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Santolaria A, Perales A, Montesinos P, Sanz MA. Acute Promyelocytic Leukemia during Pregnancy: A Systematic Review of the Literature. Cancers (Basel) 2020; 12:cancers12040968. [PMID: 32295152 PMCID: PMC7225915 DOI: 10.3390/cancers12040968] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 11/16/2022] Open
Abstract
The management of pregnant women with acute promyelocytic leukemia (APL) is a challenging situation where limited evidence-based information is available. We performed a systematic literature review to analyze the outcomes reported for both mother and fetus when APL is diagnosed during pregnancy. PubMed, Scopus and Web of Science databases were systematically searched to identify studies reporting cases of APL during pregnancy. Sixty-six articles met the eligibility criteria (53 single case reports). Ninety-two patients were eligible for induction therapy, with most them being treated with all-trans retinoic acid alone (32%) or combined with chemotherapy (43%), while the remaining patients received chemotherapy alone. Three patients were treated with arsenic-based regimens after delivery. Overall complete remission rate was 89%, with no statistically significant differences according to the type of induction and gestational age. During the first trimester, women were more likely to experience spontaneous and induced abortion compared to those during the second trimester (88% vs. 30%) (p < 0.0001), while only one patient diagnosed during the third trimester terminated in stillbirth. Twelve of 16 infants with neonatal complications had respiratory distress syndrome. Except two early deaths (Potter’s syndrome and pulmonary hemorrhage), all neonates evolved favorably. This study confirms that gestational age does not affect the results in the mother, but is closely related to fetal viability. Our results may be useful for the process of decision making that requires the involvement of the patient, hematologist, obstetrician and neonatologist.
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Affiliation(s)
- Andrea Santolaria
- Department of Obstetrics and Gynecology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (A.S.); (A.P.)
| | - Alfredo Perales
- Department of Obstetrics and Gynecology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (A.S.); (A.P.)
- Department of Obstetrics and Gynecology, University of Valencia, 46010 Valencia, Spain
| | - Pau Montesinos
- Department of Hematology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain;
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, 28029 Madrid, Spain
| | - Miguel A. Sanz
- Department of Hematology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain;
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, 28029 Madrid, Spain
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
- Correspondence:
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Fei F, Faye-Petersen OM, Vachhani P, Jamy O, Reddy VV. Acute promyelocytic leukemia during pregnancy: A case report and 10-year institutional review of hematologic malignancies during pregnancy. Pathol Res Pract 2019; 215:152672. [PMID: 31587825 DOI: 10.1016/j.prp.2019.152672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
Acute promyelocytic leukemia (APL) manifesting during pregnancy is a very rare but highly challenging gestational complication in part due to its associated profound coagulopathy. We present the case of a 23-year-old Gravida 3 Para 2002 woman admitted to our hospital at 26 weeks of gestation for severe pre-eclampsia with documentation of intrauterine fetal demise (IUFD), thrombocytopenia, and placental abruption. A peripheral blood smear revealed promyelocytes with azure granules, highly concerning for APL. Additional peripheral blood studies confirmed APL. Placental examination also revealed circulating blasts in decidual vessels and scattered blast entrapment in diffuse perivillous fibrinoid deposits, but none in the chorionic villi. Treatment for APL was initiated immediately and she is in complete molecular remission. Our case underscores the importance of close collaboration among obstetric, hematology, and pathology teams in the care of patients with pre-eclampsia, thrombocytopenia, and postpartum coagulopathy. We also describe five additional cases of gestations complicated by hematologic malignancies identified upon a 10-year institutional retrospective review.
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Affiliation(s)
- Fei Fei
- Department of Pathology, Divisions of Anatomic and Clinical Pathology, The University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Ona M Faye-Petersen
- Department of Pathology, Divisions of Anatomic and Clinical Pathology, The University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Pankit Vachhani
- Department of Medicine, Division of Hematology/Oncology, The University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Omer Jamy
- Department of Medicine, Division of Hematology/Oncology, The University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Vishnu V Reddy
- Department of Pathology, Divisions of Anatomic and Clinical Pathology, The University of Alabama at Birmingham, Birmingham, AL 35249, USA.
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Abstract
The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.
