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Tadmor T, Melamed G, Alapi H, Gazit S, Patalon T, Rokach L. Pregnancy Course of 10 Women Diagnosed with Chronic Lymphocytic Leukemia. Acta Haematol 2023; 146:379-383. [PMID: 37276848 PMCID: PMC10614226 DOI: 10.1159/000531400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
Pregnancies following diagnosis of chronic lymphocytic leukemia (CLL) are rare events, mainly because the disease is typically diagnosed in the elderly. Literature on the topic is based only on case reports, and limited data are available on the influence of pregnancy on CLL course. In this retrospective study, we aimed to summarize the clinical and laboratory course of 10 women with CLL who became pregnant. None of the patients had significant changes in blood count during or after pregnancy or had complications such as infection, autoimmune phenomenon, or preeclampsia. Four out of 10 pregnancies were terminated with an early miscarriage. Following labor, 1 patient started anti-CLL treatment due to preexisting anemia, but none of the women required therapy during CLL progression during the first 2 years of follow-up. We conclude that based on our serial, pregnancy does not negatively impact on CLL course.
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Affiliation(s)
- Tamar Tadmor
- Hematology Unit, Bnai Zion Medical Center, and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Guy Melamed
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Hillel Alapi
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Sivan Gazit
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Tal Patalon
- Kahn Sagol Maccabi Research and Innovation Center, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Lior Rokach
- Department of Software and Information Systems Engineering, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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2
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Winckler P, Vanazzi A, Bozzo M, Scarfone G, Peccatori FA. Chronic lymphocytic leukaemia during pregnancy: management and thoughts. Ecancermedicalscience 2015; 9:592. [PMID: 26635896 PMCID: PMC4659706 DOI: 10.3332/ecancer.2015.592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Indexed: 12/25/2022] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in the Western world. Despite this fact, its coexistence with pregnancy is extremely rare, with few cases reported in the literature. Given the rarity of this event, it is difficult to conduct large prospective trials to evaluate diagnostic, management, and outcome aspects. The existing evidence is limited to the few published cases and scarce data from reviews on haematological malignancies and pregnancy. Here, we report a case of a 36-year-old patient who had already finished treatment for CLL and was under surveillance when she got pregnant. We describe the evolution of the pregnancy and of the disease's behaviour as well as the oncological and obstetrical management. Being an indolent disease, CLL during pregnancy can be usually followed up without treatment, but infectious and autoimmune complications might have a significant impact on the pregnancy outcome. Therefore, pregnancy must be closely monitored in specialised centres.
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Affiliation(s)
- Patricia Winckler
- Serviço de Oncologia Médica, Instituto Português de Oncologia de Lisboa, Francisco Gentil, Rua Professor Lima Basto, Lisboa 1700-023, Portugal
| | - Anna Vanazzi
- Division of Haematology Oncology, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
| | - Maddalena Bozzo
- Department of Obstetrics and Gynaecology, DMCO San Paolo, Via di Rudinì 8, Milan 20142, Italy
| | - Giovanna Scarfone
- Department of Obstetrics, Gynecology and Neonatology, IRCCS Fondazione Cà Granda, Ospedale Maggiore Policlinico, Via della Commenda 12, Milan 20122, Italy
| | - Fedro A Peccatori
- Fertility & Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy
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Hamad N, Kliman D, Best OG, Caramins M, Hertzberg M, Lindeman R, Porter R, Mulligan SP. Chronic lymphocytic leukaemia, monoclonal B-lymphocytosis and pregnancy: five cases, a literature review and discussion of management. Br J Haematol 2014; 168:350-60. [PMID: 25256787 DOI: 10.1111/bjh.13134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/04/2014] [Indexed: 11/27/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) occurs rarely with pregnancy and monoclonal B-Lymphocytosis (MBL) has not previously been described in this setting. CLL is predominantly a disease of the elderly and affects men twice as often as women and hence only an estimated 2% of patients are females of childbearing age. We identified only five reported cases of CLL in pregnancy in the literature. We describe two additional cases, plus three other women with CLL dealing with pregnancy-related decisions. We review the literature and discuss proposals for management and issues that arise in this relatively uncommon occurrence. In contrast to many other haematological malignancies where longer remissions are typically associated with a lower risk of relapse, most patients with CLL who require treatment will ultimately relapse with current therapy. This complex setting requires careful consideration and well informed patients to assist with decisions related to pregnancy.
