Gynecologic Malignancies in Pregnancy: Balancing Fetal Risks With Oncologic Safety

Cancer during pregnancy: Twenty-two years of experience from a tertiary referral center

INTRODUCTION

Cancer complicating pregnancy is a rare but potentially life-threatening condition for both the mother and her child. The aim of the present study was to assess the outcomes for mothers and children after pregnancy complicated by malignancy and to investigate which parameters are important for their 1-year survival.

MATERIAL AND METHODS

The study included 84 pregnant women diagnosed with malignant tumors during pregnancy from 2001 to 2022. The pregnancy course and outcome, as well as parameters that could influence the survival and condition of the mother and child were evaluated. Mothers and children were followed up for 1 year after delivery to assess their condition/complications and overall survival.

RESULTS

Most malignancies were gynecological (31%) or hematological (23.8%) and were diagnosed and surgically treated in the second trimester. Most children (69%) showed adequate growth and development throughout pregnancy but were delivered before term (53.6%) to allow mothers to receive therapy. Adjuvant therapy during pregnancy mostly caused a transitory deterioration of the child's condition, while surgery did not significantly impact the pregnancy course. Deliveries, on average, occurred during the 33.01 ± 6.16 gestational week (range: 20-40) and mostly by cesarean section (76.2%). For mothers, the pregnancy survival rate was 95.2% and survival after 1 year was 87.5%. However, 37.5% of women were still ill and required additional therapy 1 year postpartum. The pregnancy survival rate for children was 94%, whereas the 1-year survival rate was 76.2%. Most children had a favorable condition (alive, adequately growing and developing, and without complications) at birth (81%) as well as at the 1-year follow-up (63.7%). Regression analysis identified the following predictors of favorable 1-year maternal condition: applying therapy during pregnancy, no progression of the malignancy during pregnancy, and delivery at a later gestational week. Predictors of favorable 1-year condition of children were lower histopathological grade of malignancy, surgery as therapy for malignancy, obtaining higher birthweight, and delivery by cesarean section.

CONCLUSIONS

If the malignancy is not progressing, pregnancy should be continued as long as possible for the child to obtain adequate birthweight. Both surgery and chemotherapy were safe therapeutic choices, as most pregnancies continued successfully after therapy.

Influence of cancer in pregnancy on obstetric and neonatal outcomes: an observational retrospective cohort study

OBJECTIVE

The study aimed to review the oncological characteristics and treatment of pregnancy-associated cancers and analyze the obstetric and neonatal outcomes to provide evidence-based recommendations for reproductive function preservation, oncological treatment, and obstetric management.

METHODS

We conducted an observational retrospective cohort study among pregnant patients with cancer in 7 Chinese tertiary A hospitals from 2003 to 2021. We conducted multiple logistic regression to determine the influence of various factors on preterm birth and small-for-gestational-age infants, log-binomial regression to analyze temporal changes, and χ² tests to explore the effects of cancer type/treatment.

RESULTS

Of 204 women, 17% terminated their pregnancies; 59% received pre-delivery treatment. Every 6 years, the rates of pregnancy termination (relative risk [RR]=0.48; 95% confidence interval [CI]=0.35-0.67) and iatrogenic preterm births (RR=0.73; 95% CI=0.54-0.98) reduced, and that of pre-delivery treatment increased, mainly due to increased rates of surgery (RR=1.87; 95% CI=1.31-2.67). Maternal systemic diseases were related to small-for-gestational-age infants (odds ratio [OR]=12.02; 95% CI=1.82-79.43). Chemotherapy with taxanes plus platinum-based agents was related to adverse obstetric outcomes (OR=1.87; 95% CI=1.42-2.46; p<0.05). Thyroid (OR=0.36; 95% CI=0.22-0.57) and ovarian cancer (OR=0.70; 95% CI=0.50-0.98) were associated with fewer cesarean sections. Thyroid cancer was associated with fetal growth restriction (OR=5.21; 95% CI=1.21-22.55).

