Oral carcinoma in pregnancy

Oral cancer in pregnancy: A systematic review

PURPOSE

Oral cancers in pregnancy (OCiP) are rare, however when diagnosed it complicates both the treatment of cancer and the outcome of pregnancy. The aim of this systematic review was to assess the factors impacting the foetal and maternal outcome in OCiP.

MATERIALS AND METHODS

A systematic search was performed on the following electronic databases: PubMed, Scopus, ScienceDirect and Google Scholar. Only histopathologically diagnosed cases of oral cancer in pregnant patients were included. The Joanna Briggs Institute questionnaire for case reports was used to assess the risk of bias. Logistic regression analysis was used to assess the factors impacting foetal and maternal outcome.

RESULTS

Out of the 40 cases reported, 28 were squamous cell carcinomas and 7 osteosarcomas. Logistic regression analysis demonstrated a non-significant association between age of patient, staging, trimester and treatment to maternal and foetal outcome. The overall recurrence, maternal death and foetal death for OCiP was 25 %, 30.77 % and 3.45 % respectively.

CONCLUSION

It could be concluded with low evidence level that none of the factors explored in this SR affected the maternal and foetal outcome. A regular oral check-up, particularly the tongue of pregnant females is recommended to identify any early signs of inflammation or oral cancer and subjected to biopsy to identify malignancy or dysplasia.

Volumetric modulated arc therapy (VMAT): a review of clinical outcomes—what is the clinical evidence for the most effective implementation?

Modern conformal radiation therapy using techniques such as modulation, image guidance and motion management have changed the face of radiotherapy today offering superior conformity, efficiency, and reproducibility to clinics worldwide. This review assesses the impact of these advanced radiotherapy techniques on patient toxicity and survival rates reported from January 2017 to September 2020. The main aims are to establish if dosimetric and efficiency gains correlate with improved survival and reduced toxicities and to answer the question ‘What is the clinical evidence for the most effective implementation of VMAT?’. Compared with 3DCRT, improvements have been reported with VMAT in prostate, locally advanced cervical carcinoma and various head and neck applications, leading to the shift in technology to VMAT. Other sites such as thoracic neoplasms and nasopharyngeal carcinomas have observed some improvement with VMAT although not in line with improved dosimetric measures, and the burden of toxicity and the incidence of cancer related deaths remain high, signaling the need to further mitigate toxicity and increase survival. As technological advancement continues, large randomised long-term clinical trials are required to determine the way-forward and offer site-specific recommendations. These studies are usually expensive and time consuming, therefore utilising pooled real-world data in a prospective nature can be an alternative solution to comprehensively assess the efficacy of modern radiotherapy techniques.

Acceptable fetal dose using flattening filter-free volumetric arc therapy (FFF VMAT) in postoperative chemoradiotherapy of tongue cancer during pregnancy

Optimizing irradiation protocols for pregnant women is challenging, because there are few cases and a dearth of fetal dosimetry data. We cared for a 36-year-old pregnant woman with tongue cancer. Prior to treatment, we compared three intensity-modulated radiation therapy (IMRT) techniques, including helical tomotherapy, volumetric arc therapy (VMAT), and flattening-filter free VMAT (FFF-VMAT) using treatment planning software. FFF-VMAT achieved the minimum fetal exposure and was selected as the optimal modality. We prescribed 66 Gy to the involved nodes, 60 Gy to the tumor bed and ipsilateral neck, and 54 Gy to the contralateral neck over 33 fractions. To confirm the out-of-field exposure per fraction, surface doses and the rectal dose were measured during FFF-VMAT delivery. Postoperative chemoradiotherapy was delivered using IMRT and a cisplatin regimen. Without any shielding, the total fetal dose was 0.03 Gy, within the limits established by the ICRP. A healthy girl was born vaginally at 37 weeks' gestation.

