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

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.

Supraglottic p16+ squamous cell carcinoma during pregnancy: a case report and review of the literature

BACKGROUND

Head and neck cancer during pregnancy is uncommon. Specifically, laryngeal cancer in pregnancy has only been previously reported 10 times. HPV p16+ supraglottic cancer during pregnancy has never been described in the literature prior to this case report. This case is important to report to understand the most effective and safe diagnostic, treatment and follow-up options available for pregnant patients with laryngeal cancer.

CASE PRESENTATION

This report describes a case of a 33-year-old patient who was 24 weeks pregnant presenting with dysphonia and odynophagia. After laryngeal biopsy and MRI she was diagnosed with T3N1M0, stage three p16+ squamous cell carcinoma of the supraglottis. After inter-disciplinary consultation as well as extensive patient discussion, an awake tracheostomy, PEG tube placement and then elective C-section at 28 weeks' gestation was completed. This was followed by chemoradiotherapy. The patient has remained free from disease with a healthy child at four years post-treatment.

CONCLUSION

Supraglottic cancer during pregnancy is rare with only four previous cases reported in the literature. This case report elucidates the importance of including multiple specialities as well as patient preference in the decision-making process regarding treatment for patients with supraglottic cancer during pregnancy. Furthermore, diagnostic and treatment guidelines for pregnant patients with head and neck cancers should be established to promote the best possible oncological, obstetrical and neonatal care.

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.

Acinic cell carcinoma of the parotid gland in pregnancy: an approach to cancer in pregnancy

A 27-year-old woman presented with an enlarging painless right preauricular mass at 28 weeks' pregnant. The mass had been stable for more than 10 years, but showed rapid growth during pregnancy. Imaging and biopsy were consistent with parotid gland malignancy, with surgical resection undertaken at 33+4 weeks' gestation. Histopathology confirmed acinic cell carcinoma. Labour was induced without complication at 36+6 weeks' gestation and adjuvant radiotherapy commenced 2 weeks postpartum. At 9 months follow-up, both mother and baby were well, with no signs of disease recurrence. Rapid progression in pregnancy, of a previously stable salivary gland mass, is a common feature among reported cases and was also observed in the current case. This suggests an aetiological link between pregnancy and salivary gland tumour progression. We demonstrate successful management of a parotid gland malignancy in pregnancy and review guiding principles for cancer management in pregnancy.

Photon-beam radiotherapy in pregnant patients: can the fetal dose be limited to 10 cGy or less?

PURPOSE

To estimate fetal dose and its components from three-dimensional conformal radiotherapy for several malignancies presented during pregnancy.

MATERIALS AND METHODS

Fetal dose was measured from radiotherapy for Hodgkin's lymphoma and for tumors in the region of nasopharynx, breast and lung. Anthropomorphic phantoms were used to simulate an average pregnant patient at the first, second and third trimesters of gestation. Thermoluminescent dosemeters (TLD) were employed for fetal dose measurements. Phantom exposures were also performed to estimate fetal dose due to head leakage, scatter from collimators and beam modifiers and scatter generated inside the phantom (Din). All treatments were delivered for 6 MV photon beams.

RESULTS

Radiotherapy of Hodgkin's lymphoma resulted in a fetal dose of 5.6-57.9 cGy depending upon the gestational age and the distance between the fetal level and the field edge. The corresponding dose ranges for treatment of nasopharyngeal, breast and lung cancer was 4.0-17.1 cGy, 3.9-24.8 cGy and 5.7-74.3 cGy, respectively. The Din at the first trimester of gestation was always smaller than 10 cGy for all examined malignancies. Pregnancy progression resulted in Din values above or below 10 cGy depending upon the treatment site and gestational age.

CONCLUSION

This study provides data about the fetal exposure and the contribution of Din to the total fetal dose from conformal radiation therapy. The Din knowledge prior to patient's irradiation enables radiation oncologists and medical physicists to decide whether fetal dose may be limited to 10 cGy or less with or without the introduction of special shielding materials.

UM-SCC-103: a unique tongue cancer cell line that recapitulates the tumorigenic stem cell population of the primary tumor

OBJECTIVE

A new head and neck cancer cell line was developed from a highly aggressive HNSCC of the oral cavity diagnosed in a 26-year-old pregnant woman.

METHODS

Cells from the primary tumor were passaged in culture and genotyped as a unique cell line. The resultant cell line was assessed for its ability to replicate the primary tumor.

RESULTS

The primary tumor and cell line contained 19.03% and 19.62% CD44(high) cells, respectively. CD44(high) cancer stem cells from UM-SCC-103 formed tumors after flank injections in mice that reconstituted the heterogeneity of the primary tumor. CD44 staining and histology in the primary tumor and tumors grown in vivo from the cell line were similar. CD44(high) cells from the primary tumor resulted in lung colony formation in 2 out of 2 tail vein injections in mice, whereas CD44(low) cells did not. Similarly, CD44(high) cells from UM-SCC-103 formed lung tumors in 2 out of 4 mice, whereas CD44(low) cells did not.

