Primary diagnosis of metastatic breast cancer in the third trimester of pregnancy: A case report and review of the literature

Multidisciplinary Management of Cancer During Pregnancy

Cancer during pregnancy is relatively rare but is increasing in frequency in countries in which the maternal child-bearing age continues to rise. The complexities of medical decision making are underscored by the need to weigh the potential benefits of any intervention for the mother against the risks to the fetus. A majority of diagnostic evaluations can be performed safely in the setting of pregnancy and should not be delayed. Noninvasive prenatal testing that shows discordance with fetal karyotype can be a clue to an underlying maternal malignancy. After diagnosis, a multidisciplinary team should formulate a care plan for both the mother and the fetus. Key topics for discussion should include the mother's prognosis, standard treatment plan, and predictions of how modifications for a continuing pregnancy will affect the treatment plan and overall prognosis. In the context of this knowledge, frank discussions about pregnancy termination should be addressed with the patient, if appropriate. Selection of a plan for oncologic management in the case of a pregnant woman is based on the type of cancer, the tumor biology, and the tumor stage. Additional complexities for pregnant patients are typically related to the gestational age of the fetus, the dynamic physiologic changes of pregnancy, and the limited safety data for administration of most anticancer therapies during pregnancy. In this article, we summarize data related to different classes of anticancer therapies as well as considerations for the management of selected cancers. Finally, we provide some key principles that should be considered in the management of patients with cancer during pregnancy.

Trastuzumab administration during pregnancy: un update

BACKGROUND

Over than one third (28-58%) of pregnancy-associated breast cancer (PABC) cases are characterized by positive epidermal growth factor receptor 2-positive (HER2) expression. Trastuzumab anti-HER2 monoclonal antibody is still the benchmark treatment of HER2-positive breast tumors. However, FDA has categorized Trastuzumab as a category D drug for pregnant patients with breast cancer. This systemic review aims to synthesize all currently available data of trastuzumab administration during pregnancy and provide an updated view of the effect of trastuzumab on fetal and maternal outcome.

METHODS

Eligible articles were identified by a search of MEDLINE bibliographic database and ClinicalTrials.gov for the period up to 01/09/2020; The algorithm consisted of a predefined combination of the words "breast", "cancer", "trastuzumab" and "pregnancy". This study was performed in accordance with the PRISMA guidelines.

RESULTS

A total of 28 eligible studies were identified (30 patients, 32 fetuses). In more than half of cases, trastuzumab was administered in the metastatic setting. The mean duration of trastuzumab administration during gestation was 15.7 weeks (SD: 10.8; median: 17.5; range: 1-32). Oligohydramnios or anhydramnios was the most common (58.1%) adverse event reported in all cases. There was a statistically significant decrease in oligohydramnios/anhydramnios incidence in patients receiving trastuzumab only during the first trimester (P = 0.026, Fisher's exact test). In 43.3% of cases a completely healthy neonate was born. 41.7% of fetuses exposed to trastuzumab during the second and/or third trimester were born completely healthy versus 75.0% of fetuses exposed exclusively in the first trimester. All mothers were alive at a median follow-up of 47.0 months (ranging between 9 and 100 months). Of note, there were three cases (10%) of cardiotoxicity and decreased ejection fraction during pregnancy.

CONCLUSIONS

Overall, treatment with trastuzumab should be postponed until after delivery, otherwise pregnancy should be closely monitored.

Use of trastuzumab in treating breast cancer during pregnancy: a systematic review and meta-analysis

Background

Trastuzumab is currently the standard treatment for human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, it is not recommended for HER2-positive breast cancer patients during pregnancy as it may jeopardize safety of the fetus. Nevertheless, there is evidence that fetuses exposed to trastuzumab in early stages of pregnancy remain healthy

Methods

To evaluate the possible effects of trastuzumab on fetus and provide evidence on the safety of trastuzumab in early pregnancy in HER2-positive breast cancer patients, we analyzed 22 studies involving 22 pregnant women and 23 fetuses.

