted OR 0.96; 95% CI 0.46 to 1.77, non-significant). The GPA did not statistically differ (0.13 grade points; 95% CI -0.18 to 0.45, non-significant). The achieved educational levels were similar for the exposed group and the reference at 20 years, with an adjusted OR of 1.07 (95% CI 0.82 to 1.40) for low versus medium educational level, and at 30 years with an adjusted OR of 0.73 (95% CI 0.35 to 1.50) for low versus high educational level and of 1.07 (95% CI 0.66 to 1.72) for medium versus high educational level. CONCLUSION Our findings did not indicate poorer performance in compulsory school nor impairment of adult educational achievement after exposure to maternal cancer in utero.
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Affiliation(s)
- Iben Katinka Greiber
- Department of Gynecology and Obstetrics, Rigshospitalet, Juliane Marie Centre, Kobenhavn, Denmark
- Danish Cancer Society Research Center, Kobenhavn, Denmark
| | | | - Mona Aarenstrup Karlsen
- Department of Gynecology and Obstetrics, Rigshospitalet, Juliane Marie Centre, Kobenhavn, Denmark
| | - Øjvind Lidegaard
- Department of Gynecology and Obstetrics, Rigshospitalet, Juliane Marie Centre, Kobenhavn, Denmark
| | | | | | - Lone Storgaard
- Department of Gynecology and Obstetrics, Rigshospitalet, Juliane Marie Centre, Kobenhavn, Denmark
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Capozza MA, Romano A, Mastrangelo S, Attinà G, Maurizi P, Costa S, Vento G, Scambia G, Ruggiero A. Neonatal outcomes and follow-up of children born to women with pregnancy-associated cancer: a prospective observational study. BMC Pregnancy Childbirth 2024; 24:24. [PMID: 38172776 PMCID: PMC10763329 DOI: 10.1186/s12884-023-06182-4] [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] [Received: 07/08/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND During the last decade, there has been a growing number of cases of children born from pregnancy-associated cancer (PAC), however there are currently insufficient data on the follow up to be observed in this category of newborns. Objective of the study was to evaluate the neonatal outcomes of infants born to mother with PAC, the potential adverse effect of chemotherapy during pregnancy and the risk of metastasis to the fetus. METHODS Maternal clinical data and neonatal outcomes of child born to mothers diagnosed with PAC were collected; infants were divided into those were and were not exposed to chemotherapy during fetal life and their outcomes were compered. RESULTS A total of 37 newborn infants from 36 women with PAC were analyzed. Preterm delivery occurred in 83.8% of the cases. No significant differences in neonatal outcomes were found between infants who were and were not exposed to chemotherapy during pregnancy. The median follow-up period was 12 months. CONCLUSIONS PAC treatment during the second or third trimester does not seem to be dangerous for the fetus, however infants born from PAC must be carefully evaluated for to rule out the consequences of chemotherapy and exclude the presence of metastasis. Long-term follow-up, especially in children exposed to chemotherapy, should be encouraged to obtain relevant data on long-term toxicity.
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Affiliation(s)
- Michele Antonio Capozza
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento Scienze Della Salute Della Donna, del Bambino E Di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento Scienze Della Salute Della Donna, del Bambino E Di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simonetta Costa
- Neonatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Vento
- Neonatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento Scienze Della Salute Della Donna, del Bambino E Di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento Scienze Della Salute Della Donna, del Bambino E Di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
- Dipartimento Scienze Della Salute Della Donna, del Bambino E Di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.
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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.
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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
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Greiber IK, Viuff JH, Storgaard L, Karlsen MA, Lidegaard Ø, Mikkelsen AP, Mellemkjær L, Hjortshøj CS. Long-Term Morbidity and Mortality in Children After In Utero Exposure to Maternal Cancer. J Clin Oncol 2022; 40:3975-3984. [PMID: 35797496 DOI: 10.1200/jco.22.00599] [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] Open
Abstract
PURPOSE In utero exposure to maternal cancer and cancer treatment might influence the child's short- and long-term health and development. The objective of the study was to investigate short- and long-term somatic and psychiatric outcomes in children exposed to maternal cancer in utero. METHODS This nationwide cohort study identified all liveborn children in Denmark between January 1978 and December 2018. Exposure was defined as maternal cancer diagnosis during pregnancy, and in a subgroup analysis, exposure to chemotherapy in utero. The main outcomes of interest were overall mortality, somatic diagnoses, and psychiatric diagnoses identified in the National Health Registers. Follow-up started at birth and ended at an event, death, emigration, or end of 2018. Hazard ratios of end points adjusted for potential confounders were estimated using Cox regression analysis. RESULTS Of 2,526,163 included liveborn children, 690 (0.03%) were exposed to maternal cancer in utero. Compared with unexposed fetuses, children exposed in utero had no higher overall mortality, adjusted hazard ratio 0.8 (95% CI, 0.4 to 1.5), nor increased risk of congenital malformations, overall somatic or psychiatric disease. During the period 2002-2018, of 378 (0.03%) children exposed to cancer in utero, 42 (12.5%) were exposed to chemotherapy. Among these 42 children, in utero exposure to chemotherapy was not associated with selected somatic diseases nor to congenital malformations when compared with in utero exposure to maternal cancer without chemotherapy. CONCLUSION Overall, findings did not indicate excess risk of mortality or severe morbidity among children exposed to cancer in utero. Fetal exposure to chemotherapy was not associated with adverse health outcomes in childhood.
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Affiliation(s)
- Iben K Greiber
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark.,Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Jakob H Viuff
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lone Storgaard
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Mona A Karlsen
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Øjvind Lidegaard
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Anders P Mikkelsen
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | | | - Cristel S Hjortshøj
- Department of Pediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Greiber IK, Viuff JH, Mellemkjaer L, Hjortshøj CS, Lidegaard Ø, Storgaard L, Karlsen MA. Cancer in pregnancy and the risk of adverse pregnancy and neonatal outcomes: a nationwide cohort study. BJOG 2021; 129:1492-1502. [PMID: 34954890 DOI: 10.1111/1471-0528.17074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/30/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the obstetrical management of cancer in pregnancy and to determine adverse pregnancy and neonatal outcomes. DESIGN A nationwide cohort study. SETTING AND POPULATION We included all pregnancies (N = 4,071,848) in Denmark from 1 January 1973 to 31 December 2018. METHODS Exposure was defined as pregnancies exposed to maternal cancer (n = 1,068). The control group comprised pregnancies without cancer. The groups were compared using logistic regression analysis and adjusted for potential confounders. MAIN OUTCOME MEASURES The outcomes were induced abortion, preterm birth and adverse neonatal outcomes. RESULTS More women with cancer in pregnancy, as compared to the control group, experienced induced abortion (24.8 vs. 20.0%); first-trimester induced abortion adjusted odds ratio (aOR) 3.5 (95%CI 2.7─4.5), second-trimester induced abortion; aOR 8.8 (6.3─12.3), planned preterm birth(11.8 vs. 1.3%); aOR 10.8 (8.0─14.6), and planned preterm birth below 32 gestational weeks; aOR 16.3 (8.3─31.7). Neonates born to mothers with cancer in pregnancy had a higher risk of respiratory distress syndrome; aOR 3.5 (2.8─4.4), low birth weight; aOR 3.8 (3.1─4.8), admission to neonatal intensive care unit more than seven days; aOR 5.1 (3.9─6.6), neonatal infection; aOR 1.8 (1.1─3.1) and neonatal mortality; aOR 4.7 (2.7─8.2), but not of SGA; aOR 1.0 (0.6-1.5) and malformations; 1.2 (0.9-1.7). CONCLUSION Cancer in pregnancy increases the risk of induced abortion and planned premature birth. Neonates born to mothers with cancer in pregnancy had an increased risk of neonatal morbidity and mortality, presumably due to prematurity.
