Acute leukemia in pregnancy. Successful delivery after cytarabine and doxorubicin

Treatment of acute myeloid leukemia during pregnancy

OBJECTIVES

Systematically review the literature assessing outcomes of acute myeloid leukemia (AML) treatment during pregnancy.

DATA SOURCES

A Pubmed literature search (January 1969 to June 2014) for articles written about AML and pregnancy, and bibliographies/citations of previously published reviews.

STUDY SELECTION AND DATA EXTRACTION

Articles written in the English language that administered active AML chemotherapy during pregnancy were included.

DATA SYNTHESIS

Eighty-five fetuses were exposed to chemotherapy from 83 mothers: 8 mothers began induction chemotherapy in the first trimester, 61 mothers in the second trimester, and 14 mothers in the third trimester. Chemotherapy resulted in more fetal deaths and spontaneous abortions during the first trimester (37.5%) compared with the second (9.7%) and third trimesters (0%). All cases included cytarabine; 47 fetuses were exposed to daunorubicin and 8 fetuses to idarubicin. The percentages of fetal defects and death for cytarabine and daunorubicin combinations were 8.5% and 6.4%, respectively. With cytarabine and idarubicin combinations, the percentages of fetal defects and death were 28.6% and 12.5%, respectively. Complete remission (CR) rates were 100%, 81%, and 67% in the first, second, and third trimesters.

CONCLUSIONS

Treatment during the second and third trimesters resulted in fewer fetal complications than the first trimester. However, delaying AML treatment may adversely affect the mother's outcomes. In the reported cases, induction during pregnancy resulted in CR rates comparable to that in nonpregnant patients. The choice of anthracycline is still unclear, but the decision should be made with careful consideration, weighing the outcomes for the mother and fetus.

Maternal and fetal outcomes in pregnancy complicated with acute leukemia: a single institutional experience with 10 pregnancies at 16 years

The incidence of acute leukemia in pregnancy is low and the management of acute leukemia during pregnancy is difficult. We have observed a total of 10 pregnancies in 8 patients. Six of the patients had acute myeloblastic leukemia (AML) and two of them had acute lymphoblastic leukemia (ALL). Three of the pregnancies were diagnosed when the leukemia was in remission, six at the time of leukemia diagnosis and one at the time of leukemic relapse. Six of the pregnancies were found in first trimester, three in the second and one early in the third. Three pregnancies ended with spontaneous abortion, three with intrauterine death and three with medical termination. One of spontaneous abortions and one intrauterine death developed during combination chemotherapy (daunorubicin, cytarabine). Only 1 healthy baby survived from the 10 pregnancies and this child was the not exposed to chemotherapeutic agents. None of the cases had gynecologic and obstetric complications. Five of eight pregnant women with leukemia died because of the primary disease.

International Commission for Protection Against Environmental Mutagens and Carcinogens. Mutagenicity and carcinogenicity of topoisomerase-interactive agents

Drugs that interact with DNA topoisomerases I and II hold great promise for the treatment of cancer, however, like many other anti-cancer agents, they are a double-edged sword and may themselves cause mutation and cancer. In vitro studies show that clinically effective agents, such as etoposide, doxorubicin and others, stabilize a ternary complex where topoisomerase II is covalently linked to DNA. This complex represents an intermediate in the topoisomerase-II catalyzed DNA supercoil relaxation reaction. Camptothecin and its analogues stabilize a similar ternary complex, in vitro, consisting of topoisomerase I covalently linked to DNA at single-strand breaks. Short-term tests of genotoxicity confirm that topoisomerase-interactive agents are mutagenic and suggest common mechanisms by which they induce mutation and selectively kill tumor cells. These agents induce sister-chromatid exchange, chromosomal aberrations and mutations in specific mammalian genes. Their propensity to induce small colonies in the L5178/TK+/(-)-3.7.2C assay implies that topoisomerase-interactive agents induce large DNA rearrangements and deletions. These may result from topoisomerase-subunit exchange at drug-stabilized ternary complexes or from attempts by the cell to bypass the replication block caused by stabilized ternary complexes. Studies in bacterial mutation assays suggest that topoisomerase-interactive agents may also induce mutations, albeit at a lower rate, through simple DNA intercalation or via generation of oxygen free radicals. Second malignancies observed in patients previously treated with topoisomerase II interactive agents suggest these may be an important clinical consequence of their capacity to induce mutation. In particular, a unique form of acute myelogenous leukemia is observed at strikingly high frequencies after treatment with relatively high doses of the epipodophyllotoxins etoposide and teniposide. This form of AML has been reported after the uses of other classes of topoisomerase-interactive agents as well. Cancer induction is therefore a toxic consequence predicted by short-term tests of genotoxicity and should be weighed against the potential therapeutic benefits of topoisomerase-interactive agents.

