Conflicting priorities in surgical intervention for cancer in pregnancy

Risk of obstetric and perinatal complications in women presenting with breast cancer during pregnancy and the first year postpartum in Sweden 1973-2017: A population-based matched study

INTRODUCTION

For women presenting with breast cancer during pregnancy, treatment guidelines were historically restricted to only surgical treatment. Over the past decades, chemotherapy administered during pregnancy has been gradually introduced. Although breast cancer treatments during ongoing pregnancy have been deemed safe, detailed information on potential obstetric risks is lacking. We aimed to assess the risk of adverse obstetric and perinatal outcomes of breast cancer in pregnancy and within 1 year postpartum and in relation to trimester at breast cancer diagnosis, tumor stage, and cancer treatment during pregnancy.

MATERIAL AND METHODS

Population-based matched study. Women diagnosed with breast cancer during pregnancy in 1973-2017 were identified in the Swedish Cancer Register and the Medical Birth Register, with additional information from the National Quality Register for Breast Cancer. Each birth with maternal breast cancer (n = 208 pregnant, n = 672 postpartum) was matched by age, calendar year, and birth order to 10 unexposed births from cancer-free women in the population (n = 2080 and n = 6720). Adjusted conditional logistic and multinomial regression models were used to estimate odds ratios and relative risk ratios, commonly denoted relative risks (RR) with 95% confidence intervals (CI), of adverse obstetric and perinatal outcomes.

RESULTS

Breast cancer during pregnancy was associated with higher risks of preterm birth, both planned (RR 67.1, 95% CI 33.2-135.6) and spontaneous preterm birth (RR 3.8, 95% CI 2.0-7.5), and low birthweight (<2500 g: RR 7.5, 95% CI 4.9-11.3). The associated risks were higher if the breast cancer was diagnosed in the second trimester, and of similar magnitude irrespective of stage and treatment groups. There was a higher risk of low birthweight for gestational age (<25th centile) if breast cancer was diagnosed in the first trimester (RR 2.8, 95% CI 1.1-7.3). Risks of other pregnancy complications were similar to those of unexposed women, as were risks of neonatal mortality and malformations. Postpartum breast cancer was only associated with bleeding during pregnancy (RR 1.6, 95% CI 1.0-2.8).

CONCLUSIONS

Preterm birth and related adverse outcomes were more common in women diagnosed with breast cancer during pregnancy. Reassuringly, breast cancer was not associated with other maternal pregnancy complications or adverse outcomes in children.

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.

Cancer in pregnancy: treatment effects

PURPOSE

Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized.

METHODS

This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible.

RESULTS AND CONCLUSION

Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.

A pregnant patient with ALK-positive non-small cell lung cancer treated with alectinib: A case report and review of the literature

Oncogenic rearrangements in the anaplastic lymphoma kinase (ALK) gene account for 5% of non-small cell lung cancer (NSCLC) cases. ALK inhibitors have markedly improved the outcome of metastatic ALK-positive NSCLC (ALK⁺ mNSCLC) by increasing long-term overall survival. Although a diagnosis of NSCLC during pregnancy or the peripartum period is rare, ALK⁺ NSCLC accounts for 38% of NSCLC cases in women of childbearing age (18-45 years old). The younger age and prolonged survival of patients with ALK⁺ mNSCLC bring new challenges for lung cancer and obstetrics research, and raises questions related to pregnancy and family planning. The present study described normal fetal development and no obstetric complications in a patient infected with HIV diagnosed with ALK⁺ mNSCLC, who became pregnant during treatment with alectinib, a third-generation ALK inhibitor.

Multidisciplinary Management of Cancer During Pregnancy

Cancer during pregnancy is relatively rare but is increasing in frequency in countries in which the maternal child-bearing age continues to rise. The complexities of medical decision making are underscored by the need to weigh the potential benefits of any intervention for the mother against the risks to the fetus. A majority of diagnostic evaluations can be performed safely in the setting of pregnancy and should not be delayed. Noninvasive prenatal testing that shows discordance with fetal karyotype can be a clue to an underlying maternal malignancy. After diagnosis, a multidisciplinary team should formulate a care plan for both the mother and the fetus. Key topics for discussion should include the mother's prognosis, standard treatment plan, and predictions of how modifications for a continuing pregnancy will affect the treatment plan and overall prognosis. In the context of this knowledge, frank discussions about pregnancy termination should be addressed with the patient, if appropriate. Selection of a plan for oncologic management in the case of a pregnant woman is based on the type of cancer, the tumor biology, and the tumor stage. Additional complexities for pregnant patients are typically related to the gestational age of the fetus, the dynamic physiologic changes of pregnancy, and the limited safety data for administration of most anticancer therapies during pregnancy. In this article, we summarize data related to different classes of anticancer therapies as well as considerations for the management of selected cancers. Finally, we provide some key principles that should be considered in the management of patients with cancer during pregnancy.