CONCLUSION

Rates of pregnancy termination in cancer declined. Taxane plus platinum-based chemotherapy was associated with adverse obstetric outcomes. Cancer type influenced outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2100044292.

Clinical Features and Management of Lung Cancer During Pregnancy: A Narrative Review Based on Reported Cases

This review aims to provide a summary of the clinical characteristics and outcomes of lung cancer during pregnancy. A comprehensive literature search yielded 93 cases of lung cancer during pregnancy from 1953 to 2022, with an average maternal age of ∼34 years old. The initial symptoms reported were often nonspecific, such as cough, dyspnea, and chest pain. Cancer-related treatments, including surgery, radiotherapy, chemotherapy, and tyrosine kinase inhibitors, have shown beneficial effects on maternal outcomes. A majority of the newborns were born without malformation or diseases, but extended follow-up remains necessary. Early diagnosis of lung cancer is imperative for reducing the risks of placental and fetal metastasis and enhancing overall 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.

Vulvar cancer during pregnancy and/or breastfeeding: a report of five cases from a single center study at the University Hospital of Düsseldorf

Background

The incidence of vulvar cancer (VC) in pregnancy is unknown due to its rarity; between 1955 and 2014 only 36 case reports were reported worldwide. Underreporting may also be a contributing factor to the unknown incidence of VC in pregnancy. The aim of this study was to analyze the diagnosis, treatment and outcome of vulvar cancer cases diagnosed during pregnancy and/or breastfeeding.

Case presentation

Patient 1 was diagnosed at 18 weeks’ gestation (WG) with Grade 2 VC (pT1a, pN0, 0/4 sentinel lymph nodes biopsy (SLNB) involved) and was treated by having the tumor resected (R0). She is currently recurrence-free at 4 years post-diagnosis.

Patient 2 was diagnosed at 7 WG with Grade 2 VC (pT1b, pN1a, 1/17 SLNB, R0) and was treated during the first trimester and during the second trimester with SLNB. She is currently recurrence-free at 5 years post-diagnosis.

Patient 3 was diagnosed at 30 WG with Grade 2 VC (pT1b, pN0, 0/5 SLNB, R0). She subsequently experienced a number of local recurrences postpartum that were managed by resection and is currently recurrence-free at 3 years post-diagnosis.

Patient 4 was diagnosed a VL later, at 14 months during breastfeeding, that was diagnosed as Grade 3 VC (pT1b, pN1a, 1/14 SLNB, R0). The patient is currently recurrence-free at 9 years post-diagnosis.

Patient 5 was not diagnosed during pregnancy, but was diagnosed with G3 VC (pT2, pN2c, 2/17 SLNB, R0) 8 months postpartum. The patient due to the extent of tumor involvement and lymph node metastasis, underwent chemoradiation therapy post-surgery. Despite adjuvant therapy, the patient progressed and developed bone metastases. Analysis of the tumour tissue revealed increased expression of PD-L1 (programmed cell death protein 1) indicating that the patient may have benefited from treatment with nivolumab to block the PD-L1 interaction; unfortunately the patient passed away at 24 months post-diagnosis before immunotherapy treatment could commence.

Conclusion

Surgical resection and simultaneous SLNB in VC cases are considered safe during pregnancy, with comparable outcomes to non-pregnant women. Prompt diagnostic workup and treatment should never be delayed during pregnancy as delayed diagnosis could lead to tumour progression with fatal consequences.

Building a Personalized Medicine Infrastructure for Gynecological Oncology Patients in a High-Volume Hospital

Gynecological cancers require complex intervention since patients have specific needs to be addressed. Centralization to high-volume centers improves the oncological outcomes of patients with gynecological cancers. Research in gynecological oncology is increasing thanks to modern technologies, from the comprehensive molecular characterization of tumors and individual pathophenotypes. Ongoing studies are focusing on personalizing therapies by integrating information across genomics, proteomics, and metabolomics with the genetic makeup and immune system of the patient. Hence, several challenges must be faced to provide holistic benefit to the patient. Personalized approaches should also recognize the unmet needs of each patient to successfully deliver the promise of personalized care, in a multidisciplinary effort. This may provide the greatest opportunity to improve patients' outcomes. Starting from a narrative review on gynecological oncology patients' needs, this article focuses on the experience of building a research and care infrastructure for personalized patient management.