Pharmacology of antineoplastic agents in pregnancy

The use of antineoplastic agents in pregnant women poses obvious risks to both the patient and the developing fetus, particularly during organogenesis. While the use of antineoplastics during pregnancy is often unavoidable, the physician may limit the risks by having a clear knowledge of the pharmacology and teratogenic potential of individual agents. Specific physiologic changes in the pregnant patient, such as enhanced renal excretion of drugs, increased or decreased hepatic function, altered gastrointestinal absorption and enterohepatic circulation, altered plasma protein binding, an increase in plasma volume (50%), and creation of a fluid filled 3rd compartment (amniotic fluid) for water soluble drugs may all significantly influence the pharmacology of antineoplastic agents. These physiological changes may effect the pregnant patients ability to absorb orally administered drugs, metabolize drugs to either active or inactive metabolites, and eliminate cytotoxically active drugs. A resulting reduction in concentration x time (C x T) for drug exposure to the maternal system may reduce the efficacy of the antineoplastic agents, while an increase in C x T may expose the patient and her fetus to undue toxicity. The timing of drug administration to gestational age is also a critical factor for some drugs. While many drugs result in adverse effects on the fetus regardless of gestational age, others appear to pose less of a threat if administered beyond the first trimester. This review addresses the pharmacology, pharmacokinetics and the teratogenic potential of individual antineoplastic agents that are commonly used in pregnant patients. The aim of this review is to help the physician select, on a patient specific basis, antineoplastic agents that avoid at least some of the fetal risk involved while maintaining efficacy in the treatment of the patient.

Combination chemotherapy and radiation for stage IV breast cancer during pregnancy

A 42-year-old woman presented with a 25-week pregnancy and stage IV breast cancer with metastases in the skeleton and liver and a T-4 primary tumor. She was treated with two cycles of doxorubicin, methotrexate, and vincristine. Spontaneous labor resulted in a normal female infant, who was successfully treated for sepsis and mild respiratory distress. The placenta showed diffuse chorioamnionitis. There was no doxorubicin demonstrated in the placenta, blood, or fetal lymphocytes 3 weeks after the last treatment. Maternal and fetal chromosomal analyses were unremarkable. The child is functioning normally 2 years after delivery. The literature on anthracycline treatment during pregnancy is reviewed. Adriamycin has been shown to cross the blood-placenta barrier, but has not led to specific fetal abnormalities when given during the second or third trimester. Experience during the first trimester is still limited.

Anthracyclines in the treatment of malignancy in pregnancy

This article reports two cases and reviews the literature regarding chemotherapy using anthracyclines during pregnancy. Twenty-six additional cases using this class of agents to treat malignancy during pregnancy are summarized from 18 reports for a total of 28 pregnancies. Final outcome of pregnancy is analyzed with regard to the following factors: diagnosis, gestational age at start of therapy, total dose of anthracycline, number and type of agents used, neonatal pathologic findings and months of follow-up of infants. Final outcome of 28 pregnancies resulted in 24 normal infants including a set of twins in the current report. Limited pharmacokinetic information is inconclusive with regard to the appearance of anthracyclines and their known metabolites in placental or fetal tissue.