Maternal survival of patients with pregnancy-associated cancers in Taiwan - A national population-based study

Pregnancy-associated cancer (PAC), defined as cancers diagnosed during pregnancy or the first year after delivery, affects one to two in every 1000 pregnancies. Although PAC is expected to be a growing issue, information about PAC in the Asian population is still scarce. Women with cancer diagnosed at the age of 16-49 years between 2001 and 2015 were selected from the Taiwan Cancer Registry and linked with the National Birth Reporting Database to identify PAC patients. We compared the overall survival of patients with PAC to patients without pregnancy. Among 126,646 female cancer patients of childbearing age, 512 were diagnosed during pregnancy, and 2151 during the first postpartum year. Breast cancer was the most common PAC (N = 755, 28%). Compared with patients without pregnancy in the control group, patients with cancers diagnosed during pregnancy and the first postpartum year generally had more advanced stages (odds ratio 1.35 and 1.36, 95% confidence interval [CI] 1.02-1.77 and 1.18-1.57, respectively). For all cancer types combined and controlled for the stage, age, and year of diagnosis, patients with PAC had similar overall survival with those in the control group, with a hazard ratio (HR) of 1.07 (95% CI 0.80-1.41) for the pregnancy group and HR 1.02 (95% CI 0.88-1.18) for the postpartum group. The diagnosis of breast cancer during the first postpartum year was linked with shorter survival (HR 1.34, 95% CI 1.05-1.72). In contrast, patients with postpartum lymphoma (HR 0.11, 95% CI 0.02-0.79) and cervical cancer (HR 0.40, 95% CI 0.20-0.82) had better prognosis. In general, the diagnosis of cancer during pregnancy or the first postpartum year does not affect the survival of patients with most cancer types. Exceptions include the worse prognosis of postpartum breast cancer and the better outcome of postpartum lymphoma and cervical cancer.

Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment

OBJECTIVE

Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment.

PATIENTS AND METHODS

Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed.

RESULTS

The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology.

CONCLUSION

The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.

Spinal Emergency Surgery During Pregnancy: Contemporary Strategies and Outcome

BACKGROUND

Low back pain is a common complaint during pregnancy. However, spinal pathologies, which manifest with severe pain, radiculopathy, and acute neurologic deficits because of disk herniation or mass lesions require special attention. Here, we present our interdisciplinary experience in the surgical management of spinal emergencies during pregnancy.

METHODS

The data of pregnant women who underwent surgery for spinal pathologies over a 10-year period were collected. Patient-related characteristics such as maternal age, gestational age, preoperative workup, signs and symptoms of mothers, and diagnostic procedures were evaluated. After an interdisciplinary conference, individualized treatment plans regarding available options were developed. Fetal Doppler and cardiotocography were obtained before and after surgery.

RESULTS

Nine pregnant women presented with spinal disorders and underwent spinal emergency surgery within the study period. The mean maternal age was 32.2 years. Six women presented with lumbar disk herniations manifesting as severe sciatica or foot drop and 3 patients had thoracic mass lesions resulting in cauda equine syndrome and/or ataxia. The mean gestational age at the time of presentation was 26.5 weeks. Caesarean sections were performed in 3 women prior to the neurosurgical procedure, whereas the pregnancies were maintained in the 6 other patients. Eight infants who were healthy at birth had an unremarkable development.

CONCLUSIONS

Surgery for spinal emergencies in pregnancy can be performed safely according to individual treatment plans developed by an interdisciplinary team taking into account the expectant mother's decision. Maintenance of pregnancy is possible and feasible in most patients.

Experience of Japanese pregnant women with cancer in decision-making regarding cancer treatment and obstetric care

AIM

Women who are diagnosed with cancer during pregnancy must make difficult, life-changing decisions that affect their own life and that of their fetus. The psychological impact of distress and anxiety resulting from facing often conflicting choices can greatly influence survival in these women. We conducted this study to clarify the experience of pregnant women with cancer in decision-making and to consider the role of nurses in providing care to pregnant women with cancer during their decision-making.