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Affiliation(s)
- Iben Katinka Greiber
- Department of Gynaecology and Obstetrics, Rigshospitalet Section 4031, Juliane Maries Vej 8, DK-2100, Copenhagen O, Denmark.,Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen O, Denmark
| | - Jakob Hansen Viuff
- Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen O, Denmark
| | - Lene Mellemkjaer
- Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen O, Denmark
| | - Cristel Sørensen Hjortshøj
- Department of Paediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Paediatrics, Zealand University Hospital, Roskilde
| | - Øjvind Lidegaard
- Department of Gynaecology and Obstetrics, Rigshospitalet Section 4031, Juliane Maries Vej 8, DK-2100, Copenhagen O, Denmark
| | - Lone Storgaard
- Department of Gynaecology and Obstetrics, Rigshospitalet Section 4031, Juliane Maries Vej 8, DK-2100, Copenhagen O, Denmark
| | - Mona Aarenstrup Karlsen
- Department of Gynaecology and Obstetrics, Rigshospitalet Section 4031, Juliane Maries Vej 8, DK-2100, Copenhagen O, Denmark
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Zhu D, Tang D, Chai X, Zhang G, Wang Y. Acute leukemia in pregnancy: a single institutional experience with 21 cases at 10 years and a review of the literature. Ann Med 2021; 53:567-575. [PMID: 33821734 PMCID: PMC8032338 DOI: 10.1080/07853890.2021.1908586] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/19/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Acute leukemia (AL) occurring in pregnancy is extremely rare, and its treatment is a clinical dilemma. METHODS We retrospectively reviewed the medical records of our hospital from 2010 to 2019. RESULTS Twenty-one patients were diagnosed with AL during pregnancy. Of whom, eighteen had acute myeloid leukemia, and 3 had acute lymphoblastic leukemia. Six, eight and seven patients were diagnosed during the first, second, and third trimester, respectively. Six of the 21 patients experienced therapeutic abortion and 1 had spontaneous abortion, whereas 9 gave birth to healthy babies (4 through vaginal deliveries and 5 with Caesarean sections). Four babies had been exposed to chemotherapeutic agents, but no congenital malformations were observed. Sixteen patients received chemotherapy, while 4 patients died before chemotherapy and one was discharged after refusing chemotherapy. The complete remission rate of the 10 patients who began chemotherapy immediately after diagnosis was 80%, compared with 66.7% in the 6 patients who started chemotherapy after abortion or delivery. Three remain alive. CONCLUSIONS In general, initiation of chemotherapy as early as possible may increase the CR rate. Combined with literature data, we proposed that, for patients diagnosed in early and late stages of pregnancy (>30 weeks), elective termination or induced delivery before chemotherapy may be a good choice for better maternal (and fetal) outcome.KEY MESSAGESAcute leukaemia diagnosed in pregnancy is extremely rare, and its treatment is a clinical dilemma.In general, initiation of chemotherapy as early as possible may increase the CR rate.For patients who are diagnosed in the first trimester or late stage of pregnancy (>30 weeks), elective termination or induced delivery before starting chemotherapy may be a good choice for better maternal (and fetal) outcome.
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Affiliation(s)
- Dengqin Zhu
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Doudou Tang
- Department of Respiratory and Critical Care Medicine, the Second Xiangya Hospital, Hunan Centre for Evidence-based Medicine, Central South University, Changsha, China
| | - Xiaoshan Chai
- Department of Obstetrics and Gynecology, the Second Xiangya Hospital, Central South University, Changsha, China
| | - Guangsen Zhang
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Molecular Hematology, Central South University, Changsha, China
| | - Yewei Wang
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Molecular Hematology, Central South University, Changsha, China
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Fries C, Noronha SA, Metlay L, Zhang B. Transplacental transfer of congenital B-cell acute lymphoblastic leukemia to the maternal vasculature. Pediatr Blood Cancer 2021; 68:e29142. [PMID: 34125471 DOI: 10.1002/pbc.29142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Carol Fries
- Department of Pediatrics, Hematology and Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Suzie A Noronha
- Department of Pediatrics, Hematology and Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Leon Metlay
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Bin Zhang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
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Struys I, Lenaerts L, Thienpont B, Amant F. Novel next-generation sequencing-based methodologies to characterize the mutational consequences of (prenatal) chemotherapy exposure in noncancerous tissue. Curr Opin Oncol 2021; 33:476-484. [PMID: 34038918 DOI: 10.1097/cco.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although chemotherapeutics are considered as genotoxins for decades, their exact mutagenic impact on the genome of cancerous and normal cells of cancer patients was unknown for a long time. However, this knowledge is necessary to understand the long-term side effects of chemotherapy. A particular condition represents pregnant cancer patients being treated with chemotherapy. Since certain chemotherapeutics can cross the placenta, concerns exist about possible mutational effects on the fetus' genome with potential long-term health consequences. RECENT FINDINGS Recent advances of next-generation sequencing (NGS) techniques have opened possibilities to explore the exact mutational footprint of chemotherapies in healthy tissue from treated cancer patients. However, the ultra-low frequency of chemotherapy-induced mutations, introduction of technical artefacts, and inaccessibility of normal tissue has posed important limitations. This review discusses five state-of-the-art approaches that were recently designed to overcome these drawbacks. SUMMARY Results of the latest investigations give valuable insights into the genome-wide genotoxicity profile of frequently applied chemotherapies, with most of these drugs being associated with a signature of random base substitutions and small indels. Though these findings still might be limited to extrapolate to healthy tissue, they pave the way for studies on the origin of long-term chemotherapy-related adverse health effects.
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Affiliation(s)
| | | | | | - Frédéric Amant
- Department of Oncology
- Gynecologic Oncology, Netherlands Cancer Institute
- Gynecologic Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Korakiti AM, Zografos E, van Gerwen M, Amant F, Dimopoulos MA, Zagouri F. Long-Term Neurodevelopmental Outcome of Children after in Utero Exposure to Chemotherapy. Cancers (Basel) 2020; 12:cancers12123623. [PMID: 33287323 PMCID: PMC7761755 DOI: 10.3390/cancers12123623] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Facing cancer diagnosis during pregnancy constitutes a truly complex and challenging situation for both the patients and the physicians. Cancer diagnosis in a period of hope and joy is an unendurable situation that may affect the psychosocial functioning of the mother, causing depression, anxiety, self-blame, and social isolation. At the same time, a moral dilemma evolves among medical professionals; what is best for the mother in terms of immediate chemotherapy may have detrimental effects on the fetus, and conversely, delaying therapy and protecting the fetus may have a negative impact on the mother as the tumor progresses. Solid data on the safety profile or risks of anti-cancer agents and on the long-term neurodevelopmental outcome of children after in utero exposure to chemotherapy may provide both the patients and the physicians the information necessary for shared decision making when cancer is diagnosed during pregnancy. Abstract Pregnancy-related cancer management represents a real challenge for both the patients and the physicians. The long-term neurodevelopmental outcome of children in utero exposed to chemotherapeutic agents has only recently been addressed. This review aims to systematically integrate and highlight all existing data from the literature regarding the effect of prenatal exposure to chemotherapy on fetal brain growth and child development. All eligible studies are based on validated neurodevelopmental testing scales (e.g., Bayley Scales of Infant Development, Wechsler Preschool and Primary Scale of Intelligence) and/or well-defined questionnaires. Our systematic review including 17 studies demonstrates that no major consequences on the neurodevelopment of children after in utero exposure to anti-cancer drugs have been reported; nevertheless, longer and more thorough follow-up with large-scale multicenter prospective studies is certainly required in order to draw firm conclusions.