Multi-Region Sequence Analysis of a Pregnancy-Related Oral Squamous Cell Carcinoma Exhibiting Low-Level Aggressive Behavior

We analyzed the genetic and epigenetic profiles of an oral squamous cell carcinoma affecting a 41-year-old pregnant female. The patient presented with an oral mass located at the hard and soft palate with bone involvement and lymph node metastases (T4N1M0). She had been treated with multimodal radiotherapy and chemotherapy, and she is currently alive with no evidence of disease 8 years after treatment. DNA methylation and DNA mutation analyses were used to analyze multiple samples from the tumor mass and from the non-neoplastic mucosa to verify tumor heterogeneity. Genetic and epigenetic analyses revealed the presence of one shared TP53 driver mutation with the same DNA methylation profile in each of the 3 areas of the tumor mass; only 2 additional passenger mutations were detected, suggesting a simple clonal homogeneous carcinoma, which usually is associated with low-level aggressive behavior. Additionally, no genetic or epigenetic alteration in the non-neoplastic oral mucosa was detected, demonstrating the absence of field cancerization. The low aggressiveness of the lesion was confirmed by the patient being free of disease at a long-term follow-up examination. These data suggest a different molecular transformation pathway in pregnancy-related oral squamous cell carcinomas, providing new perspectives for further investigation.

Head and neck cancer during pregnancy

BACKGROUND

The incidence of cancer during pregnancy is low but is slightly increasing. Data on incidence and etiology of head and neck (HN) cancers in pregnant women are rare. We evaluated the frequency, tumor type, associated factors, and specific biomarkers in HN cancers occurring in pregnant (and peripartum) women.

METHODS

A systematic literature search was performed on PubMed, for any HN tumor site occurring in pregnant women.

RESULTS

Sixty cases of HN cancers occurring during pregnancy were identified. Most of them were oral cavity cancers. Relationships with oncogenic viruses, hormonal disturbance, and shift in maternal immunity profile were identified.

CONCLUSION

Carcinogenesis of HN cancers in pregnant women may be led by different cancer type-specific hallmarks. Relevance of these etiological factors with respect to treatments and birth control recommendations is being investigated by the REFCOR in an ambispective study.

Treatment of oral cancers during pregnancy: a case-based discussion

Background

Malignancies occur in approximately 1:1000 pregnancies; the most common being breast (46%) and hematological (18%) malignancies. Oral cancers account for only 2% of all cancers in pregnant women, and there are no standard guidelines for the treatment of oral cancer during pregnancy.

Methods

Between 2007 and 2014, our department managed 1109 patients with oral cancers; four (0.4%) had tongue carcinomas during pregnancy. These cases were retrospectively reviewed.

Results

The four women were aged 29–39 (median 32.5) years. Two underwent partial glossectomy at 39 and 40 weeks’ gestation, respectively, one received radiotherapy at 17 weeks’ gestation, and one underwent supraomohyoid neck dissection and hemi-glossectomy with a forearm flap reconstruction.

Conclusion

In addition to tumor factors, the wishes of the patient and her family, gestational age, and fetal and maternal conditions are important factors in deciding on a treatment protocol. Moreover, treatment decisions require multidisciplinary approach.

Obstetrical Outcomes of Head and Neck (Nonthyroid) Cancers: A 27-Year Retrospective Series and Literature Review

Objective  To describe the clinical presentation and obstetrical outcomes of nonthyroid head and neck cancers (HNCs), and to review literature on this rare condition in pregnancy. Study Design  Pregnant women with nonthyroid HNC were identified retrospectively from 1990 to 2017. Maternal, neonatal, pregnancy, and demographic data were collected. A review of the literature from January 1980 to May 2018 was performed. Results  Over the 27-year time period, 16 women with history of nonthyroid HNC were identified (9 diagnosed during and 7 diagnosed before current pregnancy). The cases were analyzed in detail and the most updated review of management of each type of HNC was provided. Conclusions  HNCs are rare with diagnosis and management challenges during pregnancy. In this series, the cases diagnosed and managed previously to pregnancy presented better perinatal outcomes than the cases presented during pregnancy. The maternal outcomes appeared similar for HNC diagnosed before or after pregnancy.