METHODS

This qualitative study included post-partum Japanese women diagnosed with cancer who had made any treatment or pregnancy decisions. Data collection was conducted using semi-structured interviews and medical record review. Data were analyzed using qualitative content analysis and classified into subcategories, categories, themes, and phases.

RESULTS

Participants comprised eight women with leukemia and cervical, breast, and digestive cancers. The decision-making experiences of these eight pregnant women with cancer were categorized into three phases: the interaction between the woman and her fetus, family members, and medical staff; confrontation with dilemma and uncertainty; and redefinition of the women's own decisions.

CONCLUSIONS

The experience of Japanese pregnant women with cancer in decision-making has two aspects: verbal and nonverbal communication with their surroundings and reflection. The role of a nurse is to guarantee these women continuous communication channels and frank dialogue, to empower them in expressing their thoughts and informational needs to medical staff and family members.

Metastatic uterine leiomyosarcoma at 26 weeks gestation

Uterine leiomyosarcoma (ULMS) is a highly malignant neoplasm which has been rarely described in pregnancy. A case of advanced metastatic ULMS presenting at 26 weeks gestation is reported. The principles in managing invasive cancer in pregnancy are discussed.

Obstetrical and infant outcomes among women with neoplasms during pregnancy

PURPOSE

One in 1,000 pregnancies is complicated by malignancies. Prevalence is greater for benign neoplasms. Adverse outcomes among women with malignancies have been reported. Less is known of postpartum outcomes for infants, or outcomes among women with benign neoplasms.

METHODS

We conducted a population-based cohort study using Washington State-linked vital-hospital discharge records. Women with neoplasms (707 malignant; 13,156 benign) with deliveries in 1987-2012 were identified, and a randomly selected comparison cohort. Obstetrical/infant outcomes and rehospitalization < 2 years post-delivery were compared separately for each group by multivariable regressions to estimate risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

Women with either condition had increased anemia, cesarean, and preterm delivery; their infants were more often < 2,500 g or jaundiced. Women with benign conditions had increased gestational diabetes (RR = 1.20; 95% CI 1.12-1.28) and preeclampsia (RR = 1.27; 95% CI 1.18-1.36); their infants had increased malformations (RR = 1.29; 95% CI 1.19-1.38). Women with neoplasms more often were hospitalized seven or more days or rehospitalized; their infants' hospitalizations were also longer.

CONCLUSION

Malignant and benign neoplasms were associated with several adverse outcomes. Reasons for relationships of benign neoplasms with gestational diabetes, preeclampsia, and congenital malformations merit further study.

Breast Cancer During Pregnancy

Breast cancer remains the most common cancer in women. A diagnosis of cancer during pregnancy is uncommon. In recent decades, obstetricians are seeing an increasing number of women who become pregnant or desire to become pregnant after breast cancer treatment because of a delay in childbearing for a variety of reasons, including cultural, educational, and professional. Consequently, breast cancer in young women often occurs before the completion of reproductive plans. A discussion among the patient, the oncologist, and the obstetrician on the relative benefits of early delivery followed by treatment versus commencement of therapy while continuing the pregnancy is of utmost importance in order to reach a consensual decision. The best available evidence suggests that pregnancy after breast cancer increases the risk of recurrence. The birth outcome in women with a history of breast cancer is no different from that in the normal female population; however, increased risks of delivery complications have been reported in the literature. As concurrent pregnancy and breast cancer are uncommon, there are no data from large randomized trials; hence, recommendations are mainly based on retrospective studies.

Current approaches in the clinical management of pregnancy-associated breast cancer-pros and cons

Malignancies are one of the leading causes of mortality in women during their reproductive life. Treatment of gynecological malignant tumors during pregnancy is possible but not simple, since it creates a conflict between care of the mother and the fetus. BC is the most prevalent malignancy diagnosed in pregnancy, ranking up to 21% of all pregnancy-related malignancies. Due to its stets increasing prevalence, aggressive cancer subtype, and severe ethical and psychological aspects linked to the disease, experts raise an alarm for an acute necessity to improve the overall management of the PABC-the issue which has strongly motivated our current paper. Comprehensive research data and clinical experience accumulated in recent years have advanced our understanding of the disease complexity. PABC treatment must be individualized with an emphasis on optimal care of the mother, while observing standard treatment protocols with regard to safety of the fetus. Treatment protocols should be elaborated based on the individualized patient profile, bearing in mind the acute danger to the mother, maximizing the therapy efficacy and minimizing harmful effects to the fetus. Complex consulting on treatment options, their impacts on pregnancy and potential teratogenic effects requires tight "doctor-patient" collaboration. Complications that may arise due to the treatment of breast cancer in pregnancy require a multiprofessional expertise including oncologists, neonatologists, perinatologists, obstetricians, teratologists, and toxicologists, and an extensive psychological support throughout the pregnancy and after giving birth. Thereby, specifically psychological aspects of PABC diagnosis and follow-up are frequently neglected, being not yet adequately explored in the entire disease management approach. Herewith, we update the status quo regarding the currently available diagnostic modalities, complex treatment algorithms, and novel clinical approaches which altogether argue for an urgent necessity of a paradigm shift moving away from reactive to predictive, preventive, and personalized medical approach in the overall management of PABC meeting the needs of young populations, persons at high risk, affected patients, and families as the society at large.