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Affiliation(s)
- Nada Hamad
- Department of Haematology, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia; Kolling Institute, University of Sydney, St Leonards, Sydney, NSW, Australia; Chronic Lymphocytic Leukaemia Australian Research Consortium (CLLARC), Sydney, NSW, Australia
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Michieli M, Peccatori FA, Lleshi A, Del Pup L, Valente D, Rupolo M, Tirelli U, Berretta M. Antiblastic treatment of haematological malignancies during pregnancy: a crucial decision. Int J Immunopathol Pharmacol 2013; 25:21S-32S. [PMID: 23092517 DOI: 10.1177/03946320120250s202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Antiblastic treatment of hematological malignancies during pregnancy poses a number of issues related to the curability of the maternal disease, the need of a prompt treatment and the potential toxicity of chemotherapy for the fetus. Here we report the results of a systematic literature search about the management of the most frequent hematological malignancies that may occur during pregnancy, focusing on specific issues related to gestational age at diagnosis, fetal toxicity and efficacy on the maternal side. The standard approach in non-pregnant women is illustrated as reference.
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Affiliation(s)
- M Michieli
- Department of Medical Oncology, National Cancer Institute, Aviano (PN), Italy.
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Azim HA, Pavlidis N, Peccatori FA. Treatment of the pregnant mother with cancer: A systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part II: Hematological tumors. Cancer Treat Rev 2010; 36:110-21. [DOI: 10.1016/j.ctrv.2009.11.004] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 11/09/2009] [Accepted: 11/15/2009] [Indexed: 11/28/2022]
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Maxwell C, Grady R, Crump M. Chronic lymphocytic leukaemia in pregnancy: a case report and literature review. Obstet Med 2009; 2:168-9. [PMID: 27579065 PMCID: PMC4989667 DOI: 10.1258/om.2009.090036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2009] [Indexed: 05/30/2024] Open
Abstract
Chronic lymphocytic leukaemia is a rare condition reported in pregnancy. We review a case of a woman presenting for pregnancy care with active disease and review the literature on this condition. This case raises several important issues with regard to managing complex medical diseases such as leukaemia in pregnant women, including the role of multidisciplinary care.
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Affiliation(s)
- Cynthia Maxwell
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital
| | - Rosheen Grady
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital
| | - Michael Crump
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Ontario, Canada
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Rizack T, Mega A, Legare R, Castillo J. Management of hematological malignancies during pregnancy. Am J Hematol 2009; 84:830-41. [PMID: 19844988 DOI: 10.1002/ajh.21547] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of hematological malignancies during pregnancy is a challenging endeavor, which not only requires technical skills and knowledge by the clinicians but also requires sound clinical judgment and compassion, keeping in mind the patient and family preferences and, ultimately, the wellbeing of the neonate. The incidence of hematological malignancies during pregnancy is rare, ranging from 1 in 1,000 to 1 in 10,000 deliveries, impeding the design and execution of large prospective studies. The purpose of this review is to evaluate the limited existing data and make useful suggestions in the management of acute and chronic leukemias, Hodgkin and non-Hodgkin lymphomas, plasma cell myeloma, and other hematological malignancies, such as myelodysplastic syndromes and hairy cell leukemia, during pregnancy.
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MESH Headings
- Abnormalities, Drug-Induced/etiology
- Abnormalities, Drug-Induced/prevention & control
- Abortion, Induced
- Adult
- Antiemetics/therapeutic use
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Cesarean Section
- Clinical Protocols
- Combined Modality Therapy
- Contraindications
- Disease Management
- Female
- Hematologic Neoplasms/drug therapy
- Hematologic Neoplasms/epidemiology
- Hematologic Neoplasms/therapy
- Humans
- Incidence
- Infant, Newborn
- Infant, Newborn, Diseases/chemically induced
- Infant, Newborn, Diseases/prevention & control
- Leukapheresis
- Pregnancy
- Pregnancy Complications, Hematologic/drug therapy
- Pregnancy Complications, Hematologic/epidemiology
- Pregnancy Complications, Hematologic/therapy
- Pregnancy Complications, Neoplastic/drug therapy
- Pregnancy Complications, Neoplastic/epidemiology
- Pregnancy Complications, Neoplastic/therapy
- Pregnancy Outcome
- Pregnancy Trimesters
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Affiliation(s)
- Tina Rizack
- Division of Hematology and Oncology, The Miriam Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island 02906, USA.
