Influence of pregnancy on glioma patients

Association of pregnancy with tumour progression in patients with glioma

BACKGROUND

A significant proportion of women in reproductive age are diagnosed with diffuse gliomas, resulting in the need to address the safety of pregnancy in patient consultation. However, data on glioma progression after and during pregnancy are sparse and controversial.

METHODS

Female adult patients in their reproductive years (≥18 years and <46 years) with histological diagnosis of glioma between 01/01/2000 and 01/12/2019 from 2 academic centers have been included in the study. Re-classification according to the 2021 WHO classification of CNS tumours was performed. The cohort was divided into 3 groups, defined as (A) nulliparae, (B) primi-/multiparae before glioma diagnosis, and (C) primi-/multiparae after glioma diagnosis. Survival analyses were performed in a time-dependent manner with parity as time-dependent covariate.

RESULTS

159/368 females met our inclusion criteria, resulting in 47 (29.6 %) nulliparae, 88 (55.3 %) primi-/multiparae before glioma diagnosis and 24 (15.1 %) primi-/multiparae after glioma diagnosis. Median follow-up was 127.4 months (range 0.7-341.9), and median overall survival and progression free survival were 247.6 months (range 0.4-269.1) and 67.9 months (range 0.7-341.9), respectively. Overall, 113/159 (71.1 %) patients had tumour progression and 53/159 (33.3 %) deceased. In total, 57.4 % of the nullipara, 76.1 % of the primi-/multipara before glioma diagnosis and 79.1 % of the primi-/multipara after glioma diagnosis groups experienced tumour progression (p > 0.05). In multivariate time-dependent analysis, primi-/multiparae after glioma diagnosis presented with shorter progression free (HR 2.45, p = 0.0079), but not overall survival (HR 0.54, p > 0.05) in comparison to the other two groups.

CONCLUSION

Pregnancy after glioma diagnosis was associated with shorter progression free survival. Longer follow-up as well as larger cohorts are needed to investigate a potential impact on overall survival.

Therapeutic Strategies and Challenges in the Management of Craniospinal Tumors in Pregnancy: A Ten-Year Retrospective Tertiary-Center Study, Systematic Review, and Proposal of Treatment Algorithms

OBJECTIVE

This study aims to review therapeutic strategies in the management of craniospinal tumors in pregnant patients and the factors that may influence the management along with their influence on maternal and fetal outcomes.

METHODS

A retrospective single-center cohort study was performed at a tertiary neurosurgical referral center. Pregnant patients referred to the neuro-oncology multidisciplinary meeting (MDM) with craniospinal tumor were included. Ten-year patient data were collected from hospital records and neuro-oncology MDM outcomes. A systematic review was performed of the available literature as per PRISMA guidelines.

RESULTS

Twenty-five patients were identified, with a mean age of 31 years. Of these patients, 88% (n = 22) had cranial lesions and 12% (n = 3) had spinal lesions. Most of the patients had World Health Organization grade I/II tumors. Of the patients, 44% underwent surgery when pregnant, whereas in 40%, this was deferred until after the due date. Of patients, 16% did not require surgical intervention and were followed up with serial imaging in the MDM. The left lateral/park bench position was the preferred position for the spinal and posterior fossa lesions. Systematic review and retrospective data led to proposal of treatment algorithms addressing the therapeutic strategy for management of craniospinal tumors during pregnancy. Factors that may influence maternal and fetal outcomes during management of these tumors were identified, including aggressiveness of the tumor and stage of pregnancy.

CONCLUSIONS

Craniospinal tumors presenting in pregnancy are challenging. The surgical management needs to be tailored individually and as part of a multidisciplinary team approach. Factors influencing maternal and fetal outcomes are to be considered during management and patient counseling.

Management and treatment of brain tumors during pregnancy: an Italian survey

PURPOSE

The management of brain tumors during pregnancy is challenging. The clinical rarity and prognostic heterogeneity of such condition makes it difficult to develop standardized guidelines of treatment. The aim of this study was to assess the treatment options used in pregnant women with brain tumors that are currently used in Italy, considering the management of these patients reported in current literature in this field.

METHODS

A survey addressing the treatments options and management of brain tumors during pregnancy was designed on behalf of an ad-hoc task-force Neuro-Oncology committee of the Società Italiana di Neurochirurgia (SINch) to analyze the management of pregnant patients with brain tumors. We conducted a search of the literature published between January 2011 and September 2021, using MEDLINE (PubMed) in accordance to PRISMA guidelines. Data were discussed to obtain recommendations after evaluation of the selected articles and discussion among the experts.

RESULTS

A total of 18 Neurosurgical centers participated in the survey. A total of 31 pregnant women were included in this retrospective study. Meningiomas and gliomas were the two most common types of brain tumors diagnosed during pregnancy. An emergency surgical procedure was required in 12.9% of cases.

CONCLUSION

A multidisciplinary and tailored approach is fundamental. In women showing clinical stability, neurosurgical options should preferably be delayed if possible, and considered during the second trimester or after delivery. In patients with acute neurological symptoms or tumor progression, medical abortion in the first trimester or a C-section in the second and third trimester need to be considered.