Effects of cancer treatment during pregnancy on fetal and child development

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.

Whole body MRI for systemic staging of breast cancer in pregnant women

When breast cancer is diagnosed during pregnancy, treatment should be as close; as possible to what is used in non-pregnant patients. This requires accurate local and systemic staging: ultrasound (US) is used for local staging and allows adequate evaluation of the liver and pelvis, but chest and bones cannot be explored and imaging techniques involving exposure to ionizing radiation would be needed. However, since imaging techniques involving ionizing radiation and the use of radionuclides should be limited, whole body magnetic resonance imaging (WB-MRI) without administration of contrast agent represents a very interesting alternative, but limited data is available. In this paper we describe the obstetrical and oncological outcome of 14 patients in whom breast cancer was diagnosed during the second or third trimester of pregnancy and that were staged using WB-MRI. Median age of the patient at diagnosis was 35 years (range 20-36), median gestational age at MRI was 30 weeks (range 13-32) and median age at delivery was 38 weeks (range 32-38). At birth, one new-born presented respiratory distress syndrome and one jaundice. We conclude that diffusion-weighted MRI is feasible accurate and safe for the mother and for the foetus. It may represent the staging technique of choice in pregnant women diagnosed with breast cancer after the first trimester of pregnancy.

Colorectal cancer diagnosed during pregnancy: systematic review and treatment pathways

The aim of this study was to identify the mode of presentation and incidence of colorectal cancer in pregnancy (CRC-p), assess the outcomes of the mother and foetus according to gestational age, treatment delivered and cancer features and location. A systematic review of the literature was carried out to identify studies reporting on CRC-p and pooled analysis of the reported data. Seventy-nine papers reporting on 119 patients with unequivocal CRC-p were included. The calculated pooled risk is 0.002% and age at diagnosis has decreased over time. The median age at diagnosis was 32 (range, 17-46) years. Twelve per cent, 41 and 47% of CRC-p were diagnosed during the first, second and third trimester. The CRC-p site was the colon in 53.4% of cases, the rectum in 44% and multiple sites in 2.6%. Bleeding occurred in 47% of patients, abdominal pain in 37.6%, constipation in 14.1%, obstruction in 9.4% and perforation in 2.4%. Out of 82 patients whose treatment was described, 9.8% received chemotherapy during pregnancy. None of their newborns developed permanent disability, one developed hypothyroidism and 72% of newborns were alive. Vaginal delivery was possible in 60% of cases. Anterior resection was performed in 30% of patients and abdominoperineal excision of the rectum in 14.9%. Five patients had either synchronous (60%) or metachronous liver resection (40%). The median survival in these patients was 42 (0-120) months. Fifty-five per cent of patients were alive at the last available follow-up. The median survival of the mother was 36 (0-360) months. Patients with rectal cancer had longer survival compared with patients with colon cancer (P=0.0072). CRC-p is rare, leading to symptoms being overlooked, and diagnosis made at advanced stages. Cases described in the literature include patients who had cancer before pregnancy or developed it after delivery. Survival has not increased over time and the management of these patients requires collaboration between specialties and active interaction with the patients.

Incidental leiomyosarcoma found at the time of cesarean hysterectomy for morbidly adherent placenta

Background

Incidental leiomyosarcoma (LMS) is a rare diagnosis in pregnancy or in the puerperium. To our knowledge, this is the first case reported in the literature of incidental LMS after cesarean hysterectomy for morbidly adherent placenta.

Case

We present a case of a cesarean hysterectomy performed for a suspected morbidly adherent placenta in a patient with three prior cesarean deliveries, an anterior placenta previa and a fundal fibroid. Subsequent pathology identified a LMS on final specimen. The patient declined bilateral oophorectomy and removal of her remaining cervix. No chemotherapy or radiation was given for her presumed stage IB disease.