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Affiliation(s)
- Anna-Maria Korakiti
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (E.Z.); (M.-A.D.)
| | - Eleni Zografos
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (E.Z.); (M.-A.D.)
| | - Mathilde van Gerwen
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek–Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (M.v.G.); (F.A.)
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Frédéric Amant
- Center for Gynecologic Oncology Amsterdam, Antoni van Leeuwenhoek–Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (M.v.G.); (F.A.)
- Department of Oncology, KU Leuven, 3000 Leuven, Belgium
- Center for Gynecologic Oncology Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (E.Z.); (M.-A.D.)
| | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (E.Z.); (M.-A.D.)
- Correspondence:
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11
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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.
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12
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Castellanos MI, Childress KJ, Ramirez M, Venkatramani R. Fetal exposure to capecitabine and temozolomide during the first trimester: A case report. J Gynecol Obstet Hum Reprod 2020; 49:101881. [PMID: 32712180 DOI: 10.1016/j.jogoh.2020.101881] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/17/2022]
Abstract
Literature on the outcome of pregnancy after exposure to capecitabine and temozolomide during the first trimester is scarce. Chemotherapy administration in the first trimester is generally not recommended due the potential risks to the fetus including fetal death and major congenital malformations. Capecitabine and temozolomide are oral chemotherapy agents and pregnancy category D medications, thus the use of these agents in pregnancy is not recommended. We present the case of a 17-year-old female who while receiving cancer treatment, had unintentional exposure to capecitabine and temozolomide during the first trimester of pregnancy, and subsequently delivered a healthy infant.
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Affiliation(s)
- Maria I Castellanos
- Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States.
| | - Krista J Childress
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, 30322, United States.
| | - Mildred Ramirez
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, 77030, United States.
| | - Rajkumar Venkatramani
- Texas Children's Cancer Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States.
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13
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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.
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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.
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14
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Amant F, Berveiller P, Boere IA, Cardonick E, Fruscio R, Fumagalli M, Halaska MJ, Hasenburg A, Johansson ALV, Lambertini M, Lok CAR, Maggen C, Morice P, Peccatori F, Poortmans P, Van Calsteren K, Vandenbroucke T, van Gerwen M, van den Heuvel-Eibrink M, Zagouri F, Zapardiel I. Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting. Ann Oncol 2019; 30:1601-1612. [PMID: 31435648 DOI: 10.1093/annonc/mdz228] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.
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Affiliation(s)
- F Amant
- Center for Gynecologic Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek and Amsterdam University Medical Centers, the Netherlands; Department of Oncology, KU Leuven, Leuven, Belgium.
| | - P Berveiller
- Department of Obstetrics and Gynecology, Centre Hospitalier de Poissy-Saint-Germain-en-Laye, Poissy, France
| | - I A Boere
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E Cardonick
- Department of Obstetrics and Gynecology, Cooper University Health Care, Camden, USA
| | - R Fruscio
- Clinic of Obstetrics and Gynecology, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - M Fumagalli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M J Halaska
- Department of Obstetrics and Gynaecology, 3rd Medical Faculty, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - A Hasenburg
- Department of Obstetrics and Gynecology, Mainz University Medical Center, Mainz, Germany
| | - A L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Lambertini
- Department of Medical Oncology, IRCCS Policlinico San Martino Hospital, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - C A R Lok
- Center for Gynecologic Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek and Amsterdam University Medical Centers, the Netherlands
| | - C Maggen
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - P Morice
- Department of Gynecologic Surgery, Institute de Cancérologie Gustave Roussy, Villejuif, France
| | - F Peccatori
- Department of Gynecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - P Poortmans
- Department of Radiation Oncology, Institut Curie and Paris Sciences & Lettres - PSL University, Paris, France
| | - K Van Calsteren
- Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | | | - M van Gerwen
- Center for Gynecologic Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek and Amsterdam University Medical Centers, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - F Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, University of Athens, Athens, Greece
| | - I Zapardiel
- Department of Gynecologic Oncology, La Paz University Hospital, Madrid, Spain
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15
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Incidence of Neonatal Neutropenia, Leukopenia, and Anemia After In Utero Exposure to Chemotherapy For Maternal Cancer. Am J Clin Oncol 2019; 42:810-811. [DOI: 10.1097/coc.0000000000000595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Eastwood-Wilshere N, Turner J, Oliveira N, Morton A. Cancer in Pregnancy. Asia Pac J Clin Oncol 2019; 15:296-308. [PMID: 31436920 DOI: 10.1111/ajco.13235] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
Abstract
Cancer in pregnancy may be increasing in incidence with advancing maternal age and higher rates of obesity. The diagnosis of cancer in pregnancy provokes complex management issues balancing short- and long-term risks for both mother and baby. Every case needs to be individualized, with a multidisciplinary team of midwives, obstetricians, oncologists, surgeons, radiation oncologists, and neonatologists assisting the family to make informed decisions regarding the best treatment course for the mother and baby. The present article reviews the evidence regarding the safety of diagnostic imaging, procedures and treatment modalities for cancer for the pregnant woman and fetus. The efficacy of novel anticancer therapies highlight the need for International Registries to accumulate safety data for these agents in pregnancy as expeditiously as possible.
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Affiliation(s)
- Naomi Eastwood-Wilshere
- Department of Obstetric Medicine, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Jessica Turner
- Department of Medical Oncology, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Niara Oliveira
- Department of Obstetrics and Gynaecology, Mater Health Brisbane, South Brisbane, Queensland, Australia
| | - Adam Morton
- Department of Obstetric Medicine, Mater Health Brisbane, South Brisbane, Queensland, Australia
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17
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Burns EA, Ahmed A, Sunkara A, Khan U, Sharif R, Abdelrahim M, Reardon M, Trachtenberg B. Primary cardiac angiosarcoma diagnosed in the first trimester of pregnancy. Ecancermedicalscience 2019; 13:922. [PMID: 31281419 PMCID: PMC6546259 DOI: 10.3332/ecancer.2019.922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Indexed: 11/06/2022] Open
Abstract
Primary cardiac angiosarcoma (PCAS) is a malignancy seldom seen in pregnancy. A 23-year-old G1P0 Chinese female was found to have PCAS during her first trimester when she presented with tamponade physiology. The transthoracic echocardiography (TTE) results did not indicate the presence of an intracardiac lesion, and pericardial fluid cytology analysis showed no evidence of malignancy. Cardiac magnetic resonance imaging (CMRI) exhibited a right atrial mass, and tissue biopsy indicated a high-grade angiosarcoma. MRI of the abdomen was suggestive of liver metastasis. She underwent an abortion and was started on combination chemotherapy, with a reduction in both the cardiac and liver masses. In cardiac angiosarcomas, advanced imaging modalities such as MRI should be utilised when there is high clinical suspicion or in the case of pregnancy when trying to minimise foetal harm. Prognosis is poor, and a standardised treatment protocol regardless of pregnancy continues to elude the medical community.
