Chemotherapy in Pregnancy

Pregnancy-associated Cancer and Chemotherapy during Pregnancy

The diagnosis of pregnancy-associated cancer, although rare, is a condition of great human and social significance and difficult clinical management. A pregnancy-associated neoplasm is defined as a cancer diagnosis made during pregnancy or within 12 months after delivery/abortion. The most common cancers in pregnancy occur most frequently in women of reproductive age with an incidence overall like that observed in non-pregnant women of the same age. This incidence is likely to increase in view of both the expected increase in certain malignancies among young women (particularly breast cancer and melanoma) and the increasing frequency of pregnancies undertaken later in life (fourth and fifth decades of life) that is characterizing modern society. Chemotherapy is generally contraindicated before 12 weeks of pregnancy due to the increased risk of congenital anomalies while exposure in the second and third trimester of pregnancy to chemotherapy has been associated with more growth restriction and preterm delivery. Clinical decisions about the optimal management should consider maternal and fetal characteristics with the involvement of a multidisciplinary team.

Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

Pregnancy and Gastric Cancer: A Narrative Review

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30-39 years (and not exceptionally 40-49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners' hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Prognosis, counseling, and indications for termination of pregnancy

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

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.

Hematopoietic Progenitor Cell Donation from Healthy Female Donors During Pregnancy: A Report of 10 Cases

The golden rule when collecting hematopoietic progenitors (HPs) from healthy volunteers is "donor safety." Pregnancy is an absolute contraindication for HP collection from unrelated donors; however, collection from a related pregnant donor is sometimes considered based on the urgency of the indication for transplantation and the available alternatives. Data on the safety and efficacy of this practice are limited. We conducted a retrospective chart review of an institution's transplantation database to characterize the safety and efficacy of HP donation from pregnant donors. Ten cases of HP donation from pregnant donors were identified, including 6 bone marrow grafts and 4 peripheral blood stem cell grafts. The median age of donors was 27.5 years. The median volume of the collected product was 521 mL (range, 128 to 1160 mL), the median number of total nucleated cells (TNCs) in the graft was 252 × 10⁸ (range, 30.5 to 794 × 10⁸), the median TNC concentration in the graft was 37 × 10⁶ per mL (range, 4.7 to 214.6 × 10⁶ per mL). The median number of CD34 cells in the graft was 142 × 10⁶ (range, 6 to 763 × 10⁶), and the median CD34 concentration in the graft was 20 × 10⁴ per mL (range, 2 to 206 × 10⁴ per mL). There were no safety issues or signals related to the procedure. HP collection from pregnant donors is relatively safe. This case series provides valuable information for practicing transplant physicians on how to counsel pregnant donors when this scenario is encountered in clinical practice.

Neoadjuvant chemotherapy with paclitaxel plus cisplatin before radical surgery for locally advanced cervical cancer during pregnancy: A case series and literature review

RATIONALE

Despite the development of human papillomavirus vaccines and significant improvement in cervical cancer screening over the past few years, cervical cancer remains the fourth most common cancer in women of childbearing age after breast cancer, melanoma, and thyroid cancer.

PATIENT CONCERNS

In this case report, the patients are all cervical cancer with stage IB2 and IB3 during pregnancy, the management constitutes a major medical challenge related to the impact of treatment on both maternal and fetal outcomes. Neoadjuvant chemotherapy (NACT) is an innovative option for cervical cancer patients with stage IB2 and IB3 before cesarean delivery and radical hysterectomy, and many chemotherapeutic agents are available, cisplatin plus paclitaxel yielded good maternal and fetal outcomes to the authors' knowledge.

DIAGNOSES

Masses were discovered in the cervix of 4 pregnant women with a history of vaginal bleeding. Biopsy examination of the masses revealed cervical carcinoma, which was staged in accordance with the International Federation of Gynecology and Obstetrics (i.e., FIGO) system.

INTERVENTIONS

The patients were treated with paclitaxel plus cisplatin, followed by cesarean delivery and radical hysterectomy.

OUTCOMES

The 4 patients were treated successfully, with no recurrence during follow-up periods of 14 to 56 months, and all of the children were doing well with no anomalies.

