Glioma in the third trimester of pregnancy: Two cases and a review of the literature

Awake craniotomy during pregnancy: A systematic review of the published literature

Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.

Clinical management of brain tumors in pregnancy

PURPOSE OF REVIEW

We review the diagnostic tools, treatment options, and clinical management for brain tumors diagnosed in pregnancy with consideration for management approaches that are best suited to preserve maternal and fetal health.

RECENT FINDINGS

Women of child-bearing age are at risk of developing brain tumors and are at increased risk compared with male counterparts for tumors that are hormonally driven. Brain tumors are rare neoplasms, and diagnosis of brain tumors in pregnancy is uncommon, such that management guidelines and treatment recommendations are lacking for most tumor types. We discuss the standard treatment options for brain tumors and the relative risks and safety when these treatments are considered during pregnancy. We review the neoplasms most commonly affecting pregnant women and the existing literature and guidelines.

SUMMARY

Pregnancy is a unique phase of life in which hormonal, immunologic, and vascular changes may impact tumor growth and presentation. Treatment decisions should consider the symptoms and stability of the pregnant patients, the gestational age and health of the fetus, and the location and behavior of the neoplasm.

Malignant transformation of pleomorphic xanthoastrocytoma in pregnant patient: Clinical case and ethical dilemma

Background:

Pleomorphic xanthoastrocytoma (PXA) is a rare astrocytic tumor, accounting for <1% of astrocytic tumors. Due to its rarity, etiology, natural history, and biologic behavior is not completely explained. We present a case of malignant transformation of a PXA to glioblastoma in pregnant patient 6 month after tumor biopsy.

Case Description:

A 28-year-old female patient was presented with a newly onset of headache, nausea, and right-sided hemiparesis at 21^st week of pregnancy. Magnetic resonance imaging (MRI) revealed cystic mass in the left frontal region. Patient underwent biopsy to confirm pathohistological analysis; the tumor tissue corresponded to an anaplastic PXA. Two weeks after initial biopsy, open surgery along with gross total tumor removal was performed confirming pathohistological analysis. Six months later, after childbirth, and control MRI revealed a recurrent tumor mass: the patient underwent surgical resection and the tumor tissue corresponded to a glioblastoma. The patients were further treated with radiation and chemotherapy according to oncologist.

Conclusion:

Distinguishing between PXA patients who have a good prognosis and those at risk for early progression is very important for the PXA clinical management. Despite cellular pleomorphism, mitotic index and the extent of resection are shown to be the main predictors for recurrence-free survival and overall survival rates. The standard therapy management is not yet established. Our patient treatment was associated with a significant ethical dilemma. Respecting patient’s wishes to deliver a baby, nor radio or chemo treatments were done. Further studies are necessary to provide factors responsible for malignant transformation of PXA. In addition, in ethically sensitive situation, such as tumor in pregnant patient, good communication, respecting patient’s wishes, and a multidisciplinary teamwork is the key for better outcome.

Ethical and therapeutic dilemmas in glioblastoma management during pregnancy: Two case reports and review of the literature

Introduction:

There are no guidelines about the management of glioblastoma multiforme (GBM) during pregnancy: treatment of these patients presents therapeutic and ethical challenges.

Case Description:

Two patients, respectively, 28 years old at the 14^th week of gestation with a thalamic GBM and 38 years old at the 28^th week of gestation with fronto-mesial GBM. Patients and their relatives were deeply informed about the natural history of GBM and potential risks and benefits of surgery, radiotherapy (XRT), and chemotherapy (CTX) for both, mother and fetus. The first patient’s will was to preserve her fetus from any related, even minimal, risk of XRT, and CTX until safe delivery despite progression of GBM, accepting only surgery (tumor debulking and shunting of hydrocephalus). The second one asked to deliver the baby as soon as possible (despite the risks of prematurity) to receive the standard treatments of GBM. The two patients survived, respectively, 16 and 46 months after delivery. The first patient’s son is in good clinical conditions; the second one suffered problems linked to prematurity.

Conclusions:

Standard treatment of GBM in a pregnant woman could improve the mother’s survival but can expose the fetus to several potential risks. Ethically, relatives should understand that mother has anyway a poor prognosis and, at the same time, fetus prognosis depends on mother’s condition and therapy. It is not possible to warrant absence of risk for both. Considering the absence of guidelines and the relatively poor current data available about management of GBM in a pregnant woman, after a deep explanation of the situation, we think that the will of the mother and her relatives should prevail.

