Frequency of Pregnancy Related Cancer: A Population Based Linkage Study in Lombardy, Italy

Risk factors for the increasing incidence of pregnancy-associated cancer in Sweden - a population-based study

INTRODUCTION

The incidence of cancer during pregnancy and within first year post-delivery, ie pregnancy-associated cancer (PAC), is increasing in many countries, but little is known about risk factors for these trends. This study quantified incidence of PAC by trimesters and post-delivery periods, and assessed the role of maternal age, parity, immigrant status, education, smoking and body mass index for the risk and incidence trends of PAC.

MATERIAL AND METHODS

We used data from the national birth and cancer registers in Sweden during 1973-2017 to define a register-based cohort of women aged 15-44 years. Incidence rates of PAC during pregnancy and up to 1 year post-delivery were calculated per 100 000 deliveries per year. Poisson regression with multiple imputation estimated incidence rate ratios with 95% confidence intervals adjusted by year, age, previous parity, immigrant status, education, smoking and BMI during 1990-2017, when information on risk factors was available.

RESULTS

Among 4 557 284 deliveries, a total of 1274 (during pregnancy) and 3355 (within 1 year post-delivery) cases of PAC were diagnosed, with around 50 cases/year diagnosed during pregnancy and 110 cases/year during the first year post-delivery in the latest period 2015-2017. The most common cancer types during pregnancy were malignant melanoma, breast and cervical cancer, together accounting for 57% of cases during pregnancy and 53% during the first year post-delivery. The numbers of PAC were lower during pregnancy than during post-delivery for all tumor types with lowest numbers during first trimester. The PAC incidence rates increased over calendar time. High maternal age at diagnosis, smoking, nulliparity and non-immigrant background were associated with significantly higher risks of PAC. The increasing PAC incidence was in part explained by higher maternal age over time, but not by the other factors.

CONCLUSIONS

High maternal age is the strongest risk factor for PAC. We show for the first time that smoking, nulliparity and non-immigrant background are also contributing risk factors for PAC. However, only high maternal age contributed significantly to the increasing incidence. Further studies on other potential risk factors for PAC are warranted, since our results indicate that age on its own does not fully explain the increase.

Breast cancer during pregnancy-The oncologist's point of view

Breast cancer is the most common malignancy diagnosed during or directly after pregnancy. Differences in pathogenesis and prognosis identify two distinct patient groups, those with breast cancer during pregnancy and those with postpartum breast cancer which, for reasons not completely understood, is associated with worse outcomes. Compared with breast cancer in the non-pregnant patient, several limitations in terms of both local and systemic therapy are applied to limit fetal harm. Treatment is nevertheless delivered with curative intent, therefore avoiding harmful delays in therapy initiation, unnecessary therapy de-escalation or chemotherapy dose modifications is strongly recommended. In this short commentary, we briefly review current evidence and treatment guidelines and provide recommendations for optimal oncologic management of pregnancy-related breast cancer.

The Future Direction of Women in Nuclear Medicine and Nuclear Medicine in Women's Health

This work discusses the role of Nuclear Medicine for women's health, the role of women in the development of this emerging field and the various issues which arise from both. It emphasizes the importance of young women and their competing needs due to factors like pregnancy and work-related challenges. The objectives of this overview include improving imaging techniques, preserving fertility during cancer treatment, diagnosing pelvic and uterine conditions, developing radiopharmaceuticals for women's health, protecting female employees in Nuclear Medicine, and considering the role of artificial intelligence.

Pregnancy and neonatal outcomes following malignancy in pregnancy at a tertiary care Canadian center: a retrospective chart review

Objective: Data on pregnancy-associated cancers (PACs) are lacking. The objectives of this study were to determine the incidence of PACs and describe the characteristics and outcomes of pregnancies affected by malignancy at a single tertiary care center in Ottawa, Canada.Methods: This was a retrospective chart review of individuals with PAC at The Ottawa Hospital (TOH) between 2011-2022. Eligible cases were identified from the TOH Data Warehouse, the TOH instance of the Better Outcomes Registry & Network Ontario, and the TOH Division of Maternal Fetal Medicine's Perinates database. Chart reviews were conducted to confirm case eligibility and to extract demographic, oncologic, obstetrical, and neonatal measures. The annual incidence of PAC over the 11-year period was reported per 1000 deliveries. Descriptive statistics were used to describe the sample, including frequency (n) and proportions (%) for categorical variables and mean and standard deviation (SD) for continuous variables.Results: The final cohort included 59 individuals with PAC at TOH between 2011-2022. The annual incidence of PAC ranged from 0.47 to 1.54 per 1000 deliveries. The most common PACs were breast cancer (28.8%), Hodgkin lymphoma (10.2%), and thyroid cancer (8.5%). Common interventions during pregnancy included chemotherapy (33.9%) and surgical intervention (32.2%). A total of 19 individuals (32.2%) did not undergo PAC-related treatment during pregnancy. There were 55 livebirths (91.7%), 2 spontaneous abortions (3.3%), 3 induced abortions (5.0%), and no stillbirths. Among livebirths, the mean gestational age was 37.4 ± 2.8 weeks and the mean birthweight was 2920.3 ± 650.0 g. All neonates had reassuring 5-minute Apgar scores, 18 (32.7%) were admitted to the Neonatal Intensive Care Unit/Special Care Nursery (NICU/SCN), and 8 (14.5%) were noted to have a mild congenital abnormality.Conclusion: This study shows promising perinatal outcomes for patients with PAC and their neonates. Ongoing surveillance of PAC is needed to better inform care for this patient population.

Spontaneous and induced abortions in women with a diagnosis of gestational related neoplasm: a population-based linkage study in Lombardy, 2010-2020

BACKGROUND

A diagnosis of cancer during pregnancy or within one year after the end of pregnancy is a major clinical and public health issue. The current study aimed at estimating the incidence of pregnancy-associated cancer (PAC) and assessing whether the risk of abortion is increased in women diagnosed with cancer.

METHODS

This population-based cohort study used the regional healthcare utilization (HCU) databases of Lombardy, the largest region in Italy, to identify the women who delivered between 2010 and 2020. PAC were identified by oncological ICD-9-CM codes reported in the hospital discharge forms. We computed the ratio of PAC cases to the total number of pregnancies. Following a diagnosis of PAC, the prevalence ratio (PR) of abortion and the corresponding 95% confidence interval (CI), was estimated using a log-binomial model adjusted for maternal age.

RESULTS

During the study period, 926 women who gave birth (1.29 cases per 1000 births) and 341 women who had an abortion (1.52 cases per 1000 abortions) were diagnosed with PAC. Regardless of the outcome of pregnancy, the risk of PAC increased with increasing age. The rate of PAC was initially lower among births, but it came very close to the rate of PAC among abortions in the last two calendar years. The proportion of abortions among women with PAC gradually decreased from 27.7% in 2010-2012 to 18.5% in 2019-2020 (p-value < 0.001). Overall, a diagnosis of PAC was related to an approximately 10% increased risk of abortion (PR = 1.11, 95%CI:1.01-1.22). However, no association was observed in 2019-2020 (PR = 0.87, 95%CI:0.65-1.17). Considering only diagnoses made during the first trimester of pregnancy, the risk of abortion was about 2.5 times higher (PR = 2.53, 95%CI:2.05-3.11) and the risk of induced abortion was almost 4 times higher (PR = 3.71, 95%CI:2.82-4.90).