Juvenile granulosa cell tumor in pregnancy: case series and literature review

BACKGROUND

Pregnancy complicated with juvenile granulosa cell tumor (JGCT) is very rare; thus, the experience on clinical diagnosis and management is limited.

CASES

Two patients presented with abdominal pain, two were incidentally discovered, one by ultrasonography, and one during a caesarian section. One case received an emergency caesarian section because of tumor rupture at 38th week's gestation, the rest were treated at full term and no abnormalities were detected in the newborns. Three cases received further staging surgery, two of which received postoperative adjuvant chemotherapy. No patient had recurrent disease after a follow-up period spanning from 13 to 57 months.

CONCLUSION

In the absence of emergency, surgery can be delayed without affecting the fetus. More research is needed to determine the value of chemotherapy in FIGO stage I patients.

Small cell neuroendocrine tumour of the cervix in pregnancy: the importance of multidisciplinary management

A woman in her mid-20s presented with bleeding at 18 weeks gestation from a cervical 'polyp'. Histopathology demonstrated a rare small cell neuroendocrine of the cervix. There were only 18 cases of neuroendocrine tumours of the cervix in and around pregnancy in the literature, so the evidence base for treatment was scarce. She was treated with neoadjuvant chemotherapy, using a regimen used for small cell neuroendocrine tumours of the lung, to allow for fetal lung maturity. Disease initially responded, then progressed and she was delivered at 32 weeks by caesarean radical hysterectomy. Adjuvant treatment included further chemotherapy and radical pelvic radiotherapy. The woman and her child are doing well over 6 years after treatment, although the woman has significant side effects of both radical surgery and radiotherapy. This case emphasises the need for excellent communication between multidisciplinary professionals, patients and their families and using external colleagues to help with rare clinical problems.

Common Malignancies During Pregnancy: A Comprehensive Review

Malignant disease complicates pregnancy in up to 1 per 1,000-2,000 cases. Pregnancy itself does not constitute a predisposing factor for malignancy. Management and treatment of patients suffering from a malignancy during pregnancy still represents a challenge in everyday clinical practice. Recent advances in imaging, diagnostic and overall treatment modalities have tailored the management of patients, specifically those who wish to maintain the pregnancy. The aim of this review was to provide clinicians with concise information on the management of the most common malignancies during pregnancy. We performed a review of the current literature including review articles, original research articles and guidelines, which are used for the management of the most common malignancies during pregnancy. Breast, cervical and ovarian malignant tumours are the most common during pregnancy. However, the overall outcome and survival per stage for these cancers do not appear to be influenced by pregnancy. Ethical, emotional and treatment dilemmas may be encountered during treatment planning. Individualization of treatment planning should be made by a multidisciplinary team but the final decision rests with the parents.

Approaches to the Diagnosis and Management of Ovarian Cancer in Pregnancy

Ovarian cancer is one of the most common gynecological cancers diagnosed in pregnancy. Its management is often very problematic due to the proximity of the adnexa to the developing fetus and chemotherapy-related toxicity risk. Tumor markers and imagining studies play important roles in diagnosis, help differentiate benign masses from malignancy and allow to plan the treatment. Due to the physiological changes that occur in pregnancy, levels of tumor markers can be altered and reduce their diagnostic value. We review current recommendations for the management and treatment of ovarian cancer in pregnant patients considering gestational age at diagnosis, tumor histology, stage of the disease, risk of obstetrical complications, and patient’s preferences.