Systemic lupus erythematosus, pregnancy and carcinoma of the tongue

We present a case which describes a 29-year-old woman with systemic lupus erythematosus who was treated aggressively with cytotoxic immunosuppression. Five years later and approximately 12 weeks pregnant, she is confirmed as having carcinoma of the tongue. Not wishing to consider termination of her pregnancy, she underwent surgical resection, which included partial glossectomy with microvascular reconstruction. Good oral function (speech and swallowing) was restored within 2 weeks. The pregnancy proceeded relatively uneventfully to 37 weeks gestation when proteinuric hypertension necessitated induction of labour. She remains well with no evidence of recurrence. This case highlights the options available in the treatment of carcinoma of the tongue during pregnancy together with the ethical considerations required, balanced against optimising maternal outcomes.

Head and neck squamous cell carcinoma in pregnant women

BACKGROUND

The aim of this study was to investigate oral cancer in pregnant women, a rare but therapeutically challenging patient subset.

METHODS

After institutional review board approval, an EMERSE search was used to identify all women treated at the University of Michigan from 1998 to 2010 with head and neck squamous cell carcinoma (HNSCC) during pregnancy. This identified 4 patients with tongue cancer. Biomarkers and human papillomavirus (HPV) were assessed by immunohistochemistry and multiplex PCR/mass spectrometry, respectively.

RESULTS

Two patients responded well to therapy and are alive more than 10 years after diagnosis; 2 patients died of disease. All tumors overexpressed EGFR and Bcl-xL, 3 of 4 overexpressed c-Met, both tumors that progressed overexpressed p53. All tumors were negative for HPV, p16, estrogen receptor, progesterone receptor, and HER-2.

CONCLUSIONS

Biomarkers of aggressive tumors (high EGFR, c-Met; high Bcl-xL-low p53) did not correlate with outcome. Additional studies are needed to determine whether perineural invasion, delay in diagnosis, and p53 overexpression are factors in poor survival.

[Managment of head and neck cancers during pregnancy]

The coincidence of malignant disease during pregnancy is uncommon. The incidence of cancer in pregnancy has increased, due to the tendency to postpone childbirth to an older age. Cancer complicates approximately 0.1% of all pregnancies. Managing head and neck cancers during pregnancy requires additional pregnancy-related understanding of the aetiological effect of pregnancy on cancer, knowledge of the direct and indirect effects of cancer on pregnancy, and the effect of diagnostic and treatment modalities on pregnancy. The timing of treatment is an important determinant on foetal wellbeing. A multidisciplinary approach should be adopted to enable parents and clinicians to make the best clinical decision. Clinicians must be cognizant with the ethical dilemmas of treatment. In head and neck cancers, pregnancy has no effect on maternal prognosis when compared to non-pregnant patients matched by age, cancer stage and treatment.

Tongue cancers during pregnancy: Case reports and review of literature

BACKGROUND

Due to its rarity, there is no standard treatment for tongue cancers that concur with pregnancy. Treatment depends on the stage of cancer, gestational age of the pregnancy, and the wish of the mother to maintain the pregnancy. The purpose of this study was to review the literature and to report 5 new cases.

METHODS

Twelve cases of tongue cancer during pregnancy were already reported between 1987 and 2009. We report 5 new cases and first administration of concomitant radiochemotherapy for tongue cancer.

RESULTS

Median age of the patients was 29 years, 65% of diagnoses were made after the first trimester of pregnancy. Different treatment modalities are used to treat tongue cancer during pregnancy.

CONCLUSION

We hypothesize that tongue cancer treatment adhering to standard protocols provides the best guarantee to cure the mother. Based on a growing experience and insight taking fetal safety into consideration, the available data suggest that standard treatment is a realistic option.