Acute leukemia and pregnancy

Acute leukemia was diagnosed in five pregnant patients who received chemotherapy during the course of pregnancy. Three were undergoing chemotherapy at conception. One patient died in the fifth month of pregnancy and the anatomic study of the fetus was normal. Four babies had low birth weights at birth. Of the four one was born prematurely, but without malformations. Later development was normal. The results are reviewed and compared with data from the literature, leading to the conclusion that pregnancy is not an absolute contraindication for cytostatic treatment, except in the first trimester, in which cytostatic treatment should be avoided.

Long-term follow-up of children born to mothers with acute leukemia during pregnancy

Seventeen children born to mothers with acute leukemia who received chemotherapy during pregnancy were examined for physical health, growth, and development. The hematologic and neurologic status and school performance were also evaluated. Chromosomal studies were done in the long-term survivors ranging in age from 4 to 22 years. The children had thorough history and physical examinations to detect any abnormal symptoms or signs. The mothers' previous treatment was documented. In each child growth and development, school performance, intelligence testing, neurologic examination, and hematologic evaluation including bone marrow were normal. Bone marrow cytogenetic studies were also normal. Chemotherapy was given during the pregnancy in each case, including 11 cases during the first trimester. No fetal malformations were found and no late side effects could be demonstrated. The results of this study indicate that pregnancy is not a counterindication for treatment of patients with acute leukemia, and in the cases described here chemotherapy is not associated with excessive risk to the fetus.

Growth and development of children born to patients after cancer therapy

Eighteen children born to parents who had previously received chemotherapy or radiotherapy were examined for physical health, growth, and development. The immunologic and the hematologic status of these children was also evaluated. Their ages ranged from birth to 15 years. The children had a careful history and physical examination to detect any abnormal symptoms or signs, and the parent's previous treatment was carefully documented. Four sets of parents had children while one of the parents was on active treatment (2 male and 2 female). Of the male patients, one patient's wife had a baby that was "small for gestational age" at birth and had transient failure to thrive; the other child was normal. Of the female patients, one offspring was small for gestational age at birth and the other was normal, but both continued to have failure to thrive for up to 17 months and 26 months, respectively. Ten parents procreated after being treated with chemotherapy and/or radiotherapy, to whom 14 children were born. One child was a stillbirth with multiple congenital abnormalities, and another child had trisomy 13-15 and died 6 months later. The other 12 children were normal at birth, but one child is under the 5th percentile for growth at twelve months of age. In all children studied, immune function test, complete blood count, and viral titers were considered normal for age. In our study, we found that three out of four children born to parents who were on chemotherapy had failure to thrive. Of the 14 children born to parents who conceived after being off chemotherapy, 11 were found to be normal in growth and development. These results imply that there is a high risk of complications in children born to parents who procreated while receiving chemotherapy. Further studies are needed to develop better guidelines for counseling cancer patients who want to have children.

Multiagent chemotherapy for sarcoma diagnosed during pregnancy

A 21-year-old, gravida 1, para O, woman presented at approximately 25 weeks gestation with a large Ewing's sarcoma involving her iliac wing. She was treated with multiagent chemotherapy before a successful Cesarean delivery of a normal infant at approximately 34 weeks gestation. Four years later both the mother and child are doing well. The literature regarding sarcoma occurring during pregnancy and that regarding multiagent chemotherapy in pregnant patients is reviewed. Chemotherapy should be instituted early in the course of many malignant sarcomas, despite pregnancy, to prevent the occurrence of metastases.