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Verma V, Giri S, Manandhar S, Pathak R, Bhatt VR. Acute promyelocytic leukemia during pregnancy: a systematic analysis of outcome. Leuk Lymphoma 2015; 57:616-22. [PMID: 26110880 DOI: 10.3109/10428194.2015.1065977] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The outcomes of acute promyelocytic leukemia (APL) in pregnancy are largely unknown. The MEDLINE database was systematically searched to obtain 43 articles with 71 patients with new-onset APL during pregnancy. Induction therapy included various regimens of all-trans retinoic acid (ATRA), cytarabine, and anthracycline and resulted in a complete remission rate of 93%. Obstetric and fetal complications included pre-term deliveries (46%), spontaneous/therapeutic abortion/intrauterine death (33.3%) and other neonatal complications (25.9%). Mothers diagnosed in the first trimester were more likely to experience obstetric (p < 0.01) and fetal (p < 0.01) complications. To our knowledge, this is the largest systematic review of APL in pregnancy. The vast majority of APL patients in pregnancy may achieve remission with initial induction therapy. APL or its therapy in pregnancy, however, is associated with a high risk of fetal and obstetrical complications. The results of our study may help in patient counseling and informed decision-making.
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Affiliation(s)
- Vivek Verma
- a Department of Radiation Oncology , University of Nebraska Medical Center , Omaha , NE , USA
| | - Smith Giri
- b Department of Internal Medicine , University of Tennessee Health Science Center , Memphis , TN , USA
| | - Samyak Manandhar
- c Department of Medicine , University of Pittsburgh Medical Center - Mercy Hospital , Pittsburgh , PA , USA
| | - Ranjan Pathak
- d Department of Internal Medicine , Reading Health System , West Reading , PA , USA
| | - Vijaya Raj Bhatt
- e Department of Internal Medicine , Division of Hematology/Oncology, University of Nebraska Medical Center , Omaha , NE , USA
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Maternal and fetal outcomes in pregnant women with acute promyelocytic leukemia. Ann Hematol 2015; 94:1357-61. [DOI: 10.1007/s00277-015-2372-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
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Selig BP, Furr JR, Huey RW, Moran C, Alluri VN, Medders GR, Mumm CD, Hallford HG, Mulvihill JJ. Cancer chemotherapeutic agents as human teratogens. ACTA ACUST UNITED AC 2012; 94:626-50. [DOI: 10.1002/bdra.23063] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 06/29/2012] [Accepted: 07/04/2012] [Indexed: 12/11/2022]
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Abstract
Management of the pregnant patient with acute promyelocytic leukemia (APL) is a challenge. Immediate treatment of APL is critical, as it is an oncologic emergency, with a high risk of morbidity and mortality associated with disseminated intravascular coagulation. However, administration of chemotherapy and differentiating agents in pregnancy is controversial because of potential teratogenic effects. In addition, complications associated with APL, including retinoic acid syndrome, add to the complexity of management. To better understand how to manage this complex patient care situation, we searched the PubMed database (January 1972-May 2008) for English-language articles about maternal and fetal outcomes resulting from APL treatment during pregnancy. A total of 42 cases from 35 articles were identified: 12 first-trimester, 21 second-trimester, and 9 third-trimester cases. The most commonly administered agents were all-trans-retinoic acid (ATRA), anthracyclines, and antimetabolites. Complete remission was reported in 35 (83%) of 42 patients. Administration of ATRA or chemotherapy in the first trimester was associated with an increased risk of fetal malformations and spontaneous abortion, whereas administration in the second and third trimesters was associated with relatively favorable fetal outcomes. The overall treatment of the pregnant patient with APL should include a discussion about pregnancy termination, especially if APL is diagnosed in the first trimester. If the pregnancy is to continue, then the appropriate chemotherapy regimen needs to be determined. Frequent fetal monitoring, along with aggressive management of potential APL-related complications, is necessary to allow for optimal maternal and fetal outcomes.