[Pregnancy-preserving and maternal-fetal management in a patient with rare large cell neuroendocrine carcinoma of the uterine cervix]

OBJECTIVE

To explore the strategy of pregnancy-preserving and maternal- fetal management in patients with primary gynecologic neuroendocrine tumors (gNETs) during pregnancy.

METHODS

We performed whole genome sequencing (WGS) for analyzing maternal and fetal somatic and germline single nucleotide variations (SNVs) and small insertions and deletions (InDels) for a 29-year-old pregnant woman diagnosed with stage IB2 large cell neuroendocrine carcinoma (LCNEC) and adenocarcinoma in the cervix. A systematic literature review was performed to explore the strategies for treatment of such rare histological type while maintaining pregnancy.

RESULTS

Global case analysis of cervical NETs during pregnancy suggested that negative lymph node metastasis and an early FIGO stage were potentially associated with a good prognosis of the patients. In the case presented herein, a pregnancy-preserving strategy was adopted and favorable maternal-fetal outcomes were achieved after neoadjuvant chemotherapy, radical surgery and postoperative systemic chemotherapy. At 35⁺⁵ weeks, the fetus was delivered by caesarian section, and the patient has by now had a disease-free survival of 19 months postoperatively. WGS analysis revealed 6 missense somatic pathogenic mutations in two cancer tissues of the patient, and among them KARS and VEGFA were related with targeted therapy. Five pathogenic germline variants were detected in the patient and her son, suggesting the necessity of a long-term follow-up schedule including precise genetic counselling for both the mother and the child.

CONCLUSIONS

Although gNETs in pregnancy are rare and highly risky, pregnancy-preserving managements of gNETs can still be considered and favorable maternalfetal outcomes are possible with proper assessment of the clinical indications and implementation of multimodal treatments. Precise treatment and follow-up strategies based on the results of WGS for risk-reducing intervention of cancer recurrence or occurrence can potentially benefit the patient and the neonate.

Extraovarian dysgerminoma in a pregnant woman: an extremely rare finding

Extraovarian germ cell tumors are very rare and their occurrence during pregnancy is exceptional. In this case report an abdominal mass was shown by ultrasonography, during a routine monitoring of a 26-year-old pregnant woman. The patient was left under radiological control in the following months in order to bring the pregnancy to term. A few months after the delivery, the patient underwent surgery and a diagnosis of extraovarian (abdominal) dysgerminoma was made. To the best of our knowledge, there are only 3 other case reports describing an extra-gonadal dysgerminoma occurring during pregnancy. The aim of this study was to report an extremely rare tumor, whose management can be challenging first because this neoplasm has some differences from its ovarian and testicular counterparts. Furthermore, the occurrence during pregnancy makes the multidisciplinary approach mandatory since 3 distinct but not independent entities are involved (tumor, mother and fetus).

Good news on the active management of pregnant cancer patients

Cancer occurs in approximately 1/1000 to 1/2000 pregnancies and presents complex medical and ethical dilemmas for patients and providers. The most common cancers diagnosed in the gestational period include breast, cervical, melanoma, and lymphomas. The majority of existing evidence regarding the treatment of cancer during pregnancy is derived from experiences with breast cancer. Other cancers often pose unique challenges given the location of the tumors and their traditional mode of treatment with pelvic surgery and radiation. Additionally, many emerging therapies for cancer target mechanisms that are necessary for fetal development, such as angiogenesis, and are contraindicated in pregnant women. Although limitations on the treatment of cancer during pregnancy currently exist, increasing evidence shows that many surgical and systemic therapies can be effective for a mother’s oncologic outcomes without significant detriment to the developing fetus. Traditional perspectives of cancer during gestation may sway providers to encourage pregnancy termination, delays in therapy, or early delivery. However, recent studies and reviews discourage such practices. Although every cancer diagnosis in pregnancy requires an individualized approach and should use the multidisciplinary perspectives of maternal–fetal medicine specialists as well as medical and surgical oncologists, providers should feel empowered to safely employ systemic, surgical, and even reserved cases of radiation therapies for their pregnant patients with cancer. The aim of this review is to highlight some of the recent advances in cancer therapies for common cancer subtypes and encourage providers to use this growing body of evidence to employ treatments with curative intent while continuing to evaluate the long-term effects of these therapies on mothers and their children.

