Non-Hodgkin's lymphoma and pregnancy

Non-Hodgkin's lymphoma (NHL) is infrequently diagnosed during pregnancy. Most NHL's complicating pregnancy are aggressive and disseminated. This presentation together with the possible teratogenecity of diagnostic methods dictate a limited staging workup during pregnancy. Although prognosis had been reported to be poor, there is recent evidence to suggest that when properly treated, pregnancy does not affect the course of lymphoma. The risk to the fetus can also be reduced by an appropriate therapeutic approach.

Cisplatin protein binding in pregnancy and the neonatal period

The most effective combination regimes for ovarian cancer contain cisplatin, but there is little knowledge about cisplatin use during pregnancy. The high protein binding of cisplatin means that small changes in protein binding result in large changes in the fraction of free drug. It is the free form of cisplatin that crosses the placenta and may contribute to fetal toxicity. The purpose of the present study was to compare protein binding of cisplatin in pregnant women, non-pregnant women, and newborn infants. We found that babies and pregnant women had significantly lower concentrations of both protein and albumin compared to non-pregnant women. Analysis of variance found overall significant differences in protein binding among the three groups over time (P < .05). Babies had statistically less cisplatin protein binding than non-pregnant women at 80 minutes and all time points thereafter (P < .05). In contrast, pregnant women had statistically less cisplatin protein binding than non-pregnant women at 3.3 and 8 hours (P < .05). Of interest, at 75.2 hours, the percentage of free cisplatin was 15% in babies as compared with 9% in non-pregnant women and 10% in pregnant women. This means that the fetus is exposed to 50% higher platinum levels at equal total concentration. Cisplatin protein binding significantly correlated with albumin concentrations at 3.3, 8, and 24 hours (P < .01). Our analysis reveals that pregnancy and fetal changes in cisplatin protein binding are caused in large part by lower albumin levels. The resulting higher levels of free drug in the mother and fetus may increase the risk of toxicity in both.

Teratogenicity and carcinogenicity in a twin exposed in utero to cyclophosphamide

A 29-year-old pregnant woman diagnosed with acute lymphocytic leukemia maintained remission with daily cyclophosphamide and intermittent prednisone treatment. She delivered a male twin with multiple congenital abnormalities who was diagnosed with papillary thyroid cancer at 11 years of age and stage III neuroblastoma at 14 years of age. The female twin was unaffected and has exhibited normal development to date. First trimester exposure to cyclophosphamide has been associated with major malformations. Metabolites of cyclophosphamide have been demonstrated to be teratogens and carcinogens in animals. Differences in placental or fetal hepatic cytochrome P-450 may account for the variability in response between the twins. In addition, disparity between the twins may be the result of differences in metabolite inactivating enzymes present either in fetal liver or placenta. The risk of second malignancies caused by alkylating agents such as cyclophosphamide has been well documented in adults and children but to the best of our knowledge this is the first description of transplacental second cancer.

Maternal and fetal outcome after breast cancer in pregnancy

We compared 118 women with breast cancer (119 pregnancies) with 269 nonpregnant control subjects matched on important prognostic factors. The distribution of breast cancer stages among the 118 pregnant women was compared with that among 5115 cases of breast cancer in women of reproductive age. Fetal outcome was compared with that of a control group matched for maternal age. Women having breast cancer in pregnancy were 2.5 times more likely to have metastatic disease (95% confidence interval 1.1 to 5.3) and had a significantly lower chance of having stage I disease (p = 0.015). Survival of pregnant women did not differ from that of the controls. Birth weights of babies born to women with breast cancer were significantly lower than those of control babies after gestational age was adjusted for (3010 +/- 787 vs 3451 +/- 515 gm, p = 0.016). The two stillbirths in 85 pregnancies that continued to term (2.4%) was not statistically different from the 1.1% rate for Ontario. We analyzed all 223 births occurring in women who had any form of cancer in the same hospital during the same 30 years. There were 10 stillbirths among these 223 cases (4.4%), significantly more than expected in Ontario (p less than 0.0005; relative risk of 4.23 with 95% confidence interval 2.0 to 7.8). Our data suggest that pregnant women are at a higher risk of presenting with advanced disease because pregnancy impedes early cancer detection.

