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Abstract
PURPOSE OF REVIEW Pregnancy-associated lymphoma (PAL) is an uncommon entity that lacks detailed prospective data. It poses significant management challenges that incorporate maternal and fetal risks associated with treatment or delayed intervention. Herein, we review the current literature for the diagnosis, management, and supportive care strategies for PAL. RECENT FINDINGS Establishment of a multidisciplinary team, including hematology-oncology, maternal-fetal medicine, and neonatology, is critical in the management of PAL. For staging, ultrasound and MRI are preferred modalities with use of computerized tomography in select situations. Data for the safety and effectiveness of therapy for PAL is largely based on retrospective studies. The timing of lymphoma-directed antenatal systemic therapy depends on the trimester, gestational age, lymphoma subtype and aggressiveness, and patient wishes. Therapy in the first trimester is usually not advocated, while treatment in the second and third trimesters appears to result in similar outcomes for PAL compared with non-pregnant patients with lymphoma. An overarching goal in most PAL cases should be to plan for delivery at term (i.e., gestational age > 37 weeks). For supportive care, most antiemetics, including agents such as neurokinin-1 receptor antagonists, have been used safely during pregnancy. For prevention or treatment of infections, particular antibiotics (i.e., macrolides, cephalosporins, penicillins, metronidazole), antivirals (i.e., acyclovir, valacyclovir, famciclovir), and antifungals (amphotericin B) have demonstrated safety and with use of growth factors reserved for treatment of neutropenia (vs. primary prophylaxis). Therapy for PAL should be individualized with goals of care that balance maternal and fetal well-being, which should include a multidisciplinary care team and overall intent for term delivery in most cases.
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Murgia F, Marinaccio M, Cormio G, Loizzi V, Cicinelli R, Bettocchi S, Cicinelli E. Pregnancy related cancer in Apulia. A population based linkage study. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100025. [PMID: 31404420 PMCID: PMC6687370 DOI: 10.1016/j.eurox.2019.100025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/25/2019] [Accepted: 04/16/2019] [Indexed: 12/18/2022] Open
Abstract
Objective Despite a quite large number of papers in literature, the current incidence of pregnancy associated cancer still remains uncertain. Moreover, different inclusion criteria and time intervals considered after delivery make these data poorly comparable. The aim of this study was to investigate the incidence of PACs in Apulia, an Italian region, while stressing differences or similarities with other populations. Study design We collected 682,173 pregnancies from national discharge forms, regarding hospitals in Apulia from January 2003 to December 2015. Our aim was not only to obtain the raw incidence of PACs but also to estimate the odds ratio (OR) for some potential risk predictors such as calendar year, age, nationality and pregnancy outcome using a logistic model. Women were sorted into different groups by age (<30, 30–34, 35–39, >=40) and by nationality (Italian or foreign nationals). Each pregnancy had two possible outcomes: delivery or abortion. Results We achieved a final cohort of 867 PACs: therefore, the raw incidence is 127.1 per 100,000 pregnancies. Breast cancer was the most common cancer (37.7 cases per 100,000 pregnancies) and as a typical feature in our population thyroid cancers followed it by incidence (22.3 per 100,000 pregnancies). Cervical cancer is, as expected, the first gynaecological cancer by incidence(3.8 per 100,000). Younger women have the lowest risk for PACs (64.5 per 100,000, OR = 1) while the highest risk for PACs was for women aged >=40 years (OR = 4.29, p < 0.05). Considering calendar years, we observed an increased OR from 2006 to 2009 (OR = 1.39 and OR = 1.41 respectively) without spotting a trend throughout the whole decade. Conclusions The ranking of each tumour by incidence more or less reflects its demographics in reproductive age females in western countries and the incidence for any cancer is expected to grow as the rate of first deliveries in older women continues to rise. We reported noticeable differences regarding the incidence of some cancers (such as thyroid cancer) with previous literature, reflecting an epidemiologic feature of our cohort. Women older than 40 years have a more than fourfold risk for oncologic diagnosis during pregnancy, and this finding is of pivotal clinical and social importance because of the tendency of women living in developed countries to postpone childbearing.