Gestational carcinoma of the female breast

Few neoplastic diseases can equal the amazing complexity and sheer perversity of carcinoma of the breast. No doubt as many decades of research lie ahead in its study as already have passed. Clinicians have long appreciated the special relationship of the disease to gestation. Diagnosis and treatment of breast cancer during pregnancy represent only a small part of this fascinating relationship. Although indispensable as research tools, animal models pertain to the human disease only in limited, ill-defined ways. The etiology of human breast cancer remains unclear; chemical, viral, hormonal, genetic, and immunologic theories have all been put forward as possibilities. Although gestation clearly alters both the initiation and growth of mammary tumors, its exact role in the various theoretical considerations remains a mystery. The obstetrician-gynecologist holds an important front-line position in the war against breast cancer, as does any provider of primary care to women, and, indeed, as do women themselves. Rather than decrease vigilance during pregnancy, the physician should pursue with extra vigor any breast mass discovered in the gravid patient, when the clinical examination is even less reliable than usual. The finding of a breast mass usually necessitates biopsy. Except for the inclusion of specific pregnancy-related problems, such as galactocele, the diagnostic spectrum of breast masses removed during pregnancy does not differ from that in nonpregnant women. The discovery of a highly suspicious breast mass, or the confirmed biopsy diagnosis of malignancy, in a pregnant patient should indicate the need for referral to a surgical oncologist versed in this unusual problem. The best approach to gestational breast cancer continues to be the team approach, with consultation from specialists in obstetrics, surgical oncology, anesthesiology, nuclear medicine, radiology, radiation oncology, pathology, and medical oncology. The age and general condition of the patient, the extent of the tumor, the stage of gestation, and the informed opinions of the patient and her spouse help to determine the therapeutic strategy. Careful staging not only guides present therapy but also the therapy of future victims through continued investigation. Most surgeons favor operation without delay if cure seems within reach. Mastectomy, with or without cesarean section, can be accomplished without detriment in the hands of a knowledgeable surgeon-anesthesiologist team. By following certain guidelines, the search for metastasis can be conducted safely and appropriately. The clinical situation occasionally may require the initiation of adjuvant radiotherapy or chemotherapy during pregnancy, by experienced consultants. Ongoing studies of tissue hormone receptors and cell kinetics will continue to give insight into the effects of gestational hormones on breast cancer and can aid in the selection of treatment options for the individual patient...

Normal infant after combination chemotherapy including teniposide for Burkitt's lymphoma in pregnancy

A 32-year-old woman was treated for Burkitt's lymphoma diagnosed during the 22nd week of pregnancy. Chemotherapy consisting of doxorubicin (Adriamycin), vincristine, teniposide (VM-26), cyclophosphamide, and prednisolone (AVTEP) was given each 2.5 to 3 weeks from the time of the diagnosis until delivery in the 37th week. Bleomycin and intrathecal methotrexate were also given from the 35th week. The infant was born after an assisted vaginal delivery and was fully developed and normal in all respects. This paper confirms prior reports that cytotoxic chemotherapy may safely be given during the second and third trimesters of pregnancy without adverse effects on the fetus. To our knowledge it is the first report of the use of teniposide, a new podophyllin derivative, during pregnancy.

Acute leukemia in pregnancy: transient neonatal myelosuppression after combination chemotherapy in the mother

An 18-year-old primagravida received combination chemotherapy with vincristine, prednisone, L-asparaginase, cyclophosphamide, daunomycin, 6-mercaptopurine and central nervous system (CNS) prophylaxis with intrathecal methotrexate and whole-brain irradiation for acute lymphoblastic leukemia (ALL) beginning in the 12th week of pregnancy. Therapy resulted in sustained complete remission of the leukemia and delivery of a normally developed female infant whose immediate neonatal course was complicated by transient severe bone marrow hypoplasia. Our experience confirms the reports of others that intensive chemotherapy can be administered in the last two trimesters of pregnancy without serious teratogenic complications. However, we conclude that such therapy may cause significant myelosuppression in the newborn.