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Affiliation(s)
- Daisy Yang
- Department of Pharmacy, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Abstract
The prevalence of pregnancy associated leukemia is approximately 1 case out of 10,000 pregnancies. This rare occurrence precludes the conducting of large, prospective studies to examine diagnostic, management and outcome issues. The treatment of a pregnant woman with leukemia may be associated with severe adverse fetal outcome including death and malformations, and therefore poses a difficult challenge for both the patient and the attending physician. Chemotherapy during the 1st trimester is associated with an increased risk for congenital malformations. However, this risk diminishes as pregnancy advances. When acute leukemia is diagnosed during the 1st trimester, patients should be treated promptly similar to non-pregnant patients. However, the aggressive induction therapy should follow pregnancy termination. When the diagnosis is made later in pregnancy standard chemotherapy regimen should be considered and usually pregnancy termination is not mandatory. However, both the mother and the fetus should be under close observation and delivery should be postponed to a non-cytopenic period. Pregnancy associated chronic myelogenous leukemia (CML) can be treated with interferon throughout pregnancy with no apparent increase in adverse fetal outcome. In the very rare case of chronic lymphocytic leukemia (CLL) during pregnancy treatment can usually be delayed until after delivery.
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Pereg D, Lishner M. Maternal and fetal effects of systemic therapy in the pregnant woman with cancer. Recent Results Cancer Res 2008; 178:21-38. [PMID: 18080440 DOI: 10.1007/978-3-540-71274-9_3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- D Pereg
- Department of Internal Medicine A, Meir Medical Center, Kfar Sava, Israel
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Ali R, Ozkalemkaş F, Ozçelik T, Ozkocaman V, Ozan U, Kimya Y, Tunali A. Maternal and fetal outcomes in pregnancy complicated with acute leukemia: a single institutional experience with 10 pregnancies at 16 years. Leuk Res 2003; 27:381-5. [PMID: 12620288 DOI: 10.1016/s0145-2126(02)00182-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The incidence of acute leukemia in pregnancy is low and the management of acute leukemia during pregnancy is difficult. We have observed a total of 10 pregnancies in 8 patients. Six of the patients had acute myeloblastic leukemia (AML) and two of them had acute lymphoblastic leukemia (ALL). Three of the pregnancies were diagnosed when the leukemia was in remission, six at the time of leukemia diagnosis and one at the time of leukemic relapse. Six of the pregnancies were found in first trimester, three in the second and one early in the third. Three pregnancies ended with spontaneous abortion, three with intrauterine death and three with medical termination. One of spontaneous abortions and one intrauterine death developed during combination chemotherapy (daunorubicin, cytarabine). Only 1 healthy baby survived from the 10 pregnancies and this child was the not exposed to chemotherapeutic agents. None of the cases had gynecologic and obstetric complications. Five of eight pregnant women with leukemia died because of the primary disease.
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Affiliation(s)
- Ridvan Ali
- Division of Haematology, Department of Internal Medicine, Uludag University School of Medicine, Uludag University Hospital, Bursa, Turkey.
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Carradice D, Austin N, Bayston K, Ganly PS. Successful treatment of acute promyelocytic leukaemia during pregnancy. CLINICAL AND LABORATORY HAEMATOLOGY 2002; 24:307-11. [PMID: 12358893 DOI: 10.1046/j.1365-2257.2002.00459.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A case is reported of a pregnant 16-year-old-woman diagnosed with Acute promyelocytic leukaemia (APL) at 25 weeks gestation and treated with all-trans retinoic acid (ATRA) (45 mg/m2) for 25 days in combination with chemotherapy. She achieved a complete cytogenetic and molecular remission. Clinical course was complicated, with an intracerebral bleed, respiratory failure requiring ventilation and prolonged pancytopenia following initial chemotherapy. A live female infant was born at 28 weeks gestation who survived to discharge with significant pulmonary complications. She remains oxygen dependent at 6 months of age. ATRA has been used from the 3rd week of gestation, but fetal malformations are common during the first trimester. In contrast it seems to be safe in the second and third trimesters with regard to teratogenesis but can cause other side-effects. Most successful outcomes in treatment of APL during pregnancy are seen after treatment with ATRA and delivery of the baby at as late a stage as possible. Pregnancies terminated before remission has been obtained or those treated in the first trimester have a poor maternal outcome.
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Affiliation(s)
- D Carradice
- Department of Haematology, Christchurch Hospital, New Zealand.
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