Cancer in pregnancy

Cervical cancer in pregnancy

Cervical cancer is one of the most common and challenging malignancies diagnosed during pregnancy, requiring a complex balance between effective oncological management and pregnancy preservation. This narrative review synthesizes current evidence and clinical experience regarding the management of cervical cancer in pregnant patients. While treatment should generally follow standard protocols for nonpregnant patients, emerging data suggest that pregnancy can often be safely maintained without compromising oncological outcomes. Nevertheless, robust prognostic data from larger patient cohorts are still needed. Individualized treatment approaches that incorporate the patient's preferences and values are crucial. Given the complexities involved, referral to specialized tertiary centers with expertise in the oncological and obstetric care of pregnant cancer patients is strongly recommended to ensure optimal outcomes for both mother and child.

Trends and outcomes associated with cancer diagnoses during delivery hospitalizations

Pregnancy associated cancer is fortunately rare. However, cancer risk is age related, and the proportion of births to older women in the United States appears to be increasing. As a result of delayed childbearing and better detection, cancer may be increasing in the obstetric population. A review of data from the United States Inpatient Sample found that from 2000 to 2019 the proportion of deliveries with an active cancer diagnosis doubled and deliveries with a diagnosis of a history of cancer more than tripled. These trends and associations are similar to findings from other registries and population-based studies which show that pregnancy associated cancer is increasing and associated with a range of adverse obstetric outcomes including severe maternal morbidity and preterm birth. Given these trends and findings it is likely pregnancy associated cancer will continue to be of public health and clinical importance and represent an ongoing challenge given the maternal and neonatal risks and specialized, coordinated care required to optimize outcomes.

Review of the Imaging Modalities in the Gynecological Neoplasms During Pregnancy

The aim of this review is to provide an update on the imaging triage, safety considerations, and cancer-imaging features of common and uncommon gynecological tumors during pregnancy. Clinical examination can be inconclusive, especially for the evaluation of intra-abdominal diseases since symptoms related to cancer such as fatigue, vomiting, or nausea overlap with common pregnancy-associated symptoms. Delayed pregnancy, advanced maternal age, and improvements in diagnostic imaging in developed countries have increased the incidence of cancer diagnosis in gravid populations. Non-invasive diagnostic imaging has a central role in the initial diagnosis and management of pregnancy tumors. Sonography is the first modality for the abdominal evaluation of gravid patients because it is widely available, low cost, and lacks adverse effects on the mother and fetus. MR imaging is considered the imaging modality of choice for diagnosis and staging of gynecologic cancer during pregnancy due to its larger imaging field of view, better reproducibility, and excellent soft tissue contrast. Moreover, whole-body diffusion-weighted imaging (DWI) has been proposed for the oncologic staging of pregnant patients; however, large prospective studies are needed to support its clinical implementation. Gynecological cancer diagnosed during pregnancy requires accurate diagnosis and staging to determine optimal treatment based on gestational age, and therefore multidisciplinary team collaboration is pivotal.

Influence of cancer in pregnancy on obstetric and neonatal outcomes: an observational retrospective cohort study

OBJECTIVE

The study aimed to review the oncological characteristics and treatment of pregnancy-associated cancers and analyze the obstetric and neonatal outcomes to provide evidence-based recommendations for reproductive function preservation, oncological treatment, and obstetric management.

METHODS

We conducted an observational retrospective cohort study among pregnant patients with cancer in 7 Chinese tertiary A hospitals from 2003 to 2021. We conducted multiple logistic regression to determine the influence of various factors on preterm birth and small-for-gestational-age infants, log-binomial regression to analyze temporal changes, and χ² tests to explore the effects of cancer type/treatment.

RESULTS

Of 204 women, 17% terminated their pregnancies; 59% received pre-delivery treatment. Every 6 years, the rates of pregnancy termination (relative risk [RR]=0.48; 95% confidence interval [CI]=0.35-0.67) and iatrogenic preterm births (RR=0.73; 95% CI=0.54-0.98) reduced, and that of pre-delivery treatment increased, mainly due to increased rates of surgery (RR=1.87; 95% CI=1.31-2.67). Maternal systemic diseases were related to small-for-gestational-age infants (odds ratio [OR]=12.02; 95% CI=1.82-79.43). Chemotherapy with taxanes plus platinum-based agents was related to adverse obstetric outcomes (OR=1.87; 95% CI=1.42-2.46; p<0.05). Thyroid (OR=0.36; 95% CI=0.22-0.57) and ovarian cancer (OR=0.70; 95% CI=0.50-0.98) were associated with fewer cesarean sections. Thyroid cancer was associated with fetal growth restriction (OR=5.21; 95% CI=1.21-22.55).

CONCLUSION

Rates of pregnancy termination in cancer declined. Taxane plus platinum-based chemotherapy was associated with adverse obstetric outcomes. Cancer type influenced outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2100044292.

Protective effect of alpha‑lipoic acid against in utero cytarabine exposure-induced hepatotoxicity in rat female neonates

Cytarabine, an anti-metabolite drug, remains the mainstay of treatment for hematological malignancies. It causes various toxic effects including teratogenicity. Alpha lipoic acid (ALA) is a natural antioxidant reported to offer protection against hepatotoxicity induced by various pathological conditions, drugs, or chemicals. We investigated the protective effect of ALA against prenatal cytarabine exposure-induced hepatotoxicity in rat female neonates. A total of 30 dams were randomly assigned to five groups and received normal saline, ALA 200 mg/kg, cytarabine 12.5 mg/kg, cytarabine 25 mg/kg, and cytarabine 25 mg/kg + ALA 200 mg/kg, respectively, from gestational day (GD)8 to GD21. Cytarabine and ALA were administered via intraperitoneal and oral (gavage) routes, respectively. On postnatal day (PND)1, all the live female neonates (pups) were collected and weighed. The blood and liver from pups were carefully collected and used for histopathological, and biochemical evaluations. A significant and dose-dependent decrease in maternal food intake and weight gain was observed in the pregnant rats (dams) of the cytarabine groups as compared to the dams of the control group. The pups exposed to cytarabine showed a significant and dose-dependent (a) decrease in body weight, liver weight, hepatosomatic index, catalase, superoxide dismutase, glutathione, glutathione peroxidase, serum albumin levels and (b) increase in malondialdehyde, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, AST/ALT ratio, and histopathological anomalies. Maternal co-administration of ALA ameliorated these biochemical changes and histopathological abnormalities by combating oxidative stress. Future studies are warranted to explore the molecular mechanisms involved in the ALA's protective effects against prenatal cytarabine-induced hepatotoxicity.

