Management of cancer in pregnancy: a case of Ewing's sarcoma of the pelvis in the third trimester

Transplacental Passage and Fetal Effects of Antineoplastic Treatment during Pregnancy

Simple Summary

In this paper we perform an introduction about pregnancy-associated cancer (PAC) and transplacental passage of antineoplastic agents. Furthermore, we describe therapeutic use and potential toxic effects of chemotherapeutic drug (alkylating agents, antimetabolites agents, anthracyclines, topoisomerase inhibitors, antimitotic agents, actinomycin-D, bleomycin) and targeted agents during pregnancy. This manuscript may be a useful and practical guide for the management of PAC, which is a challenge for clinicians that have to consider alike maternal benefits and fetal potential risks correlated to the antineoplastic treatment.

Abstract

The incidence of PAC is relatively infrequent among pregnant women. However, it has gradually increased in recent years, becoming a challenging area for clinicians that should take into account in the same way maternal benefits and fetal potential risks correlated to the antineoplastic treatment. None of the antineoplastic drugs is completely risk-free during the pregnancy, the timing of exposure and transplacental transfer properties influence the toxicity of the fetus. Despite the lack of guidelines about the management of PAC, several studies have described the use and the potential fetal and neonatal adverse events of antineoplastic drugs during pregnancy. We provide a review of the available literature about the transplacental passage and fetal effects of chemotherapy and targeted agents, to guide the clinicians in the most appropriate choices for the management of PAC.

Pregnancy outcomes related to the treatment of sarcomas with anthracyclines and/or ifosfamide during pregnancy

Background

Sarcomas are rare diagnoses but are seen with relative frequency in adolescents and young adults and thus can present in pregnancy. We sought to study the administration of anthracyclines and/or ifosfamide in pregnancy‐associated sarcomas.

Patients and Methods

We conducted a multi‐institutional retrospective study, identifying sarcoma patients who received anthracyclines and/or ifosfamide during pregnancy. Chart review identified variables related to demographics, cancer diagnosis, therapies, and outcome of the patient and fetus. Wilcoxon rank‐sum test compared two independent samples.

Results

We identified 13 patients at seven institutions with sarcoma who received anthracyclines and/or ifosfamide during pregnancy, including four bone sarcomas and nine soft tissue sarcomas diagnosed at a mean gestational age of 16.7 ± 5.9 weeks. Only nine patients had live births (9/13, 69.2%), with mean gestational age of 30.8 ± 3.8 weeks at delivery. The four patients with pregnancy loss all received both doxorubicin and ifosfamide, with chemotherapy initiated at 15.5 weeks as compared with 21.3 weeks for those patients with live births (p = 0.016).

Conclusion

In this multi‐institutional study of sarcoma chemotherapy regimens administered during pregnancy, we found a high rate of fetal demise that was seen only in patients receiving both doxorubicin and ifosfamide and statistically more likely with chemotherapy initiation earlier in the second trimester. While limited by a small sample size, our study represents the largest study of sarcoma patients that received anthracyclines and/or ifosfamide in pregnancy thus far reported and supports development of an international registry to study concerns raised by our study.

The safety of early pregnancy exposure to granisetron

OBJECTIVE

Current guidelines suggest that granisetron is an optional treatment for nausea and vomiting in pregnancy (NVP) despite lack of evidence to support fetal safety. We aimed to determine the association between early pregnancy exposure to granisetron and fetal/neonatal outcomes.

DESIGN

Medical records of patients treated for NVP during the first and second trimester between June 2013 to September 2015 were reviewed. Patients were asked to participate in the study by answering a detailed questionnaire regarding newborn's health and complementary data. Pregnancy outcomes of patients exposed to granisetron were compared with those of patients who were not exposed to granisetron.

RESULTS

100 Granisetron exposed pregnancies were compared with 108 granisetron unexposed pregnancies. Exposure to granisetron occurred in the first trimester in 88 patients (94 fetuses). Maternal characteristics, history of anomalies in first degree relatives, co-exposure to other substances and extent of prenatal sonographic surveillance were comparable between both groups. Miscarriage rate was significantly lower among granisetron exposed patients compared to controls (0 vs 5.5 %, respectively, p = 0.03). Three major malformations were identified prenatally or postnatally in each of the groups (2.77 % Vs 2.83 %, p = 1). The rate of major malformations was similar between exposed and unexposed fetuses even after excluding second trimester exposure (3.2 % vs. 2.83 %, respectively p = 1). Mean gestational age at delivery, mean newborn weight and incidence of small for gestation age, were not significantly different between the groups.