Conclusion

An incidental finding of a LMS is infrequent; the risk of recurrence is > 50% even if the sarcoma is removed in its entirety.

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Occult uterine sarcomas may be found even during cesarean hysterectomy.

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Imaging should be performed when a leiomyosarcoma is diagnosed postoperatively.

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Recurrence risk can be > 50% even if a leiomyosarcoma is confined to the uterus.

A Case of Nuclear Protein in Testis Midline Carcinoma Arising From the Submandibular Gland Duct in a Pregnant Patient

This report describes the first reported case of a nuclear protein in testis midline carcinoma (NMC) arising from the submandibular gland (SMG) duct in a pregnant woman. A 29-year-old pregnant woman presented with a left-side mass in the floor of the mouth. An NMC arising from the SMG duct was confirmed by excisional biopsy examination. Intensive treatment, including surgery and chemotherapy, was provided without termination of the pregnancy. Additional chemotherapy and radiotherapy were provided after delivery. The treatment was successful. Neither the patient nor her infant had any complications and the patient remained disease free 20 months after her initial surgery. This report describes the successful diagnosis and treatment of a rare presentation of an NMC of the SMG duct in a pregnant woman.

Treatment of gynecological cancers diagnosed during pregnancy

Because of a notable increase in age at delivery, the incidence of malignancy diagnosed during pregnancy has substantially increased. This review aims to summarize the literature and expert knowledge on gynecologic cancers diagnosed in pregnancy regarding epidemiology, examination and staging procedures, description of treatment modalities and management of gynecological malignancies with special interest in cervical and ovarian cancer. Thorough attention is paid to the surgery and chemotherapy administration for early-stage cervical cancer diagnosed during pregnancy.

Review on renal cell carcinoma and pregnancy: A challenging situation

Renal cell carcinoma is rarely diagnosed during pregnancy. Its management is a real challenge due to the sparse literature and lack of standard guidelines. In this situation, the diagnosis is often delayed as the clinical presentation might resemble other pregnancy-related disorders but it should be one of the diagnostic possibilities in women with recurrent or refractory urinary tract symptoms, renal pain, or mass that could be palpated. Diagnostic approach may include ultrasound examination and sometimes magnetic resonance imaging. If localized, surgery would be the preferred line of treatment. Other treatment modalities, end results of treatment, and review of literature of this rare association will be presented.

Breast cancer in pregnancy: A brief clinical review

As global wealth increases and demographic changes similar to Europe and North America start affecting other societies, the global breast cancer epidemic will coincide with a delayed maternal age during first and subsequent pregnancies. Breast cancer in pregnancy will continue to increase, and standardized treatment strategies are required to be developed. This study will review current diagnostic and treatment approaches.

Therapeutic strategy and outcome of spine tumors in pregnancy: a report of 21 cases and literature review

STUDY DESIGN

A retrospective study was performed.

OBJECTIVE

To illustrate the characteristics of spine tumors during pregnancy and obtain better insight into therapeutic strategies of such tumors by analyzing 21 cases treated in Changzheng Hospital and reviewing previous reports in the literature.

SUMMARY OF BACKGROUND DATA

The concurrence of spine tumors and pregnancy is relatively rare. There are controversies over the treatment options for this disease, which increase the difficulty of the clinical treatment.

METHODS

Between 2002 and 2013, 21 pregnant patients were identified with spine tumors. Clinical data including symptoms, signs, treatment options, and obstetrical and neonatal outcomes were recorded and preserved. Clinical data and treatment efficacy were analyzed via medical record review.

RESULTS

The median age of the 21 patients was 28.87 years (interquartile range, 6.00 yr). Tumor types in this series were giant cell tumor (5 cases), hemangioma (5 cases), schwannoma (4 cases), eosinophilic granuloma (2 cases), neurofibroma (1 case), multiple myeloma (1 case), and with metastatic tumor (3 cases). Two patients underwent spine surgery during pregnancy and 8 patients accepted tumor resection immediately after delivery. Pregnancy termination occurred in 5 patients, whereas the rest of the patients smoothly gave birth to healthy babies including 3 premature infants. Two patients died and 2 patients experienced local recurrence during follow-up.

CONCLUSION

With close observation, it was found that most of pregnant patients with benign spine tumors could postpone surgery after delivery. Surgical treatment should be adopted during pregnancy when patients are with highly malignant tumor or experience a sharp deterioration and the guard of it is safer than radiotherapy and chemotherapy during pregnancy.

LEVEL OF EVIDENCE

4.