LESSONS

Although further data are required, in pregnant women with invasive cervical cancer, NACT with cisplatin plus paclitaxel followed by cesarean delivery and radical hysterectomy was a practical treatment option.

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.

The fetal outcomes after neoadjuvant platinum and paclitaxel chemotherapy during pregnancy: analysis of three cases and review of the literature

OBJECTIVE

Data on the outcomes of fetus who are exposed to neoadjuvant platinum and paclitaxel chemotherapy during pregnancy are lacking.

METHODS

Relevant data were abstracted from patients in our institution, PubMed, Embase and Cochrane Library databases. The primary assessment was the frequency of fetal death and congenital abnormalities. The secondary assessment was other negative fetal/infant outcomes including FGR, RDS, secondary malignant diseases and other recorded adverse events.

RESULTS

Of the three infants in our center who exposed to platinum and paclitaxel chemotherapy during pregnancy, the physical evaluation and qualified Denver Developmental Screening Test showed normal findings at the last follow-up (19-24 months). Hearing evaluation among three children also showed normal findings. Another 34 infants (including a twins) of 21 studies in previous studies who exposed to platinum and paclitaxel chemotherapy during pregnancy were included in the final analysis. Of the 37 infants identified, 24 were exposed to cisplatin plus paclitaxel, and 13 were exposed to carboplatin plus paclitaxel. None of the 37 fetuses was abortion or dead during the pregnancy. 97.3% (36/37) infants were delivered by cesareans and the median gestational ages of delivery were 34.76 weeks (95% CI, 34.08-35.44). 1 fetus showed intrauterine growth restriction and one was found with left-sided ventriculomegaly and hydramnios before chemotherapy. Adverse events occurred in 18.9% (7/37) infants at birth, including two RDS, one hearing loss, one pathological jaundice, one first-degree intraventricular hemorrhage, one erythema, one corresponding to -0.5 standard deviation from average body weight of the same gestational weeks. No reports of neonatal cardiologic abnormalities are reported in these infants after the initiating of chemotherapy. The infant with congenital anomaly died 5 days after birth. During the follow-up, 5.4% (2/37) of the infants were diagnosed with malignant diseases. One retroperitoneal embryonal rhabdomyosarcoma at 5 years old and one acute myeloid leukemia at 22 months of age. 32/37 (86.5%) children were healthy at the end of follow-ups (median 33 months, IQR 15.75-54.25 months).

CONCLUSIONS

Our results showed that neoadjuvant platinum and paclitaxel combined chemotherapy was a feasible and safe choice for the management of patients with cervical and ovarian cancer during the second and third trimesters of gestation.

Neoadjuvant chemotherapy in pregnant patients with cervical cancer: a Latin-American multicenter study

OBJECTIVE

To describe oncologic and obstetric outcomes in patients diagnosed with cervical cancer during pregnancy who had a successful delivery after neoadjuvant chemotherapy.

METHODS

A multicenter retrospective review was conducted in 12 institutions from six Latin American countries, between January 2007 and December 2018. Data collected included clinical characteristics, neoadjuvant chemotherapy agents, treatment, obstetric and oncologic outcomes.

RESULTS

Thirty-three patients were included. Median age was 34 years (range 31-36). Twenty (60.6%) women were diagnosed at early stage (IB), and 13 (39.4%) with locally advanced stage (IIA-IIIB) according to FIGO 2009 classification. Carboplatin and paclitaxel was the most frequent combination used (60.6%). Partial and complete response rates were 27.3% and 9.1%, respectively. Median gestational age at delivery was 35 weeks (range 34-36). All patients had live births delivered by cesarean section. Obstetric pathology: pre-term labor, placenta percreta or intra-uterine growth restriction, was documented in seven patients (21.2%). Two (6.1%) neonates had low birth weight. Definitive treatment was primary chemo-radiation in 19 (57.6%) patients, radical hysterectomy in 11 (33.3%), abandoned radical hysterectomy with para-aortic lymphadenectomy and ovarian transposition in 1 patient (3.0%), and no further treatment in 2 (6.1%) patients. After a median follow-up of 16.3 months (range 2.0-36.9), 8 (26.7%) patients had recurrent disease. Of these, four (13.3%) died due to disease.