CONCLUSION

Granisetron exposure was not associated with increased risk for minor or major fetal anomalies. This study provides preliminary reassurance regarding the safety of in-utero exposure to granisetron.

Maternal and Fetal Outcomes in Pregnancies affected by Bone and Soft Tissue Tumors

Objective  This study was aimed to describe perinatal outcome of a cohort of pregnant patients with bone and soft tissue tumors and to compare the current series with our group's previously reported experience. Methods  Pregnant women diagnosed before and during pregnancy were identified, retrospectively, for the years 2004 to 2014. Relevant maternal and neonatal data were collected. Results  Forty-eight patients were identified. Ten cases were diagnosed during pregnancy. Pelvis, abdomen, and extremities were the most common tumor locations. Osteosarcoma, liposarcoma, and Ewing's sarcoma were the most common histological types and comprise more than 50% of the cases. Metastases occurred in nine cases. Most of the cases (60%) were treated surgically during pregnancy and delivery occurred at term. Chemotherapy was delayed until after delivery. There were no perinatal or infant deaths. Patients presented with advanced maternal disease in 18% in previous report (1983-2003) versus 40% in present report (2004-2014). Metastases were present in 40% and maternal death rate was approximately 20% in both cohorts. Conclusion  Pregnant women with bone and soft tissue tumors are candidates for standard surgical management during pregnancy. Other treatments, such as chemotherapy and radiotherapy must be evaluated for each woman on a case-by-case basis. Iatrogenic prematurity was common in our findings.

Extra-skeletal Ewing sarcoma of the lumbosacral region in an adult pregnant patient: a case report

Extra-skeletal Ewing sarcoma in pregnancy is rare. There is thus limited scientific evidence to guide clinicians in its complicated management, particularly within the context of early gestation. We therefore share our successful outcome in a 32-year-old pregnant patient, following a unique management strategy of complete aggressive surgical resection prior to neo-adjuvant therapy. The case involved a 2-month history of right-sided back and gluteal pain, with associated paraesthesia. Lumbosacral magnetic resonance imaging (MRI) revealed an approximate 40×50 mm indeterminate mass in the lower right paraspinal musculature. The mass extended into the first right sacral foramen and the central canal; and also impinged on the S2 exiting nerve. After considering the patients' rapid deterioration, pregnant status and other clinical factors, it was elected to proceed with complete surgical resection prior to any other therapeutic modality. Following surgery, the patient experienced immediate resolution of her pain and by 6 weeks was able to cease the use of all analgesics. At 32-weeks' gestation she underwent an uncomplicated vaginal delivery. At 9 months follow up, she remains disease free and has experienced complete resolution of her back pain and radiculopathy.

Multidisciplinary Management of Breast Cancer During Pregnancy

BACKGROUND

Although breast cancer during pregnancy (BCDP) is rare (occurring with only 0.4% of all BC diagnoses in female patients aged 16-49 years), management decisions are challenging to both the patient and the multidisciplinary team.

MATERIALS AND METHODS

Experts in breast cancer at the University of North Carolina conducted a targeted literature search regarding the multidisciplinary treatment approaches to BCDP: medical, surgical, and radiation oncology. Supportive care, including antiemetic agents, and imaging approaches were also reviewed.

RESULTS

Review of the literature revealed key points in the management of BCDP. Surgical management is similar to that in nonpregnant patients; pregnant patients may safely undergo breast-conserving surgery. Recommendations should be tailored to the individual according to the clinical stage, tumor biology, genetic status, gestational age, and personal preferences. Anthracycline-based chemotherapy can be safely initiated only in the second and third trimesters. The rate of congenital abnormalities in children exposed to chemotherapy is similar to the national average (approximately 3%). Dosing of chemotherapy should be similar to that in the nonpregnant patient (i.e., actual body surface area). Antihuman epidermal growth factor receptor 2 therapy, radiation, and endocrine treatment are contraindicated in pregnancy and lactation. Care should include partnership with obstetricians. The literature regarding prognosis of BCDP is mixed.