Lived Experiences of Pregnant Women With Cancer in South Korea: A Qualitative Study

PURPOSE

The incidence of cancer during pregnancy is increasing, presenting several challenges to the treatment of cancer in pregnant women. However, research focusing on the lived experiences of pregnant women with cancer in South Korea is limited. This study aimed to explore and describe the day-to-day lived experiences of women diagnosed with or treated for cancer during pregnancy and their husbands.

METHODS

The study employed a qualitative descriptive design and utilized purposive sampling to recruit participants. The participants comprised six women living in Korea diagnosed with cancer during pregnancy and one husband of a female participant. In-depth semi-structured interviews were conducted, audiotaped, and transcribed. Five of the participants agreed to a second interview, resulting in a total of 12 individual interviews. A thematic analysis was then performed. The participants' ages ranged from 31 to 40 years, and their diagnoses during pregnancy were either breast or thyroid cancer.

RESULTS

Four main themes were identified: (1) Participants faced various heart-breaking difficulties maintaining their pregnancies throughout cancer treatment; (2) Pregnant women with cancer experienced complex but responsible feelings toward their children; (3) Patients with cancer also fulfilled their roles as parents even with their own diseases; and (4) Family support had a significant impact on the pregnant women to overcome the path.

CONCLUSIONS

These findings provide a comprehensive understanding of the lived experiences of being diagnosed with cancer during pregnancy. A recommended strategy is to develop a nursing education program for pregnant women with cancer to provide necessary information and support, and to help them cope positively with their situation.

Pregnancy-associated gynecological cancer in New South Wales, Australia 1994-2013: A population-based historical cohort study

INTRODUCTION

Pregnancy-associated gynecological cancer (PAGC) refers to cancers of the ovary, uterus, fallopian tube, cervix, vagina, and vulva diagnosed during pregnancy or within 12 months postpartum. We aimed to describe the incidence of, and perinatal outcomes associated with, invasive pregnancy-associated gynecological cancer.

MATERIAL AND METHODS

We conducted a population-based historical cohort study using linked data from New South Wales, Australia. We included all women who gave birth between 1994 and 2013, with a follow-up period extending to September 30, 2018. Three groups were analyzed: a gestational PAGC group (women diagnosed during pregnancy), a postpartum PAGC group (women diagnosed within 1 year of giving birth), and a control group (women with control diagnosis during pregnancy or within 1 year of giving birth). We used generalized estimation equations to compare perinatal outcomes between study groups.

RESULTS

There were 1 786 137 deliveries during the study period; 70 women were diagnosed with gestational PAGC and 191 with postpartum PAGC. The incidence of PAGC was 14.6/100 000 deliveries and did not change during the study period. Women with gestational PAGC (adjusted odds ratio [aAOR] 6.81, 95% confidence interval [CI] 2.97-15.62) and with postpartum PAGC (aOR 2.65, 95% CI 1.25-5.61) had significantly increased odds of a severe maternal morbidity outcome compared with the control group. Babies born to women with gestational PAGC were more likely to be born preterm (aOR 3.11, 95% CI 1.47-6.59) and were at increased odds of severe neonatal complications (aOR 3.47, 95% CI 1.45-8.31) compared with babies born to women without PAC.

CONCLUSIONS

The incidence of PAGC has not increased over time perhaps reflecting, in part, the effectiveness of cervical screening and early impacts of human papillomavirus vaccination programs in Australia. The higher rate of preterm birth among the gestational PAGC group is associated with adverse outcomes in babies born to these women.

Development and validation of the low-cost pregnant female physical phantom for fetal dosimetry in MV photon radiotherapy

BACKGROUND

Monte Carlo (MC) simulations or measurements in anthropomorphic phantoms are recommended for estimating fetal dose in pregnant patients in radiotherapy. Among the many existing phantoms, there is no commercially available physical phantom representing the entire pregnant woman.

PURPOSE

In this study, the development of a low-cost, physical pregnant female phantom was demonstrated using commercially available materials. This phantom is based on the previously published computational phantom.

METHODS

Three tissue substitution materials (soft tissue, lung and bone tissue substitution) were developed. To verify Tena's substitution tissue materials, their radiation properties were assessed and compared to ICRP and ICRU materials using MC simulations in MV radiotherapy beams. Validation of the physical phantom was performed by comparing fetal doses obtained by measurements in the phantom with fetal doses obtained by MC simulations in computational phantom, during an MV photon breast radiotherapy treatment.

RESULTS

Materials used for building Tena phantom are matched to ICRU materials using physical density, radiation absorption properties and effective atomic number. MC simulations showed that percentage depth doses of Tena and ICRU material comply within 5% for soft and lung tissue, up to 25 cm depth. In the bone tissue, the discrepancy is higher, but again within 5% up to the depth of 5 cm. When the phantom was used for fetal dose measurements in MV photon breast radiotherapy, measured fetal doses complied with fetal doses calculated using MC simulation within 15%.