CONCLUSION

Neoadjuvant chemotherapy may be offered to patients wishing to preserve an ongoing pregnancy in order to achieve fetal maturity. Long-term consequences of chemotherapy in the child are yet to be determined.

Recommendations for treating life-threatening Kaposi sarcoma during pregnancy in HIV-positive women in low income countries

In areas of high HIV and human herpes virus 8 prevalence, life-threatening forms of Kaposi sarcoma (KS) can occur in HIV-positive women during pregnancy. Treating KS in pregnancy must balance both the well-being of the mother with the health of the fetus, yet data and recommendations on the best treatment approach for KS during pregnancy are limited. Without effective treatment, which can be difficult to obtain in low income countries (LICs), the mother and infant are at risk for poor outcomes. A successful case report is used as teaching example, followed by a detailed review of the literature that culminates in recommendations for treating KS during pregnancy among HIV-positive women in LICs. A 31-year-old HIV-positive woman presented for care in April 2016 at 28 weeks gestation with extensive KS skin lesions, KS lymphadenopathy, and a large oropharynx KS lesion causing partial airway obstruction. She had initiated antiretroviral therapy (ART) months prior and was virally suppressed, suggesting KS-immune reconstitution inflammatory syndrome. Due to the severity of KS and her third trimester status, combination chemotherapy was initiated using bleomycin, vincristine, and doxorubicin followed by maintenance therapy with paclitaxel. She showed remarkable response to the chemotherapy and had a normal vaginal delivery of a healthy baby at full term. Full clinical remission was achieved, and her baby was HIV-negative with no negative health effects of the KS or the chemotherapy. Review of the sparse existing literature demonstrates the importance, safety, and effectiveness of treating KS during pregnancy. We offer simple adaptable treatment recommendations for use in treating HIV-positive women with KS during pregnancy in LICs. Life-threatening KS can be treated using chemotherapy and ART in resource-limited settings, allowing for good outcomes in mother and infant. While monotherapy with liposomal doxorubicin or paclitaxel is preferred, these are often not available in LICs. As alternatives, bleomycin, vincristine, and doxorubicin can be safely used during the second and/or third trimesters for treating KS. Following a simple treatment approach can be an effective way to treat KS in pregnancy for pregnant women living with HIV in an LIC setting.

Efficacy of neoadjuvant platinum-based chemotherapy during the second and third trimester of pregnancy in women with cervical cancer: an updated systematic review and meta-analysis

Purpose

To evaluate the efficacy and safety of neoadjuvant platinum-based chemotherapy during pregnancy in women with cervical cancer.

Methods

The PubMed, Embase, and Cochrane Library databases were fully searched to find eligible studies regarding platinum use during pregnancy in women with cervical cancer from January 1980 to September 2018. Data were extracted from the selected studies independently by two authors. Descriptive statistics were calculated for categorical data (frequency and percentage) and numeration data (mean and SD for normally distributed data and median and range for abnormally distributed data). Survival analyses were performed using Kaplan–Meier survival curves and log-rank tests to estimate overall survival and progression-free survival for all patients.

Results

A total of 39 studies including 88 cervical cancer patients with platinum administration during pregnancy were selected in this meta-analysis, and 64 women provided International Federation of Gynecology and Obstetrics stage information. Among the latter, 56 of 64 (87.5%) were diagnosed with early stages (I and IIA) and the remaining 8 of 64 (12.5%) had advanced stages (IIB, III, and IV). In relation to cisplatin, 86 pregnant women were identified, whereas only 2 pregnant women with carboplatin application were retrieved. Overall, 88 newborns were delivered from 84 pregnancies, including two sets of twins and one set of triplets, among which 71 neonates (71 of 88, 80.7%) were completely healthy at birth. All children were healthy at the end of follow-up (median 17 months, range 0–149.5 months), except one who was diagnosed with retroperitoneal embryonal rhabdomyosarcoma at 5 years old and one who had acute myeloid leukemia at 22 months of age. At the end of follow-up (range 4.75–156 months), 16 of 81 (19.8%) patients were diagnosed with recurrence of cervical cancer, and 11 (90%) of those died because of cancer relapse. Neither median overall survival nor median progression-free survival were reached.

