Obstetric and Neonatal Outcomes of Cancer Treated During Pregnancy

Ewing's sarcoma in pregnancy

Here is a case of a woman in her mid-20s, with primary infertility for a duration of 6 years with irregular cycles, following which she spontaneously conceived. Unaware of her pregnancy status, she underwent concurrent radiotherapy and chemotherapy for extraosseous Ewing's sarcoma. During the workup following treatment of Ewing's sarcoma, she underwent ultrasonographic examination, which showed a single, live intrauterine gestation. The pregnancy was terminated due to cytotoxic effects of the chemoradiation. Treatment of Ewing's sarcoma involves a combination of surgery, chemotherapy and radiotherapy. In pregnant women with Ewing's sarcoma, a multidisciplinary approach is needed to diagnose and treat the condition. Any form of teratogenic drug or radiation exposure during the first trimester and early second trimester can have potential damage on the fetus.

Immediate breast reconstruction with expander following recurrent lesion resection and exchange to silicon breast implant in a pregnant triple negative breast cancer patient: case report

A 39-year-old gravida 1 para 1 pregnant Japanese woman underwent skin-sparing mastectomy and axillary lymph node dissection with immediate breast reconstruction (IBR) using a tissue expander (TE) at 32 weeks of pregnancy under general anesthesia. Inserted TE (300 cc) was expanded during breast feeding while the volume was 240 cc of the resected breast tissue. One month after delivery, 2 months after surgery, the contralateral healthy breast increased in size and the inframammary line was deviated toward a caudal site which was larger than 300 cc-inflated TE. She stopped breast feeding to receive a systemic chemotherapy after one months-breast feeding. At 3 months after delivery, the healthy breast size was smaller than the 250 cc-expanded breast and both the inframammary lines were at the same level. She was diagnosed local recurrence 3 month-postoperatively, so we resected the recurrent lesion and exchanged TE to silicon breast implant immediately. Finally, a good symmetry was obtained after insertion of the 220 cc SBI. At an IBR using TE, we should know the dynamic change of breast volume and the level of inframammary line of the healthy breast during those phases of pregnancy, delivery, and nursing.

After Chemotherapy Treatment for Maternal Cancer During Pregnancy, Is Breastfeeding Possible?

OBJECTIVE

To report breastfeeding complaints of women diagnosed with cancer during pregnancy and correlate success with characteristics of their treatment.

MATERIALS AND METHODS

This is a prospective cohort study of women diagnosed with cancer during pregnancy who attempted breastfeeding. We surveyed participants about breast engorgement, milk let down, and consistent breast milk production through mailed questionnaires. Treatment details, including the type and number of chemotherapy cycles given during pregnancy and antepartum or postpartum depression, were collected. A single pathologist evaluated surgical specimens to note lactational changes while blinded to patient's treatment. The primary endpoint was successful breastfeeding without reporting any lack of or decreased breast milk production.

RESULTS

When comparing women who underwent chemotherapy during pregnancy to women who did not, there was a significant difference in reporting a lack of or a perceived decrease in breast milk supply and the need to provide supplemental feeding to their infants (63.5% and 9%, respectively, p < 0.001). In the women who received chemotherapy, there was no significant difference in maternal age, cancer type, or stage with regard to breastfeeding difficulties. Gestational age at the first cycle and the number of cycles were significant factors associated with breastfeeding difficulties (p = 0.006 and p = 0.0003, respectively). Antepartum and postpartum depression was not associated with decreased breast milk production. A lack of lactational changes and significant lobular atrophy were noted in the women given neoadjuvant chemotherapy.

CONCLUSION

Women who undergo chemotherapy during a pregnancy are more likely to report breastfeeding difficulties.

Chemotherapy against cancer during pregnancy: A systematic review on neonatal outcomes

BACKGROUND

The concomitant incidence of cancer and pregnancy has increased in recent years because of the increase in maternal age at the time of the 1st pregnancy. The diagnosis of cancer in a pregnant woman causes ethical and therapeutic problems for both the patient and the physician. The main aim of this paper is to describe the available evidence concerning the short- and long-term neonatal impact of chemotherapy given to pregnant women.

METHODS

The relevant publications in English were identified by a systematic review of MEDLINE and PubMed for the last 15 years. The search strategy included "cancer[Title/Abstract] OR tumor[Title/Abstract] AND pregnancy[Title/Abstract] OR pregnant[Title/Abstract] AND embryo[Title/Abstract] or fetus[Title/Abstract] or neonate[Title/Abstract] or newborn[Title/Abstract] or pediatric[Title/Abstract] or child[Title/Abstract] AND English[lang]."

