Rapidly growing thyroid carcinoma during pregnancy

Maternal and obstetrical outcome in 35 cases of well-differentiated thyroid carcinoma during pregnancy

OBJECTIVES/HYPOTHESIS

Thyroid cancer, with 6% to 10% of cancer diagnoses, is one of the most common malignancies during pregnancy. Its treatment poses a risk for the pregnancy, as the thyroid gland plays a crucial role in the evolution of pregnancy. The aim of this study is to evaluate treatment of primary well-differentiated thyroid carcinoma during pregnancy and fetal and maternal outcomes.

STUDY DESIGN

This is an international cohort study.

METHODS

Primary thyroid cancer patients were identified from the database of the International Network on Cancer, Infertility, and Pregnancy registration study. Data on histopathological characteristics, diagnostic and therapeutic interventions, outcome (obstetrical, neonatal, and maternal) and maternal follow-up were analyzed.

RESULTS

Thirty-five patients with well-differentiated thyroid carcinoma were eligible. All 35 patients underwent surgery, 29 (83%) of which during pregnancy. Procedures during pregnancy were mainly total thyroidectomies (n = 24). The median number of days between diagnosis and surgical treatment was different between the groups with surgery during and after pregnancy (27 vs. 139 days, P < .001). Both maternal and neonatal outcomes were uncomplicated, regardless of gestational age during surgery.

CONCLUSIONS

Well-differentiated thyroid carcinoma diagnosed during pregnancy has a favorable outcome for both mother and child. Surgical management during pregnancy has no negative impact on the pregnancy regardless of the trimester at the time of surgery. However, the potential negative effects of thyroid surgery early in pregnancy demand management of these patients in an experienced multidisciplinary team to provide the best possible care for these patients and their unborn babies.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1493-1500, 2018.

[Thyroid and pregnancy]

Pregnancy is associated with an increased requirement of hormone secretion by the thyroid, within the first weeks after conception. To this greater demand to occurs, pregnancy induces a series of physiological changes that affect thyroid function and, consequently, the tests of glandular function. For normal pregnant women living in areas with a sufficient supply of iodine, this challenge regarding the adjustment of thyroid hormone releases to this new state of equilibrium and its maintenance until the end of pregnancy it meets no difficulties. However, among women with impaired thyroid function due to some thyroid disease or among women residing in areas with an insufficient iodine supply, this does not occur. The management of thyroid dysfunction during gestation requires special considerations, since both hypothyroidism and hyperthyroidism can lead to maternal and fetal complications. In addition, thyroid nodules are detected at reasonable frequency among pregnant women, a fact that requires a differential diagnosis between benign and malignant growths during the pregnancy itself.

Risk factors for well-differentiated thyroid carcinoma in patients with thyroid nodular disease

OBJECTIVES

Evaluate current accepted risk factors for well-differentiated thyroid carcinoma, and develop a predictive model to determine one's risk of malignancy given a thyroid nodule.

STUDY DESIGN

Retrospective analysis of 600 patients.

SUBJECTS AND METHODS

Patients with benign thyroid nodular disease and with well-differentiated thyroid cancer were randomly selected. Patient, clinical, and investigational data were compared by means of univariate and multivariate regression analyses.

RESULTS

Age, regional lymphadenopathy, ipsilateral vocal cord palsy, solid and/or calcified nodules, and an aspiration biopsy being malignant or suspicious predicted for cancer (P < 0.05). Regional lymphadenopathy and vocal cord palsy are perfect predictors of malignancy. Multivariate analysis indicated age, solid and/or calcified nodules, and all fine-needle aspiration biopsy results to be significant in assessing risk (P < 0.05).

CONCLUSION

Taking individual risk factors in isolation is not always reliable. Using a predictive model, one can anticipate a patient's risk of malignancy when the diagnosis is unclear.

Impact of pregnancy on serum thyroglobulin and detection of recurrent disease shortly after delivery in thyroid cancer survivors

OBJECTIVE

Since pregnancy can stimulate thyroid growth, we examined the effect of pregnancy on recurrence and serum thyroglobulin (Tg) shortly after delivery in thyroid cancer survivors.

DESIGN

Retrospective analysis of thyroid cancer survivors who became pregnant after completing initial therapy.

MAIN OUTCOME

36 women (age 34 +/- 4 years) who became pregnant a median of 4.3 years after initial therapy for differentiated thyroid cancer were evaluated a median of 4 months after delivery. As part of their initial therapy, 23 women underwent total thyroidectomy with radioactive iodine remnant ablation (RRA), six had total thyroidectomy without RRA, and seven underwent lobectomy without RRA. Following total thyroidectomy with or without RRA, no evidence of recurrence was detected in the early postpartum period in women with negative prepregnancy ultrasound and either undetectable or low suppressed Tg levels. However, disease progression was documented as enlargement of a previously stable cervical lymph node in one of three patients and a marked rise in serum Tg without evidence of structural disease progression in a patient with previously stable distant metastases. When analyzed based on initial therapy, the mean suppressed Tg after delivery was not significantly different than the prepartum value. However, eight women had Tg values after delivery more than 20% higher than the baseline Tg before pregnancy (three with known disease, five with no clinical evidence of disease).