CONCLUSIONS

Physical anthropomorphic phantom of pregnant patient can be manufactured using commercial materials and with low expenses. The files needed for 3D printing are now freely available. This enables further studies and comparison of numerical and physical experiments in diagnostic radiology or radiotherapy.

Pregnancy and neonatal outcomes following malignancy in pregnancy at a tertiary care Canadian center: a retrospective chart review

Objective: Data on pregnancy-associated cancers (PACs) are lacking. The objectives of this study were to determine the incidence of PACs and describe the characteristics and outcomes of pregnancies affected by malignancy at a single tertiary care center in Ottawa, Canada.Methods: This was a retrospective chart review of individuals with PAC at The Ottawa Hospital (TOH) between 2011-2022. Eligible cases were identified from the TOH Data Warehouse, the TOH instance of the Better Outcomes Registry & Network Ontario, and the TOH Division of Maternal Fetal Medicine's Perinates database. Chart reviews were conducted to confirm case eligibility and to extract demographic, oncologic, obstetrical, and neonatal measures. The annual incidence of PAC over the 11-year period was reported per 1000 deliveries. Descriptive statistics were used to describe the sample, including frequency (n) and proportions (%) for categorical variables and mean and standard deviation (SD) for continuous variables.Results: The final cohort included 59 individuals with PAC at TOH between 2011-2022. The annual incidence of PAC ranged from 0.47 to 1.54 per 1000 deliveries. The most common PACs were breast cancer (28.8%), Hodgkin lymphoma (10.2%), and thyroid cancer (8.5%). Common interventions during pregnancy included chemotherapy (33.9%) and surgical intervention (32.2%). A total of 19 individuals (32.2%) did not undergo PAC-related treatment during pregnancy. There were 55 livebirths (91.7%), 2 spontaneous abortions (3.3%), 3 induced abortions (5.0%), and no stillbirths. Among livebirths, the mean gestational age was 37.4 ± 2.8 weeks and the mean birthweight was 2920.3 ± 650.0 g. All neonates had reassuring 5-minute Apgar scores, 18 (32.7%) were admitted to the Neonatal Intensive Care Unit/Special Care Nursery (NICU/SCN), and 8 (14.5%) were noted to have a mild congenital abnormality.Conclusion: This study shows promising perinatal outcomes for patients with PAC and their neonates. Ongoing surveillance of PAC is needed to better inform care for this patient population.

Emergency Presentation of Invasive Cervical Cancer in Late Pregnancy: A Case Report and Literature Review

Antepartum hemorrhage (APH) often prompts consideration of the presence of obstetric disorders. Here, we describe a case with active APH in which invasive cervical cancer was the cause. A 41-year-old woman, fifth gravida, fourth para (G5, P4), presented to the emergency department at 38 weeks of gestation with an acute severe attack of vaginal bleeding, which occurred immediately after a per-vaginal examination at another local institute. Despite initial stabilization measures and investigations to exclude common causes of APH, a protruding cervical mass was discovered during a Cusco speculum examination. The patient underwent an emergent cesarean section (CS). Postoperatively, the patient was referred to the gynecological oncology unit for further evaluation and management. Magnetic resonance imaging (MRI) confirmed the presence of a large cervical mass. A punch biopsy revealed squamous cell carcinoma (SCC) of the cervix. All these confirmed the condition as cervical carcinoma stage IB3. This case and literature review highlight the obstacles that might delay the diagnosis of cervical cancer and the importance of continuing the screening program strategies even during pregnancy to avoid complications of invasive cervical cancer. In addition, bleeding due to cervical cancer should always be considered one of the important differential diagnoses of APH even in full-term pregnancy.

Mediastinal gray zone lymphoma in a pregnant woman presenting with cardiac tamponade

BACKGROUND

Mediastinal gray zone lymphoma is a newly recognized rare B cell neoplasm, which is challenging in diagnosis and treatment.

CASE PRESENTATION

In the current study, we aimed to report a 25-year-old pregnant woman at 25 weeks of gestation who presented with chronic cough and progressive shortness of breath, hypotension, tachycardia, and tachypnea. A large circumferential pericardial effusion with compressive effect on the right atrium and right ventricle and a large extracardiac mass with external pressure to mediastinal structures were seen on trans thoracic echocardiography. The emergency pericardiocentesis was performed with the diagnosis of cardiac tamponade. Also, CMR revealed a huge heterogeneous anterior mediastinal mass, and the pathology and the immunohistochemistry of the mass biopsy revealed gray zone lymphoma with positive CD3, CD20, CD30, CD45, PAX5, and negative CD15 expression. Three courses of chemotherapy with the CHOP regimen were performed with an acceptable response every three weeks before delivery. A caesarian section was performed at 37 weeks without any problem for the patient and fetus, and chemotherapy will be started three weeks after delivery.

CONCLUSION

Cardiac tamponade as an emergency condition occurred in this pregnant patient by malignant pericardial effusion and mediastinal mass pressure. Accurate diagnosis and on time interventions caused a significant improvement and a successful delivery.

Manifestations of Ovarian Cancer in Relation to Other Pelvic Diseases by MRI

Imaging plays a pivotal role in the diagnostic approach of women with suspected ovarian cancer. MRI is widely used for preoperative characterization and risk stratification of adnexal masses. While epithelial ovarian cancer (EOC) has typical findings on MRI; there are several benign and malignant pelvic conditions that may mimic its appearance on imaging. Knowledge of the origin and imaging characteristics of a pelvic mass will help radiologists diagnose ovarian cancer promptly and accurately. Finally, in special subgroups, including adolescents and gravid population, the prevalence of various ovarian tumors differs from that of the general population and there are conditions which uniquely manifest during these periods of life.