RESULTS

An analysis of the literature showed that only the administration of chemotherapy during the embryonic stage of conceptus is dangerous and can lead to the termination of the pregnancy. When the disease is diagnosed in the 2nd or 3rd trimester of gestation or when it is possible to delay the initiation of chemotherapy beyond the 14th week, the risk of severe problems for the fetus are low, and pregnancy termination is not required.

CONCLUSION

Data regarding the final outcome of children who have received in utero chemotherapy seem reassuring. Only the administration in the embryonal stage of conceptus is dangerous and can lead to the termination of pregnancy. When the disease is diagnosed in the 2nd or 3rd trimester of gestation or when it is possible to delay the initiation of chemotherapy beyond the 14th week, the risk of severe problems for the fetus are low and pregnancy termination is not needed. Increased knowledge of how to minimize the risks of chemotherapy can reduce improper management including unnecessary termination of pregnancy, delayed maternal treatment, and iatrogenic preterm delivery.

Effects of prenatal exposure to cancer treatment on neurocognitive development, a review

Due to the increasing incidence of cancer during pregnancy, the need to better understand long-term outcome after prenatal exposure to chemo- and/or radiotherapy has become more urgent. This manuscript focuses on the neurocognitive development after prenatal exposure to cancer treatment. We will review possible pathways for brain damage that could explain the subtle changes in neurocognition and behavior found after in utero exposure to cancer treatment. Contrary to radiation, which has a direct effect on the developing nervous system, chemotherapy has to pass the placental and blood brain barrier to reach the fetal brain. However, there are also indirect effects such as inflammation and oxidative stress. Furthermore, the indirect effects of the cancer itself and its treatment, e.g., poor maternal nutrition and high maternal stress, as well as prematurity, can be related to cognitive impairment. Although the available evidence suggests that cancer treatment can be administered during pregnancy without jeopardizing the fetal chances, larger numbers and longer follow up of these children are needed.

Malignancies associated with pregnancy: an analysis of 21 clinical cases

AIM

This study aimed at investigating the clinical characteristics of malignancies associated with pregnancy and to provide information for the development of suitable strategies of treating maternal malignancies.

METHODS

We conducted a retrospective analysis of 21 pregnant women with cancer who were admitted to our hospital between 2006 and 2012. The patients' clinical characteristics, treatment during pregnancy and postpartum, and pregnancy outcome were recorded.

RESULTS

There were 21 cases of malignancies associated with pregnancy, including 6 cases of cervical cancer, 6 cases of breast cancer, 3 cases of liver cancer, 2 cases of ovarian cancer, 2 cases of thyroid cancer, 1 case of nasopharyngeal carcinoma, and 1 case of malignant brain tumor. Of the 21 patients, 15 patients continued their pregnancies (9 of these patients received cancer treatment), whereas the other 6 terminated pregnancy. The modes of delivery included cesarean section (12 cases) and vaginal delivery (3 cases), which resulted in 17 newborns, 12 of them with preterm birth (12/17, 70.6 %). The gestational age was from 30 weeks + 5 days to 39 weeks. No neonatal malformations were found.

CONCLUSIONS

The management of malignancies associated with pregnancy is a challenge for doctors and patients. It should be based on histological subtype, disease stage, gestational age, obstetrics complications, and patient's preference regarding continuing the pregnancy.

Effects of fetal exposure to maternal chemotherapy

Approximately 1 in 1,000-2,000 pregnancies are complicated by cancer. Today, different treatment options are considered as safe during pregnancy: chemotherapy, radiotherapy, surgery, or a combination of these. Surgery is considered safe during all trimesters of pregnancy; radiotherapy can be administered during the first and the second trimester, and chemotherapy after the first trimester of pregnancy. The placenta, acting as a barrier between the mother and the fetus, plays a key role in the safe administration of chemotherapy during pregnancy. A few studies have investigated the short- as well as the long-term health, general development, and cognitive and cardiac outcomes on children exposed to chemotherapy in utero. In general, these results were reassuring. Nevertheless, better safety data are required. This means data with longer follow-up periods and comparison with appropriate control groups. Moreover, important biasing factors should be taken into account when interpreting these results. Firstly, a great proportion of children were born prematurely due to the maternal condition. Preterm birth in general has been associated with cognitive impairment. Secondly, cancer during pregnancy is clearly a stressful situation, and maternal stress is associated with attention deficits. In sum, we state that chemotherapy can be administered safely after the first trimester of pregnancy. Moreover, iatrogenic prematurity in order to start postpartum administration of chemotherapy should be avoided. Nonetheless, decisions concerning treatment in these specific cases should always be made in a multidisciplinary setting with internationally recognized expertise in the coexistence of cancer and pregnancy.