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Affiliation(s)
- Ethan A Burns
- Internal Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Amna Ahmed
- Internal Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Anusha Sunkara
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX 77030, USA
| | - Usman Khan
- Houston Methodist Cancer Center, Houston, TX 77030, USA
| | | | | | - Michael Reardon
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX 77030, USA
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX 77030, USA
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18
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Maggen C, van Gerwen M, Van Calsteren K, Vandenbroucke T, Amant F. Management of cancer during pregnancy and current evidence of obstetric, neonatal and pediatric outcome: a review article. Int J Gynecol Cancer 2019; 29:ijgc-2018-000061. [PMID: 30659032 DOI: 10.1136/ijgc-2018-000061] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 12/28/2022] Open
Abstract
The diagnosis of cancer during pregnancy imposes a medical-ethical dilemma in weighing the risks of both mother and child. Increasing awareness of the feasibility of chemotherapy during pregnancy results in more pregnant patients receiving treatment for cancer. Information on obstetric and pediatric outcome of these high-risk pregnancies is greatly needed to guide physicians in patient counseling. In this review we present reported evidence for the incidence, diagnostic options, therapeutic management, obstetric risks, and neonatal outcome when cancer treatment is initiated during pregnancy. Decision-making when a cancer is diagnosed in a pregnant patient should be multidisciplinary, always taking the patient's perspective into account. Cancer treatment during pregnancy is associated with low birth weight and preterm delivery, therefore frequent obstetric follow-up during oncological treatment in a specialized center is mandatory. Short-term clinical, cardiac, and cognitive outcome of children pre-natally exposed to cancer treatment is overall reassuring. Long-term follow-up of children is warranted to define the possible effect of pre-natal cancer treatment on general health, fertility outcome, and the risk of secondary cancers.
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Affiliation(s)
- Charlotte Maggen
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Mathilde van Gerwen
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kristel Van Calsteren
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Tineke Vandenbroucke
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Frédéric Amant
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands
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19
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Jeremic K, Stefanovic A, Dotlic J, Kadija S, Kontic O, Gojnic M, Jeremic J, Kesic V. Cancer during pregnancy - clinical characteristics, treatment outcomes and prognosis for mothers and infants. J Perinat Med 2018; 46:35-45. [PMID: 28222037 DOI: 10.1515/jpm-2016-0212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 01/12/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess which obstetrical characteristics and treatment improved outcomes and prognosis of pregnant women with malignancy. METHODS A prospective study, undertaken between 2005 and 2014, involving 35 pregnant women who were diagnosed with malignant tumors during pregnancy. Patients were followed-up for 1 year after delivery. The pregnancy course and outcome and parameters that could influence the condition of mother and fetus were evaluated. RESULTS Most malignancies were hematological, diagnosed in the second trimester and treated with combined therapy (surgery/adjuvant) after pregnancy. Most fetuses were in good state throughout pregnancy, but were delivered by caesarean section (CS) before term. Adjuvant therapy during pregnancy mostly caused transitory deterioration of fetal conditions. The majority of both mothers and infants were in a good state 12 months postpartum, although numerous mothers were still ill and on therapy. Surviving pregnancy and preventing tumors progression during pregnancy were the best predictors of mothers' future condition (P=0.022). High birthweight and term delivery were the most important factors for good outcome of the infants (P=0.001). CONCLUSIONS If the tumor is not progressing, pregnancy should be continued as long as possible to obtain adequate birthweight of the infant. Second trimester surgery is safe, while other therapies should preferably be applied after delivery.
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Affiliation(s)
- Katarina Jeremic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Aleksandar Stefanovic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Jelena Dotlic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Sasa Kadija
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Olivera Kontic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Miroslava Gojnic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
| | - Jelena Jeremic
- Clinic for Plastic and Reconstructive Surgery, Clinical Center of Serbia, Zvecanska 9, Belgrade, Serbia
| | - Vesna Kesic
- Clinic of Obstetrics and Gynecology, Clinical Centre of Serbia, Dr Koste Todorovica 26, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, Serbia
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20
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Avilés A, Nambo MJ, Neri N. Treatment of Early Stages Hodgkin Lymphoma During Pregnancy. Mediterr J Hematol Infect Dis 2018; 10:e2018006. [PMID: 29326803 PMCID: PMC5760061 DOI: 10.4084/mjhid.2018.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 11/29/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To assess maternal and fetal outcome of women and newborns who received chemotherapy during pregnancy to treat Hodgkin lymphoma (HL)in early stages (IA, IIA), we performed a retrospective analysis of a cohort of 44 pregnant women with HL and early stages, diagnosed and treated between 1988 to 2013, at a tertiary reference cancer center. METHODS We analyzed data on HL characteristics and treatment, with a particular attention to maternal and fetal complications; in children, we performed a longer follow-up to detect any anomaly in physical development, scholar performance, psychological, cardiac, neurological function, and intelligence tests. RESULTS Median age was 29.4 (range 21-37) years; Most patients were stage IIA (86%), had M a bulky mediastinal disease (78%) and 60% had > 3 nodal sites involved; thus these patients were considered to have a not favorable condition. Abortion was refused when it was proposed. All patients received chemotherapy during pregnancy; ABVD (adryamicin, bleomycin, vinblastine, and dacarbazine) at standard doses and schedule, even during the first trimester. Radiotherapy, when indicated, was administered after delivery in 39 patients. No obstetrical complications were observed, delivery occurred between 33 to 36 weeks in 10 cases (22%); and >37 weeks in 34 cases (87%). Four newborns were low-weight: 2012 g median (range 1750 - 2350 g). No clinical malformations were observed, and development of newborns was physiological without evidence of cardiac and neurological damage, behavior, intelligence, and scholar attendance were normal. At median follow-up range of 120.4 (48-299) months, the progression-free survival and overall survival of patients were 95% and 93%respectively. CONCLUSION Combined chemotherapy, as initial therapy appears to be the best approach in this setting of patients, with an excellent outcome to both mothers and children. If radiotherapy is necessary, it could be administered after delivery.
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Affiliation(s)
- Agustin Avilés
- Oncology Research Unit, Oncology Hospital National Medical Center, IMSS, México D.F. MEXICO
| | - Maria-Jesus Nambo
- Oncology Research Unit, Oncology Hospital National Medical Center, IMSS, México D.F. MEXICO
| | - Natividad Neri
- Oncology Research Unit, Oncology Hospital National Medical Center, IMSS, México D.F. MEXICO
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21
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Vandenbroucke T, Verheecke M, Fumagalli M, Lok C, Amant F. Effects of cancer treatment during pregnancy on fetal and child development. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:302-310. [PMID: 30169185 DOI: 10.1016/s2352-4642(17)30091-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 01/08/2023]
Abstract
It has become clear that, for specific cancers and under well defined circumstances, oncological treatment in pregnancy is possible. In this Review, we summarise the evidence on fetal, neonatal, short-term, and long-term effects of prenatal exposure to cancer treatment on the child. So far, outcomes of children are generally reassuring, but long-term follow-up is insufficient. The most important risks of chemotherapy during pregnancy are preterm birth and babies being small for gestational age. Chemotherapy in the first trimester is contraindicated because of an increased risk of congenital malformations. Studies on outcomes of children exposed to radiotherapy, targeted therapy, or hormonal therapy in pregnancy are scarce. Careful registration of women undergoing cancer treatment in pregnancy and long-term follow-up of their children are important. Comprehensive documentation of the mental and physical status of children exposed to cancer treatment in utero will allow physicians and parents to best decide whether to treat cancer during pregnancy.