Delayed cancer diagnosis in the pregnant patient: navigating a complex medical and ethical dilemma

Prompt diagnosis of cancer in pregnancy is necessary to ensure timely management and improve outcomes. However, there are a several reasons why diagnosis may be delayed in pregnancy. Three major contributors to delayed diagnosis and treatment are patient delay, provider delay, and referral delay. This article aims to (1) increase physician awareness of this problem by providing a detailed review of the main culprits of delayed diagnosis and treatment of cancer in the pregnant patient, (2) discuss the complex ethical issues at hand in these cases, and (3) provide suggestions on how to better address such cases with the goal of improving patient outcomes.

Cancer in pregnancy: treatment effects

PURPOSE

Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized.

METHODS

This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible.

RESULTS AND CONCLUSION

Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.

Development of a computational pregnant female phantom and calculation of fetal dose during a photon breast radiotherapy

BACKGROUND

The incidence of carcinoma during pregnancy is reported to be 1:1000-1:1500 pregnancies with the breast carcinoma being the most commonly diagnosed. Since the fetus is most sensitive to ionizing radiation during the first two trimesters, there are mixed clinical opinions and no uniform guidelines on the use of radiotherapy during pregnancy. Within this study the pregnant female phantom in the second trimester, that can be used for radiotherapy treatment planning (as DICOM data), Monte Carlo simulations (as voxelized geometry) and experimental dosimetry utilizing 3D printing of the molds (as .STL files), was developed.

MATERIALS AND METHODS

The developed phantom is based on MRI images of a female patient in her 18th week of pregnancy and CT images after childbirth. Phantom was developed in such a manner that a pregnant female was scanned "in vivo" using MRI during pregnancy and CT after childbirth. For the treatment of left breast carcinoma, 3D conformal radiotherapy was used. The voxelized geometry of the phantom was used for Monte Carlo (MC) simulations using Monte Carlo N-Particle transport code^TM 6.2 (MCNP).

CONCLUSIONS

The modeled photon breast radiotherapy plan, applied to the phantom, indicated that the fetus dose is 59 mGy for 50 Gy prescribed to the breast. The results clearly indicate that only 9.5% of the fetal dose is caused by photons that are generated in the accelerator head through scattering and leakage, but the dominant component is scattered radiation from the patient's body.

Gallbladder cancer during pregnancy treated with surgery and adjuvant gemcitabine: A case report and review of the literature

Background

Gallbladder cancer (GBC) represents the most common biliary tract cancer. Prognosis remains poor with 5-year overall survival rates less than 5% in advanced stages. GBCs are diagnosed more frequently in women, supposedly due to endocrine factors.

Case

A 35-year-old woman, diagnosed with a non-metastatic GBC in the 22nd week of gestation, underwent a complete surgical resection 5 weeks later. Adjuvant gemcitabine was administered without complications, temporarily discontinued in the 32nd week to allow childbirth. The patient was disease-free for more than 3 years with ongoing remission at the last visit in July 2022. During the follow-up period, the child had no developmental, cognitive, or other health issues.

Conclusion

Malignant tumors occur in about 0.1% of pregnant women, many are treated with chemotherapy. In oncology, the need to deliver optimal treatment in these patients represents a major concern. Both surgery and adjuvant chemotherapy of locally advanced GBC can be performed safely, with certain considerations, in the second trimester of pregnancy.

[Cancer during pregnancy: Proposal of a clinical care pathway based on a regional cohort]

OBJECTIVES

Cancer during pregnancy affects 1 in 1000 pregnancies. This situation requires multidisciplinary team, however there is no care pathway dedicated to these patients. The main objective was to describe oncological, obstetrical, and neonatal care through a regional inventory. Our secondary objective was to define a regional "cancer and pregnancy" care pathway.

MATERIAL AND METHOD

We carried out an observational, retrospective study from 2013 to 2019 including 48 women (all cancer types) from 2013 to 2019 in Occitania. Then, we defined an "optimal care pathway" and we assessed whether it was respected in the breast cancer subgroup of our cohort.

RESULTS

Live births occurred in 79% of the women included. Maternal treatment was initiated during pregnancy for 67% of our population (44% chemotherapy). The most frequent pregnancy complication was preterm delivery (39%), mainly iatrogenic (86.6%). No patient in the group of breast cancer benefited from all of the ten criteria of the "optimal care pathway" that we proposed.

CONCLUSIONS

A coordinated regional care pathway seems necessary to optimize communication between the healthcare providers (oncologists, gynecologists and multidisciplinary prenatal diagnosis centers, pharmacologists, pediatricians, psychologists, and general practitioners). This study identifies weaknesses in the management of women with cancer during pregnancy and suggests regional improvement opportunities.

Maternal supplementation of α-lipoic acid attenuates prenatal cytarabine exposure-induced oxidative stress, steroidogenesis suppression and testicular damage in F1 male rat fetus

Background

Cytarabine (Ara-C) is an anticancer drug, which is considered as the mainstay in the treatment of hematological malignancies, known to cause various teratogenic effects. Alpha-lipoic acid (ALA) is a natural antioxidant and its supplementation proved to improve pregnancy outcomes in several pathological conditions. We aimed at exploring the benefits of maternal supplementation of ALA against in-utero Ara-C exposure-induced testicular toxicity in rat fetuses.

Methods

Pregnant rats (dams) received normal saline (control group), ALA 200 mg/kg (ALA group), Ara-C 12.5 mg/kg (Ara-C 12.5 group), Ara-C 25 mg/kg (Ara-C 25 group), and Ara-C 25 mg/kg + ALA 200 mg/kg (protection group) from gestational day (GD)8 to GD21. Ara-C and ALA were administered via the intraperitoneal and oral routes, respectively. The day of parturition was considered as postnatal day (PND)1. On PND1, all the live male pups were collected. The maternal parameters evaluated include (a) food intake, (b) bodyweight, and (c) oxidative stress (OS) markers. The fetal parameters evaluated include (a) bodyweight, (b) anogenital distances (AGD), (c) testicular weight (d) testicular testosterone levels (e) testicular histopathology, and (f) morphometrical parameters.