CONCLUSION

In this population the risk of abortion was about 10% higher in women with PAC than in women without PAC. However, this association tended to decrease in more recent calendar periods. This trend seemed to be influenced more by spontaneous than by induced abortions.

ESMO Expert Consensus Statements on the management of breast cancer during pregnancy (PrBC)

The management of breast cancer during pregnancy (PrBC) is a relatively rare indication and an area where no or little evidence is available since randomized controlled trials cannot be conducted. In general, advances related to breast cancer (BC) treatment outside pregnancy cannot always be translated to PrBC, because both the interests of the mother and of the unborn should be considered. Evidence remains limited and/or conflicting in some specific areas where the optimal approach remains controversial. In 2022, the European Society for Medical Oncology (ESMO) held a virtual consensus-building process on this topic to gain insights from a multidisciplinary group of experts and develop statements on controversial topics that cannot be adequately addressed in the current evidence-based ESMO Clinical Practice Guideline. The aim of this consensus-building process was to discuss controversial issues relating to the management of patients with PrBC. The virtual meeting included a multidisciplinary panel of 24 leading experts from 13 countries and was chaired by S. Loibl and F. Amant. All experts were allocated to one of four different working groups. Each working group covered a specific subject area with two chairs appointed: Planning, preparation and execution of the consensus process was conducted according to the ESMO standard operating procedures.

Cancer and Pregnancy: Estimates in Italy from Record-Linkage Procedures between Cancer Registries and the Hospital Discharge Database

The aim of this study is to describe the frequency and trend of pregnancy-associated cancer (PAC) in Italy, an increasingly relevant phenomenon due to postponing age at childbirth. To this purpose, a population-based retrospective longitudinal study design based on cohorts of women aged 15-49 diagnosed with cancer and concomitant pregnancy is proposed. The study uses 19 population-based Cancer Registries, covering about 22% of Italy, and linked at an individual level with Hospital Discharge Records. A total of 2,861,437 pregnancies and 3559 PAC are identified from 74,165 women of the cohort with a rate of 1.24 PAC per 1000 pregnancies. The most frequent cancer site is breast (24.3%), followed by thyroid (23.9%) and melanoma (14.3%). The most frequent outcome is delivery (53.1%), followed by voluntary termination of pregnancy and spontaneous abortion (both 12.0%). The trend of PAC increased from 2003 to 2015, especially when the outcome is delivery, thus confirming a new attitude of clinicians to manage cancer throughout pregnancy. This represents the first attempt in Italy to describe PAC from Cancer Registries data; the methodology is applicable to other areas with the same data availability. Evidence from this study is addressed to clinicians for improving clinical management of women with PAC.

Adverse birth outcomes among offspring born to women diagnosed with cancer: a population-based cohort study

BACKGROUND

With increasing cancer incidence and survival rates, the prevalence of maternal cancer and its effect on adverse birth outcomes are important for prenatal care and oncology management. However, the effects of different types of cancer at different gestational stages have not been widely reported.

OBJECTIVE

This study aimed to describe the epidemiologic characteristics of pregnancy-associated cancers (during and 1 year after pregnancy) and evaluate the association between adverse birth outcomes and maternal cancers.

METHODS

Of 983,162 cases, a history of maternal cancer, including pregestational cancer, pregnancy-associated cancer, and subsequent cancer, was identified in 16,475 cases using a health information network. The incidence and 95% confidence interval of pregnancy-associated cancer were calculated with the Poisson distribution. The adjusted risk ratio with 95% confidence interval of the association between adverse birth outcomes and maternal cancer were estimated using the multilevel log-binomial model.

RESULTS

A total of 38,295 offspring were born to mothers with a cancer history. Of these, 2583 (6.75%) were exposed to pregnancy-associated cancer, 30,706 (80.18%) had a subsequent cancer diagnosis, and 5006 (13.07%) were exposed to pregestational cancer. The incidence of pregnancy-associated cancer was 2.63 per 1000 pregnancies (95% confidence interval, 2.53‰-2.73‰), with cancer of the thyroid (1.15‰), breast (0.25‰), and female reproductive organs (0.23‰) being the most common cancer types. The increased risks of preterm birth and low birthweight were significantly associated with cancer diagnosed during the second and third trimester of pregnancy, whereas increased risks of birth defects (adjusted risk ratio, 1.48; 95% confidence interval, 1.08-2.04) were associated with cancer diagnosed in the first trimester. Increased risks of preterm birth (adjusted risk ratio, 1.16; 95% confidence interval, 1.02-1.32), low birthweight (adjusted risk ratio, 1.24; 95% confidence interval, 1.07-1.44), and birth defects (adjusted risk ratio, 1.22; 95% confidence interval, 1.10-1.35) were observed in thyroid cancer survivors.

CONCLUSION

Careful monitoring of fetal growth should be implemented for women diagnosed with cancer in the second and third trimester to ensure timely delivery and balance the benefits of neonatal health and cancer treatment. The higher incidence of thyroid cancer and increased risk of adverse birth outcomes among thyroid cancer survivors suggested that the regular thyroid function monitoring and regulation of thyroid hormone levels are important in maintaining pregnancy and promoting fetal development among thyroid cancer survivors before and during pregnancy.

Gestational Breast Cancer - a Review of Outcomes, Pathophysiology, and Model Systems

The onset of pregnancy marks the start of offspring development, and represents the key physiological event that induces re-organization and specialization of breast tissue. Such drastic tissue remodeling has also been linked to epithelial cell transformation and the establishment of breast cancer (BC). While patient outcomes for BC overall continue to improve across subtypes, prognosis remains dismal for patients with gestational breast cancer (GBC) and post-partum breast cancer (PPBC), as pregnancy and lactation pose additional complications and barriers to several gold standard clinical approaches. Moreover, delayed diagnosis and treatment, coupled with the aggressive time-scale in which GBC metastasizes, inevitably contributes to the higher incidence of disease recurrence and patient mortality. Therefore, there is an urgent and evident need to better understand the factors contributing to the establishment and spreading of BC during pregnancy. In this review, we provide a literature-based overview of the diagnostics and treatments available to patients with BC more broadly, and highlight the treatment deficit patients face due to gestational status. Further, we review the current understanding of the molecular and cellular mechanisms driving GBC, and discuss recent advances in model systems that may support the identification of targetable approaches to block BC development and dissemination during pregnancy. Our goal is to provide an updated perspective on GBC, and to inform critical areas needing further exploration to improve disease outcome.

The Safe Use of 125I-Seeds as a Localization Technique in Breast Cancer during Pregnancy

INTRODUCTION

Some aspects of the treatment protocol for breast cancer during pregnancy (PrBC) have not been thoroughly studied. This study provides clarity regarding the safety of the use of ¹²⁵I-seeds as a localization technique for breast-conserving surgery in patients with PrBC.

METHODS

To calculate the exposure to the fetus of one ¹²⁵I-seed implanted in a breast tumor, we developed a model accounting for the decaying ¹²⁵I-source, time to surgery, and the declining distance between the ¹²⁵I-seed and the fetus. The primary outcome was the maximum cumulative fetal dose of radiation at consecutive gestational ages (GA).

RESULTS

The cumulative fetal dose remains below 1 mSv if a single ¹²⁵I-seed is implanted at a GA of 26 weeks. After a GA of 26 weeks, the fetal dose can be at a maximum of 11.6 mSv. If surgery takes place within two weeks of implantation from a GA of 26 weeks, and one week above a GA of 32 weeks, the dose remains below 1 mSv.