Clinical challenges of glioma and pregnancy: a systematic review

INTRODUCTION

This review aims to summarize challenges in clinical management of concomitant gliomas and pregnancy and provides suggestions for this management based on current literature.

METHODS

PubMed and Embase databases were systematically searched for studies on glioma and pregnancy. Observational studies and articles describing expert opinions on clinical management were included. The strength of evidence was categorized as arguments from observational studies, consensus in expert opinions, or single expert opinions. Risk of bias was assessed by the Newcastle-Ottawa Scale (NOS).

RESULTS

27 studies were selected, including 316 patients with newly diagnosed (n = 202) and known (n = 114) gliomas during pregnancy. The median sample size was 6 (range 1-65, interquartile range 1-9). Few recommendations originated from observational studies; the remaining arguments originated from consensus in expert opinions.

CONCLUSION

Findings from observational studies of adequate quality include (1) There is no known effect of pregnancy on survival in low-grade glioma patients; (2) Pregnancy can provoke clinical deterioration and tumor growth on MRI; (3) In stable women at term, there is no benefit of cesarean section over vaginal delivery, with respect to adverse events in mother or child. Unanswered questions include when pregnancy should be discouraged, what best monitoring schedule is for both mother and fetus, and if and how chemo- and radiation therapy can be safely administered during pregnancy. A multicenter individual patient level meta-analysis collecting granular information on clinical management and related outcomes is needed to provide scientific evidence for clinical decision-making in pregnant glioma patients.

Interactions between glioma and pregnancy: insight from a 52-case multicenter series

OBJECTIVE The goal of this study was to provide insight into the influence of gliomas on gestational outcomes, the impact of pregnancy on gliomas, and the identification of patients at risk. METHODS In this multiinstitutional retrospective study, the authors identified 52 pregnancies in 50 women diagnosed with a glioma. RESULTS For gliomas known prior to pregnancy (n = 24), we found the following: 1) An increase in the quantified imaging growth rates occurred during pregnancy in 87% of cases. 2) Clinical deterioration occurred in 38% of cases, with seizures alone resolving after delivery in 57.2% of cases. 3) Oncological treatments were immediately performed after delivery in 25% of cases. For gliomas diagnosed during pregnancy (n = 28), we demonstrated the following: 1) The tumor was discovered during the second and third trimesters in 29% and 54% of cases, respectively, with seizures being the presenting symptom in 68% of cases. 2) The quantified imaging growth rates did not significantly decrease after delivery and before oncological treatment. 3) Clinical deterioration resolved after delivery in 21.4% of cases. 4) Oncological treatments were immediately performed after delivery in 70% of cases. Gliomas with a high grade of malignancy, negative immunoexpression of alpha-internexin, or positive immunoexpression for p53 were more likely to be associated with tumor progression during pregnancy. Deliveries were all uneventful (cesarean section in 54.5% of cases and vaginal delivery in 45.5%), and the infants were developmentally normal. CONCLUSIONS When a woman harboring a glioma envisions a pregnancy, or when a glioma is discovered in a pregnant patient, the authors suggest informing her and her partner that pregnancy may impact the evolution of the glioma clinically and radiologically. They strongly advise a multidisciplinary approach to management. ■ CLASSIFICATION OF EVIDENCE Type of question: association; study design: case series; evidence: Class IV.

Advanced case of glioblastoma multiforme and pregnancy. An ethical dilemma

Glioblastoma multiforme (GBM) is the most common and malignant form of the glial tumors. Advanced and treated GBM is rarely associated with pregnancy for many reasons. Glioblastoma multiforme presenting during pregnancy carries unique challenges to the patient, baby, family, and health care providers. We describe an unusual case of advanced GBM that was treated with maximum doses of chemotherapy and radiations, and she became pregnant and presented at eighteenth weeks of gestation. Her medical management was associated with a significant ethical dilemma. We managed to deliver the baby safely through cesarean section at week 28 despite the critical condition of the mother. Unfortunately, the mother died 2 weeks post delivery. We concluded that although recurrent and treated GBM is rarely associated with pregnancy and carries dismal prognosis, but if it occurs, it can still be carried, and a multidisciplinary team work is the key for successful outcome.