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Affiliation(s)
- Tineke Vandenbroucke
- Department of Oncology, KU Leuven-University of Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Magali Verheecke
- Department of Oncology, KU Leuven-University of Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Monica Fumagalli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | - Christianne Lok
- Center Gynecologic Oncology, Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Frédéric Amant
- Department of Oncology, KU Leuven-University of Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Center Gynecologic Oncology, Antoni van Leeuwenhoek Netherlands Cancer Institute, Amsterdam, Netherlands; Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
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22
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Aviles A, Nambo MJ, Neri N. Lymphoma and pregnancy. Jpn J Clin Oncol 2017; 47:467-468. [PMID: 28159981 DOI: 10.1093/jjco/hyx004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Maria-Jesús Nambo
- Department of Hematology, Oncology Hospital, National Medical Center, IMSS, México DF,MEXICO
| | - Natividad Neri
- Department of Hematology, Oncology Hospital, National Medical Center, IMSS, México DF,MEXICO
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23
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Marwah S, Gaikwad HS, Mohindra R, Sharma M. Up the Duff With Non-Hodgkin's Lymphoma: The Traumas and the Dilemmas. J Clin Diagn Res 2017; 11:QD03-QD05. [PMID: 28384939 DOI: 10.7860/jcdr/2017/23972.9221] [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: 09/06/2016] [Accepted: 11/04/2016] [Indexed: 11/24/2022]
Abstract
Lymphoma is fourth most frequent malignancy diagnosed prenatally (~1:6000 cases), with Hodgkin's Lymphoma (HL) forming the major chunk. However, in recent times, there has been an increase in occurrence of Non-Hodgkin's Lymphoma (NHL) due to late child bearing age and high incidence of AIDS-related NHL in developing countries. Managing NHL in pregnancy involves intricate medical, ethical and psychological issues. Diagnostic and treatment delays may influence the prognosis for indolent cases. Seen the complexity of the management decisions associated with NHL, interdisciplinary and individualized approach becomes imperative for each woman. We present a case of 25-year-old G2P0010 at 32 weeks Period of Gestation (PoG) with right sided deep cervical lymphadenopathy, who was diagnosed as aggressive malignant NHL and was subsequently started on chemotherapy after confirmation of diagnosis and eventually had an optimal feto-maternal outcome. The critical appraisal of the accessible data, identification of controversies and unresolved issues and proposal of elucidations about varied facets of NHL in pregnancy are also provided.
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Affiliation(s)
- Sheeba Marwah
- Research Officer, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital , New Delhi, India
| | - Harsha Shailesh Gaikwad
- Professor, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital , New Delhi, India
| | - Ritin Mohindra
- Senior Resident, Department of Internal Medicine, VMMC and Safdarjung Hospital , New Delhi, India
| | - Manjula Sharma
- Professor and Consultant, Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital , New Delhi, India
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Pinnix CC, Osborne EM, Chihara D, Lai P, Zhou S, Ramirez MM, Oki Y, Hagemeister FB, Rodriguez AM, Samaniego F, Fowler N, Romaguera JE, Turturro F, Fayad L, Westin JR, Nastoupil L, Neelapu SS, Cheah CY, Dabaja BS, Milgrom SA, Smith GL, Horace P, Milbourne A, Wogan CF, Ballas L, Fanale MA. Maternal and Fetal Outcomes After Therapy for Hodgkin or Non-Hodgkin Lymphoma Diagnosed During Pregnancy. JAMA Oncol 2017; 2:1065-9. [PMID: 27227654 DOI: 10.1001/jamaoncol.2016.1396] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The management of lymphoma diagnosed during pregnancy is controversial and has been guided largely by findings from case reports and small series. OBJECTIVE To determine maternal and fetal outcomes of women diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) during pregnancy. DESIGN, SETTING, AND PARTICIPANTS This retrospective analysis studied a cohort of 39 pregnant women diagnosed with HL and NHL (31 HL and 8 NHL) at a single specialized cancer institution between January 1991 and December 2014. MAIN OUTCOMES AND MEASURES We examined data on disease and treatment characteristics, as well as maternal and fetal complications and outcomes. The Kaplan-Meier method was used to compare progression free survival (PFS) and overall survival (OS) according to receipt of antenatal therapy and other clinical factors. Univariate and multivariate analyses were performed by using Cox proportional hazard regression models to identify potential associations between clinical and treatment factors and survival. RESULTS The median (range) age of the 39 women in the patient cohort was 28 (19-38) years; 32 women (82%) had stage I or II disease at diagnosis, and 13 had bulky disease. Three women electively terminated the pregnancy to allow immediate systemic therapy; of the remaining 36 women, 24 received antenatal therapy (doxorubicin based combination chemotherapy in 20 of 24 patients), and 12 deferred therapy until after delivery. Four women experienced miscarriage, all of whom had received antenatal systemic therapy and 2 during the first trimester. Delivery occurred at a median (range) of 37 (32-42) weeks and was no different based on receipt of antenatal (median [range], 37 [33-42] weeks) vs postnatal (median [range], 37 [32-42] weeks) therapy (P = .21). No gross fetal malformations or anomalies were detected. At a median (range) follow-up time of 67.9 (8.8-277.5) months since the diagnosis of lymphoma, 5-year rates of PFS and OS were 74.7% and 82.4%, respectively; these rates did not differ according to timing of therapy. On univariate analysis, bulky disease (>10 cm), extranodal nonbone marrow involvement, and poor performance status (Eastern Cooperative Oncology Group score, ≥2) predicted increased risk of disease progression. On multivariate analysis, extranodal nonbone marrow disease and performance status remained significant for both PFS and OS. CONCLUSIONS AND RELEVANCE Systemic therapy given for lymphoma after the first trimester of pregnancy is likely safe and results in acceptable maternal and fetal outcomes.
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Affiliation(s)
- Chelsea C Pinnix
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Eleanor M Osborne
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Dai Chihara
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Peter Lai
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Shouhao Zhou
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred M Ramirez
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Yasuhiro Oki
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Alma M Rodriguez
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Felipe Samaniego
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Nathan Fowler
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Jorge E Romaguera
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Francesco Turturro
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Luis Fayad
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Jason R Westin
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Loretta Nastoupil
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Sattva S Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Chan Y Cheah
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Bouthaina S Dabaja
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sarah A Milgrom
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Grace L Smith
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Patricia Horace
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Andrea Milbourne
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Christine F Wogan
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Leslie Ballas
- Department of Radiation Oncology, University of Southern California, Los Angeles
| | - Michelle A Fanale
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
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25
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Garofalo S, Degennaro V, Salvi S, De Carolis M, Capelli G, Ferrazzani S, De Carolis S, Lanzone A. Perinatal outcome in pregnant women with cancer: are there any effects of chemotherapy? Eur J Cancer Care (Engl) 2016; 26. [DOI: 10.1111/ecc.12564] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 12/22/2022]
Affiliation(s)
- S. Garofalo
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
| | - V.A. Degennaro
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
| | - S. Salvi
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
| | - M.P. De Carolis
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - G. Capelli
- Department of Hygiene; University of Cassino; Cassino Italy
| | - S. Ferrazzani
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
| | - S. De Carolis
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
| | - A. Lanzone
- High Risk Pregnancy Unit; Catholic University of Sacred Heart; Rome Italy
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26
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Farhadfar N, Cerquozzi S, Hessenauer MR, Litzow MR, Hogan WJ, Letendre L, Patnaik MM, Tefferi A, Gangat N. Acute leukemia in pregnancy: a single institution experience with 23 patients. Leuk Lymphoma 2016; 58:1052-1060. [PMID: 27562538 DOI: 10.1080/10428194.2016.1222379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Management of acute leukemia during pregnancy presents a considerable challenge. Herein, we review our experience of 23 patients diagnosed with acute leukemia; during pregnancy at the Mayo Clinic between 1962 and 2016. Ten (43.4%), seven (30.4%), and six (26.2%) patients were diagnosed in first, second, and third trimester, respectively. In approximately, 50% (n = 11) therapeutic terminations or spontaneous abortions occurred. Fifty percent (2/4) of patients diagnosed during either first or second trimester who delayed chemotherapy by greater than one week died during induction therapy. Eleven patients received chemotherapy while pregnant which led to four fetal losses and seven deliveries (five full-term and two preterm deliveries). No congenital malformations were reported. Eighteen patients (78%) achieved complete remission. At a median follow up of 55 months, seven patients (30%) remain alive. In summary, we provide a comprehensive description of maternal and fetal outcomes and insight into management of acute leukemia during pregnancy.
