Cancer during pregnancy

Mediastinal gray zone lymphoma in a pregnant woman presenting with cardiac tamponade

BACKGROUND

Mediastinal gray zone lymphoma is a newly recognized rare B cell neoplasm, which is challenging in diagnosis and treatment.

CASE PRESENTATION

In the current study, we aimed to report a 25-year-old pregnant woman at 25 weeks of gestation who presented with chronic cough and progressive shortness of breath, hypotension, tachycardia, and tachypnea. A large circumferential pericardial effusion with compressive effect on the right atrium and right ventricle and a large extracardiac mass with external pressure to mediastinal structures were seen on trans thoracic echocardiography. The emergency pericardiocentesis was performed with the diagnosis of cardiac tamponade. Also, CMR revealed a huge heterogeneous anterior mediastinal mass, and the pathology and the immunohistochemistry of the mass biopsy revealed gray zone lymphoma with positive CD3, CD20, CD30, CD45, PAX5, and negative CD15 expression. Three courses of chemotherapy with the CHOP regimen were performed with an acceptable response every three weeks before delivery. A caesarian section was performed at 37 weeks without any problem for the patient and fetus, and chemotherapy will be started three weeks after delivery.

CONCLUSION

Cardiac tamponade as an emergency condition occurred in this pregnant patient by malignant pericardial effusion and mediastinal mass pressure. Accurate diagnosis and on time interventions caused a significant improvement and a successful delivery.

Prevalence of anxiety and depressive disorders in pregnant women with malignancy

OBJECTIVE

To examine national-level prevalence of anxiety and depressive disorders among pregnant women with malignancy.

METHODS

This is a pre-planned secondary analysis of a previous retrospective cohort study using the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 14 648 135 deliveries including 10 145 patients with malignancy from 2016 to 2019. A multivariable binary logistic regression model was fitted to assess the association of malignancy and anxiety or depressive disorder.

RESULTS

Pregnant women with malignancy were 49% more likely to have the diagnosis of either anxiety or depressive disorder compared with those without malignancy (prevalence rate 114 vs. 61 per 1000 cases, adjusted odds ratio [aOR] 1.49, 95% confidence interval [CI] 1.40-1.58). The increase in the risk associated with malignancy on either anxiety or depressive disorder was more than two-fold among patients with brain and other nervous system tumors (aOR 2.69, 95% CI 2.01-3.60), bone and joint tumors (aOR 2.32, 95% CI 1.33-4.04), and leukemia (aOR 2.12, 95% CI 1.81-2.48).

CONCLUSIONS

This national-level analysis suggests that pregnant women with malignancy experience increased rates of psychological distress more often than pregnant women without malignancy.

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.

Management of Melanoma during Pregnancy: A Case Series of 11 Women Treated at NYU Langone Health

OBJECTIVES

Melanoma is one of the most common malignancies diagnosed during pregnancy. This study examined the impact of pregnancy on management decisions of melanoma patients treated at NYU Langone Health (NYULH).

METHODS

We analyzed data for patients who were pregnant at initial or recurrent melanoma diagnosis at NYULH from 2012 to 2019 with prospective protocol-driven follow-up.

RESULTS

Of the 900 female patients accrued during this period, 11 women in the childbearing range were pregnant at melanoma diagnosis. Six patients presented with early (stage 0 or I) disease and five with advanced (stage III or IV) melanoma. Women with early stage disease had normal deliveries and minimal changes to their treatment timeline and regimen. However, patients with more advanced stage disease opted for either termination of the pregnancy or early delivery and altered treatment timelines because of pregnancy.

CONCLUSION

Both melanoma stage and gestational age at diagnosis contribute to the differences in the therapeutic management of melanoma in pregnant women. Given the complexity and variety of each case of melanoma during pregnancy, informed discussion between patients and physicians allows for individualized treatment plans that address each patient's unique situation.