Conclusion

Our results demonstrated that neoadjuvant platinum-based chemotherapy could be a favorable choice for the management of patients with cervical cancer during the second and third trimesters. To reduce the side effects of chemotherapy, cisplatin might be good to use as monotherapy in these patients.

Management of gynecological cancer in pregnant patients

INTRODUCTION

Cancer during pregnancy is a rare but challenging condition. More women delay childbearing and consequently the incidence of cancer during pregnancy is constantly increasing.

EVIDENCE ACQUISITION

An extensive electronic search was performed in PubMed and Scopus. Only studies written after 1985 were considered eligible for this review. Abstracts, conference papers, book chapters, animal studies, commentaries as well as editorials articles were excluded from this review.

EVIDENCE SYNTHESIS

Cancer treatment during pregnancy is possible, but both maternal and fetal conditions need to be preserved. Randomized clinical trials are not feasible and current evidence are mainly based on case-series, small case reports and expert opinion. Cervical and ovarian cancers are the most common gynecological cancers diagnosed during pregnancy. Surgery and chemotherapy after the first trimester seem to be relatively safe for the newborn. Platinum-based chemotherapy administered during the 2nd-3rd trimester showed comparable adverse effects in newborns to those in the general population. Babies exposed to antenatal chemotherapy might be more likely to develop small for gestational age and NICU admission, than babies not exposed.

CONCLUSIONS

Management of pregnant women with cancer should be performed in specialized cancer centers and all cases should be discussed with a multidisciplinary approach. In the present review, we discuss the current recommendations for the management of pregnancies complicated by cancer and neonatal outcomes.

Current management of gynecologic cancer in pregnancy

Cancer during pregnancy is a particularly challenging complication. The incidence has increased in recent years due to childbearing at advanced maternal ages due to career choices and/or the development of reproductive technology. Approximately two thirds of cancer cases during pregnancy comprise invasive cervical cancers and breast cancer. Cancer during gestation is characterized by a need for specialized treatment due to major changes in the hormonal profile (estrogen-progesterone), metabolism (enhancement of anabolism), hemodynamic changes (hyperdynamic circulation), immunologic changes (cell-mediated and humoral immunity), and increased angiogenesis (increased blood flow towards the uterus). Moreover, the management of such patients is based on the trimester of pregnancy, type and stage of cancer, and informed consent of the mother based on her wishes. The optimal treatment of cancer during pregnancy remains elusive because there are limited data from retrospective studies with small samples. As a result, it is crucial that data regarding survival of the women and long-term follow-up of the children from different cancer centers and registries are shared. This need is dictated by the fact that the incidence of cancer during pregnancy will continue to rise as child-bearing age continues to increase.

Ovarian dysgerminoma in pregnancy: A case report and literature review

BACKGROUND

Dysgerminoma is an uncommon malignant tumor arising from the germ cells of the ovary. Its association with pregnancy is extremely rare; the incidence is about 0.2-1 per 100,000 pregnancies. Because of its infrequency, there are few recommendations regarding its management in pregnancy; therefore, it is important to discuss and summarize the treatment strategy.

CASE

We presented a case of a 23-year-old pregnant woman with a large dysgerminoma originated from the right ovary, which had the unusual coincidence of being associated with an abdominal desmoid tumor simultaneously. We did not find any similar cases published in the PubMed database after 1947. A cesarean section was performed at 34 + 6 weeks gestation secondary to her abdominal pain worsening. The patient delivered a healthy boy and had fertility-preserving surgery, followed by 6 cycles of chemotherapy. This case is compared with 21 other reported cases of pure ovarian dysgerminoma in the literature to evaluate the clinical characteristics, feto-maternal compromise, treatment, long-term survival, and fertility outcome.

CONCLUSION

The treatment strategy in women with ovarian dysgerminoma should be discussed and structured on an individual basis. If pregnancy is desired, surgical intervention undertaken in the second trimester seems to be the first choice. When chemotherapy is indicated, unless delivery can be accomplished within a few weeks of diagnosis, it should not necessarily be delayed until after delivery. Good reproductive function and high survival rate can be achieved in patients treated with conservative surgery and adjuvant chemotherapy.