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Affiliation(s)
- Nosha Farhadfar
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Sonia Cerquozzi
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Michael R Hessenauer
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Mark R Litzow
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - William J Hogan
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Louis Letendre
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Mrinal M Patnaik
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Ayalew Tefferi
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Naseema Gangat
- a Division of Hematology , Mayo Clinic College of Medicine , Rochester , MN , USA
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27
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Paydas S. Management of hemopoietic neoplasias during pregnancy. Crit Rev Oncol Hematol 2016; 104:52-64. [DOI: 10.1016/j.critrevonc.2016.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 03/12/2016] [Accepted: 05/10/2016] [Indexed: 11/30/2022] Open
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28
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Abstract
The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.
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29
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Winckler P, Vanazzi A, Bozzo M, Scarfone G, Peccatori FA. Chronic lymphocytic leukaemia during pregnancy: management and thoughts. Ecancermedicalscience 2015; 9:592. [PMID: 26635896 PMCID: PMC4659706 DOI: 10.3332/ecancer.2015.592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Indexed: 12/25/2022] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in the Western world. Despite this fact, its coexistence with pregnancy is extremely rare, with few cases reported in the literature. Given the rarity of this event, it is difficult to conduct large prospective trials to evaluate diagnostic, management, and outcome aspects. The existing evidence is limited to the few published cases and scarce data from reviews on haematological malignancies and pregnancy. Here, we report a case of a 36-year-old patient who had already finished treatment for CLL and was under surveillance when she got pregnant. We describe the evolution of the pregnancy and of the disease's behaviour as well as the oncological and obstetrical management. Being an indolent disease, CLL during pregnancy can be usually followed up without treatment, but infectious and autoimmune complications might have a significant impact on the pregnancy outcome. Therefore, pregnancy must be closely monitored in specialised centres.
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Affiliation(s)
- Patricia Winckler
- Serviço de Oncologia Médica, Instituto Português de Oncologia de Lisboa, Francisco Gentil, Rua Professor Lima Basto, Lisboa 1700-023, Portugal
| | - Anna Vanazzi
- Division of Haematology Oncology, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Maddalena Bozzo
- Department of Obstetrics and Gynaecology, DMCO San Paolo, Via di Rudinì 8, Milan 20142, Italy
| | - Giovanna Scarfone
- Department of Obstetrics, Gynecology and Neonatology, IRCCS Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via della Commenda 12, Milan 20122, Italy
| | - Fedro A Peccatori
- Fertility & Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
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30
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Lishner M, Avivi I, Apperley JF, Dierickx D, Evens AM, Fumagalli M, Nulman I, Oduncu FS, Peccatori FA, Robinson S, Van Calsteren K, Vandenbroucke T, Van den Heuvel F, Amant F. Hematologic Malignancies in Pregnancy: Management Guidelines From an International Consensus Meeting. J Clin Oncol 2015; 34:501-8. [PMID: 26628463 DOI: 10.1200/jco.2015.62.4445] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The incidence of hematologic malignancies during pregnancy is 0.02%. However, this figure is increasing, as women delay conception until a later age. Systemic symptoms attributed to the development of a hematologic cancer may overlap with physiologic changes of pregnancy. A favorable prognosis is contingent upon early diagnosis and treatment. Therefore, a high index of suspicion is required by health care providers. Although timely, accurate diagnosis followed by appropriate staging is essential and should not be delayed due to pregnancy, management guidelines are lacking due to insufficient evidence-based research. Consequently, treatment is delayed, posing significant risks to maternal and fetal health, and potential pregnancy termination. This report provides guidelines for clinical management of hematologic cancers during the perinatal period, which were developed by a multidisciplinary team including an experienced hematologist/oncologist, a high-risk obstetrics specialist, a neonatologist, and experienced nurses, social workers, and psychologists. METHODS These guidelines were developed by experts in the field during the first International Consensus Meeting of Prenatal Hematologic Malignancies, which took place in Leuven, Belgium, on May 23, 2014. RESULTS AND CONCLUSION This consensus summary equips health care professionals with novel diagnostic and treatment methodologies that aim for optimal treatment of the mother, while protecting fetal and pediatric health.
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Affiliation(s)
- Michael Lishner
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium.
| | - Irit Avivi
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Jane F Apperley
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Daan Dierickx
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Andrew M Evens
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Monica Fumagalli
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Irena Nulman
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Fuat S Oduncu
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Fedro Alessandro Peccatori
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Susan Robinson
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Kristel Van Calsteren
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Tineke Vandenbroucke
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Frank Van den Heuvel
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
| | - Frederic Amant
- Michael Lishner, Meir Medical Center, Kfar Saba, and Tel Aviv University; Irit Avivi, Ichilov Medical Center, Tel Aviv, Israel; Jane F. Apperley, Hammersmith Hospital; Susan Robinson, Guy's and St Thomas' National Health Service Foundation Trust, London; Frank Van den Heuvel, University of Oxford, Oxford, United Kingdom; Andrew M. Evens, Tufts Medical Center, Boston, MA; Monica Fumagalli, University of Milan; Fedro Alessandro Peccatori, European Institute of Oncology, Milan, Italy; Irena Nulman, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada; Fuat S. Oduncu, University of Munich, Munich, Germany; Kristel Van Calsteren, University Hospital Gasthuisberg; Tineke Vandenbroucke and Frederic Amant, Katholieke Universiteit Leuven; Daan Dierickx, University of Leuven; and Tineke Vandenbroucke, University Hospitals Leuven, Leuven, Belgium
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Avilès A, Nambo MJ, Huerta-Guzmàn J, Neri N, Cleto S. Speckle-Tracking Echocardiography to Detect Cardiac Toxicity in Children Who Received Anthracyclines During Pregnancy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 16:1-4. [PMID: 26549215 DOI: 10.1016/j.clml.2015.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/25/2015] [Indexed: 11/27/2022]
Abstract
Cardiac toxicities remain a possible risk to fetuses that received anthracyclines during pregnancy. The introduction of new echocardiographic techniques will improve the detection of early cardiac damage. Thus, we began a observational study using speckle-tracking echocardiography (STE) in children who had received anthracyclines during pregnancy, including the first trimester. From 2009 to 2013, we performed STE on patients > 5 years old, whose mothers had received anthracyclines during pregnancy. Siblings or cousins of equivalent age and gender were used as the control group. A total of 90 children fulfilled the entry criteria. Our results with STE were normal in all echocardiography parameters and did not show any differences when compared with the findings from the control group. We consider that the use of anthracyclines during pregnancy does not produce cardiac damage in newborns and can be safely administered, because no cardiac toxicity was evident in these children and it is of benefit to the mother.