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Affiliation(s)
- Ferdinando Murgia
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Marco Marinaccio
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Gennaro Cormio
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Vera Loizzi
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Rossana Cicinelli
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Stefano Bettocchi
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
| | - Ettore Cicinelli
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncological Science (DIMO), University of Bari, 70124, Bari, Italy
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Moshe Y, Bentur OS, Lishner M, Avivi I. The management of hodgkin lymphomas in pregnancies. Eur J Haematol 2017; 99:385-391. [DOI: 10.1111/ejh.12956] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Yakir Moshe
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Ohad Shimshon Bentur
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
| | - Michael Lishner
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Department of Medicine A; Meir Medical Center; Kfar Saba Israel
| | - Irit Avivi
- Department of Hematology and Bone Marrow Transplantation; Tel Aviv Sourasky Medical Center; Tel Aviv Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Vlijm-Kievit A, Jorna NGE, Moll E, Pajkrt E, Pals ST, Middeldorp S, Biemond BJ, Zeerleder SS, Tio MA, Kemper EM, Hazenberg MD. Acute lymphoblastic leukemia during the third trimester of pregnancy. Leuk Lymphoma 2017; 59:1274-1276. [DOI: 10.1080/10428194.2017.1375104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Anniek Vlijm-Kievit
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nori G. E. Jorna
- Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Etelka Moll
- Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven T. Pals
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J. Biemond
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha S. Zeerleder
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Immunopathology, Sanquin Research, Amsterdam, The Netherlands
| | - Marieke A. Tio
- Department of Pharmacy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - E. Marleen Kemper
- Department of Pharmacy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mette D. Hazenberg
- Department of Hematology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Peccatori FA, Codacci-Pisanelli G, Del Grande M, Scarfone G, Zugni F, Petralia G. Whole body MRI for systemic staging of breast cancer in pregnant women. Breast 2017; 35:177-181. [PMID: 28756339 DOI: 10.1016/j.breast.2017.07.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 12/16/2022] Open
Abstract
When breast cancer is diagnosed during pregnancy, treatment should be as close; as possible to what is used in non-pregnant patients. This requires accurate local and systemic staging: ultrasound (US) is used for local staging and allows adequate evaluation of the liver and pelvis, but chest and bones cannot be explored and imaging techniques involving exposure to ionizing radiation would be needed. However, since imaging techniques involving ionizing radiation and the use of radionuclides should be limited, whole body magnetic resonance imaging (WB-MRI) without administration of contrast agent represents a very interesting alternative, but limited data is available. In this paper we describe the obstetrical and oncological outcome of 14 patients in whom breast cancer was diagnosed during the second or third trimester of pregnancy and that were staged using WB-MRI. Median age of the patient at diagnosis was 35 years (range 20-36), median gestational age at MRI was 30 weeks (range 13-32) and median age at delivery was 38 weeks (range 32-38). At birth, one new-born presented respiratory distress syndrome and one jaundice. We conclude that diffusion-weighted MRI is feasible accurate and safe for the mother and for the foetus. It may represent the staging technique of choice in pregnant women diagnosed with breast cancer after the first trimester of pregnancy.
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Affiliation(s)
- Fedro A Peccatori
- Fertility and Procreation Unit, Department of Gynaecological Oncology, European Institute of Oncology (IEO), Milan, Italy
| | | | - Maria Del Grande
- Fertility and Procreation Unit, Department of Gynaecological Oncology, European Institute of Oncology (IEO), Milan, Italy
| | - Giovanna Scarfone
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Zugni
- Post-graduation School in Radiodiagnostics, University of Milan, Italy
| | - Giuseppe Petralia
- Department of Radiology, European Institute of Oncology (IEO), Milan, Italy
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Abstract
The diagnosis and management of hematologic malignancy during pregnancy is a significant challenge. This is due to both medical and ethical considerations regarding when and how to treat this special sub-group of patients. Recurring uncertainties remain around appropriate imaging techniques, timing and dosage of chemotherapy, and timing of delivery. In this article we examine and summarize current literature in this field to assist physicians in their understanding and management of this patient group. Special attention has been given to diagnostic and staging procedures, risks associated with chemotherapy at different stages of gestation, and chemotherapy-dose adaption during pregnancy. In addition, recommended guidelines for management of lymphoma, leukemia, and planning delivery are discussed. A multidisciplinary team approach is critical for patient care, as is shared decision making with the patient and family.