CONCLUSION

The use of ¹²⁵I-seeds is safe in PrBC. The maximum fetal exposure remains well below the threshold of 100 mSv, and therefore, does not lead to an increased risk of fetal tissue damage. Still, we propose keeping the fetal dose as low as possible, preferably below 1 mSv.

Patient-Centered Care in the Management of Cancer During Pregnancy

The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.

Pregnancy-associated breast cancer: a multicenter study comparing clinicopathological factors, diagnosis and treatment outcomes with non-pregnant patients

PURPOSE

Pregnancy-associated breast cancer (PABC), defined as breast carcinoma diagnosed during pregnancy or in the first post-partum year, is one of the most common gestation-related malignancies with reported differences in tumor characteristics and outcomes. This multicenter study aims to review cases of PABC in Singapore, including their clinicopathological features, treatment, and clinical outcomes compared to non-PABC patients.

METHODS

Demographic, histopathologic and clinical outcomes of 93 PABC patients obtained from our database were compared to 1424 non-PABC patients.

RESULTS

PABC patients presented at a younger age. They had higher tumor and nodal stages, higher tumor grade, were more likely to be hormone receptor negative and had a higher incidence of multicentric and multifocal tumors. Histological examination after definitive surgery showed no significant difference in tumor size and number of positive lymph nodes suggesting similar neoadjuvant treatment effects. Despite this, PABC patients had worse outcomes with poorer overall survival and disease-free survival, OS (P < 0.0001) and DFS (P < 0.0001). Termination of pregnancy did not improve survival.

CONCLUSION

Patients with PABC present at a higher stage with more aggressive disease and have poorer outcomes compared to non-PABC patients. Reducing delay in diagnosis and treatment may help improve survival.

Personalized treatment of malignant tumors during pregnancy

The combination of pregnancy and cancer is a challenge for the patient and a problematic clinical dilemma for the doctor. In this retrospective observational cohort study, we have tried to analyze our experience in the management of such patients. This review includes 41 patients with malignant neoplasms detected during pregnancy who received treatment at the Almazov National Medical Research Centre from 2015-2021. The majority of patients received treatment during pregnancy (n=26, 63.4%): chemotherapy - 19 (46.3%) (in 2 cases in combination with surgery), surgical treatment - 7 (17, 1%) patients. In most cases, delivery was at term (n=28, 68.3%). All children born at term were mature and had no growth restriction, regardless of whether the mothers received treatment during pregnancy or not. When detecting cancer during pregnancy, an immediate follow-up examination is required to assess the extent of the tumor and current fetal state. If pregnancy prolongation is requested, the treatment should not be postponed, except for systemic chemotherapy in the first trimester of pregnancy, pelvic radiation at any term.

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.

Ten-year experience of a national multidisciplinary tumour board for cancer and pregnancy in the Netherlands

BACKGROUND

Most physicians encounter pregnant women with cancer incidentally, leading to a lack of expertise or confidence to inform and treat these patients based on the most recent guidelines and expert opinions. In the Netherlands, a national multidisciplinary tumour board for cancer, infertility and pregnancy (CIP-MDT) was founded in December 2012, including 35 specialists from a variety of disciplines. This study evaluates the frequency of consultation of the CIP-MDT, the types of questions asked and the satisfaction of consulting physicians with its existence.

METHODOLOGY

Of all requests to the CIP-MDT between December 2012 and June 2021, tumour type, stage, gestational age at diagnosis and recommendations were collected and analysed. For evaluating the methods of the CIP-MDT, a survey with questions regarding experiences with the CIP-MDT and its impact on treatment decisions was sent out to physicians that consulted the CIP-MDT.

RESULTS

Recommendations (n = 213) concerned preferred and safest options for imaging, treatment options during pregnancy, possible effects on the child and fertility preserving options. Most frequently discussed malignancies were breast cancer (n = 66), cervical cancer (n = 34), haematological malignancies (n = 32) and melanoma (n = 21). The questionnaire was completed by 54% of the physicians (n = 50). Satisfaction with the recommendations of the CIP-MDT was high, and 94% of the physicians informed their patients about consulting the CIP-MDT and felt supported by the received recommendations.

DISCUSSION

The national Dutch CIP-MDT contributes to a high level of satisfaction among physicians requesting advice. Further research should be executed to confirm that a CIP-MDT improves the outcomes for pregnant women and their children.

Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities

Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. While treatment for pregnant patients should adhere to treatment guidelines for non-pregnant patients, there exist specific considerations concerning diagnosis, staging, oncological treatment, and obstetrical care. Imaging and staging are preferably performed using breast ultrasound and mammography. Other ionizing radiation imaging modalities, including computed tomography (CT) and Positron Emission Tomography/ Computed Tomography (PET/CT), can be selectively performed when the estimated benefit for the mother outweighs the risks to the foetus, e.g., when the results will change clinical management. MRI is appropriate to stage for distant disease on the indication. Breast cancer during pregnancy is less often hormone receptor-positive and more frequently triple-negative breast cancer compared to age-matched controls. The basic principle is that women should receive state-of-the-art oncological treatment without delay if possible and that the pregnancy should be maintained as long as possible. Treatment strategy should be multidisciplinary defined, carefully weighing the selection, sequence, and timing of treatment modalities depending on patient-, tumour-, and pregnancy-related characteristics, as well as patient preferences. Initiating cancer treatment during pregnancy often decreases the risks of early delivery and prematurity. Breast cancer surgery is possible during all trimesters. Radiotherapy is possible during pregnancy in the first half of pregnancy. Chemotherapy can be safely administered starting from 12 weeks of gestational age, but endocrine and HER2 targeted therapy are contraindicated throughout the whole pregnancy. Importantly, foetal growth should be monitored and long-term follow-up of the children is encouraged in dedicated centres.

Timing of Presentation and Outcomes of Women with Stage IV Pregnancy-Associated Breast Cancer (PABC)

BACKGROUND

Pregnancy-associated breast cancer (PABC) and concurrent, or early development of, stage IV disease is uncommon. Given this rarity, and complexities surrounding pregnancy, data are limited regarding PABC treatment and outcomes. We evaluated oncologic, obstetric, and fetal outcomes of women with stage IV PABC in relation to presentation timing and treatment.

PATIENTS AND METHODS

Our retrospective review of an institutional database identified women with stage IV PABC from 1998 to 2018. PABC was defined as diagnosis during pregnancy or ≤ 1 year postpartum. Clinicopathologic, treatment, and outcome variables were compared between women diagnosed during pregnancy versus postpartum.

RESULTS

We identified 77 women (median age 35 years; interquartile range [IQR] 32-37 years): 51 (66%) in the postpartum group and 26 (34%) in the pregnant group, including 9 with therapeutic or spontaneous abortion. Among 17 women who continued pregnancy, no obstetric or fetal complications were noted. Clinicopathologic and treatment variables did not differ between groups. Of 43 women dead from disease, 15 had triple negative (TN) tumors. Median overall survival (OS) of TN tumors was 14 months (range 5-39 months); OS was associated with hormone receptor-positive and human epidermal growth factor receptor 2 (HER2) positive tumors (p < 0.01). At 31 months (range 0-137 months) median follow-up, the 5-year OS was 34% (95% confidence interval 21-46%), and did not differ among pregnant and postpartum groups (p = 0.2).