Experience of Japanese pregnant women with cancer in decision-making regarding cancer treatment and obstetric care

AIM

Women who are diagnosed with cancer during pregnancy must make difficult, life-changing decisions that affect their own life and that of their fetus. The psychological impact of distress and anxiety resulting from facing often conflicting choices can greatly influence survival in these women. We conducted this study to clarify the experience of pregnant women with cancer in decision-making and to consider the role of nurses in providing care to pregnant women with cancer during their decision-making.

METHODS

This qualitative study included post-partum Japanese women diagnosed with cancer who had made any treatment or pregnancy decisions. Data collection was conducted using semi-structured interviews and medical record review. Data were analyzed using qualitative content analysis and classified into subcategories, categories, themes, and phases.

RESULTS

Participants comprised eight women with leukemia and cervical, breast, and digestive cancers. The decision-making experiences of these eight pregnant women with cancer were categorized into three phases: the interaction between the woman and her fetus, family members, and medical staff; confrontation with dilemma and uncertainty; and redefinition of the women's own decisions.

CONCLUSIONS

The experience of Japanese pregnant women with cancer in decision-making has two aspects: verbal and nonverbal communication with their surroundings and reflection. The role of a nurse is to guarantee these women continuous communication channels and frank dialogue, to empower them in expressing their thoughts and informational needs to medical staff and family members.

Acceptable fetal dose using flattening filter-free volumetric arc therapy (FFF VMAT) in postoperative chemoradiotherapy of tongue cancer during pregnancy

Optimizing irradiation protocols for pregnant women is challenging, because there are few cases and a dearth of fetal dosimetry data. We cared for a 36-year-old pregnant woman with tongue cancer. Prior to treatment, we compared three intensity-modulated radiation therapy (IMRT) techniques, including helical tomotherapy, volumetric arc therapy (VMAT), and flattening-filter free VMAT (FFF-VMAT) using treatment planning software. FFF-VMAT achieved the minimum fetal exposure and was selected as the optimal modality. We prescribed 66 Gy to the involved nodes, 60 Gy to the tumor bed and ipsilateral neck, and 54 Gy to the contralateral neck over 33 fractions. To confirm the out-of-field exposure per fraction, surface doses and the rectal dose were measured during FFF-VMAT delivery. Postoperative chemoradiotherapy was delivered using IMRT and a cisplatin regimen. Without any shielding, the total fetal dose was 0.03 Gy, within the limits established by the ICRP. A healthy girl was born vaginally at 37 weeks' gestation.

Maternal and neonatal outcomes of cancer during pregnancy: a multi-center observational study

Cancer during pregnancy has increased because of the increased maternal age at the time of the first pregnancy and/or second child policy in China. The main purpose of the study is to report the existing data concerning the maternal and children's outcomes in pregnant women complicating cancer. In this multi-center, prospective cohort study, we compared women diagnosed with cancer during pregnancy and their children with matched women without cancer diagnoses. The primary outcomes were maternal and children's mortalities, as well as the Ages and Stages Questionnaires-3(ASQ) of children. A total of 80,524 pregnant women were screened. Of whom 83(0.1%) were diagnosed with cancer during pregnancy. Death occurs in 42.2% (35/83) women during follow-up. During pregnancy, 24 women terminated pregnancy before 28 weeks and among this 8(33.3%) died. Ten women received chemotherapy and 49 did not receive chemotherapy. Compared with the matched controls, there were less incidences of premature rupture of membrane (5.1% vs 35.6%, P=0.000) and more caesarean rates (84.7% vs 52.5%, P=0.001) and with higher pregnancy order (2.7±1.7 vs 2.0±1.0, P=0.007) in pregnant women with cancer. These women also had increased mortality compared with control group (45.8% vs 1.7%, P=0.000). Women who received chemotherapy had a statistically significant lower mortality rate when compared to the non-chemotherapy group (1:9 vs 26:23, P=0.016). However, there were no differences found in mortality of children and ASQ assessment between two groups. Chemotherapy may result in reduced mortality of women diagnosed with cancer during pregnancy, without affecting the mortality of children and ASQ-associated development.