Surgical management of tongue cancer during pregnancy

There are ethical dilemmas in managing head and neck cancers during pregnancy. Diagnostic and treatment modalities need to be carefully determined. We herein describe 3 cases of tongue cancer during pregnancy. The details of the management would contribute to the daily practices for head and neck cancers. All three patients were Japanese female patients, two of them were 29 years old and one was 26 years old. All patients were admitted to the Nippon Medical School Hospital during pregnancy, complaining of oral pain and/or discomfort. Case 1 was diagnosed as tongue cancer stage T3N0M0, however, the tumor was superficial and controllable by partial glossectomy. Case 2 was stage T2N0M0 with deep invasion with ulcer, and the hemi-glossectomy with neck dissection and the reconstruction was thought to be the standard modality. However, she underwent partial glossectomy in order to reduce the stress of the fetus. Case 3 could not be diagnosed on admission by biopsy and she underwent partial glossectomy after delivery. In case 3, the pathological diagnosis was pT1 tongue cancer. In case 1 and case 3, the patient and baby were healthy. In case 2, however, the patient died of recurrence at the primary site. In decision making of the strategy, the most important factors are not only oncological evaluation but also ethical and emotional factors.

Management of head and neck tumours during pregnancy: case report and literature review

Ethical dilemmas arise in managing head and neck cancers during pregnancy. The timing of treatment is an important determinant on foetal wellbeing. Diagnostic and treatment modalities may harm the foetus, while delaying or choosing suboptimal treatment in order to preserve foetal health may worsen maternal outcome. A multidisciplinary approach should be adopted to enable parents and clinicians to make the best clinical decision. We report on two cases. Case 1 is a 34-year-old female who presented with squamous cell carcinoma of the tongue at 29 weeks' gestation. Partial glossectomy, selective neck dissection and posterior tibial flap reconstruction was performed at 31 weeks. She underwent induction and early delivery at 38 weeks prior to receiving radiotherapy. Case 2 is a 36-year-old female who presented with carcinoma of the cervical oesophagus complicated by tracheal invasion, thyroid and cervical lymph node metastasis at 13 weeks' gestation. Pregnancy was terminated at 16 weeks. She received a course of neoadjuvant chemoirradiation.

Advanced Oral Tongue Cancer in a 22-Year-Old Pregnant Woman

Objectives:

Oral squamous cell carcinoma generally occurs in older men and is associated mostly with tobacco and alcohol as the primary risk factors. The incidence of oral squamous cell carcinoma in younger patients has increased. We report a case of a young woman, 25 weeks pregnant, who presented with stage IV carcinoma of the oral tongue.

Methods:

The following is a case presentation and literature review.

Results:

The patient presented with T4 N3 M0 oral tongue cancer. A team consisting of a head and neck surgeon, a radiation oncologist, a medical oncologist, and a maternal-fetal medicine specialist was assembled. The patient initially refused surgery. Chemotherapy was initiated until 32 weeks' gestation. After an infant boy was delivered via cesarean section, the patient began concurrent irradiation and chemotherapy, which induced complete regression of the primary tongue neoplasm with a partial response of the neck nodes. The patient underwent bilateral neck dissection followed by hemiglossectomy for recurrence.

Conclusions:

Management of advanced oral carcinoma in pregnancy presents a unique set of challenges. Few studies have described chemotherapy and radiotherapy during pregnancy, and long-term results are needed. Care must be taken to balance appropriate and adequate treatment of disease and to ensure the safety of the patient and the fetus.

Management principles of head and neck cancers during pregnancy: A review and case series

Head and neck cancers during pregnancy are rising in incidence. Clinicians need to be aware of the principles of managing these cases. This paper is a review of the literature of head and neck cancers during pregnancy with a short case series of six non-thyroid pregnancy-associated cancers treated by a head and neck oncology surgeon. The age range is 20-34 years. Tumour types include carcinoma of the tongue, nasopharynx, maxillary sinus, parotid gland, subglottic region, and the neck. Five patients were treated surgically and four were treated with either chemotherapy or radiotherapy. Both foetal and maternal death occurred in two cases. The range of follow-up is 15 months to 14 years. Managing head and neck cancers during pregnancy requires the addition of a pregnancy-related layer of understanding to the armoury of existing specialist knowledge, encompassing a triad of effects, (i) the aetiological effect of pregnancy on cancer, (ii) the direct and indirect effects of cancer on pregnancy, and (iii) the effect of diagnostic and treatment modalities on pregnancy. Consideration must also be given to the ethical dilemmas of decision making.