Fetal outcome after in utero exposure to cancer chemotherapy

BACKGROUND

Cancer is the second leading cause of death of women during the reproductive years, and its occurrence in pregnancy is between 0.07% and 0.1%.

METHODS

To analyze the effect of cancer on pregnancy, we compared 21 pregnancies occurring during 30 years in women who received chemotherapy for their cancer with a control group matched for maternal age and composed of women not exposed to known teratogens or reproductive risks during pregnancy.

RESULTS

Of 13 women exposed to chemotherapy during the first trimester, two of five whose pregnancies continued to term had major malformations in their infants, four had spontaneous abortions, and four had therapeutic abortions. Of four women with second-trimester exposure to chemotherapy, two had normal live births, one had a stillbirth, and one had a therapeutic abortion. All four pregnancies exposed to chemotherapy during the third trimester resulted in healthy live births. Infants exposed to chemotherapy had statistically significantly lower birth weights than their matched controls (2227 +/- 558 g vs 3519 +/- 272 g, P less than .001), due to both significantly lower gestational age and substantial intrauterine growth retardation (P less than .01). The trend for higher rate of stillbirth (1/11) agrees well with 10 stillbirths among all women with cancer in pregnancy without and with chemotherapy who gave birth (n = 223), when compared with the population of Ontario (P less than .0005).

CONCLUSIONS

This study confirms the increased likelihood of spontaneous abortions and major birth defects when chemotherapy is used during embryogenesis, whereas such a risk is not apparent beyond the first trimester. Because of the higher risk of stillbirth and intrauterine growth retardation, women with cancer should be monitored closely by a high-risk obstetric unit to define the optimal time of delivery.

Maternal and foetal outcome following Hodgkin's disease in pregnancy

The peak incidence of Hodgkin's disease occurs during the reproductive age, and its association with pregnancy is at a rate of between 1:1,000-1:6,000. We studied the effects of Hodgkin's Disease on the course and survival of 48 women who had Hodgkin's Disease and who were pregnant, and compared their outcome with non-pregnant matched women who were of similar stage of disease, age at diagnosis, and calenderic year of treatment. Twenty-year survival of pregnant women with Hodgkin's Disease was not different from that of their matched controls. Pregnant women with Hodgkin's Disease had similar distribution of stages to the controls.

Maternal and fetal outcome after invasive cervical cancer in pregnancy

Invasive carcinoma of the cervix is the most common gynecologic malignancy to occur during the reproductive years. To analyze the effects of pregnancy on the course and survival of invasive cervical cancer, we compared 40 women with invasive cervical cancer to 89 nonpregnant controls matched for age, calendric year of diagnosis, stage, and tumor type. Additionally, we compared the distribution of invasive cervical cancer stages among the 40 pregnant women with that among the 1,963 cases of invasive cervical cancer treated during the same 30 years in women less than 45 years of age registered in the same hospital. To evaluate pregnancy outcome, we compared babies born to women with invasive cervical cancer to babies born of women matched for maternal age and not exposed to known teratogens or reproductive risks during pregnancy. Thirty-year survival of pregnant women with invasive cervical cancer was identical to that of their matched controls. Women having invasive cervical cancer were 3.1 times more likely to be diagnosed with stage I disease (95% confidence interval, 1.6 to 6.2). Additionally, they had a significantly lower chance of being diagnosed with stages III and IV (P = .02). Babies born to women with invasive cervical cancer were similar in gestational age and rates of prematurity but had a lower birth weight than the matched controls. There were two stillbirths among the 24 pregnancies that continued to term (8%), not statistically different from the 1.1% rate for Ontario. Our data suggest that pregnancy per se does not adversely affect the survival of women with invasive cervical cancer. However, this study provides evidence that pregnant women are more likely to present with early disease because of regular, pregnancy-related obstetric exams. Moreover, there is an increased risk for stillbirth, which should lead to follow-up of these patients by a high-risk perinatal unit.