Imaging Cancer in Pregnancy

Chemotherapy drug combinations induced maternal ovarian damage and long-term effect on fetal reproductive system in mice

With the postponement of female reproductive age and the higher incidence of cancer in young people, fertility preservation has become increasingly important in childbearing age. Chemotherapy during pregnancy is crucial for maternal cancer treatments and fetal outcomes. It is a need to further study ovarian damage caused by chemotherapy drug combinations and long-term effects on offspring development, and a detailed understanding of side effects of chemotherapy drugs. In this study, chemotherapy drug combinations significantly impacted on ovarian function, especially epirubicin/cyclophosphamide (EC) combination led to an unbalance in the development of the left and right ovary. Exposure to EC and cisplatin/paclitaxel (TP) increased the number of progenitor follicles while decreased the count of antral follicles and corpora luteum. As to the estrus cycle, EC exposure resulted in a longer estrus period and diestrus period, while TP exposure only extended the diestrus period. EC and TP affected steroid biosynthesis by reducing the expression of SF1 and P450arom.γ-H2AX was detected in both EC and TP exposure groups. As to the impact on the offspring from 4T1 tumor-bearing pregnant mice injected with EC, no significant difference was observed in the physical and neurological development compared to the control, but the ovarian weights, estrus cycles of the offspring were significantly different. Chemotherapy drug combinations exhibit ovarian toxicity, not only causing direct damage on the follicle cells but also disrupting steroid biosynthesis. The reproductive system of offspring from maternal tumor-bearing mice exposed to chemotherapy drugs was observed disorder, but the concrete mechanism still needs further exploration.

Melanoma in Pregnancy-Diagnosis, Treatment, and Consequences for Fetal Development and the Maintenance of Pregnancy

Cutaneous malignant melanoma is one of the most common neoplasms among pregnancy-associated cancers (PACs). Risk factors include excessive exposure to ultraviolet radiation, the presence of benign and dysplastic nevi, and a patient or family history of melanoma. Self-examination and careful inspection of nevi are crucial, especially in the context of their progression over time. Physiological changes that occur during pregnancy, such as the darkening and enlargement of the nevi, delay the diagnosis of CMM. In the fetus, metastases are very rare, and if they do occur, they concern the placenta or fetal tissues. The choice of treatment is influenced by the cancer stage, symptoms, the time of termination of pregnancy, and the patient's decision. Essential procedures which are safe for the fetus are diagnostic biopsy, ultrasound, and the therapeutic excision of the lesion and the affected lymph nodes. Other imaging methods can be used with a safe radiation dose limit of 100 mGy. Immunotherapy and targeted treatments must be carefully considered, because of their possible adverse effects on the fetus. An interdisciplinary approach to the problem of melanoma during pregnancy is necessary, involving doctors of various specialties.

Cancer and Pregnancy in the Post-Roe v. Wade Era: A Comprehensive Review

Cancer during pregnancy, affecting 1 in 1000 pregnancies, is rising in incidence due to delayed childbearing and improved detection. Common types include breast cancer, melanoma and cervical cancer and Hodgkin's Lymphoma. There are several physiological changes that occur during pregnancy that make its management a challenge to clinicians. Managing it requires multidisciplinary approaches and cautious test interpretation due to overlapping symptoms. To minimize fetal radiation exposure, non-ionizing imaging is preferred, and the interpretation of tumor markers is challenging due to inflammation and pregnancy effects. In terms of treatment, chemotherapy is avoided in the first trimester but may be considered later. Immunotherapy's safety is under investigation, and surgery depends on gestational age and cancer type. Ethical and legal concerns are growing, especially with changes in U.S. abortion laws. Access to abortion for medical reasons is vital for pregnant cancer patients needing urgent treatment. Maternal outcomes may depend on the type of cancer as well as chemotherapy received but, in general, they are similar to the non-pregnant population. Fetal outcomes are usually the same as the general population with treatment exposure from the second trimester onwards. Fertility preservation may be an important component of the treatment discussion depending on the patient's wishes, age and type of treatment. This article addresses the complicated nature of a diagnosis of cancer in pregnancy, touching upon the known medical literature as well as the ethical-legal implications of such a diagnosis, whose importance has increased in the light of recent judicial developments.