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Manage haematological malignancies during pregnancy according to cancer type and gestational stage. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zagouri F, Dimitrakakis C, Marinopoulos S, Tsigginou A, Dimopoulos MA. Cancer in pregnancy: disentangling treatment modalities. ESMO Open 2016; 1:e000016. [PMID: 27843602 PMCID: PMC5070264 DOI: 10.1136/esmoopen-2015-000016] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 01/25/2023] Open
Abstract
Pregnancy-associated cancer constitutes an uncommon and difficult to manage clinical situation. It is defined as the cancer diagnosed from the first day of childbearing to 1 year post partum. Coexistence of cancer with pregnancy adds complexity to treatment recommendations, as both the mother and the fetus may be affected. The optimal therapeutic management of pregnant women with cancer diagnosis should take into account, apart from medical factors, a host of other parameters (ethical, psychological, religious, legal, etc). Unfortunately, this situation becomes more complex as more women delay childbearing, and consequently the incidence of cancer during pregnancy is constantly increasing. This manuscript summarises the general principles in managing pregnant patients with cancer and gives detailed instructions in the management of pregnant patients with breast cancer, ovarian cancer, melanoma, lymphoma, lung cancer, soft-tissue sarcoma and cervical cancer. Of note, management of pregnant women with cancer diagnosis should be performed in specialised centres with experience and all cases should be discussed in multidisciplinary meetings composed of multiple specialists (medical oncologists, obstetricians, surgeons, radiologists and paediatricians).
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Affiliation(s)
- Flora Zagouri
- Department of Clinical Therapeutics , Alexandra Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Constantine Dimitrakakis
- Department of Obstetrics and Gynecology , Alexandra Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Spyridon Marinopoulos
- Department of Obstetrics and Gynecology , Alexandra Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Alexandra Tsigginou
- Department of Obstetrics and Gynecology , Alexandra Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Meletios-Athanassios Dimopoulos
- Department of Clinical Therapeutics , Alexandra Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
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Houghtelin AB, Kopp LM, Pelayo-Katsanis L, Kuo PH, Yeager AM, Katsanis E. Extramedullary Breast Relapse of Acute Lymphoblastic Leukemia Controlled with a Second Allogeneic/Autologous Hematopoietic Cell Transplant. J Adolesc Young Adult Oncol 2015; 4:50-3. [PMID: 26812431 DOI: 10.1089/jayao.2014.0018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Relapse of acute lymphoblastic leukemia (ALL) in the breast is uncommon and often precedes systemic relapse, resulting in poor survival. We report the development of breast involvement of ALL in a 20-year-old woman 32 months after a related allogeneic peripheral blood hematopoietic cell transplantation (PBHCT) in first remission. This extramedullary relapse occurred in the continuous presence of complete donor chimerism. After systemic re-induction chemotherapy and a second PBHCT using donor cells that had been cryopreserved at first transplant, our patient has remained in second complete remission for more than 44 months.
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Affiliation(s)
- Amy B Houghtelin
- 1 Department of Pediatrics, University of Arizona , Tucson, Arizona
| | - Lisa M Kopp
- 2 Division of Hematology/Oncology/BMT, Department of Pediatrics, University of Arizona , Tucson, Arizona
| | | | - Philip H Kuo
- 4 Department of Medical Imaging, University of Arizona , Tucson, Arizona
| | - Andrew M Yeager
- 5 Division of Hematology/Oncology, Department of Medicine, University of Arizona , Tucson, Arizona
| | - Emmanuel Katsanis
- 2 Division of Hematology/Oncology/BMT, Department of Pediatrics, University of Arizona , Tucson, Arizona
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Quigley J, Keating A, Byrd L. Fatigue and breathlessness in pregnancy: a rare and sinister cause. BMJ Case Rep 2014; 2014:bcr-2014-205441. [PMID: 25323281 DOI: 10.1136/bcr-2014-205441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a rare but sinister presentation of fatigue and dyspnoea in a 39-year-old woman at 16 weeks gestation. Blood tests and bone marrow aspirate confirmed the diagnosis of multiple myeloma. The patient was managed expectantly during pregnancy with plasma exchange and blood transfusion. The pregnancy continued without event; labour was induced at 35 weeks gestation and a healthy female infant weighing 3100 g was delivered vaginally following a 2 h, 5 min labour. The patient subsequently underwent six cycles of cyclophosphamide, thalidomide and dexamethasone (CTD) chemotherapy followed by an autologous stem cell transplant (SCT) and reduced intensity conditioning matched unrelated donor (RIC MUD) transplant.
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Affiliation(s)
| | | | - Louise Byrd
- St. Mary's Hospital, Manchester Royal Infirmary, Manchester, UK
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