CONCLUSION

To maximize benefit and minimize risk to the mother and fetus, an informed discussion with the patient and her medical team should result in an individualized treatment plan, taking into account the timing of the pregnancy and the stage and subtype of the breast cancer. Because BCDP is rare, it is essential to collect patient data in international registries. The Oncologist 2017;22:324-334 IMPLICATIONS FOR PRACTICE: Breast cancer during pregnancy is a major ethical and professional challenge for both the patient and the multidisciplinary treatment team. Although the oncologic care is based on that of the non-pregnant breast cancer patient, there are many challenges from regarding the medical, surgical and radiation oncology and obstetrical aspects of care that need to be considered to deliver the safest and best treatment plan to both the mother and developing fetus.

Bone and soft tissue sarcomas during pregnancy: A narrative review of the literature

Bone or soft tissue sarcomas are rarely diagnosed during pregnancy. Until today 137 well documented cases have been reported in the English literature between 1963 and 2014. Thirty-eight pregnant mothers were diagnosed with osteosarcoma, Ewing's sarcoma or chondrosarcoma, whereas 95 other cases of soft tissue sarcomas of various types have been documented. We present the clinical picture and therapeutic management of this coexistence.

Evaluation and management of the pregnant patient with suspected primary musculoskeletal tumor or metastatic carcinoma to bone

Primary musculoskeletal cancer and metastatic disease to bone in pregnant patients presents major treatment challenges. Although uncommon, musculoskeletal malignancies in pregnant women have been reported. When diagnosing and treating these patients, the mother's health must be managed appropriately while ensuring that fetal development is not deleteriously affected. Extensive radiographic imaging and more advanced techniques are often necessary to fully characterize the extent of disease. When possible, magnetic resonance imaging should be used instead of computed tomography to limit exposure of the conceptus to radiation. If treatment is needed, therapeutic radiation, chemotherapy, and surgery should be considered. Surgical resection is the foundation of treatment of early-stage primary bone tumors and soft-tissue sarcomas during pregnancy. With surgery, anesthesia and thromboprophylaxis are important considerations. If chemotherapy is required, administration should be avoided in the first trimester to limit harm to the fetus. Therapeutic radiation should similarly be avoided during the first trimester and often can be postponed until after delivery.

Treatment of acute myeloid leukemia during pregnancy

OBJECTIVES

Systematically review the literature assessing outcomes of acute myeloid leukemia (AML) treatment during pregnancy.

DATA SOURCES

A Pubmed literature search (January 1969 to June 2014) for articles written about AML and pregnancy, and bibliographies/citations of previously published reviews.

STUDY SELECTION AND DATA EXTRACTION

Articles written in the English language that administered active AML chemotherapy during pregnancy were included.

DATA SYNTHESIS

Eighty-five fetuses were exposed to chemotherapy from 83 mothers: 8 mothers began induction chemotherapy in the first trimester, 61 mothers in the second trimester, and 14 mothers in the third trimester. Chemotherapy resulted in more fetal deaths and spontaneous abortions during the first trimester (37.5%) compared with the second (9.7%) and third trimesters (0%). All cases included cytarabine; 47 fetuses were exposed to daunorubicin and 8 fetuses to idarubicin. The percentages of fetal defects and death for cytarabine and daunorubicin combinations were 8.5% and 6.4%, respectively. With cytarabine and idarubicin combinations, the percentages of fetal defects and death were 28.6% and 12.5%, respectively. Complete remission (CR) rates were 100%, 81%, and 67% in the first, second, and third trimesters.

CONCLUSIONS

Treatment during the second and third trimesters resulted in fewer fetal complications than the first trimester. However, delaying AML treatment may adversely affect the mother's outcomes. In the reported cases, induction during pregnancy resulted in CR rates comparable to that in nonpregnant patients. The choice of anthracycline is still unclear, but the decision should be made with careful consideration, weighing the outcomes for the mother and fetus.

Sarcoma of the ewing family in pregnancy: a case report of intrauterine fetal death after induction of chemotherapy

Ewing's sarcoma is an ultra-orphan disease (2/1,000,000/year) which requires a multimodal therapy approach in high-volume centers. Treatment consists of pre-operative therapy followed by surgery and post-operative combination of chemo-radiotherapy. Experience with diagnosis and therapy of Ewing's sarcoma in pregnancy is very limited. We herein report the case of an atypical Ewing's sarcoma detected in the second trimester of gestation. Neoadjuvant chemotherapy was initiated and resulted in substantial tumor shrinkage and intrauterine fetal death. The rare nature of this condition underlines once more the need for a multidisciplinary team to improve the quality of care for this highly special patient collective.