Results

A significant and dose-dependent decrease in maternal food intake, weight gain, and an increase in oxidative stress (OS) were observed in the pregnant rats of the Ara-C groups as compared to pregnant rats of the control group. Further, a significant and dose-dependent (a) reduction in bodyweight, AGD, testicular weight, and testosterone levels, (b) increase in OS, and (c) structural and morphometrical anomalies in fetal testes were observed in fetuses of Ara-C groups as compared to fetuses of the control rats. These deleterious effects observed in the Ara-C groups were found to be diminished in the pregnant rats and fetuses of the Protection group as compared to the pregnant rats and fetuses of the Ara-C 25 group.

Conclusions

From the results of this study, we conclude that the maternal supplementation of ALA may ameliorate the Ara-C exposure-induced impairment in prenatal development and function of the testes in the rat fetuses. However, future experimental and clinical studies are warranted to explore the possible mechanisms involved in the protection offered by maternal supplementation of ALA against Ara-C induced testicular toxicity.

Graphical Abstract

Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.

Does radical trachelectomy (RT) during pregnancy have higher obstetrical and oncological risks than RT before pregnancy?

PURPOSE

Radical trachelectomy (RT) with pelvic lymphadenectomy has become a new treatment option for young patients with uterine cervical cancer stages 1A2-1B1 who desire the preservation of their fertility. However, the application of RT for pregnant patients is still controversial. We comparatively studied both obstetrical and oncological outcomes of pregnant patients who underwent vaginal RT during pregnancy and those who underwent vaginal RT before pregnancy.

METHODS

Both obstetrical and oncological results of eight patients who underwent vaginal RT with pelvic lymphadenectomy during pregnancy in our institute between 2010 and 2020 (Group A), and ten pregnant patients who underwent vaginal RT with pelvic lymphadenectomy before pregnancy during the same period (Group B) were reviewed based on their medical charts.

RESULTS

There were neither significant differences in blood loss, surgical time, or surgical completeness between Group A and Group B, nor were there significant differences in obstetrical outcomes between the two groups. However, two of the eight patients in Group A had recurrence of the cancer. None of the patients in Group B has shown any signs of recurrence thus far.

CONCLUSION

Vaginal RT during pregnancy does not affect the obstetrical prognoses of patients with early invasive uterine cervical cancer, and it might be a tolerable treatment modality for them. However, oncologically, it should be performed carefully as there is a risk of recurrence.

Anaplastic ganglioglioma in pregnancy a cause of cerebral edema and maternal death

Objectives

The true incidence of anaplastic ganglioglioma during pregnancy is extremely rare, very few cases have been reported in the literature.

Case presentation

This is a report of a case of anaplastic ganglioglioma diagnosed in pregnancy. The patient is a 23-year-old primigravida who presented at 19 weeks of gestation headache and a convulsive episode. Her workup revealed a rare cerebral tumor that progressed to a neurological decline and died during the postpartum period.

Conclusions

Anaplastic ganglioglioma is an aggressive counterpart of Glial tumors; in pregnancy they are rare and symptoms are nonspecific. The outcome for the mother in this case fatal and a protocol for these cases has not yet been reported.

Cancer in pregnancy and the risk of adverse pregnancy and neonatal outcomes: a nationwide cohort study

OBJECTIVES

To investigate the obstetrical management of cancer in pregnancy and to determine adverse pregnancy and neonatal outcomes.

DESIGN

A nationwide cohort study.

SETTING AND POPULATION

We included all pregnancies (N = 4,071,848) in Denmark from 1 January 1973 to 31 December 2018.

METHODS

Exposure was defined as pregnancies exposed to maternal cancer (n = 1,068). The control group comprised pregnancies without cancer. The groups were compared using logistic regression analysis and adjusted for potential confounders.

MAIN OUTCOME MEASURES

The outcomes were induced abortion, preterm birth and adverse neonatal outcomes.

RESULTS

More women with cancer in pregnancy, as compared to the control group, experienced induced abortion (24.8 vs. 20.0%); first-trimester induced abortion adjusted odds ratio (aOR) 3.5 (95%CI 2.7─4.5), second-trimester induced abortion; aOR 8.8 (6.3─12.3), planned preterm birth(11.8 vs. 1.3%); aOR 10.8 (8.0─14.6), and planned preterm birth below 32 gestational weeks; aOR 16.3 (8.3─31.7). Neonates born to mothers with cancer in pregnancy had a higher risk of respiratory distress syndrome; aOR 3.5 (2.8─4.4), low birth weight; aOR 3.8 (3.1─4.8), admission to neonatal intensive care unit more than seven days; aOR 5.1 (3.9─6.6), neonatal infection; aOR 1.8 (1.1─3.1) and neonatal mortality; aOR 4.7 (2.7─8.2), but not of SGA; aOR 1.0 (0.6-1.5) and malformations; 1.2 (0.9-1.7).

CONCLUSION

Cancer in pregnancy increases the risk of induced abortion and planned premature birth. Neonates born to mothers with cancer in pregnancy had an increased risk of neonatal morbidity and mortality, presumably due to prematurity.

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses

OBJECTIVE

To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery.

METHODS

We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database.

RESULTS

We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth.

CONCLUSION

Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.

Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management

Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.

Yolk Sac Tumour of the Ovary in Pregnancy Treated With Surgery and Chemotherapy: A Case Report

BACKGROUND

Ovarian carcinoma diagnosed in pregnancy is rare. Treatment should take both mother and fetus into consideration.

CASE

We present the case of a patient diagnosed with a stage IC1 yolk sac tumour of the ovary at 15 weeks gestation, who underwent surgical staging and adjuvant chemotherapy during pregnancy. Intrauterine growth restriction was diagnosed and the patient delivered by cesarean at 36 weeks gestation for obstructed labour.