Feto-maternal outcomes of pregnancy complicated by epithelial ovarian cancer: a systematic review of literature

Although cancer diagnosed during pregnancy is rare, epithelial cell type ovarian cancers (EOCs) comprise approximately one quarter to one half of cases of ovarian malignancy diagnosed during pregnancy. The behavior of EOC during pregnancy and its implications for maternal and fetal outcomes is not well understood. In order to better define these outcomes, a systematic literature search was conducted in PubMed/MEDLINE using entry keywords "pregnancy" and "ovarian cancer" for the period from 1955 to 2013. The literature search identified 105 cases eligible for analysis. Clinical characteristics, pregnancy outcome, tumor characteristics, clinical management, and survival outcomes were all evaluated. Serious adverse events were defined as complications related to EOC that resulted in severe morbidity or mortality for the mother and/or fetus. The mean age of cases was 31.6 years. The most common histology was serous (47.6%), followed by mucinous (27.6%) and endometrioid types (10.5%). The most common presenting symptom was abdominal or pelvic pain (26.7%) while incidentally detected tumors accounted for one third of cases. The majority of cases were stage I at diagnosis (63.8%) followed by stage III disease (24.8%), and the median tumor size was 12cm. Live births occurred in 81.3% of cases, and of the remainder 72.2% were due to elective termination. Intrapartum surgery primarily took place in the second trimester (43%) with fetal conservation in 61.9% of operations. Over half of cases received chemotherapy (55.2%), approximately one third of which received it during the pregnancy (36.2%). Among the 21 cases treated with chemotherapy during pregnancy, there was no association with small for gestational age or fetal malformations. Serious adverse events occurred in 21.9% of cases, of which the most common was tumor rupture during pregnancy (10.5%). Three (2.9%) maternal death following surgery during pregnancy and five (6.4%) neonatal deaths were reported. Gestational age at tumor diagnosis (2-year overall survival rate, 1st trimester 94.6%, 2nd trimester 88.8%, and 3rd trimester 72.9%, p=0.041) type of histology (serous 88.1%, mucinous 84.6%, endometrioid 89.5%, clear cell 100%, mixed type 75.0%, and undifferentiated 30.0%, p<0.01), stage (stage I 96.9%, stage II 85.7%, stage III 56.3%, and stage IV 25.0%, p<0.01), and serious adverse events (yes versus no, 68.1% versus 92.2%, p=0.041) were significantly related to maternal overall survival in univariate analysis. In multivariate analysis, stage III/IV disease remained the independent prognostic factor associated with decreased maternal overall survival (stage III, hazard ratio 44.6, p<0.01; and stage IV, hazard ratio 399, p<0.01). In conclusion, although the majority of EOC cases during pregnancy resulted in live birth, maternal and neonatal mortality needs to be considered in the counseling and management of these pregnancies.

Cancer treatment in pregnant women

In general, strategies for the treatment of cancer in pregnancy should not differ significantly from the treatment regimens in non-pregnant women. However, this is difficult due to either the effects of anticancer drugs on the developing foetus or the possibility of long-term complications after the exposure to drugs and radiation. The decision about the introduction and continuation of treatment in the event of pregnancy should be preceded by a detailed analysis of the potential benefits and risks. There are no data to suggest that pregnancy termination alters the biological behaviour of the tumour or patient prognosis in the presence of appropriate antineoplastic therapy. All patients should be given appropriate advice and informed that there are insufficient scientific data to determine any generally accepted consensus. It is very important to always respect the will of the patient, and the moral judgment of the physician should have no impact on the decisions taken by the woman. If the woman decides to undergo active treatment and maintain her pregnancy, it is necessary to carry out consultations with experts in the field appropriate to the type of cancer. This paper presents a basic review of the literature on the targeted therapies currently used in selected cancers diagnosed during pregnancy: breast cancer, cervical cancer, Hodgkin's disease, melanoma, thyroid cancer, ovarian cancer, and colorectal cancer.

Utilization of an ex vivo human placental perfusion model to predict potential fetal exposure to carboplatin during pregnancy

OBJECTIVE

The objective of this study was to determine the fetal drug compartment concentrations when various concentrations of carboplatin cross the placental-trophoblastic barrier and the effect on the fetal kidneys.