CONCLUSIONS

Women with stage IV TN PABC had high mortality rates despite multimodality therapy. Timing of presentation did not affect management decisions or OS, even for women who completed pregnancy. Further research to understand PABC biology, focusing on TN tumors, is warranted.

Feasibility, Safety and Impact of (18F)-FDG PET/CT in patients with pregnancy-associated cancer: experience of the French CALG (Cancer Associé à La Grossesse) network

BACKGROUND

The incidence of pregnancy-associated cancers has been increasing for decades. (18F)-FDG Positron Emission Tomography (PET)/Computed Tomography (CT) imaging has become a golden standard in the staging of many malignant diseases. The aims of the current study were to evaluate the feasibility, safety and impact of (18F)-FDG PET/CT performed during pregnancy.

MATERIAL AND METHODS

A retrospective analysis from the prospective database of the Cancer Associé à La Grossesse (CALG) network (Tenon Hospital, France) including patients who underwent (18F)-FDG PET/CT during their pregnancy between 2015 and 2020.

RESULTS

Of the 536 patients for whom advice from the CALG network was requested during the study period, 359 were diagnosed with cancer during pregnancy. Study population was composed of 63 (17.5%) patients who underwent (18F)-FDG PET/CT. Most cancers were diagnosed during the second trimester. Seventy-five percent were diagnosed with breast cancer, mostly locally advanced invasive ductal carcinomas. Median term of pregnancy at PET/CT was 24.8 weeks of gestation. Twelve (19%), 24 (38.1%) and 22 (34.9%) patients underwent the exam during the 1st, 2nd and 3rd trimester, respectively. (18F)-FDG PET/CT resulted in stage modification for 38 (60.3%) of the patients (28 with more extensive lymph node involvement and 10 with metastatic disease) with subsequently/accordingly modified first-line medical treatment. Fifty patients gave birth to healthy newborns. Two patients had a medical termination of pregnancy, five had a medical abortion, one neonatal death occurred in a patient with severe preeclampsia (unrelated to (18F)-FDG PET/CT). The data of 46 children were available at 6 months, 29 at 12 months, and 15 at 24 months. No cases of mental retardation, childhood cancer, or malformation were reported within 2 years.

CONCLUSION

(18F)-FDG PET/CT has a major impact on the management of pregnancy-associated cancers and does not appear to cause fetal side effects suggesting that the exam is feasible during pregnancy as maternal benefits outweigh fetal risks.

Prognosis of pregnancy-associated breast cancer: inferior outcome in patients diagnosed during second and third gestational trimesters and lactation

PURPOSE

Pregnancy-associated breast cancer, although most commonly defined as breast cancer diagnosed during pregnancy or ≤1 year following delivery, knows a variety of definitions, likely related to the diversity of reported clinicopathological features and prognosis. More insight into the different breast cancer subgroups during pregnancy, time after delivery and the postpartum period is therefore warranted.

METHODS

Patients with breast cancer diagnosed during pregnancy or ≤6 months postdelivery were included, and subdivided according to gestational trimester, and postpartum patients according to lactational status. Subgroups were compared to matched non-PABC patients, to investigate the influence of pregnancy and lactation on clinical course and outcome.

RESULTS

Overall, 662 PABC patients were included (median age 34 years, median follow-up 6.5 years). PABC patients showed an advanced stage at diagnosis and an inferior 5-years-OS (75.4% vs. 83.2%, p = 0.000) compared to 1392 matched non-PABC patients. In subgroup analysis, first trimester PABC patients showed a significantly lower tumor size and stage as compared to other trimesters. Patients diagnosed during the first trimester and postpartum non-lactating patients had a relatively good OS (81.3% and 77.9%, respectively) versus patients diagnosed during the second and third trimesters and during lactation (OS 60.0%, 64.9% and 65.6%, respectively, p = 0.003).

CONCLUSION

In this large (uniquely specified) PABC cohort, an inferior outcome was found for patients diagnosed within the second and third gestational trimesters and during lactation. These findings indicate that PABC is clinically a heterogeneous group of breast cancer patients that should be redefined based on trimester of diagnosis and lactational status.

MRI in Pregnancy and Precision Medicine: A Review from Literature

Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.

Pregnancy-associated cancer and the risk of second primary cancer

PURPOSE

Hormonal changes related to pregnancy and lactation among women treated for cancer might influence the risk of second primary cancer. We investigated whether pregnancy near the time of breast cancer, Hodgkin lymphoma or other cancer diagnoses is associated with increased risk of developing a new primary cancer.

METHODS

Women born after 1 April 1935 diagnosed with cancer at ages 15-44 years during 1968-2006 were identified in the Danish Cancer Registry. Information about pregnancies from various nationwide registers was used to identify women with a pregnancy-associated cancer defined as a cancer diagnosed 6 or fewer months before the pregnancy, during the pregnancy or up to 1 year after the pregnancy. Second primary cancers were ascertained through 2013, and hazard ratios (HRs) were calculated using Cox regression models adjusted for age, calendar-period and number of pregnancies with the reference defined as cancer not associated with a pregnancy.

RESULTS

We identified 2,974 women with pregnancy-associated cancer and 31,970 women who were not pregnant near the time of their cancer diagnosis. There was no association between pregnancy-associated cancer and a second cancer (HR 0.91; 95% CI 0.79-1.05). Among 680 women with either breast cancer or Hodgkin lymphoma associated with pregnancy, a HR of 1.16 (95% CI 0.87-1.56) for second breast cancer was observed based on 48 cases.

CONCLUSION

While hormonal changes might stimulate development of specific cancers, in particular breast cancer, it is reassuring that risk of breast and other second cancers was not related to pregnancy near the time of a first primary cancer diagnosis.

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.

Placental pathology in cancer during pregnancy and after cancer treatment exposure

Cancer during pregnancy has been associated with (pathologically) small for gestational age offspring, especially after exposure to chemotherapy in utero. These infants are most likely growth restricted, but sonographic results are often lacking. In view of the paucity of data on underlying pathophysiological mechanisms, the objective was to summarize all studies investigating placental pathology related to cancer(treatment). A systematic search in PubMed/Medline, Embase (OVID) and SCOPUS was conducted to retrieve all studies about placental pathology in cancer during pregnancy or after cancer treatment, published until August 2020. The literature search yielded 5784 unique publications, of which 111 were eligible for inclusion. Among them, three groups of placental pathology were distinguished. First, various histopathologic changes including maternal vascular malperfusion have been reported in pregnancies complicated by cancer and after cancer treatment exposure, which were not specific to type of cancer(treatment). Second, cancer(treatment) has been associated with placental cellular pathology including increased oxidative damage and apoptosis, impaired angiogenesis and genotoxicity. Finally, involvement of the placenta by cancer cells has been described, involving both the intervillous space and rarely villous invasion, with such fetuses are at risk of having metastases. In conclusion, growth restriction is often observed in pregnancies complicated by cancer and its cause can be multifactorial. Placental histopathologic changes, cellular pathology and genotoxicity caused by the cancer(treatment) may each play a role.

Complete remission of choriocarcinoma with pulmonary vein thrombosis in the third trimester of pregnancy treated with systemic chemotherapy and anticoagulation: A case report

RATIONALE

Choriocarcinoma is a highly aggressive tumor. It occurs infrequently during pregnancy. The management of choriocarcinoma during pregnancy poses several challenges.

PATIENT CONCERNS

At 34 weeks of gestation, a 21-year-old primigravida was transferred to the emergency room for cephalgia, reduced fetal movements, and left intra-atrial intracavitary thrombus.