Cancer in pregnancy. Part I: basic diagnostic and therapeutic principles and treatment of gynecological malignancies

PURPOSE

Cancer in pregnancy is a rare circumstance. However, the coincidence of pregnancy and malignancy is supposed to increase due to a general tendency of postponing childbearing to older age. To date, clinical guidelines are scarce and experience regarding therapeutic management is limited to case reports.

METHODS

This review focuses on general diagnostic and therapeutic principles including systemic therapy for malignancies in pregnancy.

RESULTS

In part I, we report on diagnosis and therapy of gynecological tumors.

CONCLUSION

The diagnosis of gestational cancer faces both oncologist and obstetrician to the dilemma of applying appropriate diagnostic techniques and adequate local and systemic therapy to an expectant mother without harming the fetus.

Metastatic primitive neuroectodermal tumor of the ovary in pregnancy

Primitive neuroectodermal tumor (PNET) is a small round tumor belonging to the PNET/Ewing's sarcoma family. We hereby report a case of PNET of the ovary, which was detected at the second trimester of pregnancy. Chemotherapy was administered and a healthy baby was delivered by cesarean section. After the pregnancy, the mother was found to have metastatic disease. Chemotherapy was continued, but she died due to progressive disease 13 months after the initial diagnosis. In this case report, we discuss chemotherapy options during pregnancy and the importance of multidisciplinary approach to unusual presentations of rare tumors

Maternal and Neonatal Outcomes in Pregnancies Complicated by Bone and Soft-Tissue Tumors

OBJECTIVE

Primary bone and soft-tissue tumors occur rarely in pregnancy. The objective of this study was to describe the outcome of a large cohort of pregnant patients with these rare tumors.

METHODS

Pregnant women diagnosed with bone or soft-tissue tumors during pregnancy or within 3 months after delivery were identified retrospectively for the years 1983-2003 in the University Health Network database, University of Toronto. Relevant maternal and neonatal data were collected on a standardized data form.

RESULTS

In more than 60,000 deliveries during the study period, 17 patients were identified. Gestational age at diagnosis ranged from 11 weeks to 2 months postpartum. Eight cases involved the lower extremity and 6 involved the upper extremity. Osteosarcoma, chondrosarcoma, and giant-cell tumors were the most common histological types. Metastases occurred in 7 cases. Nine cases were treated surgically during the course of pregnancy. The majority of patients were delivered at term. Chemotherapy was deferred until the postpartum period. One patient elected for early termination of pregnancy. Three patients were delivered before 37 weeks of gestation to proceed with therapy. One neonate delivered at 34 weeks developed respiratory distress syndrome and required intubation. Three patients died, all as the result of metastatic disease. There were no perinatal or infant deaths.

CONCLUSION

Most cases of soft-tissue and bone tumors during pregnancy can be successfully managed with surgery during gestation. Therapies with fetal toxicity were more likely to be deferred to the postpartum period.

Good outcome for infant of mother treated with chemotherapy for ewing sarcoma at 25 to 30 weeks' gestation

There have been only three previous reports of women with Ewing sarcoma who received chemotherapy while pregnant. A 17-year-old woman with Ewing sarcoma was treated with a combination of doxorubicin (Adriamycin) and ifosfamide during the 25th to 30th week of gestation, and the baby was delivered at the 32nd week. The baby was developing normally at follow-up at 8 months of age. This case report supports the idea that in this situation, the pregnancy can be continued to await fetal growth, and second-trimester chemotherapy may not have a deleterious effect on the fetus.

Pregnancy and melanoma

Numerous malignant diseases reach their incidence peak in female fertile years. That is the reason why these diseases are the second most common cause of death of women in their generative age. However, neoplastic processes are rarely diagnosed in pregnancy and there are no clear-cut guidelines on whether the pregnancy should be terminated in order that a proper treatment could be applied. We have not enough knowledge jet about the consequences for both the mother and her child if the pregnancy is allowed to continue despite the diagnosis of malignancy. Melanoma is one of the most common tumours diagnosed in pregnancy (8% of all diagnosed neoplasms). Some studies present the data on successfully terminated pregnancies in these women but also point out the risks the fetus is exposed to due to possible application of cytotoxic therapy, as well as the danger of transplacental spread of this process to the placenta and fetus.