STUDY DESIGN

An ex vivo human placenta perfusion model was utilized. Term human placentae (n = 9) were collected immediately after delivery and then reperfused with plasma concentrations achieved with carboplatin an area under the curve of 5 (1000 ng/mL), 7.5 (5000 ng/mL), or 11 (11,000 ng/mL). Antipyrine was used as a reference compound. Samples were collected over 2 hours. Placental transfer was evaluated by computation of transport fraction and clearance index. Primary cells isolated by explant culture of 16-18 week old fetal organ tissues were incubated with carboplatin for up to 48 hours with untreated cell as controls. Immunohistochemical, flow cytometry analysis, and immunoblotting were applied for the expression of apoptosis-related proteins.

RESULTS

Mean transport fractions for carboplatin at low, middle, and high concentrations were 0.05 ± 0.02, 0.04 ± 0.01, and 0.10 ± 0.01, respectively, with clearance indexes of 0.22 ± 0.01, 0.14 ± 0.08, and 0.50 ± 0.07, respectively. The fetal peak concentrations of carboplatin achieved were 61 ± 39 ng/mL (low), 375 ± 248 ng/mL (middle), and 2081 ± 529 ng/mL (high). Fetal kidney cells exposed to carboplatin showed a concentration-dependent increased expression of apoptosis-inducing factor and p53 apoptosis proteins and a time-dependent increase in expression Bax apoptosis protein expression. Apoptosis was confirmed at the high concentration by flow cytometry.

CONCLUSION

Doses of carboplatin up to an area under the curve of 7.5 were not associated with significant placental transfer, fetal exposure, or fetal toxic effects. This suggests it might not be necessary to empirically reduce carboplatin doses in pregnant women.

[Management of cervical cancer during pregnancy: report of 05 cases]

L'association d'un cancer du col utérin avec une grossesse est une éventualité rare. Son incidence est assez mal évaluée, elle se situe selon les études entre 1 et 2/10 000. Lorsque la découverte en est faite, il faut conjuguer deux impératifs parfois totalement divergents: le traitement de la mère et la prise en charge du foetus. Cette association pose schématiquement quatre grands problèmes, qui sont: Celui du diagnostic, qui est loin d’être évident, compte tenu des remaniements cervicaux observés en début de gestation, le pronostic de l'affection, la date du traitement chirurgical et du délai entre le diagnostic et la prise en charge thérapeutique, enfin et de manière plus accessoire, le devenir de la grossesse et le mode d'accouchement. Nous rapportons une série de 5 cas de cancer du col utérin découverts au cours de la grossesse colligés dans notre service entre 2010 et 2013. La prise en charge thérapeutique est identique à celle des patientes en dehors de la grossesse même si quelques adaptations sont nécessaires du fait de l’état gravide, le pronostic du cancer ne semble pas être modifié par la grossesse.

Feto-maternal outcomes of pregnancy complicated by ovarian sex-cord stromal tumor: a systematic review of literature

Sex-cord stromal tumors (SCSTs) are rare ovarian cancers and their behavior during pregnancy is not well understood. To evaluate the maternal and fetal outcomes of pregnancy complicated by ovarian SCST, a systematic literature search was conducted in PubMed/MEDLINE using entry key words "pregnancy" and each type of ovarian SCST ("sex cord stromal tumor," "granulosa cell tumor," "thecoma," "Sertoli-Leydig cell tumor," or "gynandroblastoma") between 1955 and 2012 that identified 46 cases eligible for the analysis. Clinical characteristics, pregnancy outcome, tumor characteristics, and survival outcomes were evaluated. Serious adverse events were defined as complications related to the SCST that resulted in severe morbidity or mortality for mother, fetus, or both. The most common histology was granulosa cell tumor (22.0%), followed by thecoma (18.6%) and Sertoli-Leydig cell tumor (8.5%). Abdomino-pelvic pain (45.7%), palpable mass (30.4%), and virilization (26.1%) were the three most common symptoms. The majority were stage I (76.1%), tumor size <15cm (64.9%), and underwent unilateral adnexectomy (80.4%). Fetal conservation surgery was seen in 54.3%. Most cases had live births (78.3%) at full term (60.9%). Among cases proceeded expectant delay of delivery (45.7%), most cases resulted in live birth (95.2%) with median expectant interval of 20.7 weeks. Maternal and/or fetal serious adverse events (SAEs) were observed in 41.3% with maternal shock/hemoperitoneum being the most common complication (13.0%). Logistic regression test identified younger age (<30 versus ≥30, 73.3% versus 26.7%, odds ratio [OR] 11.7, 95%CI 1.35-101, p=0.026), large tumor (size ≥15cm versus <15cm, 64.9% versus 35.1%, OR 10.0, 95%CI 1.29-26.2, p=0.004), and advanced-stage (stages II-IV versus I, 76.1% versus 23.9%, OR 5.82, 95%CI 2.05-48.9, p=0.022) as risk factors of increased SAE. Overall survival of patients diagnosed with ovarian SCST during pregnancy was comparable to ovarian SCST not related to pregnancy (5-year rate, stages I and II-IV, 100% and 70.0%, respectively). In conclusion, although the majority of cases resulted in live birth, ovarian SCST-complicated pregnancy falls into the category of high-risk pregnancy. Risk factors for SAE identified in our study will help to guide strategic management of pregnancy complicated by ovarian SCST.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Contemporary multidisciplinary treatment of pregnancy-associated breast cancer