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Abstract
The prevalence of pregnancy associated leukemia is approximately 1 case out of 10,000 pregnancies. This rare occurrence precludes the conducting of large, prospective studies to examine diagnostic, management and outcome issues. The treatment of a pregnant woman with leukemia may be associated with severe adverse fetal outcome including death and malformations, and therefore poses a difficult challenge for both the patient and the attending physician. Chemotherapy during the 1st trimester is associated with an increased risk for congenital malformations. However, this risk diminishes as pregnancy advances. When acute leukemia is diagnosed during the 1st trimester, patients should be treated promptly similar to non-pregnant patients. However, the aggressive induction therapy should follow pregnancy termination. When the diagnosis is made later in pregnancy standard chemotherapy regimen should be considered and usually pregnancy termination is not mandatory. However, both the mother and the fetus should be under close observation and delivery should be postponed to a non-cytopenic period. Pregnancy associated chronic myelogenous leukemia (CML) can be treated with interferon throughout pregnancy with no apparent increase in adverse fetal outcome. In the very rare case of chronic lymphocytic leukemia (CLL) during pregnancy treatment can usually be delayed until after delivery.
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9
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Abstract
In summary, the management of women diagnosed with leukaemia in pregnancy needs an interdisciplinary approach, including a careful oncological work-up as well as close monitoring of the pregnancy until delivery and beyond. Patients with acute leukaemias normally must receive anti-leukaemic treatment at full dosage prior to delivery, except for selected women diagnosed very close to term. Treatment should be avoided in the first trimester. The prognosis of pregnant women with acute leukaemia corresponds to that of an age-matched and diagnosis-matched non-pregnant cohort of patients, provided appropriate treatment is given. If given as of the second trimester, the typical chemotherapy regimes used for acute leukaemias imply acceptable acute toxicities to the fetus, with a somewhat increased risk of premature birth or developmental retardation, but no clear evidence of late sequelae in children and adolescents who were exposed to cytostatic agents whilst in utero. In chronic leukaemias and MDS, treatment may often be delayed until after delivery. In CML targeted therapy with imatinib mesylate is safe as of the second trimester, and possibly even before. Obstetric care and monitoring of women with leukaemia are essential throughout the pregnancy to ensure the best possible outcome for mother and child.
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Affiliation(s)
- M F Fey
- Department of Medical Oncology, Inselspital and University, Bern, Switzerland
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Pulte D, Olson KE, Broekman MJ, Islam N, Ballard HS, Furman RR, Olson AE, Marcus AJ. CD39 activity correlates with stage and inhibits platelet reactivity in chronic lymphocytic leukemia. J Transl Med 2007; 5:23. [PMID: 17480228 PMCID: PMC1885243 DOI: 10.1186/1479-5876-5-23] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 05/04/2007] [Indexed: 01/10/2023] Open
Abstract
Background Chronic lymphocytic leukemia (CLL) is characterized by accumulation of mature appearing lymphocytes and is rarely complicated by thrombosis. One possible explanation for the paucity of thrombotic events in these patients may be the presence of the ecto-nucleotidase CD39/NTDPase-1 on the surface of the malignant cells in CLL. CD39 is the major promoter of platelet inhibition in vivo via its metabolism of ADP to AMP. We hypothesize that if CD39 is observed on CLL cells, then patients with CLL may be relatively protected against platelet aggregation and recruitment and that CD39 may have other effects on CLL, including modulation of the disease, via its metabolism of ATP. Methods Normal and malignant lymphocytes were isolated from whole blood from patients with CLL and healthy volunteers. Enzyme activity was measured via radio-TLC assay and expression via FACS. Semi-quantititative RT-PCR for CD39 splice variants and platelet function tests were performed on several samples. Results Functional assays demonstrated that ADPase and ATPase activities were much higher in CLL cells than in total lymphocytes from the normal population on a per cell basis (p-value < 0.00001). CD39 activity was elevated in stage 0–2 CLL compared to stage 3–4 (p < 0.01). FACS of lymphocytes demonstrated CD39 expression on > 90% of normal and malignant B-lymphocytes and ~8% of normal T-lymphocytes. RT-PCR showed increased full length CD39 and splice variant 1.5, but decreased variant 1.3 in CLL cells. Platelet function tests showed inhibition of platelet activation and recruitment to ADP by CLL cells. Conclusion CD39 is expressed and active on CLL cells. Enzyme activity is higher in earlier stages of CLL and decreased enzyme activity may be associated with worsening disease. These results suggest that CD39 may play a role in the pathogenesis of malignancy and protect CLL patients from thrombotic events.