CONCLUSION

Yolk sac tumour of the ovary in pregnancy with concomitant chemotherapy is uncommon. Adverse outcomes, including restricted fetal growth, are possible and their identification may help guide timing of delivery.

Cancer in pregnancy increases the risk of venous thromboembolism: a nationwide cohort study

OBJECTIVE

To investigate if cancer in pregnancy causes a higher risk of venous thromboembolism (VTE) during pregnancy and postpartum compared with pregnant women without cancer.

DESIGN

A historical prospective cohort study using data from nationwide registries.

SETTING AND POPULATION

We assessed all pregnancies in Denmark between 1 January 1977 and 31 December 2017.

METHODS

We linked information concerning cancer diagnosis, pregnancy and VTE diagnosis and potential confounders. Event rates of VTE for women with pre-pregnancy cancer, cancer in pregnancy and without cancer were calculated per 10 000 pregnancies and compared using logistic regression analysis.

MAIN OUTCOME MEASURES

Occurrence of VTE during pregnancy or the postpartum period.

RESULTS

A total of 3 581 214 pregnancies were included in the study and we found 1330 women with cancer in pregnancy. In pregnant women with cancer, the event rate of VTE was 75.2 per 10 000 pregnancies compared with 10.7 per 10 000 pregnancies in the no cancer group. The findings correspond to an increased adjusted odds ratio of 6.50 (95% CI3.5-12.1) in the cancer in pregnancy group in comparison with the no cancer group.

CONCLUSIONS

Women with cancer in pregnancy have a markedly higher risk of pregnancy-associated VTE compared with women without cancer. In pregnancy-related VTE risk assessment, the presence of cancer alone may be sufficient to indicate thromboprophylaxis.

TWEETABLE ABSTRACT

Cancer in pregnancy increases the risk of VTE during pregnancy and the postpartum period.

Cancer During Pregnancy: How to Handle the Bioethical Dilemmas?-A Scoping Review With Paradigmatic Cases-Based Analysis

Ethical issues that arise during the care of a pregnant woman with cancer are challenging to physicians, policymakers, lawyers, and the bioethics community. The main purpose of this scoping review is to summarize existing literature regarding the bioethical dilemmas when a conflict arises in the maternal-fetus dyad, like the one related to cancer and pregnancy outcomes. Moreover, we illustrate the decision-making process of real-life case reports. Published data were searched through the PubMed and Google Scholar databases, as well as in grey literature, using appropriate controlled keywords in English and Portuguese. After identification, screening, eligibility and data extraction from the articles, a total of 50 was selected. There are several established ethical frameworks for conflict resolution and decision-making. Pragmatic theoretical approaches include case-based analysis, the ethics of care, feminist theory, and traditional ethical principlism that scrutinizes the framework of autonomy, justice, beneficence, and non-maleficence. In addition, society and practitioner values could mediate this complex ethical interplay. The physician must balance autonomy and beneficence-based obligations to the pregnant woman with cancer, along with beneficence-based obligations to the fetus. Ethical challenges have received less attention in the literature, particularly before the third trimester of pregnancy. Best, unbiased and balanced information must be granted both to the patient and to the family, regarding the benefits and harms for the woman herself as well as for the fetal outcome. Based on a previously validated method for analyzing and working up clinical ethical problems, we suggest an adaptation of an algorithm for biomedical decision-making in cancer during pregnancy, including recommendations that can facilitate counseling and help reduce the suffering of the patient and her family.

Ovarian Cancer and Pregnancy-A Current Problem in Perinatal Medicine: A Comprehensive Review

The frequency of concomitant adnexal tumors in pregnancy is reported to be at 0.15-5.7%, while ovarian cancer complicates 1 in 15,000 to 1 in 32,000 pregnancies, being the second most common gynecologic cancer diagnosed during pregnancy. The aim of this review is to discuss the problem of ovarian cancer complicating pregnancy and the current recommendations for diagnostics and treatment, with an emphasis on the risk to the fetus. A detailed analysis of the literature found in the PubMed and MEDLINE databases using the keywords "ovarian cancer", "ovarian malignancy", "adnexal masses", "ovarian tumor" and "pregnancy" was performed. There were no studies on a large series of pregnant women treated for ovarian malignancies and the management has not been well established. The diagnostics and therapeutic procedures need to be individualized with respect to the histopathology of the tumor, its progression, the gestational age at the time of diagnosis and the mother's decisions regarding pregnancy preservation. The multidisciplinary cooperation of specialists in perinatal medicine, gynecological oncology, chemotherapy, neonatology and psychology seems crucial in order to obtain the best possible maternal and neonatal outcomes.

Maternal survival of patients with pregnancy-associated cancers in Taiwan - A national population-based study

Pregnancy-associated cancer (PAC), defined as cancers diagnosed during pregnancy or the first year after delivery, affects one to two in every 1000 pregnancies. Although PAC is expected to be a growing issue, information about PAC in the Asian population is still scarce. Women with cancer diagnosed at the age of 16-49 years between 2001 and 2015 were selected from the Taiwan Cancer Registry and linked with the National Birth Reporting Database to identify PAC patients. We compared the overall survival of patients with PAC to patients without pregnancy. Among 126,646 female cancer patients of childbearing age, 512 were diagnosed during pregnancy, and 2151 during the first postpartum year. Breast cancer was the most common PAC (N = 755, 28%). Compared with patients without pregnancy in the control group, patients with cancers diagnosed during pregnancy and the first postpartum year generally had more advanced stages (odds ratio 1.35 and 1.36, 95% confidence interval [CI] 1.02-1.77 and 1.18-1.57, respectively). For all cancer types combined and controlled for the stage, age, and year of diagnosis, patients with PAC had similar overall survival with those in the control group, with a hazard ratio (HR) of 1.07 (95% CI 0.80-1.41) for the pregnancy group and HR 1.02 (95% CI 0.88-1.18) for the postpartum group. The diagnosis of breast cancer during the first postpartum year was linked with shorter survival (HR 1.34, 95% CI 1.05-1.72). In contrast, patients with postpartum lymphoma (HR 0.11, 95% CI 0.02-0.79) and cervical cancer (HR 0.40, 95% CI 0.20-0.82) had better prognosis. In general, the diagnosis of cancer during pregnancy or the first postpartum year does not affect the survival of patients with most cancer types. Exceptions include the worse prognosis of postpartum breast cancer and the better outcome of postpartum lymphoma and cervical cancer.