Chromatin assembly factor-1 (CAF-1)-mediated regulation of cell proliferation and DNA repair: a link with the biological behaviour of squamous cell carcinoma of the tongue?

AIMS

Squamous cell carcinoma (SCC) of the tongue shows aggressive behaviour and a poor prognosis. Clinicopathological parameters fail to provide reliable prognostic information, so the search continues for new molecular markers for this tumour. Chromatin assembly factor-1 (CAF-1) plays a major role in chromatin assembly during cell replication and DNA repair and has been proposed as a new proliferation marker. The aim of this study was to investigate its expression in SCC of the tongue.

METHODS AND RESULTS

The immunohistochemical expression of the p60 and p150 subunits of CAF-1 were evaluated in a series of SCCs of the tongue. The findings were correlated with the expression of proliferation cell nuclear antigen (PCNA) and patients' clinicopathological and follow-up data. CAF-1/p60 was expressed in all the tumours, whereas CAF-1/p150 was down-regulated in a number of cases. Overexpression of CAF-1/p60 and down-regulation of CAF-1/p150 identified SCCs with poor outcome, in addition to the classical prognostic parameters.

CONCLUSIONS

Simultaneous CAF-1-mediated deregulation of cell proliferation and DNA repair takes place in aggressive SCC of the tongue. Therefore, the evaluation of CAF-1 expression may be a valuable tool for evaluation of the biological behaviour of these tumours. This may be relevant to the introduction of improved follow-up protocols and/or alternative therapeutic regimens.

Cancers presenting in the head and neck during pregnancy

PURPOSE OF REVIEW

The purpose of this review is to document the information reported on cancers presenting in the head and neck area during pregnancy.

RECENT FINDINGS

Accidents and cancer account for most deaths during the reproductive years. Cancer complicates approximately 0.1% of all pregnancies and, in order of frequency, the incidence of cancers by site are breast, melanoma, thyroid, cervix, lymphoma, and ovary. Some of these cancers may present in the head and neck region, as well as more uncommon cancers such as mucosal squamous cell carcinoma.

SUMMARY

It is recognized that with the dramatic rise in births among "reproductively" older women and with the changing epidemiology of squamous cell carcinoma of the head and neck in nonsmoking and nonalcohol-drinking women, there is to be expected an increased incidence and presentation. Management of such patients must consider the gestational age of the pregnancy and must include alternatives to current treatments to accommodate the individual's wishes regarding her pregnancy.

Microvascular free tissue transfer in the management of squamous cell carcinoma of the tongue during pregnancy

We describe a 36-year-old patient with a stage III carcinoma (pT2N1M0) of the tongue that presented in the second trimester of pregnancy. It was treated by primary excision and reconstruction with a free flap. To our knowledge this is the first reported case of successful microvascular free tissue transfer for oral cancer during pregnancy.

Squamous carcinoma of the tongue: review

Carcinoma of the tongue is a common condition treated by oral and maxillofacial surgeons. The tongue is a complex anatomical site at the entrance of the oropharynx, bounded by the floor of mouth and lingual mandibular cortex; its form and mobility are crucial for efficient swallowing; speech, and the appreciation of taste. Single and multiple treatments have been used, but the tongue remains a difficult area to assess and treat. In this paper, we have attempted to review some of the papers published over the last 20 years with particular reference to prognosis and functional outcome. We have dealt exclusively with squamous cell carcinoma of the tongue and its management by surgery, radiotherapy, brachytherapy, photodynamic therapy, and chemotherapy.