DIAGNOSIS

Choriocarcinoma in the third trimester with lung and brain metastases, pulmonary vein thrombosis (PVT), and systemic thrombosis.

INTERVENTION

An emergency cesarean section was performed. Subsequently, low-molecular-weight heparin anticoagulation combined with multiagent chemotherapy was administered.

OUTCOME

A 1.59 kg live female was born. Multiagent chemotherapy combined with anticoagulation led to complete regression of the cerebral and pulmonary lesions and the dissolution of pulmonary vein thrombus. At the 11-month follow-up, the patient remained in complete remission without complications, and her child was disease-free.

LESSONS

This is the first case of gestational choriocarcinoma with PVT. Our case suggests that conservative therapy can be the first choice for small, asymptomatic PVT secondary to choriocarcinoma.

Germline mutations in a clinic-based series of pregnancy associated breast cancer patients

Background

Pregnancy-associated breast cancer (PABC) defined as breast cancer diagnosed during gestation, lactation or within 1 year after delivery, represents a truly challenging situation with significantly increasing incidence rate. The genomic background of PABC has only recently been addressed while the underlying mechanisms of the disease still remain unknown. This analysis aims to further elucidate the frequency of PABC cases attributable to genetic predisposition and identify specific cancer susceptibility genes characterizing PABC.

Methods

A comprehensive 94-cancer gene panel was implemented in a cohort of 20 PABC patients treated in our clinic and descriptive correlation was performed among the results and the patients’ clinicopathological data.

Results

In the present study, 35% of PABC patients tested carried pathogenic mutations in two known cancer predisposition genes (BRCA1 and CHEK2). In total, 30% of the patients carried BRCA1 pathogenic variants. An additional 5% carried pathogenic variants in the CHEK2 gene. Variants of unknown/uncertain significance (VUS) in breast cancer susceptibility genes BRCA2, CHEK2 and BRIP1 were also identified in three different PABC patients (15%). Not all patients carrying germline mutations reported known family history of cancer.

Conclusions

Genetic testing should be considered as an option for PABC patients since the disease is highly associated with genetic susceptibility among other predisposing factors. Germline mutation identification may further modify PABC management approach and improve the prognostic outcome.

[Formula: see text]Long-term neurodevelopmental outcome after prenatal exposure to maternal hematological malignancies with or without cytotoxic treatment

Data on the long-term neurodevelopmental outcomes of children exposed to hematological maternal cancer with or without treatment during pregnancy are lacking. A total of 57 children, of whom 33 males and 24 females, prenatally exposed to hematological malignancies and its treatment, were invited for neuropsychological and physical examinations at 18 months, 36 months, 6, 9, 12, 15 and 18 years of age. Oncological, obstetrical, neonatal and follow-up data of these children were collected. Parents were asked to complete questionnaires on their child's general health, school performances, social situation, behavioral development, executive functioning, and if their child receives supportive care. Non-Hodgkin lymphoma was diagnosed in 35.1%, Hodgkin lymphoma in 28.1%, acute myeloid leukemia in 15.8%, chronic myeloid leukemia in 12.3%, and acute lymphoblastic leukemia in 8.8%. Cognitive development at a median age of 10.7 years was within the normal range. In subgroup analyses of children in early childhood, the gestational age at birth was correlated with the cognitive outcome at a median age of 1.7 years. Scores for language development, intelligence, attention, memory and behavior, as well as clinical neurological and general pediatric examinations were within normal ranges. In subgroup analyses, the need for supportive care in the child was associated with the loss of the mother. Prenatal exposure to hematological maternal malignancies with or without treatment did not affect the neurodevelopment of the child in the long term. Yet, caution is indicated and surveillance of the emotional development of the child is needed, especially when the mother is deceased to cancer.

Incidence of Pregnancy-Associated Cancer in Two Canadian Provinces: A Population-Based Study

Pregnancy-associated cancer—that is diagnosed in pregnancy or within 365 days after delivery—is increasingly common as cancer therapy evolves and survivorship increases. This study assessed the incidence and temporal trends of pregnancy-associated cancer in Alberta and Ontario—together accounting for 50% of Canada’s entire population. Linked data from the two provincial cancer registries and health administrative data were used to ascertain new diagnoses of cancer, livebirths, stillbirths and induced abortions among women aged 18–50 years, from 2003 to 2015. The annual crude incidence rate (IR) was calculated as the number of women with a pregnancy-associated cancer per 100,000 deliveries. A nonparametric test for trend assessed for any temporal trends. In Alberta, the crude IR of pregnancy-associated cancer was 156.2 per 100,000 deliveries (95% CI 145.8–166.7), and in Ontario, the IR was 149.4 per 100,000 deliveries (95% CI 143.3–155.4). While no statistically significant temporal trend in the IR of pregnancy-associated cancer was seen in Alberta, there was a rise in Ontario (p = 0.01). Pregnancy-associated cancer is common enough to warrant more detailed research on maternal, pregnancy and child outcomes, especially as cancer therapies continue to evolve.

Cancer during Pregnancy: A Review of Preclinical and Clinical Transplacental Transfer of Anticancer Agents

The occurrence of cancer during pregnancy is observed in 1 in 1000 pregnancies and is expected to increase given the trend of delaying childbearing. While breast cancer is the most common, the incidence of other cancers, such as cervical, ovarian, and lung cancers as well as hemopathies and melanomas, is also increasing. Thus, cancer occurrence in pregnant women raises questions of management during pregnancy and, especially, assessment of the treatment benefit-risk ratio to ensure optimal management for the mother while ensuring the safety of the fetus. Chemotherapy remains a cornerstone of cancer management. If the use of anticancer agents appears possible during pregnancy, while avoiding the first trimester, the extent of placental transfer of different anticancer agents varies considerably thereafter. Furthermore, the significant physiological pharmacokinetic variations observed in pregnant women may have an impact on the placental transfer of anticancer agents. Given the complexity of predicting placental transfer of anticancer agents, preclinical studies are therefore mandatory. The aim of this review was to provide updated data on in vivo and ex vivo transplacental transfer of anticancer agents used in the management of the most common pregnancy-associated cancers to better manage these highly complex cases.

Cancer in pregnancy increases the risk of venous thromboembolism: a nationwide cohort study

OBJECTIVE

To investigate if cancer in pregnancy causes a higher risk of venous thromboembolism (VTE) during pregnancy and postpartum compared with pregnant women without cancer.

DESIGN

A historical prospective cohort study using data from nationwide registries.

SETTING AND POPULATION

We assessed all pregnancies in Denmark between 1 January 1977 and 31 December 2017.

METHODS

We linked information concerning cancer diagnosis, pregnancy and VTE diagnosis and potential confounders. Event rates of VTE for women with pre-pregnancy cancer, cancer in pregnancy and without cancer were calculated per 10 000 pregnancies and compared using logistic regression analysis.

MAIN OUTCOME MEASURES

Occurrence of VTE during pregnancy or the postpartum period.

RESULTS

A total of 3 581 214 pregnancies were included in the study and we found 1330 women with cancer in pregnancy. In pregnant women with cancer, the event rate of VTE was 75.2 per 10 000 pregnancies compared with 10.7 per 10 000 pregnancies in the no cancer group. The findings correspond to an increased adjusted odds ratio of 6.50 (95% CI3.5-12.1) in the cancer in pregnancy group in comparison with the no cancer group.