Experiences and challenges in the management of pregnancy-associated breast cancer at the Korle Bu Teaching Hospital: a review of four cases

Breast cancer is the commonest female cancer worldwide and the most common malignancy during pregnancy. The current management of breast cancer is based on patient and tumour characteristics, preferences and disease stage. In pregnancy-associated breast cancer, the gestational age influences treatment options. Sequencing of therapies is guided by safe imaging options, timing of delivery and prognosis. Systemic therapy options in the neoadjuvant, adjuvant and palliative settings are limited due to safety concerns of the unborn foetus. In resource-constrained regions, the application of safe options may be challenging. This paper reports four of such cases managed in Ghana using a multidisciplinary approach and local resource-appropriate evidence-based practices. Maternal and foetal outcomes were acceptable with none resulting in termination of pregnancy.

Case Report: Retroperitoneal Laparoscopic Partial Nephrectomy for T2 Renal Cell Carcinoma During Pregnancy

Introduction: Renal cell carcinoma (RCC) found during pregnancy is rare. Treatment strategies and timing of surgeries are controversial. Retroperitoneal laparoscopic partial nephrectomy for T2 RCC during pregnancy has not been reported before.

Patient Concerns and Diagnosis: Herein, we report a case of T2 RCC found in a 36-year-old woman during her 21st week of pregnancy. Both ultrasound and magnetic resonance imaging (MRI) suggested a malignancy, possibly renal cell carcinoma.

Interventions and Outcomes: After discussion with a multidisciplinary team, the tumor was removed completely via retroperitoneal laparoscopic partial nephrectomy, and pathology result was clear cell RCC. A male infant was delivered full-term uneventful, and both the patient and the boy were in good health after a 46-month follow-up.

Conclusion: Partial nephrectomy with retroperitoneal laparoscopic technique is feasible and recommended in some T2 RCC patients.

Postpartum Involution and Cancer: An Opportunity for Targeted Breast Cancer Prevention and Treatments?

Childbirth at any age confers a transient increased risk for breast cancer in the first decade postpartum and this window of adverse effect extends over two decades in women with late-age first childbirth (>35 years of age). Crossover to the protective effect of pregnancy is dependent on age at first pregnancy, with young mothers receiving the most benefit. Furthermore, breast cancer diagnosis during the 5- to 10-year postpartum window associates with high risk for subsequent metastatic disease. Notably, lactation has been shown to be protective against breast cancer incidence overall, with varying degrees of protection by race, multiparity, and lifetime duration of lactation. An effect for lactation on breast cancer outcome after diagnosis has not been described. We discuss the most recent data and mechanistic insights underlying these epidemiologic findings. Postpartum involution of the breast has been identified as a key mediator of the increased risk for metastasis in women diagnosed within 5-10 years of a completed pregnancy. During breast involution, immune avoidance, increased lymphatic network, extracellular matrix remodeling, and increased seeding to the liver and lymph node work as interconnected pathways, leading to the adverse effect of a postpartum diagnosis. We al discuss a novel mechanism underlying the protective effect of breastfeeding. Collectively, these mechanistic insights offer potential therapeutic avenues for the prevention and/or improved treatment of postpartum breast cancer.

Pancreatic Tumors Complicating Pregnancy: A Concern for Fetomaternal Well Being

INTRODUCTION

Hemoperitoneum resulting from the rupture of pancreatic tumors is a rare condition, especially during pregnancy.

CASE PRESENTATION

We report a case of a 21-year-old gravida 2, para 1, at 25+5 weeks of gestation, who presented to the hospital with severe epigastric pain and decreased fetal movement. Ultrasonography showed intrauterine fetal death, a retroperitoneal mass in the epigastric region, and hemoperitoneum. Computed tomography scan revealed a heterogeneously enhancing pancreatic mass suggestive of pancreatic neoplasm. However, the late diagnosis and the delay in treatment resulted in a deterioration of maternal status with eventual mortality.

CONCLUSION

Diagnostic difficulties occur because of the rarity of the condition and vague clinical presentations. In case of a pregnancy complicated by hemoperitoneum, prompt effort to stop the intraperitoneal bleeding is imperative.

Radiotherapy in Pregnancy-Associated Breast Cancer

Breast radiotherapy during pregnancy is a matter of debate as both the efficacy of treatment and the safety of the developing fetus should be considered. Currently there is not enough data to support the safety of in-utero exposure to radiation even with modern radiotherapy techniques. So it is highly recommended that breast radiotherapy is postponed to after delivery, though it might be considered in very selected patients according to risk-benefit assessment.