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MESH Headings
- Adenosine Diphosphate/pharmacology
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Apyrase/genetics
- Apyrase/metabolism
- B-Lymphocytes/metabolism
- B-Lymphocytes/pathology
- Chromatography, Thin Layer
- Female
- Flow Cytometry
- Gene Expression Regulation, Leukemic/drug effects
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Lymphocyte Subsets/metabolism
- Male
- Middle Aged
- Platelet Activation/drug effects
- Platelet Activation/physiology
- Platelet Aggregation/drug effects
- Reverse Transcriptase Polymerase Chain Reaction
- T-Lymphocytes/metabolism
- T-Lymphocytes/pathology
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Affiliation(s)
- Dianne Pulte
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
| | - Kim E Olson
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
| | - M Johan Broekman
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
| | - Naziba Islam
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
| | - Harold S Ballard
- Medical Service, VA NY Harbor Healtcare System, New York, NY 10010, USA
| | - Richard R Furman
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
| | - Ashley E Olson
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
| | - Aaron J Marcus
- Research Service, Veterans Affairs New York Harbor Healthcare System, New York, NY 10010, USA
- Medicine-Hematology/Oncology, Weill Medical College Cornell University, New York, NY 10021, USA
- Medical Service, VA NY Harbor Healtcare System, New York, NY 10010, USA
- Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY 10021, USA
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11
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Dilek I, Topcu N, Demir C, Bay A, Uzun K, Gul A, Faik Oner A, Ugras S. Hematological malignancy and pregnancy: a single-institution experience of 21 cases. ACTA ACUST UNITED AC 2006; 28:170-6. [PMID: 16706933 DOI: 10.1111/j.1365-2257.2006.00781.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The incidence of hematological malignancies during pregnancy is low, and treatment in this setting is problematic. This study observed 21 pregnancies in 18 patients with hematological malignancies. Patients' ages were between 19 and 43 (median 25) years. Two pregnancies ended with spontaneous abortion, one pregnancy ended with in utero death, three therapeutic abortions were carried out, and 15 infants were born alive but three of them died later. The median birth weight was 2.47 kg. Twelve babies survived to a median age of 36 (range 4-117) months. Eight babies were exposed to chemotherapy during the in utero period. One baby was exposed to chemotherapy during all the trimesters and was born prematurely and later died because of intracranial bleeding. Four babies were exposed to chemotherapy during the first trimester, one of them had low birth weight and floating thumb malformation, two of them had only low birth weight, and one was born healthy, but died at 3 months of age as a result of severe gastroenteritis. Two babies were exposed to chemotherapy during the second and third trimesters; one of them had low birth weight, and the other pregnancy ended in in utero death. One infant was exposed to chemotherapy during the third trimester and was born at term, but died because of pulmonary hemorrhage. We concluded that chemotherapy during all trimesters of pregnancy carries a significant risk for an unfavorable outcome.
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MESH Headings
- Abortion, Spontaneous/chemically induced
- Abortion, Therapeutic
- Adult
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Fatal Outcome
- Female
- Fetus/abnormalities
- Fetus/drug effects
- Hodgkin Disease/drug therapy
- Humans
- Infant, Newborn
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myeloid, Acute/drug therapy
- Lymphoma, Non-Hodgkin/drug therapy
- Male
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Pregnancy
- Pregnancy Complications, Hematologic/drug therapy
- Pregnancy Complications, Neoplastic/drug therapy
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Affiliation(s)
- I Dilek
- Department of Haematology, Faculty of Medicine, Yüzüncü Yil University, Van, Turkey.
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