CONCLUSION

In thyroid cancer survivors, pregnancy is unlikely to cause clinically significant disease recurrence in the early postpartum period when structural imaging studies confirm the absence of residual disease but can occasionally be associated with progression of known metastatic lesions. Even though the serum Tg did not differ significantly before and after pregnancy, the long-term implications of minor rise in serum Tg seen in some individual patients cannot be assessed without longer studies in larger cohorts.

Optimal timing of surgery in well-differentiated thyroid carcinoma detected during pregnancy

BACKGROUND

To determine the optimal timing at which to perform surgery for well-differentiated thyroid carcinoma detected during pregnancy.

OBJECTIVES

We retrospectively analyzed 20 cases of women diagnosed during pregnancy with well-differentiated thyroid carcinoma between July 1991 and June 2004, all of whom underwent surgery. The patients were divided into three groups according to the timing of surgery. Group I (n = 9) had thyroidectomy after delivery, Group II (n = 6) had thyroidectomy during the second trimester, and Group III (n = 5) had thyroidectomy after abortion. Group III was excluded from the study because we were interested in determining the optimal timing of surgery in pregnant women.

RESULTS

No significant differences were noted between Groups I and II with regard to patient age, tumor size, TNM stage, and the timing of diagnosis. There were no TNM stage changes in Group I, although there was a slight increase in tumor size during pregnancy in this group. Surgical outcome, with regard to type of operation, operation time, perioperative complications, length of hospital stay, and treatment outcome, did not differ significantly between Groups I and II.

CONCLUSIONS

In most patients, surgery on well-differentiated thyroid carcinoma detected during pregnancy can be delayed until after delivery.

Timing and special concerns regarding endocrine surgery during pregnancy

Pregnancy may occur in the setting of endocrine diseases or be the first time these diseases manifest clinically. Management of pregnancy in these circumstances is challenging and requires a high degree of vigilance on the part of the treating physicians. The best outcome is achieved by a multidisciplinary approach consisting of endocrinology, obstetrics, anesthesiology, and endocrine surgery.

Cancer in pregnancy: maternal-fetal conflict

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

Pregnancy and malignant neoplasms of the head and neck

This paper, based on a literature review, deals with the occasional development of a head and neck neoplasm in the pregnant woman. This rare event makes for some challenging problems in patient management, insofar as the otolaryngologist is actually responsible for taking care of 2 patients -- the mother and her unborn child. In particular, 4 tumor types have figured prominently among those head and neck tumors arising in pregnant women: cancer of the larynx, cancer of the thyroid, malignant melanomas, and malignant lymphomas of the head and neck. Of these, the most common appear to be melanomas, followed by lymphomas, thyroid carcinomas, and, finally, laryngeal carcinomas. The thyroid tumors, lymphomas, and laryngeal carcinomas do not appear to behave more aggressively in pregnant than in nonpregnant patients; there is, however, some anecdotal evidence to suggest that melanomas in pregnant women may be more aggressive neoplasms than similar-stage tumors in nonpregnant women. One difficulty in treating any of these tumor types in this clinical setting is the limitation that may be imposed on the use of adjuvant therapy by the presence of the unborn child, which may put the attending physicians in the difficult position of balancing less aggressive therapy for the mother against the potential for harming the baby through use of toxic systemic therapy.

Thyroid cancer complicating pregnancy

Thyroid nodules and thyroid cancer are more common in women than in men. It is not uncommon to find a thyroid nodule during pregnancy that requires investigation. Fortunately, most cancers found during pregnancy are differentiated thyroid cancers with an excellent prognosis. Fine-needle aspiration is safe and accurate during pregnancy. Cancer discovered early in pregnancy can safely be operated on in the second trimester. Cancers or nodules discovered later in pregnancy can have work-up and treatment delayed until after delivery. No data support pregnancy termination or the proscription of future pregnancy in these patients.

Evaluation and management of common thyroid disorders in women

Thyroid disorders are very common in women. Many important changes occur in thyroid physiologic characteristics during different phases of a woman's life. Thus it is important to understand these changes in managing thyroid disorders in women. These changes are especially important during pregnancy and in postmenopausal women because the consequences of thyroid diseases are quite different. This Clinical Opinion presents current understanding of pathophysiologic features and clinical management of various common thyroid disorders in women.

Thyroid cancer in children, pregnant women, and patients with Graves' disease

Differentiated thyroid cancer may have a different clinical course when it develops in children, pregnant women, and patients with Graves' disease. Thyroid nodules which develop in these patients appear to have a greater risk of malignancy and should be evaluated aggressively. Treatment in all cases includes operation followed by radioactive iodine ablation (in the nonpregnant patient) and thyroid hormone suppression. Follow-up, including serum Tg and yearly thyroid scans, should be continued as long as possible.

Cancer in pregnancy: a review of the literature. Part I

Cancer is an important cause of death in the United States in women of childbearing age. Approximately 1 per 1000 pregnant women will develop cancer. This review (Part II follows in this issue) examines the diagnosis, prognosis, and management of cancer during pregnancy; both in terms of the cancer's effect on the pregnancy, and the pregnancy's effect on the cancer. Some diagnostic modalities and some therapies are problematic to the fetus and placenta. However, in most cases and the pregnancy can be managed concurrently with a good outcome for the baby and without compromising the mother's prognosis.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.