Adenocarcinoma of the lung with positive epidermal growth factor receptor mutation in pregnancy

Lung cancer during pregnancy is a rare condition. We report a case of 28-year-old nonsmoker female, who was admitted to our hospital with massive left pleural effusion in the 21^st week of gestation. Chest radiograph showed total left hemithorax opacity with contralateral mediastinal deviation. Pleural biopsy and cytological examination of pleural fluid revealed adenocarcinoma invasion with positive epidermal growth factor receptor mutation status. Cesarean section was performed at 32 weeks of pregnancy, and targeted therapy was given to this patient after delivery. Computed tomography of the thorax showed a mass lesion in the left hemithorax with liver metastases. Unfortunately, the patient died 10 days after delivery.

Chronic lymphocytic leukaemia during pregnancy: management and thoughts

Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in the Western world. Despite this fact, its coexistence with pregnancy is extremely rare, with few cases reported in the literature. Given the rarity of this event, it is difficult to conduct large prospective trials to evaluate diagnostic, management, and outcome aspects. The existing evidence is limited to the few published cases and scarce data from reviews on haematological malignancies and pregnancy. Here, we report a case of a 36-year-old patient who had already finished treatment for CLL and was under surveillance when she got pregnant. We describe the evolution of the pregnancy and of the disease's behaviour as well as the oncological and obstetrical management. Being an indolent disease, CLL during pregnancy can be usually followed up without treatment, but infectious and autoimmune complications might have a significant impact on the pregnancy outcome. Therefore, pregnancy must be closely monitored in specialised centres.

How much platinum passes the placental barrier? Analysis of platinum applications in 21 patients with cervical cancer during pregnancy

OBJECTIVE

Cervical cancer is the most common solid cancer diagnosed in pregnancy. Platinum is an active drug in the treatment of patients with cervical cancer. In the second and third trimesters, platinum is used to prevent cancer progression until fetal maturity is reached. However, knowledge about the transplacental passage of platinum is very limited.

STUDY DESIGN

Between May 2008 and June 2014, platinum-based neoadjuvant chemotherapy was applied to 21 consecutive patients with cervical cancer diagnosed in their second trimester. At the time of delivery by cesarean delivery, synchronous samples from maternal blood, umbilical cord blood, and amniotic fluid were taken and analyzed for platinum concentrations.

RESULTS

The mean week of gestation at cancer diagnosis was 17 (13-23). On average 3 (range, 2-4) cycles of chemotherapy were applied. Cesarean deliveries were carried out between 30.4 and 36.5 weeks of gestation. Twenty-two healthy babies without renal, hepatic, auditory, or hematopoietic impairment were delivered. Platinum concentrations in umbilical cord blood and amniotic fluid were 23-65% and 11-42% of the maternal blood, respectively.

CONCLUSION

This series on in vivo measurement of platinum concentrations in the fetomaternal compartment observed that because of consistently lower platinum values in the fetoplacental unit, a placental filtration mechanism of platinum may be assumed.

Management of musculoskeletal tumors during pregnancy: a retrospective study

Background

In recent years, scientific research has increasingly focused on malignancies during pregnancy. However, the development of musculoskeletal tumors during pregnancy has only been the subject of a few studies so far. The primary aim of this study was to identify the incidence of sarcomas during pregnancy at our musculoskeletal tumor center (MSTC). Secondarily we intended to analyze these cases and discuss possible recommendations regarding diagnostic work-up as well as therapy on the basis of the literature.

Methods

All female patients who had been treated for soft tissue or bone sarcoma at our academic MSTC in the period between the years 2002 and 2010 were screened retrospectively for anamnestic annotations of pregnancy or records of pregnancy in the obstetrical database of our university hospital. The patients who met the criteria for inclusion (diagnosed sarcoma and pregnancy) were enrolled. For every pregnant patient two age-matched female control patients that suffered from tumors with the same histologic type were included.

Results

In the period between 2002 and 2010, 240 female patients between the age of 16 and 45 were treated for sarcoma. In eight out of the 240 cases the tumor disease developed or progressed during pregnancy. The delay in diagnosis was approximately eight months and turned out to be significantly higher for pregnant patients compared to non- pregnant controls. Each woman’s tumor was misdiagnosed at least once.