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Affiliation(s)
- Agustin Avilès
- Oncology Research Unit, Oncology Hospital National Medical Center, IMSS, Mexico City, Mexico.
| | - Marìa-Jesus Nambo
- Hematology Department, Oncology Hospital National Medical Center, IMSS, Mexico City, Mexico
| | - Judith Huerta-Guzmàn
- Hematology Department, Oncology Hospital National Medical Center, IMSS, Mexico City, Mexico
| | - Natividad Neri
- Hematology Department, Oncology Hospital National Medical Center, IMSS, Mexico City, Mexico
| | - Sergio Cleto
- Hematology Department, Oncology Hospital National Medical Center, IMSS, Mexico City, Mexico
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32
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Abstract
Although acute myeloid leukemia (AML) mostly occurs in older patients, it could be seen in women of childbearing age. It is therefore not surprising that in some patients, the management of AML will be complicated by a coexistent pregnancy. However, the association of leukemia and pregnancy is uncommon. Its incidence is estimated to be 1 in 75,000-100,000 pregnancies. During pregnancy, most leukemias are acute: two-thirds are myeloid and one-third are lymphoblastic. There is no standard approach for this clinical dilemma, in part because of variables such as the type of AML, the seriousness of the symptoms, and the patient's personal beliefs. In many cases, the diagnostic workup has to be altered because of the pregnancy, and often available treatments have varying risks to the fetus. While chemotherapy is reported to have some risks during the first trimester, it is admitted that it can be administered safely during the second and the third trimesters.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Pierre Bénite, France
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33
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Abstract
Diagnosis of acute leukemia during pregnancy presents significant medical challenges. Pancytopenia, caused by bone marrow substitution with leukemic cells, impairs maternal and fetal health. Chemotherapeutic agents required to be immediately used to save the mother's life are likely to adversely affect fetal development and outcome, especially if administered at an early gestational stage. Patients diagnosed with acute leukemia during the first trimester are, therefore, recommended to undergo pregnancy termination. At later gestational stages, antileukemic therapy can be administered, although in this case, fetal outcome is still associated with increased incidence of growth restriction and loss. Special attention to the issue of future reproduction, adopting a personalized fertility preservation approach, is required. This article addresses these subjects, presenting women diagnosed with acute myeloid and acute promyelocytic leukemia in pregnancy. The rarity of this event, resulting in insufficient data, emphasizes the need for collaborative efforts to optimize management of this complicated clinical condition.
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Affiliation(s)
- Irit Avivi
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
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34
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Amant F, Han SN, Gziri MM, Vandenbroucke T, Verheecke M, Van Calsteren K. Management of cancer in pregnancy. Best Pract Res Clin Obstet Gynaecol 2015; 29:741-53. [PMID: 25797199 DOI: 10.1016/j.bpobgyn.2015.02.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 02/18/2015] [Accepted: 02/23/2015] [Indexed: 12/20/2022]
Abstract
A multidisciplinary discussion is necessary to tackle a complex and infrequent medical problem such as cancer occurring during pregnancy. Pregnancy does not predispose to cancer, but cancers occurring in women of reproductive age are encountered during pregnancy. Ultrasonography and magnetic resonance imaging are the preferred staging examinations, but also a sentinel node staging procedure is possible during pregnancy. Standard cancer treatment is aimed for. Operations can safely be performed during pregnancy, but surgery of genital cancers can be challenging. The observation that chemotherapy administered during the second or third trimester of pregnancy, that is, after the period of organogenesis, has little effect on the long-term outcome of children adds to the therapeutic armamentarium during pregnancy. Cancer treatment during pregnancy adds in the continuation of the pregnancy and the prevention of prematurity.
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Affiliation(s)
- Frédéric Amant
- Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Department of Oncology, KU Leuven, Leuven, Belgium.
| | - Sileny N Han
- Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Mina Mhallem Gziri
- Department of Obstetrics and Gynecology, Cliniques Universitaires St Luc, UCL, Brussels, Belgium
| | - Tineke Vandenbroucke
- Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Magali Verheecke
- Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Kristel Van Calsteren
- Department of Obstetrics and Gynecology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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35
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Eyre TA, Lau IJ, Mackillop L, Collins GP. Management and controversies of classical Hodgkin lymphoma in pregnancy. Br J Haematol 2015; 169:613-30. [DOI: 10.1111/bjh.13327] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Toby A. Eyre
- Department of Haematology; Oxford University Hospitals NHS Trust; Oxford UK
| | - I-Jun Lau
- Department of Haematology; Oxford University Hospitals NHS Trust; Oxford UK
| | - Lucy Mackillop
- Department of Obstetrics & Gynaecology; John Radcliffe Hospital; Oxford University Hospitals NHS Trust; Oxford UK
| | - Graham P. Collins
- Department of Haematology; Oxford University Hospitals NHS Trust; Oxford UK
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36
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Zaidi A, Johnson LM, Church CL, Gomez-Garcia WC, Popescu MI, Margolin JF, Ribeiro RC. Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature. J Adolesc Young Adult Oncol 2014; 3:160-175. [PMID: 25538861 DOI: 10.1089/jayao.2014.0014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The usual age range of acute lymphoblastic malignancies (acute lymphoblastic leukemia and advanced-stage lymphoblastic lymphoma) includes teenagers and young adults (<22 years of age) and coincides with the age of fertility. Concurrence of acute lymphoblastic malignancy with pregnancy is therefore most likely to happen during the younger childbearing ages. However, the therapeutic challenges posed by the dual diagnosis of lymphoblastic malignancy and pregnancy have not specifically been studied in the context of age, and management guidelines for pregnant young patients are lacking. Inconsistency in defining the legal decision-making rights of pregnant teenaged patients adds a further level of complexity in this age group. Management of this challenging combination in the young patient therefore entails unique ethical considerations. Here we present two illustrative cases of teenage pregnancy complicated by acute lymphoblastic malignancy, review the available literature, and offer suggestions for the therapeutic management of such cases in adolescent and young adult patients. Importantly, practical management recommendations are provided in the context of clinical ethics principles that are universally applicable, including in developing countries, where the highest incidence of adolescent pregnancies has been documented.
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Affiliation(s)
- Alia Zaidi
- International Outreach Program, St. Jude Children's Research Hospital , Memphis, Tennessee. ; Department of Oncology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Liza-Marie Johnson
- Department of Oncology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Christopher L Church
- Division of General and Health Studies, Baptist College of Health Sciences , Memphis, Tennessee
| | - Wendy C Gomez-Garcia
- Department of Pediatric Hematology and Oncology, Hospital Infantil Dr. Robert Reid Cabral , Santo Domingo, Dominican Republic
| | - Marcela I Popescu
- Department of Pediatric Hematology and Oncology, St. Jude Tri-Cities Affiliate , Johnson City, Tennessee
| | - Judith F Margolin
- Department of Pediatric Hematology and Oncology, Texas Children's Hospital , Houston, Texas
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital , Memphis, Tennessee
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Hamad N, Kliman D, Best OG, Caramins M, Hertzberg M, Lindeman R, Porter R, Mulligan SP. Chronic lymphocytic leukaemia, monoclonal B-lymphocytosis and pregnancy: five cases, a literature review and discussion of management. Br J Haematol 2014; 168:350-60. [PMID: 25256787 DOI: 10.1111/bjh.13134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/04/2014] [Indexed: 11/27/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) occurs rarely with pregnancy and monoclonal B-Lymphocytosis (MBL) has not previously been described in this setting. CLL is predominantly a disease of the elderly and affects men twice as often as women and hence only an estimated 2% of patients are females of childbearing age. We identified only five reported cases of CLL in pregnancy in the literature. We describe two additional cases, plus three other women with CLL dealing with pregnancy-related decisions. We review the literature and discuss proposals for management and issues that arise in this relatively uncommon occurrence. In contrast to many other haematological malignancies where longer remissions are typically associated with a lower risk of relapse, most patients with CLL who require treatment will ultimately relapse with current therapy. This complex setting requires careful consideration and well informed patients to assist with decisions related to pregnancy.