Large infratentorial cystic oligodendroglioma in a pregnant patient: A case report of a rare presentation and literature review

Oligodendrogliomas (ODGs) are rare brain tumors in adults, mostly presenting as a supratentorial solid mass, while less than 10% occur infratentorially. Infratentorial cystic ODGs are extremely rare. We reported a large partially cystic cerebellar ODG in a 31-week pregnant patient with an unusual presentation and discussed the challenging management.

Patterns of Interaction Between Diffuse Low-Grade Glioma and Pregnancy: An Institutional Case Series

BACKGROUND

The occurrence of pregnancy in patients with low-grade glioma (LGG) constitutes a unique therapeutic challenge. Owing to the rarity of cases, there is a dearth of information in existing literature.

METHODS

We retrospectively identified all patients with a diagnosis of LGG and pregnancy at some point during their illness. Clinical course and obstetrical outcomes were reviewed. A volumetric analysis of tumor growth rate in association with pregnancy was performed.

RESULTS

Of 15 women identified, 13 (86.7%) had a prepregnancy LGG diagnosis. Of the 2 patients in whom LGG was diagnosed during pregnancy, one underwent upfront surgery, and the other had watchful waiting with resection after 60 weeks. Nine patients (60.0%) remained asymptomatic during pregnancy, while 5 (33.3%) experienced recurrence of seizures. There was one case of transformation of an astrocytoma to glioblastoma during the third trimester, which was resected emergently. In 10 cases, progression occurred after pregnancy at a median interval of 24.2 months (interquartile range 6.6-37.5 months), with progression within 6 months of delivery in 2 cases. Mean (SD) growth rate during pregnancy was 7.8 (22.2) mm/year compared with 0.62 (1.12) mm/year before pregnancy and 0.29 (1.18) mm/year after pregnancy; the difference did not reach statistical significance (P = 0.306).

CONCLUSIONS

Pregnancy was associated with clinical deterioration in one third of patients. No significant change in growth rate was identified. Time to progression and malignant dedifferentiation were unaffected. Patients with LGG wishing to pursue pregnancy should be counseled regarding the risk of complications, and if pregnancy is pursued, close neurological and obstetrical follow-up is recommended.

Pregnancy and brain tumors; a systematic review of the literature

The incidence of primary brain tumors during pregnancy is uncommon. The etiology of these can range from different genetic syndromes such as Li Fraumeni, neurofibromatosis type I, and hormonal associated tumors. The number of meningiomas gradually tends to increase during pregnancy, suggesting a relationship between non-malignant meningiomas and hormonal changes. Clinical features are non specific or can be misinterpreted with pregnancy symptoms such as headache, vomiting and dizziness. It is worth mentioning that the symptoms due to intracranial tumors are no different in pregnant compared with non pregnant patients. However, retrospective studies in glioma behavior suggested that both tumor volume and growth, increased during pregnancy. These changes were correlated with clinical worsening and increased frequency of seizures. The diagnosis requires a proper neurologic exploration and the support of imaging studies. Treatment of tumors is very controversial since we look for the preservation of both mother and fetus. In theory, the best therapy for the mother will also be the best therapy for the fetus. During pregnancy, ideally the treatment is symptomatic, to preserve the fetus, and definite treatment may be performed after birth; the latter is not always accomplished since patients may present with impending herniation or a malignant tumor for which immediate management is necessary. We intend to give an updated review in the literature on the adequate treatment of brain tumors during pregnancy and the anesthetic management during the definite treatment. Literature data was obtained from Pubmed using the search terms: "Pregnancy", "Brain", "Tumors". A total of forty-three articles were selected.

A narrative review of pregnancy after malignancies in young women that don't originate in the female genital organs or in the breast

While cancer during pregnancy and its treatment has grown to be a popular topic in recent years, little is known on how to advise patients looking to conceive or conceiving after cancer treatment. The aim of this paper is to review the available literature on the impact of pregnancy on survivors of the most common childhood cancers, brain cancer, haematological malignancies, thyroid cancer, melanomas and sarcomas. Its main objective is to be a source of information for clinicians looking to counsel patients in these delicate moments exploiting all the available literature, albeit scarce. Given the available literature, we conclude that the presence of a multidisciplinary team is of great importance in supporting the patient and her loved ones when facing pregnancy with a previous cancer diagnosis.

Astrocytoma: A Hormone-Sensitive Tumor?

Astrocytomas and, in particular, their most severe form, glioblastoma, are the most aggressive primary brain tumors and those with the poorest vital prognosis. Standard treatment only slightly improves patient survival. Therefore, new therapies are needed. Very few risk factors have been clearly identified but many epidemiological studies have reported a higher incidence in men than women with a sex ratio of 1:4. Based on these observations, it has been proposed that the neurosteroids and especially the estrogens found in higher concentrations in women's brains could, in part, explain this difference. Estrogens can bind to nuclear or membrane receptors and potentially stimulate many different interconnected signaling pathways. The study of these receptors is even more complex since many isoforms are produced from each estrogen receptor encoding gene through alternative promoter usage or splicing, with each of them potentially having a specific role in the cell. The purpose of this review is to discuss recent data supporting the involvement of steroids during gliomagenesis and to focus on the potential neuroprotective role as well as the mechanisms of action of estrogens in gliomas.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.