Conclusions

Diagnostic follow-up of pregnant women presenting with a growing or painful mass, which is suspected to be a musculoskeletal tumor, should be performed at a specialized tumor center. We recommend a multidisciplinary approach and discussing all possible consequences for mother and child intensively in accordance with the available literature.

Two cases of breast carcinoma during pregnancy and review of the literature

Pregnancy-associated breast cancer is the most common solid tumor in pregnancy after cervical carcinoma but still has a low incidence. It has been associated with a poor prognosis; though based on a limited number of retrospective case-control studies, some authors have reported no differences from that of non-pregnant patients. There is no consensus about the treatment; it requires an interdisciplinary approach and it is necessary to balance between the benefit for the mother and risk for the fetus. Each case requires an individual decision taking into account the stage of disease, patient preferences and gestational age. Above chemotherapy, it is only recommended after the first trimester of pregnancy and anthracyclin-based schemes have the higher evidence, but taxanes are also considered as an alternative in patients who do not respond to anthracyclines or its use is contraindicated. For the time being, there is a lack of data, and clinical decisions are based on small retrospective cohorts, case-control studies and case reports. We report two cases of patients being diagnosed with breast cancer while being pregnant and treated with surgery and chemotherapy, including anthracyclines, during the second and third trimester of pregnancy. In both reported cases, childbirth was induced before the 37th week of gestation and only one presented low birth weight with no more complications. The echocardiogram monitorization showed normal cardiac function in mothers and fetus.

Large malignant ovarian tumors during pregnancy: two cases

The present study reports two cases of large ovarian malignancy during pregnancy, which is very rare. The two patients were received between Nov 2012 and Feb 2013 at Gynecological and Obstetrical Department, Women's Hospital, School of Medicine, Zhejiang University (People's Republic of China). Both cases present tumor sized more than 20 cm, with one case of 40 cm. Both patients underwent timely cesarean section, with survival of the Child, and successful removal of the tumor. All patients showed good outcome in the follow-up period. Therefore the large ovarian malignancy during pregnancy could be well treated after careful clinical evaluation.

Neoadjuvant and postoperative chemotherapy with paclitaxel plus cisplatin for the treatment of FIGO stage IB cervical cancer in pregnancy

Cervical cancer is one of the most common malignancy diagnosed during pregnancy. The experience of the use of neoadjuvant chemotherapy (NACT) with paclitaxel plus cisplatin during pregnancy is limited. Three pregnant women with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer received NACT with paclitaxel plus cisplatin until fetal lung maturity, and then underwent cesarean delivery and radical hysterectomy. Two of our patients had intermediate pathologic risk factors, and received adjuvant chemotherapy with the same regimen used in NACT. All patients did not have any evidence of disease recurrence for follow-up of 3, 4, and 8 years, respectively. NACT with paclitaxel plus cisplatin followed by radical hysterectomy and adjuvant chemotherapy could be considered as one of feasible alternatives to primary radical surgery or concurrent chemoradiation therapy with the termination of pregnancy in pregnant women with FIGO stage IB cervical cancer who have two or more intermediate pathologic-risk factors.

Chronic lymphocytic leukaemia, monoclonal B-lymphocytosis and pregnancy: five cases, a literature review and discussion of management

Chronic lymphocytic leukaemia (CLL) occurs rarely with pregnancy and monoclonal B-Lymphocytosis (MBL) has not previously been described in this setting. CLL is predominantly a disease of the elderly and affects men twice as often as women and hence only an estimated 2% of patients are females of childbearing age. We identified only five reported cases of CLL in pregnancy in the literature. We describe two additional cases, plus three other women with CLL dealing with pregnancy-related decisions. We review the literature and discuss proposals for management and issues that arise in this relatively uncommon occurrence. In contrast to many other haematological malignancies where longer remissions are typically associated with a lower risk of relapse, most patients with CLL who require treatment will ultimately relapse with current therapy. This complex setting requires careful consideration and well informed patients to assist with decisions related to pregnancy.

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.