Results

Based on the meta-analysis, the gestational week of exposure to trastuzumab is 0–34 weeks, the average duration of use is 17 weeks, and the average gestational week of delivery is 34.3 weeks. Complications occurred in 77.27% of patients during pregnancy and 56.52% of newborns。The main complication during pregnancy was anhydramnios (68.18%), while the main complications at birth were Respiratory distress or tachypnea (30%). After an average of 25.28 months of follow-up, 17.39% (4/23) of the children died. There was no complication during pregnancy or at birth in patients treated with trastuzumab during early pregnancy (P = 0.043). Patients older than 30 who received trastuzumab during pregnancy were more likely to have neonatal complications (OR = 7.778, 95%CI = 1.2–50.424, P = 0.04).

Conclusion

These results suggest that trastuzumab use during pregnancy can cause pregnancy,fetal and newborn complications. However, exposed to trastuzumab only in the first trimester are less likely to have pregnancy and fetal complications. Patients with gestational age below 30 years are less likely to have neonatal complications after trastuzumab during pregnancy. Terminating pregnancy should not be the only option for such patients. But more evidence is needed to verify this conclusion.

Trastuzumab in the Treatment of Pregnant Breast Cancer Patients - an Overview of the Literature

Breast cancer is one of the most common malignancies which appear during pregnancy. Since women are increasingly not giving birth until they are at a more advanced age, it can be assumed that the incidence of pregnancy-related breast cancers will continue to increase in the future. Because of pregnancy-induced changes and conservative diagnosis, these carcinomas are frequently not detected until they are at an advanced stage and thus generally require systemic adjuvant therapy. The available data on optimal chemotherapeutic management are limited. Particularly for the use of the target agent trastuzumab which could crucially contribute to improving the prognosis in the therapy of HER2-overexpressing breast cancer in non-pregnant women, there is a lack of definitive information regarding the profile of action and safety in pregnancy as well as with regard to any long-term effects on the child. Thirty-eight pregnancies on trastuzumab for the treatment of breast cancer were able to be analysed in the literature currently available. Information can be gained from this and conclusions can be drawn which can individualise and decisively improve therapeutic options in the future for the pregnant breast cancer patient.

Treatment of massive liver metastasis of breast cancer during pregnancy: first report of a complete remission with trastuzumab and review of literature

Background: Metastatic breast cancer diagnosis is the most common malignancy in pregnancy and the incidence of it has been increasing among the pregnant women due to advancing maternal age within the populations. However, there are limited data about the use of trastuzumab during pregnancy with conflicting results.Case history: A 37-year-old pregnant female patient was admitted to our hospital with the metastatic breast cancer diagnosis. An MRI study showed metastatic solid masses in all lobes and segments of the patient's liver. Patient was treated with weekly docetaxel and trastuzumab regimen from 22 to 34 weeks and labored electively at the 35th gestational week. Antenatal follow-up of the fetus showed all normal ranges without any complications. An abdominal MRI following the labor revealed complete clearance of liver metastasis.Conclusions: Use of trastuzumab during pregnancy is debated due to the limited number of cases reported in the literature. This article gives a summary of the existing data where the outcome was a complete remission in disease with normal fetal development during pregnancy.

Current approaches in the clinical management of pregnancy-associated breast cancer-pros and cons