Prediction of the Risk of Malignancy of Adnexal Masses during Pregnancy Comparing Subjective Assessment and Non-Contrast MRI Score (NCMS) in Radiologists with Different Expertise

Ovarian cancer represents 7% of all cancers in pregnant women. Characterising an ovarian mass during pregnancy is essential to avoid unnecessary treatment and, if treatment is required, to plan it accordingly. Although ultrasonography (US) is the first-line modality to characterise adnexal masses, MRI is indicated when adnexal masses are indeterminate at the US examination. An MRI risk stratification system has been proposed to assign a malignancy probability based on the adnexal lesion's MRI, but features of the scoring system require the administration of intravenous gadolinium-based contrast agents, a method that might have a limited use in pregnant women. The non-contrast MRI score (NCMS) has been used and evaluated in non-pregnant women to characterise adnexal masses indeterminate at the US examination. Therefore, we evaluated the diagnostic accuracy of the NCMS in pregnant women, analysing 20 cases referred to our specialised institution. We also evaluated the diagnostic agreement between two radiologists with different expertise. The two readers classified ovarian masses as benign or malignant using both subjective assessment (SA), based on the interpretive evaluation of imaging findings derived from personal experience, and the NCMS, which includes five categories where 4 and 5 indicate a high probability of a malignant mass. The expert radiologist correctly classified 90% of the diagnoses, using both SA and the NCMS, relying on a sensitivity of 85.7% and a specificity of 92.3%, with a false positive rate of 7.7% and a false negative rate of 14.3%. The non-expert radiologist correctly identified patients at a lower rate, especially using the SA. The analysis of the inter-observer agreement showed a K = 0.47 (95% CI: 0.48-0.94) for the SA (agreement in 71.4% of cases) and a K = 0.8 (95% CI: 0.77-1.00) for the NCMS (agreement in 90% of cases). Although in pregnant patients, non-contrast MRI is used, our results support the use of a quantitative score, i.e., the NCMS, as an accurate tool. This procedure may help less experienced radiologists to reduce the rate of false negatives or positives, especially in centres not specialised in gynaecological imaging, making the MRI interpretation easier and more accurate for radiologists who are not experts in the field, either.

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.

Pregnancy-associated Cancer and Chemotherapy during Pregnancy

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

Melanoma in pregnancy

Melanoma is one of the most common types of cancer diagnosed during pregnancy. Patients with advanced disease require frequent staging examinations (e.g., CT, PET, MRI, ultrasound), which, during pregnancy must be modified from routine protocol to minimize risk to the fetus. We will review the diagnostic and treatment approach to pregnant patients with melanoma, with a discussion and pictorial examples of imaging protocol modifications, and the appearance of metastatic melanoma on radiology exams using modified protocols due to pregnancy.

Medicolegal considerations associated with cancer during pregnancy

The management of pregnant patients with cancer is complex and requires a multidisciplinary team to effectively diagnose, stage, and manage the cancer while also being cognizant of the potential harm that diagnosis and treatment may have on the maternal and fetal well-being. Beyond the complex clinical management of these patients is additional medicolegal consideration. Radiologists play a crucial role in the management of these patients as their knowledge of diagnostic and interventional radiology techniques allows for appropriate and safe imaging for both the mother and fetus. In addition, radiologist are able to educate patient on the different imaging modalities and techniques, thus allowing patients to make informed decisions and maintain autonomy over there care. This article will review safety considerations associated with different imaging modalities, contrast agents, interventional radiology procedures and moderate sedation related to the imaging of pregnant patient with cancer with specific attention paid to the medicolegal aspects.

Noninvasive prenatal screening and maternal malignancy: role of imaging

Noninvasive prenatal screening (NIPS) tests for fetal chromosomal anomalies through maternal blood sampling. It is becoming widely available and standard of care for pregnant women in many countries. It is performed in the first trimester of pregnancy, usually between 9 and 12 weeks. Fragments of fetal cell-free deoxyribonucleic acid (DNA) floating in maternal plasma are detected and analyzed by this test to assess for chromosomal aberrations. Similarly, maternal tumor-derived cell-free DNA (ctDNA) released from the tumor cells also circulates in the plasma. Hence, the presence of genomic anomalies originating from maternal tumor-derived DNA may be detected on the NIPS-based fetal risk assessment in pregnant patients. Presence of multiple aneuploidies or autosomal monosomies are the most commonly reported NIPS abnormalities detected with occult maternal malignancies. When such results are received, the search for an occult maternal malignancy begins, in which imaging plays a crucial role. The most commonly detected malignancies via NIPS are leukemia, lymphoma, breast and colon cancers. Ultrasound is a reasonable radiation-free modality for imaging during pregnancy, specially when there are localizing symptoms or findings, such as palpable lumps. While there are no consensus guidelines on the imaging evaluation for these patients, when there are no localizing symptoms or clinically palpable findings, whole body MRI is recommended as the radiation-free modality of choice to search for an occult malignancy. Based on clinical symptoms, practice patterns, and available resources, breast ultrasound, chest radiographs, and targeted ultrasound evaluations can also be performed initially or as a follow-up for MRI findings. CT is reserved for exceptional circumstances due to its higher radiation dose. This article intends to increase awareness of this rare but stressful clinical scenario and guide imaging evaluation for occult malignancy detected via NIPS during pregnancy.