CONCLUSIONS

Women with cancer in pregnancy have a markedly higher risk of pregnancy-associated VTE compared with women without cancer. In pregnancy-related VTE risk assessment, the presence of cancer alone may be sufficient to indicate thromboprophylaxis.

TWEETABLE ABSTRACT

Cancer in pregnancy increases the risk of VTE during pregnancy and the postpartum period.

Is It Possible to Personalize the Diagnosis and Treatment of Breast Cancer during Pregnancy?

The main goal of precision medicine in patients with breast cancer is to tailor the treatment according to the particular genetic makeup and the genetic changes in the cancer cells. Breast cancer occurring during pregnancy (BCP) is a complex and difficult clinical problem. Although it is not very common, both maternal and fetal outcome must be always considered when planning treatment. Pregnancy represents a significant barrier to the implementation of personalized treatment for breast cancer. Tailoring therapy mainly takes into account the stage of pregnancy, the subtype of cancer, the stage of cancer, and the patient’s preference. Results of the treatment of breast cancer in pregnancy are as yet not very satisfactory because of often delayed diagnosis, and it usually has an unfavorable outcome. Treatment of patients with pregnancy-associated breast cancer should be centralized. Centralization may result in increased experience in diagnosis and treatment and accumulated data may help us to optimize the treatment approaches, modify general treatment recommendations, and improve the survival and quality of life of the patients.

Ovarian Cancer and Pregnancy-A Current Problem in Perinatal Medicine: A Comprehensive Review

The frequency of concomitant adnexal tumors in pregnancy is reported to be at 0.15-5.7%, while ovarian cancer complicates 1 in 15,000 to 1 in 32,000 pregnancies, being the second most common gynecologic cancer diagnosed during pregnancy. The aim of this review is to discuss the problem of ovarian cancer complicating pregnancy and the current recommendations for diagnostics and treatment, with an emphasis on the risk to the fetus. A detailed analysis of the literature found in the PubMed and MEDLINE databases using the keywords "ovarian cancer", "ovarian malignancy", "adnexal masses", "ovarian tumor" and "pregnancy" was performed. There were no studies on a large series of pregnant women treated for ovarian malignancies and the management has not been well established. The diagnostics and therapeutic procedures need to be individualized with respect to the histopathology of the tumor, its progression, the gestational age at the time of diagnosis and the mother's decisions regarding pregnancy preservation. The multidisciplinary cooperation of specialists in perinatal medicine, gynecological oncology, chemotherapy, neonatology and psychology seems crucial in order to obtain the best possible maternal and neonatal outcomes.

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.

Multidisciplinary consensus on cancer management during pregnancy

Cancer during pregnancy is a challenge for multi- and interdisciplinary collaboration due to the diagnostic, prognostic and therapeutic implications, the need for an integrated harmonization of medical action for the pregnant patient and the embryo or foetus and the characteristics of each gestational period, which will determine the protocol to be proposed and its limitations. For this reason, a group of experts appointed by participating scientific societies, which includes the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica—SEOM), the Spanish Association of Surgeons (Asociación Española de Cirujanos—AEC), the Spanish Society of Gynaecology and Obstetrics (Sociedad Española de Ginecología y Obstetricia—SEGO), the Spanish Society of Nuclear Medicine and Molecular Imaging (Sociedad Española de Medicina Nuclear e Imagen Molecular—SEMNIM), the Spanish Society of Oncological Radiotherapy (Sociedad Española de Oncología Radioterápica—SEOR) and the Spanish Society of Medical Radiology (Sociedad Española de Radiología Médica—SERAM), have worked together to establish consensus recommendations that allow the harmonization of management and ultimately the optimization of the healthcare of pregnant patients with cancer. When cancer is detected in a pregnant woman, the week of gestation in which the diagnosis is made must be considered, as well as the characteristics of the tumour. It is strongly recommended that a multidisciplinary team assesses the situation and guides the patient and her family during the informing, diagnosis and treatment process. Likewise, the foetus should be monitored and managed by specialized obstetricians who are part of a multidisciplinary cancer committee.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections) in France 2013-2015]

Maternal deaths from indirect obstetric causes are the result of a pre-existing disease or condition that appeared during pregnancy without obstetric causes, but which was aggravated by the physiological effects of pregnancy. Twenty-six deaths from indirect causes related to a pre-existing pathology, excluding disease of the circulatory system or infection, were analysed by the committee of experts. Pre-existing pathology during pregnancy was documented in 13 women (asthma, n=3, genetic diseases, n=3, previous breast cancer, n=2, major sickle cell syndrome, n=2, epilepsy, n=1 and brain tumour, n=1). In 13 women, the pathology was not known before pregnancy (breast cancer, n=6, brain tumours, n=3, uterine sarcoma, n=1, cervical cancer, n=1, malignant melanoma, n=1 and acute myeloid leukaemia, n=1). For 16 women (61%), the death is related to a neoplastic pathology. Although the majority were considered inevitable for 11/16 women, 5 deaths were considered possibly preventable, the main preventable factor being a delay in diagnosis, and/or a delay in starting a specific treatment. For 10 women, the death is related to a chronic non-neoplastic pathology, known before pregnancy for 9 women, judged most often as possibly preventable, the main preventable factor being the failure of the medical team or the patient to take the pathology and/or its treatment into account. A preconception medical consultation with a specialist should be recommended to all patients with pre-existing disease. A clinical examination of the breasts is strongly recommended at the first visit and then during pregnancy.

Oncological management of pregnancy-associated cancers: analysis from the French CALG (Cancer Associé à La Grossesse) network

Background: Pregnancy-associated cancers constitute a major medical challenge. The objective of this study was to describe their epidemiological, oncological and obstetrical outcomes from the French CALG (Cancer Associé à La Grossesse) network.Material and methods: Retrospective analysis of patients diagnosed with a cancer associated with pregnancy between January 2015 and December 2018 after advice from the CALG network.Results: Of 218 patients, 197 (90%) were diagnosed with a cancer during pregnancy and 21 the year following delivery. Requests to the CALG network increased from 36 cases in 2015 to 77 cases in 2018. The disease was diagnosed at local and regional stages in 77% of cases. Breast cancer was the most frequent (56%), followed by ovarian (12%) and uterine cervical cancers (10%). Of the 218 patients, 157 (72%) underwent a treatment during pregnancy. Surgery and chemotherapy during pregnancy were performed in 83 patients (83/218, 38%) and 101 patients (46%) at a median term of 17 (IQR 11-24) and 25 (IQR 18-30) WG, respectively. Eighteen (8.5%) of the women had a pregnancy termination, two (1%) an abortion, one (0.5%) a miscarriage, one (0.5%) had a stillbirth and one (0.5%) patient died during pregnancy. The remaining 174 patients (88%) were allowed to continue the pregnancy. Eight recurrences and four deaths were observed with a median follow-up time of 2.6 years (IQR 2.2-3.8).Conclusions: Our data further describe the incidence and management of pregnancy-associated cancers in western Europe allowing comparisons with other regions.

Management of HER2-positive breast cancer during pregnancy: a case report

INTRODUCTION

Breast cancer is one of the most common malignancies diagnosed during pregnancy, with an incidence of 1:3000 pregnancies. Its rising incidence is related to the trend to postpone childbearing during the last 30 years. Breast cancer during pregnancy should not be managed differently from the nonpregnant setting. Chemotherapy is reported to be safe after the first trimester, whereas trastuzumab and tamoxifen are contraindicated regardless of the trimester.