Malignancies are one of the leading causes of mortality in women during their reproductive life. Treatment of gynecological malignant tumors during pregnancy is possible but not simple, since it creates a conflict between care of the mother and the fetus. BC is the most prevalent malignancy diagnosed in pregnancy, ranking up to 21% of all pregnancy-related malignancies. Due to its stets increasing prevalence, aggressive cancer subtype, and severe ethical and psychological aspects linked to the disease, experts raise an alarm for an acute necessity to improve the overall management of the PABC-the issue which has strongly motivated our current paper. Comprehensive research data and clinical experience accumulated in recent years have advanced our understanding of the disease complexity. PABC treatment must be individualized with an emphasis on optimal care of the mother, while observing standard treatment protocols with regard to safety of the fetus. Treatment protocols should be elaborated based on the individualized patient profile, bearing in mind the acute danger to the mother, maximizing the therapy efficacy and minimizing harmful effects to the fetus. Complex consulting on treatment options, their impacts on pregnancy and potential teratogenic effects requires tight "doctor-patient" collaboration. Complications that may arise due to the treatment of breast cancer in pregnancy require a multiprofessional expertise including oncologists, neonatologists, perinatologists, obstetricians, teratologists, and toxicologists, and an extensive psychological support throughout the pregnancy and after giving birth. Thereby, specifically psychological aspects of PABC diagnosis and follow-up are frequently neglected, being not yet adequately explored in the entire disease management approach. Herewith, we update the status quo regarding the currently available diagnostic modalities, complex treatment algorithms, and novel clinical approaches which altogether argue for an urgent necessity of a paradigm shift moving away from reactive to predictive, preventive, and personalized medical approach in the overall management of PABC meeting the needs of young populations, persons at high risk, affected patients, and families as the society at large.

Management of pathological femoral fracture secondary to breast cancer in pregnancy: A case report

Bone metastasis resulting from breast cancer in pregnancy is rare. In the literature there are few reports regarding osteolytic lesions in pregnancy and no data on the treatment of such femoral fractures. The present study reports a case of a 29-week primigravida presenting with severe lumbosciatica in the left side, refractory to medical therapy. During neurosurgical examination a spontaneous pathological fracture of the left femur occurred. Damage control orthopedic principals were applied and a biopsy specimen from the femoral lesion was obtained, providing a diagnosis of metastases from breast adenocarcinoma. Cesarean section was performed at 32 gestational weeks. Following delivery, an internal fixator was placed in the left femur for definitive treatment of the fracture and staging of cancer was conducted. Subsequently, adjuvant treatment comprising left mastectomy and percutaneous radiofrequency thermoablation of the sacroiliac lesion were performed. A follow-up one-year following percutaneous radiofrequency thermoablation of the sacroiliac lesion detected no metastatic bone pain, and identified a stable sacroiliac lesion.

Advanced thyroid carcinoma in pregnancy: case report of two pregnancies

Differentiated thyroid carcinoma is one of the most frequently diagnosed cancers during pregnancy, second only to breast cancer. Therefore, it would be of value to determine if there are pregnancy-related physiological effects that impact long-term prognosis for patients with this disease. Hormone effects attributable to β-human chorionic gonadotropin and estrogens seem particularly likely. We present a case of a 40-year-old woman with thyroid follicular carcinoma with accompanying bone metastases. The cancer was discovered immediately after childbirth and the woman became pregnant again when the disease was in an advanced stage. We describe the cancer evolution and present the maternal and fetal results. Pregnancy in women with advanced thyroid carcinoma could affect long-term prognosis. However, more studies are needed to evaluate this hypothesis. In this unique case, there were two pregnancies and the second occurred in an advanced state of the disease. We evaluated how these pregnancies could affect short-term prognosis of the disease.

Neurology of pregnancy

Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.

Are monoclonal antibodies a safe treatment for cancer during pregnancy?

Monoclonal antibodies (mAbs) are the cornerstone of the treatment of several types of tumors, but their use in pregnant women is not clearly defined. Here, we report and analyze all available data on mAb treatment in pregnant cancer patients. A literature search was performed from 2000 until January 2013 and all articles addressing safety of mAbs during pregnancy were reviewed. We found very few data on the use of bevacizumab in pregnant women. However, owing to its antiangiogenic effects and possible consequences on fetal development, it should be avoided during pregnancy. Trastuzumab administration has been associated with an elevated incidence of oligohydramnios and poor neonatal outcomes, particularly when prescribed after the first trimester for repeated infusions, and therefore it is not recommended. Rituximab does not seem to be teratogenic, but a transient prolonged neutropenia in the newborns was reported, without major infectious consequences in most cases. Few data are available about other mAbs, and hence their use during pregnancy remains discouraged.