Breast cancer diagnosed during pregnancy poses unique challenges. Application of standard treatment algorithms is limited by lack of level I evidence from randomized trials. This study describes contemporary multidisciplinary treatment of pregnancy-associated breast cancer (PABC) in an academic setting and explores early maternal and fetal outcomes. A search of the Dana-Farber/Harvard Cancer Center clinical databases was performed to identify PABC cases. Sociodemographic, disease, pregnancy, and treatment information, as well as data on short-term maternal and fetal outcomes, were collected through retrospective chart review. 74 patients were identified, the majority with early-stage breast cancer. Most (73.5%) underwent surgical resection during pregnancy, including 40% with sentinel lymph node biopsy and 32% with immediate reconstruction. A total of 36 patients received anthracycline-based chemotherapy during pregnancy; of those, almost 20% were on a dose-dense schedule and 8.3% also received paclitaxel. 68 patients delivered liveborn infants; over half were delivered preterm (< 37 weeks), most scheduled to allow further maternal cancer therapy. For the infants with available data, all had normal Apgar scores and over 90% had birth weight >10^th percentile. The rate of fetal malformations (4.4%) was not different than expected population rate. Within a multidisciplinary academic setting, PABC treatment followed contemporary algorithms without apparent increase in maternal or fetal adverse outcomes. A considerable number of preterm deliveries were observed, the majority planned to facilitate cancer therapy. Continued attention to maternal and fetal outcomes after PABC is required to determine the benefit of this delivery strategy.

Prenatal HIV testing: the compartmentalization of women's sexual risk exposure and the return of the maternal fetal conflict

The purpose of the researchers in this study was to investigate how women who were being tested for HIV during their pregnancies were evaluating, conceptualizing, and negotiating their risk of infection. The study included two focus groups and 20 in-depth interviews with 30 patients, ages 17-38 years, from diverse ethnic/racial, social, and economic backgrounds. Qualitative analyses of the interview transcripts revealed support for the idea that pregnant women have a responsibility to minimize risks to their fetus, with all interviewees describing actions to minimize those risks while pregnant. Two sub-themes emerged that were related to the presence of differences in how interviewees conceptualized risk depending on the type of risk being discussed. In the case of diet and lifestyle influences, interviewees framed their health and the health of the fetus as connected. In contrast, when the issue of HIV risk and testing was raised, the interviewees described the risk of HIV to themselves and their fetuses as separate concerns and, with few exceptions, reported no effort to reduce the risk of becoming infected while pregnant (beyond consenting to HIV screening while receiving prenatal care). Findings suggest the importance of developing HIV prevention messages that counter the compartmentalization of risk during pregnancy.

Bladder cancer in the second trimester of pregnancy: tough decisions. A case report with review of the literature

We report a rare case of a patient presenting with a nonmuscle invasive papillomatosis transitional cell carcinoma of the bladder in the second trimester of pregnancy. We describe the management dilemmas encountered and the challenging treatment option selected to optimize outcome for the patient and infant. Close collaboration between urologists, obstetricians and medical colleagues is needed for optimal, safe and effective management of bladder tumours during pregnancy.

Breast cancer in pregnancy

Breast cancer staging and treatment are possible during pregnancy, and should be defined in a multidisciplinary setting. Tumour biology, tumour stage, and gestational stage at diagnosis determine the appropriate approach. Surgery for breast cancer is possible during all trimesters of pregnancy. Radiotherapy is possible during pregnancy but, dependent on the fetal dose received, can result in poor fetal outcomes. The decision to give radiotherapy should be made on an individual basis. Evidence increasingly supports administration of chemotherapy from 14 weeks' gestation onwards. New breast cancer treatments might be applicable to pregnant patients, but tamoxifen and trastuzumab are contraindicated during pregnancy. Cancer treatment during pregnancy will decrease the need for early delivery and thus prematurity, which is a major concern in management of breast cancer in pregnancy.

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.