CASE DESCRIPTION

A patient diagnosed with breast cancer recurrence during pregnancy was exposed to both tamoxifen and trastuzumab during the first two trimesters of pregnancy. In addition, docetaxel was administered during the second and third trimesters, without subsequent fetal malformations or obstetric complications.

CONCLUSIONS

When conception occurs inadvertently during assumption of tamoxifen or anti-HER2 agents, their effects on the fetus and on the course of pregnancy are not completely understood. Further studies are needed in this setting, highlighting the importance to share clinical experiences.

Short inter-pregnancy interval and pregnancy-associated breast cancer

The relationship between pregnancy and breast cancer risk is not fully understood. Most of the literature has described this interaction in terms of the age at first pregnancy and the number of full-term pregnancies. During the prospective accrual of the "Joven & Fuerte: Program for young women with breast cancer in Mexico" cohort, a series of cases with pregnancy-associated breast cancer and a history of a short inter-pregnancy interval was identified. To date, there is a very limited number of descriptions about the interaction between a short inter-pregnancy interval and breast cancer, but none specifically regarding the association of a short inter-pregnancy interval and pregnancy-associated breast cancer. Based on findings from a prospective cohort of young Mexican breast cancer patients, we hypothesize that a short inter-pregnancy interval may increase the incidence of pregnancy-associated breast cancer, possibly by amplifying the effects of the pregnancy-associated factors involved in the development of breast cancer.

Frequency of Pregnancy-Associated Cancer: A Systematic Review of Population-Based Studies

Despite numerous available resources of evidence, the results about the frequency of pregnancy-associated cancer (PAC) still show poor comparability due to dissimilarities in the study design and methodology, inclusion criteria, incoherent duration of follow-up and a heterogeneous reference population. We conducted a systematic review of population-based studies on PAC published up to December 2019, to provide updated research on this topic, highlighting strengths and limitations. Of the 24 papers included, 11 considered all types of tumors and 13 dealt with specific types of cancer. Differences in the procedures for estimating the frequency of PAC emerged even among population studies. However, we found consistent results for overall frequency of PAC— around 1/1000 pregnancies. Our review suggests that about 25% of PAC cases are diagnosed during pregnancy, confirming the hypothesis of an excess of diagnosis in the postpregnancy period. Sparse and inconsistent results were found regarding a potential increase in the frequency of PAC over calendar years. Alignments in the strategy to identify PAC are needed to overcome methodological weaknesses.

Postpartum Involution and Cancer: An Opportunity for Targeted Breast Cancer Prevention and Treatments?

Childbirth at any age confers a transient increased risk for breast cancer in the first decade postpartum and this window of adverse effect extends over two decades in women with late-age first childbirth (>35 years of age). Crossover to the protective effect of pregnancy is dependent on age at first pregnancy, with young mothers receiving the most benefit. Furthermore, breast cancer diagnosis during the 5- to 10-year postpartum window associates with high risk for subsequent metastatic disease. Notably, lactation has been shown to be protective against breast cancer incidence overall, with varying degrees of protection by race, multiparity, and lifetime duration of lactation. An effect for lactation on breast cancer outcome after diagnosis has not been described. We discuss the most recent data and mechanistic insights underlying these epidemiologic findings. Postpartum involution of the breast has been identified as a key mediator of the increased risk for metastasis in women diagnosed within 5-10 years of a completed pregnancy. During breast involution, immune avoidance, increased lymphatic network, extracellular matrix remodeling, and increased seeding to the liver and lymph node work as interconnected pathways, leading to the adverse effect of a postpartum diagnosis. We al discuss a novel mechanism underlying the protective effect of breastfeeding. Collectively, these mechanistic insights offer potential therapeutic avenues for the prevention and/or improved treatment of postpartum breast cancer.

Chemotherapy for breast cancer during pregnancy induces vascular alterations and impaired development of placental villi: A preliminary histopathological study

OBJECTIVE

To evaluate histological alterations in placentas of women affected by breast cancer and treated with chemotherapy during pregnancy.

STUDY DESIGN

We retrospectively reviewed histological slides of 23 placentas of patients affected by breast cancer and treated with chemotherapy during pregnancy and 23 control placentas of women without breast cancer and with physiological pregnancies of the same gestational age.

RESULTS

All the patients had breast ductal infiltrating carcinoma, 19 of 23 cases had a G3 cancer. All patients were treated with 2-6 cycles of chemotherapy starting after 16 weeks of gestation, with different protocols. No hypertensive complications and no pre-eclampsia episodes were observed; birth weight was consistent with gestational age in all babies in both group with no uneventful outcomes and no perinatal mortality or fetal malformations. Twenty out of 23 cases (86 %) showed hypoxia-induced villous alterations, including increased syncytial knotting (Tenney-Parker changes), perivillar fibrin deposits, distal villous hypoplasia or accelerated maturation and focal villous chorangiosis. These alterations were found in 19 out of 23 controls (83 %), with no statistically significant difference between the two groups.

CONCLUSIONS

These results shows that chemotherapy in the second and third trimester of pregnancy may lead to non-specific alterations in placental vasculature and morphology.

Early Recurrence of Ovarian Cancer during Pregnancy after Primary Staging Surgery in the First Trimester

Cancer during pregnancy is rare. However, even during pregnancy, there is the possibility of recurrence for the patients. We present the case of recurrence of ovarian cancer during pregnancy regardless of primary staging surgery performed in the first trimester of the same pregnancy. The patient was a 29-year-old woman who underwent fertility-sparing surgery at 15 weeks of pregnancy for ovarian cancer (mucinous adenocarcinoma, FIGO stage IC). Omitting adjuvant chemotherapy during pregnancy, we continued the prenatal checkups in the outpatient. At 31 weeks of gestation, massive ascites emerged and oliguria/anuria developed acutely. We performed emergent cesarean section, diagnosing acute kidney injury during pregnancy. On surgical finding, there were a number of 1 cm sized nodules in the small bowel wall and peritoneum. The infant was appropriate for gestational age without any abnormalities. Oliguria continued due to rapid accumulation of ascites in the early postpartum period. After two cycles of chemotherapy, ascites decreased gradually and the markers gradually decreased. However, after six courses of chemotherapy, she suddenly complained of nausea and anorexia. CT imaging showed cancerous ileus and ascites fluids. The patient chose palliative care. Even in the case of nonadvanced cancer, it has the potential to be an extremely aggressive malignancy under the irregular hormonal environment of pregnancy.

Epidemiology of Pregnancy-Associated Breast Cancer

Breast cancer diagnosed during pregnancy or lactation up to 1 year post-partum is often referred to as pregnancy-associated breast cancer (PABC) , although the definition varies with length of post-partum period. The incidence rate has been reported to range from 17.5 to 39.9 per 100,000 births, but the rate is substantially lower during pregnancy (ranging from 3.0 to 7.7) than during the post-partum period (ranging from 13.8 to 32.2). The PABC incidence rate is increasing in many populations, and higher maternal age at birth is a likely explanation. Linkable population-based data on pregnancies and cancer are required to obtain reliable estimates of PABC incidence. In studies comparing outcomes in women with PABC to other young breast cancer patients, it is crucial to adjust for age, since the age distribution of PABC depends both on age at pregnancy and age at breast cancer. Large studies have shown similar prognosis for women with PABC compared to other young women with breast cancer, when accounting for differences in age, stage and other tumour characteristics.