Signet Ring Cell Carcinoma with Lymphangitic Carcinomatosis in Pregnancy: A Case Report of an Unexpected Maternal Death and Review of the Literature

BACKGROUND Cancer in pregnancy is extremely rare, and gastric cancers are rarer still. Diagnosis is difficult in pregnancy due to overlapping symptoms with pregnancy such as nausea, pain, anemia, and fatigue. CASE REPORT A 26-year-old G1 woman at 32 weeks gestation with a past medical history of systemic lupus erythematosus presented with new-onset chest pain and shortness of breath. Computed tomography of the chest, electrocardiogram, and echocardiogram were normal. Laboratory evaluation revealed thrombocytopenia, proteinuria of 480 milligrams, and normal complement. She delivered on hospital day 3 due to worsening chest pain. During cesarean delivery, the patient became hypotensive and hypoxic and required intensive care unit admission after a cesarean hysterectomy. On postoperative day 2 she had a pulmonary embolus and was started on therapeutic anticoagulation. She clinically improved until postoperative day 4, when she was found unresponsive with pulseless electrical activity. After 38 minutes of Advanced Cardiac Life Support, death was pronounced. An autopsy was performed and the cause of death found to be complications of multi-organ system involvement of adenocarcinoma with signet ring cell features. Lymphangitic carcinomatosis was noted throughout the lungs. CONCLUSIONS This patient had adenocarcinoma with signet ring cell features and associated lymphangitic carcinomatosis, which led to her postpartum death. Lymphangitic carcinomatosis is associated with an exceedingly poor prognosis, especially in pregnancy.

The use of 5-azacytidine in pregnant patient with Acute Myeloid Leukemia (AML): a case report

BACKGROUND

The management of Acute Myeloid Leukemia (AML) during pregnancy remains challenging as both the maternal and fetal outcomes should be considered. Several reports suggested that chemotherapy can be administered safely during the second and third trimester of pregnancy. However, the use of 5-azacytidine presents limitation due to lack of data.

CASE PRESENTATION

A 28-years-old woman in the 26th week of gestation diagnosed with FLT3/ITD-mutated AML, complete remission was induced by Daunorubicin and Cytarabine, and subsequently with 5-azacytidine (75 mg/m2 daily for 7 days) with no fetal hematological or toxicity issues. Fetal ultrasound showed no aberrant morphology. Fetal size below the 5th percentile with normal umbilical artery dopplers, normal middle cerebral artery dopplers and ductus venosus doppler. Three weeks post 5-azacytidine, the team determined the most appropriate time for delivery after balancing the risks of prematurity and prevention of disease relapse since patient in hematological remission. The patient underwent elective lower segment caesarian section and had a baby girl delivered at 35 weeks of gestation weighing 1670 g without apparent anomalies.

CONCLUSION

Treatment using 5-azacytadine during last trimester of pregnancy resulted in no major fetal and maternal complications. These findings concluded that 5-azacytadine during the third trimester of pregnancy seems to be safe however, potential risks of this agent should be considered.

Treatment of Pregnancy-Associated Breast Cancer

KS is a 33-year-old Caucasian married woman who works full time as an accountant and has one daughter who is 2 years old. She enjoys reading and exercising in her spare time. She initially presented in July 2015 at the age of 31 years with a 1-cm breast mass in the left inner breast, which prompted a mammogram to be obtained. The mammogram revealed diffuse and occasionally grouped left breast calcifications. Additionally, there was focal edema at the site of the mass.

A follow-up mammogram was recommended to document stability in 6 months, which demonstrated an interval increase in number and size of segmental pleomorphic calcifications in the lower inner breast spanning 6 cm in size. A stereotactic core needle biopsy was completed and revealed high-grade ductal carcinoma in situ (DCIS) that was estrogen receptor (ER) and progesterone receptor (PR) positive.

Diagnosis and treatment of cervical cancer in pregnant women

In recent years, the incidence of gynecological malignant tumors during pregnancy has increased, mainly due to the increased number of old age pregnancy. The most common gynecological malignant tumors in pregnancy are cervical cancer, accounting for 71.6%, followed by ovarian malignant tumors, accounting for 7.0%. The incidence of cervical cancer in pregnancy is itself not very high, and the symptoms are easily confused with other diseases in pregnancy. During pregnancy, gynecological examination is limited, and therefore, the rate of misdiagnosis is higher. The treatment of cervical cancer during pregnancy is related to many factors, such as tumor size, pathological type, period of gestation, lymph node involvement, and patients' willingness to maintain pregnancy. As a reason of these factors, it is difficult to determine the optimal treatment. This article reviews the research progress on the diagnosis and treatment principles of cervical cancer in pregnancy, in order to strike a balance between effective treatment of tumors and protection of fetal health, and avoid delays in treatment and preterm delivery.

Laparoscopic Approach in Management of Renal Cell Carcinoma During Pregnancy: State of the Art

Renal cell carcinoma (RCC) is extremely rare in pregnant women. However, this is one of the most reported urologic tumors during pregnancy. The aim of this review was to evaluate RCC during pregnancy in terms of epidemiology, risk factors, diagnosis, natural history of disease, and the safety of laparoscopic approach in the management of this tumor. RCC presentation is frequently made incidentally during an ultrasonography performed for other reasons, such as hydronephrosis owing to non-neoplastic causes. The optimal time for surgery during pregnancy and the consequences of surgery on the maternal and fetal well-being are major considerations. Risks for adverse pregnancy outcomes should be explained, and the patient's decision about pregnancy termination should be considered. Ultrasound is good in diagnosing renal masses, with a sensitivity comparable to that of computed tomography only for exophytic masses larger than 3 cm. Magnetic resonance imaging is reproducible and a good, though expensive, alternative to computed tomography scans for the evaluation of renal lesions in pregnant women. Radical nephrectomy or nephron-sparing surgery are essential treatments for management of RCC. Laparoscopic surgery has historically been considered dangerous during pregnancy and avoided whenever possible, because of concerns regarding surgery-related risks, such as uterine injury, miscarriage, teratogenesis, preterm birth, and hypercapnia. The laparoscopic treatment during pregnancy is becoming increasingly accepted where feasible with low morbidity. However, the combination of a multidisciplinary approach, multi-specialty communication, and skilled surgeons can give the best possible outcomes for mother and fetus.