High-Risk Adult Wilms' Tumour in Pregnancy: A Case Report

Wilms' tumour is the most common renal neoplasm in children with an incidence of 10 cases per 1 million children and a median age at diagnosis of 3.5 years. In Western countries its occurrence in adults is 0.2 cases per million people in western countries and carries a poorer prognosis. The co-existence of Adult Wilms' tumour and pregnancy is extremely rare with less than 20 cases published in the English literature. We present a case of a Malawian woman who had progressive high-risk metastatic Adult Wilms' tumour in pregnancy after nephrectomy, radiotherapy and two lines of chemotherapy.

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 in cancer patients and survivors; experience of a university hospital in Turkey

The aim of this study was to assess the obstetrical and neonatal outcomes of pregnancies in cancer patients and survivors. A retrospective analysis of 68 pregnancies with a history of cancer and 31 newly diagnosed pregnant cancer patients were included in the study. The mean birth weight and the mean gestational age at delivery were significantly lower in the pregnant cancer patients (p < .001). The incidences of delivery less than 34 weeks were 8.8% and 29.1% in the cancer survivors and cancer diagnosed during pregnancy groups respectively (p < .01). In 23 (76.4%) pregnant cancer patients, a single or a combination of treatment modalities was initiated. There were four (12.9%) maternal deaths in pregnant cancer patients. There were no early neonatal death and any congenital anomaly detected in the newborns. Pregnancy in cancer patients and cancer survivors has completely different clinical outcome. Pregnancy in cancer patients has increased the risk of pregnancy complication.

Current Evidence for Developmental, Structural, and Functional Brain Defects following Prenatal Radiation Exposure

Ionizing radiation is omnipresent. We are continuously exposed to natural (e.g., radon and cosmic) and man-made radiation sources, including those from industry but especially from the medical sector. The increasing use of medical radiation modalities, in particular those employing low-dose radiation such as CT scans, raises concerns regarding the effects of cumulative exposure doses and the inappropriate utilization of these imaging techniques. One of the major goals in the radioprotection field is to better understand the potential health risk posed to the unborn child after radiation exposure to the pregnant mother, of which the first convincing evidence came from epidemiological studies on in utero exposed atomic bomb survivors. In the following years, animal models have proven to be an essential tool to further characterize brain developmental defects and consequent functional deficits. However, the identification of a possible dose threshold is far from complete and a sound link between early defects and persistent anomalies has not yet been established. This review provides an overview of the current knowledge on brain developmental and persistent defects resulting from in utero radiation exposure and addresses the many questions that still remain to be answered.

Persistent Impact of In utero Irradiation on Mouse Brain Structure and Function Characterized by MR Imaging and Behavioral Analysis

Prenatal irradiation is known to perturb brain development. Epidemiological studies revealed that radiation exposure during weeks 8-15 of pregnancy was associated with an increased occurrence of mental disability and microcephaly. Such neurological deficits were reproduced in animal models, in which rodent behavioral testing is an often used tool to evaluate radiation-induced defective brain functionality. However, up to now, animal studies suggested a threshold dose of around 0.30 Gray (Gy) below which no behavioral alterations can be observed, while human studies hinted at late defects after exposure to doses as low as 0.10 Gy. Here, we acutely irradiated pregnant mice at embryonic day 11 with doses ranging from 0.10 to 1.00 Gy. A thorough investigation of the dose-response relationship of altered brain function and architecture following in utero irradiation was achieved using a behavioral test battery and volumetric 3D T2-weighted magnetic resonance imaging (MRI). We found dose-dependent changes in cage activity, social behavior, anxiety-related exploration, and spatio-cognitive performance. Although behavioral alterations in low-dose exposed animals were mild, we did unveil that both emotionality and higher cognitive abilities were affected in mice exposed to ≥0.10 Gy. Microcephaly was apparent from 0.33 Gy onwards and accompanied by deviations in regional brain volumes as compared to controls. Of note, total brain volume and the relative volume of the ventricles, frontal and posterior cerebral cortex, cerebellum, and striatum were most strongly correlated to altered behavioral parameters. Taken together, we present conclusive evidence for persistent low-dose effects after prenatal irradiation in mice and provide a better understanding of the correlation between their brain size and performance in behavioral tests.