Signet Ring Cell Carcinoma with Lymphangitic Carcinomatosis in Pregnancy: A Case Report of an Unexpected Maternal Death and Review of the Literature

BACKGROUND Cancer in pregnancy is extremely rare, and gastric cancers are rarer still. Diagnosis is difficult in pregnancy due to overlapping symptoms with pregnancy such as nausea, pain, anemia, and fatigue. CASE REPORT A 26-year-old G1 woman at 32 weeks gestation with a past medical history of systemic lupus erythematosus presented with new-onset chest pain and shortness of breath. Computed tomography of the chest, electrocardiogram, and echocardiogram were normal. Laboratory evaluation revealed thrombocytopenia, proteinuria of 480 milligrams, and normal complement. She delivered on hospital day 3 due to worsening chest pain. During cesarean delivery, the patient became hypotensive and hypoxic and required intensive care unit admission after a cesarean hysterectomy. On postoperative day 2 she had a pulmonary embolus and was started on therapeutic anticoagulation. She clinically improved until postoperative day 4, when she was found unresponsive with pulseless electrical activity. After 38 minutes of Advanced Cardiac Life Support, death was pronounced. An autopsy was performed and the cause of death found to be complications of multi-organ system involvement of adenocarcinoma with signet ring cell features. Lymphangitic carcinomatosis was noted throughout the lungs. CONCLUSIONS This patient had adenocarcinoma with signet ring cell features and associated lymphangitic carcinomatosis, which led to her postpartum death. Lymphangitic carcinomatosis is associated with an exceedingly poor prognosis, especially in pregnancy.

Pregnancy-associated cancers: frequency and temporal trends in Italy

OBJECTIVE

Limited data are available on the frequency and time trends of pregnancy-associated cancers, particularly from Southern European countries. The aim of this study was to analyze the frequency and time trends of pregnancy-associated cancer in Italy.

METHODS

This was a population-based linkage study using the regional hospital discharge forms database of four Italian regions with more than 17 million inhabitants. All resident women with a hospital discharge form reporting a birth or abortion in the time period under consideration were identified. The time period of the study was 2003-2015 for the Piemonte and Puglia region, 2006-2015 for the Tuscany region, and 2005-2015 for the Veneto region. Risk of developing a pregnancy-associated cancer was calculated as the ratio of the number of pregnancy-related cancers to the total number of pregnancies.

RESULTS

A total of 2 297 648 pregnancies were identified. Overall, the pregnancy-associated cancer frequency was 134.8 per 100 000 pregnancies: the frequency ranged from 127.1 in Puglia to 157.3 in Tuscany. The frequency for 100 000 pregnancies was 66.4 in women aged <30 years; the risk increased with age, with a frequency of 275.6 among women aged 40+ years. Approximately two-thirds of cancers were associated with pregnancies resulting in a delivery and one-third with pregnancies resulting in a termination of pregnancy or spontaneous pregnancy loss. No clear trend emerged in the risk of pregnancy-associated cancer per 100 000 pregnancies and calendar year.

CONCLUSION

No clear time trend was observed in the frequency of pregnancy-associated cancers in Italy during the last 10 years, the rates being 104, 164, and 130 per 100 000 pregnancies, respectively, in 2003, 2010, and 2015.

Breast Cancer during Pregnancy-Current Paradigms, Paths to Explore

Breast cancer is the most common form of malignancy in pregnant women. The prevalence of pregnancy-associated breast cancer (PABC) is up to 0.04% of pregnancies and is expected to rise in developed countries. PABC represents a unique clinical scenario which requires a delicate balance of risks and benefits for both maternal and fetal well-being. Currently, there is paucity of data regarding the short- and long-term outcomes of in-utero exposure to anti-neoplastic agents. In general, when possible, treatment for PABC should follow the same guidelines as in non-pregnant patients. Surgery, including sentinel lymph node biopsy, is possible during all trimesters of pregnancy. Radiotherapy is contraindicated during pregnancy, although it might be considered in highly selected patients based on risk-benefit assessment. Evidence supports that administration of chemotherapy may be safe during the second and third trimesters, with cessation of treatment three weeks prior to expected delivery. Currently, hormonal therapy and anti-HER2 agents are contraindicated during pregnancy and should be postponed until after delivery. Prematurity is associated with worse neonatal and long-term outcomes, and thus should be avoided. While current data on the long-term effects of anti-neoplastic treatments are reassuring, grade of evidence is lacking, hence additional large prospective studies with long-term follow-up are essential to rule out any treatment-induced adverse effects.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

Cancer in Pregnancy

Cancer in pregnancy may be increasing in incidence with advancing maternal age and higher rates of obesity. The diagnosis of cancer in pregnancy provokes complex management issues balancing short- and long-term risks for both mother and baby. Every case needs to be individualized, with a multidisciplinary team of midwives, obstetricians, oncologists, surgeons, radiation oncologists, and neonatologists assisting the family to make informed decisions regarding the best treatment course for the mother and baby. The present article reviews the evidence regarding the safety of diagnostic imaging, procedures and treatment modalities for cancer for the pregnant woman and fetus. The efficacy of novel anticancer therapies highlight the need for International Registries to accumulate safety data for these agents in pregnancy as expeditiously as possible.

Pregnancy-Associated Breast Cancer: A Realistic Approach

Background

The number of cancers diagnosed during pregnancy is on the rise, and breast cancer is the most common malignancy. Presently, there are very limited resources and no clear guidelines for managing this peculiar patient population both worldwide and in India. The objective of this study was to find out the incidence of pregnancy-associated breast cancer (PABC) in a tertiary care referral centre and to compare the epidemiological, diagnostic and prognostic factors as well as maternal and foetal outcomes with the most recent literature worldwide.

Methods

We conducted a retrospective descriptive study of women diagnosed with breast cancer in pregnancy and post-partum period at a tertiary care centre in southern India during the period of 10 years (total number of breast cancer patients were 10). We studied the diagnostic and prognostic factors as well as maternal and foetal outcome in patients diagnosed with breast cancer for the first time in pregnancy.

Results

Overall incidence of PABC was found to be 0.6% (n = 10). Mean age at the time of presentation was 30.7 ± 4 years. All cases suspected clinically or on imaging (USG) were confirmed with FNAC, excision biopsy or Trucut biopsy. Out of 10 patients, 70% (n = 7) had an advanced-stage disease on diagnosis. Histopathology suggested 90% (n = 9) had invasive ductal carcinoma and 55.5% (n = 5) had a triple negative receptor status. 20% (n = 2) of our patients had opted for a breast conservation surgery (BCS), and 70% (n = 7) of our patients underwent modified radical mastectomy with neoadjuvant or adjuvant chemotherapy/radiotherapy. One patient had a second trimester MTP in view of stage 4 disease. 77.7% (n = 7) of the nine patients who continued pregnancy underwent LSCS, out of which 57.4% (n = 4) were elective, and MRM was done concurrently with LSCS in 50% (n = 2) of the elective LSCS. The mean birth weight of the 9 neonates was 2.2 ± 0.5 kg. Intrauterine growth retardation was seen in 22.2% (n = 2) neonates. 33.3% (n = 3) of the neonates required NICU support, and one baby expired on post-natal day 16.

Conclusion

With the increasing number of elderly primigravida amongst the urban population, a clear understanding of PABC is becoming more important. A multidisciplinary team approach shall help the clinician not only in reducing the heavy burden of patient responsibility but more importantly, in guaranteeing better quality of treatment, avoiding unnecessary delays in providing interventions and providing adequate treatment.