Effects of ionizing radiation exposure during pregnancy

PURPOSE

To review the effects of ionizing radiation to the conceptus and the relationship to the timing of the exposure during pregnancy. To consider strategies that would mitigate potential harms associated with exposure to ionizing radiation during pregnancy.

METHODS

Data reported in the peer-reviewed literature on entrance KERMA received from specific radiological examinations were combined with published results from experiment or Monte Carlo modeling of tissue and organ doses per entrance KERMA to estimate total doses that could be received from specific procedures. Data reported in the peer-reviewed literature on dose mitigation strategies, best practices for shielding, consent, counseling and emerging technologies were reviewed.

RESULTS

For procedures utilizing ionizing radiation for which the conceptus is not included in the primary radiation beam, typical doses are well below the threshold for causing tissue reactions and the risk of induction of childhood cancer is low. For procedures that include the conceptus in the primary radiation field, longer fluoroscopic interventional procedures or multiphase/multiple exposures potentially could approach or exceed thresholds for tissue reactions and the risk of cancer induction must be weighed against the expected risk/benefit of performing (or not) the imaging examination. Gonadal shielding is no longer considered best practice. Emerging technologies such as whole-body DWI/MRI, dual-energy CT and ultralow dose studies are gaining importance for overall dose reduction strategies.

CONCLUSION

The ALARA principle, considering potential benefits and risks should be followed with respect to the use of ionizing radiation. Nevertheless, as Wieseler et al. (2010) state, "no examination should be withheld when an important clinical diagnosis is under consideration." Best practices require updates on current available technologies and guidelines.

The radiologist's role in a multidisciplinary approach to cancer in pregnancy

Pregnancy-associated cancer (PAC) occurs in approximately 1 in 1000 pregnancies, and the incidence is expected to rise due to delayed childbearing (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020; Woitek et al. in ESMO Open 1:e000017, 2016). Diagnosis and management of PACs are challenging and diagnosis is often delayed as symptoms may overlap with physiologic changes of pregnancy (Jha et al. in RadioGraphics 42:220005, 2022). These patients are best cared for by a multidisciplinary healthcare team composed of experts (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020). Management of these patients must balance optimal maternal care with potentially harmful fetal effects. This involves honest, forthright, and sometimes difficult discussions between the care team and the patient throughout the entirety of care. Radiologists play a significant role in timely cancer diagnosis, staging and follow-up during and after pregnancy, accurate determination of gestational age, and in assessing fetal growth and well-being throughout pregnancy.

Cancer in pregnancy: treatment effects

PURPOSE

Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized.

METHODS

This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible.

RESULTS AND CONCLUSION

Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.

Gastrointestinal malignancies in pregnancy

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Cancer in pregnancy: overview and epidemiology

Cancer in pregnancy, one of the most distressing and demanding conditions in all of women's health care, occurs about 1:1000 pregnancies with an increasing incidence due to delayed childbearing. Diagnosis of pregnancy associated cancer is especially challenging because tumor symptoms may be masked by normal physiologic changes of pregnancy. The burden of care for both mother and child goes well beyond factual medical information. Balancing the potential risks and benefits to the mother and fetus necessitates a superior level of knowledge and expertise that includes epidemiology, pathophysiology, ionizing radiation and teratogenesis, risks and benefits of various imaging modalities, oncology, and radiotherapy, and other areas. Radiologists are an integral part of a multidisciplinary team that shares responsibility for selection of safe and effective diagnosis and management. Throughout the course of treatment, counseling and support are of paramount importance to the patient and her family. A compassionate culture of care bolsters the effectiveness of the care team to inform, counsel, and engage with the patient to achieve optimal outcomes. This special section of Abdominal Radiology is meant to offer insights for diagnostic imaging and its role in personalized management of this most serious and challenging condition. This article will provide an overview of imaging cancer in pregnancy and detail the relevant epidemiology.