Obstetrical, fetal and postnatal effects of gestational antiblastic chemotherapy: how to counsel cancer patients

At least one in a thousand pregnancies is complicated by cancer and, as the maternal age at pregnancy increases, numbers are growing. If chemotherapy cannot be postponed, both doctors and patients face complex medical and ethical issues. There is a conflict between optimal maternal therapy and fetal wellbeing. Treatment during the first trimester increases the risk of congenital malformations, spontaneous abortions and fetal death. Second and third trimester exposure is less risky, but it can cause intrauterine growth retardation and low birth weight. Other effects on pregnancy after the first trimester include premature birth, stillbirth, impaired functional development, myocardial toxicity and myelosuppression. Counseling and management of these cases are difficult, because literature is mostly represented by case reports or retrospective series while randomized prospective studies or guidelines are lacking. Moreover, personal experience is often scanty due to the rarity of the condition. This article reviews the available data regarding the different aspects of systemic treatment of cancer during pregnancy to help oncologist and obstetricians in counseling their patients and treat them accordingly.

Granulocyte-colony stimulating factor for hematopoietic stem cell donation from healthy female donors during pregnancy and lactation: what do we know?

BACKGROUND Hematopoietic growth factors (HGFs) are mostly used as supportive measures to reduce infectious complications associated with neutropenia. Over the past decade, the use of HGFs became a common method for mobilizing human CD34+ stem cells, either for autologous or allogeneic transplantation. However, since their introduction the long-term safety of the procedure has become a major focus of discussion and research. Most information refers to healthy normal donors and data concerning pregnant and lactating women are scarce. The clinical question, which is the core of this review, is whether stem cell donation, preceded by administration of granulocyte-colony stimulating factor (G-CSF) for mobilization, is a safe procedure for pregnant donors. METHODS Literature searches were performed in Pubmed for English language articles published before the end of May 2012, focusing on G-CSF administration during pregnancy, lactation and hematopoietic stem cell donation. Searches included animal and human studies. RESULTS Data from animals (n = 15 studies) and women (n = 46 studies) indicate that G-CSF crosses the placenta, stimulates fetal granulopoiesis, improves neonatal survival mostly for very immature infants, promotes trophoblast growth and placental metabolism and has an anti-abortive role. Granulocyte macrophage-CSF is a key cytokine in the maternal immune tolerance towards the implanted embryo and exerts protective long-term programming effects to preimplantation embryos. The available data suggest that probably CSFs should not be administered during the time of most active organogenesis (first trimester), except perhaps for the first week during which implantation takes place. Provided CSF is administered during the second and third trimesters, it appears to be safe, and pregnant women receiving the CSF treatment can become hematopoietic stem cell donors. There are also risks related to the anesthesia, which is required for the bone marrow aspiration. During lactation, there should be a period of at least 3 days to allow for clearance of CSF from milk before resuming breast feeding. With regard to teratogenicity or leukaemogenity, in non-pregnant or non-lactating women reports show that CSF administration is associated with a risk for leukemia; however, this risk is not higher compared with the control population. CONCLUSIONS The information available to date indicates that administration of CSF in general, and G-CSF in particular, is safe and healthy pregnant women can serve as donors of either bone marrow or peripheral blood stem cells. However, the clinical experience is rather limited and therefore until more data become available, G-CSF should not be used during pregnancy and lactation when other therapeutic options, instead of stem cell transplantation, are available.

Therapeutic management of epithelial ovarian cancer during pregnancy

Epithelial ovarian cancer (EOC) during pregnancy is a rare condition. The diagnosis and treatment strategies are therefore not well defined. The evidence is scarce and limited to small case reports or case series. In this review we describe the safety, utility and limitations of each diagnostic tool and surgical procedure in pregnant women with ovarian cancer. We also discuss the role of chemotherapy for ovarian cancer during pregnancy. Finally, we delineate different strategies of treatment according to the stage of the disease at diagnosis and gestational age. Due to the complexity of the management of EOC during pregnancy, patients should be referred to specialized centers. Gestational age at diagnosis, the initial surgical procedure, disease stage and patient's preferences are the key factors in the decision-making process to establish the best treatment strategy for each individual case.

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.