A Mother in Jeopardy: The Ethics of Pregnancy and Chemotherapy

JM is a 32-year-old primagravida with polycystic ovary disease. She had extreme difficulty conceiving and was started on clomiphene 6 months ago by her fertility specialist. After doubling the dose on the sixth cycle, she successfully became pregnant. On her second prenatal visit at 12 weeks gestation, an ovarian cyst was detected. Ultrasound showed a complex ovarian mass with nodules on the bowel and abdominal wall. There was mild-to-moderate peritoneal fluid. Cytology showed adenocarcinoma of ovarian origin. Further workup demonstrated advanced stage III epithelial ovarian cancer. JM was referred to GYN-oncology who felt pregnancy-sparing debulking was not an option. The oncologist recommended termination of pregnancy due to the risks of delaying chemotherapy. JM refused, citing her fertility difficulties in the past and her desire to carry the pregnancy to term "even if it kills me." She tells the oncologist she cannot bear the thought of terminating her pregnancy under any circumstances. The oncologist wants to comply with her wishes but feels the patient is making a choice that would result in harm to herself. The oncology team requests an ethics consult.

Cancer in pregnancy

The incidence of cancer in pregnancy is increasing. The most frequent malignancies include breast and cervical cancers. Diagnosis may be complicated by late presentation. Imaging during pregnancy should consider risks to the fetus. Diagnostic work-up, including tumor markers, can be influenced by the physiology of pregnancy. Treatment of cancer can often be safely administered with good maternal and fetal outcomes. Chemotherapy, radiotherapy, and surgery must be adapted to the pregnancy state. Counselling and emotional support are an essential part of management.

Smear cytological features of large cell neuroendocrine carcinoma of the uterine cervix in pregnancy: A case report and review of the literature

Large-cell neuroendocrine carcinoma (LCNEC) of the uterine cervix is a rare aggressive tumor. The examination of a cervicovaginal smear from a 31-year-old patient diagnosed with LCNEC after a cervical polypectomy during the 32nd week of pregnancy was carried out. The observed atypical cells had large cytoplasm, increased nucleus: cytoplasm ratio with the nucleus containing coarse, dispersed chromatin, and were arranged in a pseudorosette formation, which all confirmed the diagnosis. In addition, adenocarcinoma in situ (AIS) was determined in the histopathological examination of the subsequent hysterectomy material. Given the rarity of this condition, we present and discuss the case herein.

Cancer in Pregnancy

This article reviews some of the more common types of cancer that may be encountered during pregnancy. It reviews the unique challenges with the diagnosis and treatment of breast, cervical, hematologic, and colon cancers in pregnant patients.

Pregnancy luteoma: a rare presentation and expectant management

Pregnancy luteoma (PL) is a rare cause of non-neoplastic masses in pregnancy. PLs are usually asymptomatic. However, general symptoms like pelvic pain, lumbalgia, constipation or virilization due to active hormone secretion can be detected as the clinical findings of these benign cysts. The definitive diagnosis of PL is most commonly possible with a pathological evaluation after surgical intervention. Therefore, we present a successful management of PL with close follow-up until delivery. Beside the suspicion of malignancy by ultrasonography and magnetic resonance imaging (MRI), the cytological evaluation of ascites revealed benign cells which was helpful to decide expectant management.

Advanced ovarian cancer treated in pregnancy and detected by cell-free DNA aneuploidy screening

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Abnormal cell free DNA results may indicate occult maternal malignancy.

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Cesarean-cytoreductive surgery is feasible even with significant disease burden.

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Carboplatin/paclitaxel is first line for epithelial ovarian cancer in pregnancy.