CONCLUSION

The similarity in marker expression and tumorigenic behavior between the primary tumor and the resulting cell line strongly suggests that the cell line resembles the primary tumor that it was derived from and provides an important new research tool for the study of head and neck carcinomas in young patients.

Sarcomatoid carcinoma of the oral cavity during pregnancy

Head and neck cancer in pregnancy is a rare disease and difficult to manage. Few case reports exist in the medical literature. We present the case of a pregnant woman with squamous cell carcinoma of the oral cavity. While initial management in the general population may consist of surgery and, if not possible, concomitant chemotherapy and radiation, these modalities were not an option for this patient given her pregnant state. As an alternative, she was treated through gestation with neoadjuvant chemotherapy. She experienced significant reduction in tumor size and associated symptoms, and fetal growth remained normal and there were no fetal myelosuppresive effects noted at birth. Risks of chemotherapy and radiation in pregnancy are reviewed.

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.

[Malignant tumor of nasal cavity during pregnancy. Case report]

Malignant neoplasm of the head and neck is rare disease of pregnant woman. The most common localization of this tumors are larynx, thyroid, melanoma and lymphoma. Many diagnostic and therapeutic procedures (routinely used in patients with cancer) are contraindicated in the presence of pregnancy. The authors presents a case of a 28-year-old female with malignant tumor of nasal cavity during the 37 week of pregnancy. We performed caesarean section and radical surgery (lateral rhinotomy) with removing of the tumor. The histological examination result was: esthesioneuroblastoma. 5-weeks after surgery radiotherapy was realized. During the 6-year follow-up no recurrence was observed.

[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.

Hypopharyngeal cancer in a pregnant woman

Cancer in pregnant women is a very difficult clinical condition that profoundly affects patients and their families, as well as the medical staff who provide their care. Diagnostic and therapeutic decisions must balance adequate treatment and fetal risk. In developed societies, cancer in pregnant women has become more common during the last 30 years because of an increase in the number of relatively older women who give birth. The most common malignancies in pregnant women are melanoma; lymphoma; leukemia; and breast, cervical, ovarian, gastrointestinal, and genitourinary cancers. Cancer of the head and neck in pregnant patients is very rare. In this article, we describe a rare case of advanced squamous cell carcinoma of the hypopharyngeal area in a young pregnant woman, and we discuss the diagnosis and treatment of cancers of the head and neck in pregnant patients.

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.

The rapid growth of a pleomorphic adenoma of the parotid gland in the third trimester of pregnancy

Introduction

We report a case highlighting the multidisciplinary management of a giant pleomorphic adenoma of the parotid gland that showed rapid growth in the third trimester of pregnancy.

Case presentation

A 43-year-old Caucasian woman presented in her 32nd week of gestation with a tumor of the parotid gland. Ultrasonography of her neck showed a parotid lesion of 40 × 30 × 27.5 mm. A follow-up magnetic resonance imaging scan of the neck four weeks later revealed that the tumor had grown to 70 × 60 × 60 mm, reaching the parapharyngeal space with marked obstruction of the oropharynx of about 50%. After discussing the case with our multidisciplinary tumor board and the gynecologists it was decided to deliver the baby by caesarean section in the 38th week of gestation, and then to perform a surgical resection of the tumor.

Conclusion

Indications for early surgical intervention of similar cases should be discussed on an individual patient basis in a multidisciplinary setting.

Thyroid and parathyroid surgery in pregnancy

The consideration of surgery during pregnancy requires weighing the benefit of urgent surgery against the risk to mother and fetus. Surgery during pregnancy involves an increase in both maternal and fetal risks. Thyroid and parathyroid surgery involves physiological risks to both mother and fetus specific to the disease and function of these endocrine glands. Evaluation of a thyroid mass is similar in pregnant patients with ultrasound and fine-needle aspiration biopsy providing the most important information, while the use of radiographic imaging is severely constrained except when specifically required. In general, thyroid surgery can be delayed until after delivery except in cases of airway compromise or aggressive cancer. In contrast, parathyroid surgery is recommended during pregnancy to avoid adverse effects to the neonate.

Recent advances in oral oncology 2008; squamous cell carcinoma imaging, treatment, prognostication and treatment outcomes

This paper provides a synopsis of the main papers on diagnosis, imaging, treatment, prognostication and treatment outcomes in patients with oral and oropharyngeal squamous cell carcinoma (OSCC) and head and neck SCC (HNSCC) published in 2008 in Oral Oncology - an international interdisciplinary journal which publishes high quality original research, clinical trials and review articles, and all other scientific articles relating to the aetiopathogenesis, epidemiology, prevention, clinical features, diagnosis, treatment and management of patients with neoplasms in the head and neck, and orofacial disease in patients with malignant disease.

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.