Cancer during pregnancy and the postpartum period: A population-based study

BACKGROUND

The purpose of this study was to assess patterns of cancer occurrence during pregnancy and the postpartum period.

METHODS

This was a register-based study using data from the Swedish Multi-Generation Register and the National Cancer Register from 1963 to 2007. Pregnancy-associated cancer (PAC) was defined as a malignancy detected during pregnancy or within 2 years of delivery and was assessed in 7 time windows: pregnancy, trimesters 1-3, 0-6 months, 7-12 months, and second year postpartum. Population incidence rates by 5-year age groups and periods were used to estimate the expected number of PACs for each site. The observed versus the expected (O/E) number of cases was estimated with 95% confidence intervals (CI).

RESULTS

The 3 most common malignancies during pregnancy were melanoma (n = 232), breast (n = 139) and cervical cancer (n = 139). With a slightly different rank order, these cancers are also the most common in women of childbearing age. The number of observed cases during pregnancy was lower than expected for all cancers, with a combined O/E ratio for all sites of 0.46 (95% CI, 0.43-0.49). The O/E ratio was close to 1 during all postpartum intervals, including 0-6 months (0.93; 95% CI, 0.88-0.98), 7-12 months (0.96; 95% CI, 0.91-1.01), and during the second year after delivery (0.95; 95% CI, 0.92-0.99).

CONCLUSIONS

The rate of cancer during pregnancy was lower than expected for all sites, a finding that could not be explained entirely by delayed diagnosis. A rebound in the number of observed cases after delivery was restricted to melanoma, nervous system malignancies, and breast and thyroid cancer.

A multidisciplinary approach unravels early and persistent effects of X-ray exposure at the onset of prenatal neurogenesis

Background

In humans, in utero exposure to ionising radiation results in an increased prevalence of neurological aberrations, such as small head size, mental retardation and decreased IQ levels. Yet, the association between early damaging events and long-term neuronal anomalies remains largely elusive.

Methods

Mice were exposed to different X-ray doses, ranging between 0.0 and 1.0 Gy, at embryonic days (E) 10, 11 or 12 and subjected to behavioural tests at 12 weeks of age. Underlying mechanisms of irradiation at E11 were further unravelled using magnetic resonance imaging (MRI) and spectroscopy, diffusion tensor imaging, gene expression profiling, histology and immunohistochemistry.

Results

Irradiation at the onset of neurogenesis elicited behavioural changes in young adult mice, dependent on the timing of exposure. As locomotor behaviour and hippocampal-dependent spatial learning and memory were most particularly affected after irradiation at E11 with 1.0 Gy, this condition was used for further mechanistic analyses, focusing on the cerebral cortex and hippocampus. A classical p53-mediated apoptotic response was found shortly after exposure. Strikingly, in the neocortex, the majority of apoptotic and microglial cells were residing in the outer layer at 24 h after irradiation, suggesting cell death occurrence in differentiating neurons rather than proliferating cells. Furthermore, total brain volume, cortical thickness and ventricle size were decreased in the irradiated embryos. At 40 weeks of age, MRI showed that the ventricles were enlarged whereas N-acetyl aspartate concentrations and functional anisotropy were reduced in the cortex of the irradiated animals, indicating a decrease in neuronal cell number and persistent neuroinflammation. Finally, in the hippocampus, we revealed a reduction in general neurogenic proliferation and in the amount of Sox2-positive precursors after radiation exposure, although only at a juvenile age.

Conclusions

Our findings provide evidence for a radiation-induced disruption of mouse brain development, resulting in behavioural differences. We propose that alterations in cortical morphology and juvenile hippocampal neurogenesis might both contribute to the observed aberrant behaviour. Furthermore, our results challenge the generally assumed view of a higher radiosensitivity in dividing cells. Overall, this study offers new insights into irradiation-dependent effects in the embryonic brain, of relevance for the neurodevelopmental and radiobiological field.

Electronic supplementary material

The online version of this article (doi:10.1186/1866-1955-7-3) contains supplementary material, which is available to authorized users.