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Affiliation(s)
- Nada Hamad
- Department of Haematology, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia; Kolling Institute, University of Sydney, St Leonards, Sydney, NSW, Australia; Chronic Lymphocytic Leukaemia Australian Research Consortium (CLLARC), Sydney, NSW, Australia
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38
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Nakajima Y, Hattori Y, Ito S, Ohshima R, Kuwabara H, Machida S, Shirasugi Y, Miyazaki K, Sakai R, Tomita N, Ando K, Higashihara M, Ishigatsubo Y, Fujisawa S. Acute leukemia during pregnancy: an investigative survey of the past 11 years. Int J Lab Hematol 2014; 37:174-80. [DOI: 10.1111/ijlh.12256] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/13/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Y. Nakajima
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
| | - Y. Hattori
- Department of Hematology and Rheumatology; Fujisawa City Hospital; Yokohama Japan
| | - S. Ito
- Department of Internal Medicine and Clinical Immunology, Yokohama City University; Graduate School of Medicine; Yokohama Japan
| | - R. Ohshima
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
| | - H. Kuwabara
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
| | - S. Machida
- Department of Hematology-Oncology; Tokai University; Isehara Japan
| | - Y. Shirasugi
- Department of Hematology-Oncology; Tokai University; Isehara Japan
| | - K. Miyazaki
- Department of Hematology; Kitasato University School of Medicine; Sagamihara Japan
| | - R. Sakai
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
| | - N. Tomita
- Department of Internal Medicine and Clinical Immunology, Yokohama City University; Graduate School of Medicine; Yokohama Japan
| | - K. Ando
- Department of Hematology-Oncology; Tokai University; Isehara Japan
| | - M. Higashihara
- Department of Hematology; Kitasato University School of Medicine; Sagamihara Japan
| | - Y. Ishigatsubo
- Department of Internal Medicine and Clinical Immunology, Yokohama City University; Graduate School of Medicine; Yokohama Japan
| | - S. Fujisawa
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
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39
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Lavi N, Horowitz NA, Brenner B. An Update on the Management of Hematologic Malignancies in Pregnancy. WOMENS HEALTH 2014; 10:255-66. [DOI: 10.2217/whe.14.17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hematological malignancies during pregnancy are rare, which results in the absence of large prospective studies. The diagnosis is often delayed due to the symptom similarity to those of pregnancy and the recommendation to avoid imaging studies during gestation. Management of hematological malignancies during pregnancy poses challenges both to the patient and the medical team, given the therapy-attributable risks for mother and fetus and the need to consider patient's preferences regarding pregnancy continuation. Chemotherapy during the first trimester is associated with an increased risk for fetal demise and congenital malformations, while these risks diminish as pregnancy progresses. We hereby present a review of updated literature on the management of hematologic malignancies (Hodgkin and non-Hodgkin lymphomas, acute leukemia, multiple myeloma, chronic myeloid leukemia and myeloproliferative neoplasms) during pregnancy.
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Affiliation(s)
- Noa Lavi
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Netanel A Horowitz
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Benjamin Brenner
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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40
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Abstract
Leukemia in pregnancy remains a challenging therapeutic prospect. The prevalence is low at ∼1 in 10 000 pregnancies, and as a result data are limited to small retrospective series and case reports, rendering evidence-based recommendations for management strategies difficult. The management of the leukemias in pregnancy requires close collaboration with obstetric and neonatology colleagues as both the maternal and fetal outcomes must be taken into consideration. The decision to introduce or delay chemotherapy must be balanced against the impact on maternal and fetal survival and morbidity. Invariably, acute leukemia diagnosed in the first trimester necessitates intensive chemotherapy that is likely to induce fetal malformations. As delaying treatment in this situation is usually inappropriate, counseling with regard to termination of pregnancy is often essential. For chronic disease and acute leukemia diagnosed after the second trimester, therapeutic termination of the pregnancy is not inevitable and often, standard management approaches similar to those in nongravid patients can be used. Here, the management of the acute and chronic leukemias will be addressed.
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41
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Evens AM, Advani R, Press OW, Lossos IS, Vose JM, Hernandez-Ilizaliturri FJ, Robinson BK, Otis S, Nadav Dagan L, Abdallah R, Kroll-Desrosiers A, Yarber JL, Sandoval J, Foyil K, Parker LM, Gordon LI, Blum KA, Flowers CR, Leonard JP, Habermann TM, Bartlett NL. Lymphoma Occurring During Pregnancy: Antenatal Therapy, Complications, and Maternal Survival in a Multicenter Analysis. J Clin Oncol 2013; 31:4132-9. [DOI: 10.1200/jco.2013.49.8220] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Lymphoma is the fourth most frequent cancer in pregnancy; however, current clinical practice is based largely on small series and case reports. Patients and Methods In a multicenter retrospective analysis, we examined treatment, complications, and outcomes for Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) occurring during pregnancy. Results Among 90 patients (NHL, n = 50; HL, n = 40), median age was 30 years (range, 18 to 44 years) and median diagnosis occurred at 24 weeks gestation. Of patients with NHL, 52% had advanced-stage versus 25% of patients with HL (P = .01). Pregnancy was terminated in six patients. Among the other 84 patients, 28 (33%) had therapy deferred to postpartum; these patients were diagnosed at a median 30 weeks gestation. This compared with 56 patients (67%) who received antenatal therapy with median lymphoma diagnosis at 21 weeks (P < .001); 89% of these patients received combination chemotherapy. The most common preterm complication was induction of labor (33%). Gestation went to full term in 56% of patients with delivery occurring at a median of 37 weeks. There were no differences in maternal complications, perinatal events, or median infant birth weight based on deferred versus antenatal therapy. At 41 months, 3-year progression-free survival (PFS) and overall survival (OS) for NHL were 53% and 82%, respectively, and 85% and 97%, respectively, for HL. On univariate analysis for NHL, radiotherapy predicted inferior PFS, and increased lactate dehydrogenase and poor Eastern Cooperative Oncology Group performance status (ECOG PS) portended worse OS. For HL patients, nulliparous status and “B” symptoms predicted inferior PFS. Conclusion Standard (non-antimetabolite) combination chemotherapy administered past the first trimester, as early as 13 weeks gestation, was associated with few complications and expected maternal survival with lymphoma occurring during pregnancy.
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Affiliation(s)
- Andrew M. Evens
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Ranjana Advani
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Oliver W. Press
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Izidore S. Lossos
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Julie M. Vose
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Francisco J. Hernandez-Ilizaliturri
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Barrett K. Robinson
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Stavroula Otis
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Liat Nadav Dagan
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Ramsey Abdallah
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Aimee Kroll-Desrosiers
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Jessica L. Yarber
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Jose Sandoval
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Kelley Foyil
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Linda M. Parker
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Leo I. Gordon
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Kristie A. Blum
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Christopher R. Flowers
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - John P. Leonard
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Thomas M. Habermann
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
| | - Nancy L. Bartlett
- Andrew M. Evens, Tufts University School of Medicine, Boston; Aimee Kroll-Desrosiers, University of Massachusetts Medical School, Worcester, MA; Ranjana Advani and Stavroula Otis, Stanford University Medical Center, Stanford, CA; Oliver W. Press and Linda M. Parker, Fred Hutchinson Cancer Research Center, Seattle, WA; Izidore S. Lossos, Liat Nadav Dagan, and Jose Sandoval, University of Miami School of Medicine, Miami, FL; Julie M. Vose, University of Nebraska Medical Center, Omaha, NE; Francisco J
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