Management Strategies for Brain Tumors Diagnosed during Pregnancy: A Case Report and Literature Review

Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care

(1) Background: Caring for pregnant cancer patients is clinically and ethically complex. There is no structured ethical guidance for healthcare professionals caring for these patients. (2) Objective: This concept paper proposes a theoretically grounded framework to support ethical and patient-centred care of pregnant cancer patients. (3) Methodological approach: The framework development was based on ethical models applicable to cancer care during pregnancy-namely principle-based approaches (biomedical ethics principles developed by Beauchamp and Childress and the European principles in bioethics and biolaw) and relational, patient-focused approaches (relational ethics, ethics of care and medical maternalism)-and informed by a systematic review of clinical practice guidelines. (4) Results: Five foundational discussion themes, summarising the key ethical considerations that should be taken into account by healthcare professionals while discussing treatment and care options with these patients, were identified. This was further developed into a comprehensive ethics checklist that can be used during clinical appointments and highlights the need for a holistic view to patient treatment, care and counselling while providing ethical, patient-centric care. (5) Conclusion: The proposed framework was further operationalised into an ethics checklist for healthcare professionals that aims to help them anticipate and address ethical concerns that may arise when attending to pregnant cancer patients. Further studies exploring clinicians' attitudes towards cancer treatment in the course of pregnancy and patient experiences when diagnosed with cancer while pregnant and wider stakeholder engagement are needed to inform the development of further ethical, patient-centred guidance.

Experience of Gamma Knife radiosurgery for treatment of brain metastases in pregnancy with literature review

Brain metastases during pregnancy poses complex conundrum in management. Stereotactic radiosurgery (SRS) offers valuable option to clinicians in this scenario. We reviewed and described the safety and effectiveness of Gamma Knife (GK) SRS in treating a solitary cerebellar metastasis in a patient with recurrent breast cancer at 28 weeks of gestation. Following multidisciplinary discussion, she consented for urgent single session GK SRS to the brain metastasis with 2 cycles of 3-weekly paclitaxel chemotherapy prior to planned delivery at term. Prior to the frame-based treatment, a trial run with dosimeters placed on the superior and inferior parts of foam knee support showed radiation exposure of 3.12 mSv and 1.06 mSv respectively. A prescription dose of 16 Gy at the 50% isodose was delivered using 24 isocentres over 39.7' of beam on time. The treatment plan had 98% coverage, 89% selectivity and a gradient index of 2.98. Dosimeters placed near the uterine fundus and suprapubic region (consistent with location of fetal head) during the actual treatment recorded 2.83 mSv and 0.27 mSv, which is lower than the trial dosimeter readings. The patient successfully completed SRS treatment and gave birth to a healthy baby two months later. Follow-up MRI at three months interval showed total resolution of the lesion. GK SRS is known for the lowest extracranial dose compared to other SRS modalities. This report and literature review confirmed that GK is a sharp and effective, yet gentle and safe treatment for pregnant patients with brain metastases.

Awake craniotomy during pregnancy: A systematic review of the published literature

Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.

Neurocutaneous Disorders in Pregnancy

Importance

Neurocutaneous disorders have significant implications for care of the pregnant patient. As neurocutaneous disorders are uncommon, obstetricians may be unfamiliar with these disorders and with recommendations for appropriate care of this population.

Objective

This review aims to summarize existing literature on the interaction between neurocutaneous disorders and pregnancy and to provide a guide for physicians caring for an affected patient.

Evidence Acquisition

A PubMed, MEDLINE, and Google Scholar search was carried out with a broad range of combinations of the medical subject headings (MeSH) terms "pregnancy," "Sturge -Weber," "Neurofibromatosis Type 1," "neurofibromatosis type 2," "von Hippel Lindau," "Tuberous Sclerosis," "neurocutaneous disorder," "treatment," "congenital malformations," "neurodevelopmental defects," "miscarriage," "breastfeeding," "autoimmune," "pathophysiology," and "management." References of included articles were searched to identify any articles that may have been missed after the above method was used.

Results

Neurocutaneous disorders are associated with increased pregnancy-associated maternal and fetal/neonatal morbidity, largely surrounding hypertensive disorders, epilepsy, and medication exposure. Some features of neurocutaneous disorders may be worsened or accelerated by pregnancy. Neurocutaneous disorders can often be diagnosed prenatally. Therefore, directed assessment should be offered to affected individuals with a personal or family history of a neurocutaneous disorder.

Conclusion and Relevance

Patients affected by neurocutaneous disorders who are pregnant or planning for future pregnancy should be carefully followed by a multidisciplinary team, which could include maternal-fetal medicine, neurology, and anesthesia, as well as other relevant subspecialists. Additional research is required regarding optimal counseling and management of these patients.

Cerebral meningioma during pregnancy mimicking eclampsia: About a rare case

INTRODUCTION

Pregnancy is a physiological state whose association with any pathology gives it specific characteristics in the management of patients. Meningioma is the most frequent brain tumor but rarely develops during pregnancy. Treatment of the tumor generally follows the same principle as that proposed outside pregnancy, with priority given to the mother's life.

PRESENTATION OF CASE

We report a rare case of gestational meningioma that was wrongly attributed to prepartum eclampsia, in a poorly monitored pregnancy estimated at 34 weeks' amenorrhea, which resulted in the termination of the pregnancy by cesarean section for maternal rescue. The patient underwent complete surgical removal of the tumor postpartum.

DISCUSSION

Cerebral meningioma in pregnancy is a rare but often fatal disease characterized by unusual behavior compared to meningiomas in non-pregnant women. It is suspected that endocrine and vascular changes play a crucial role in the pathophysiology of rapid tumor growth during pregnancy. The tumor's harmful effect on the fetus is not direct but is mediated by its consequences, such as intracranial hypertension and epileptic seizures, which can be life-threatening for both mother and fetus and in some cases necessitate termination of pregnancy.

CONCLUSION

The management of cerebral meningioma during pregnancy must take into account the gestational-fetal pairing, both in diagnosis and treatment. This requires close coordination and collaboration between various experts, including anesthetists, obstetricians, neurosurgeons, and pediatricians.

Neuroanaesthetic challenges in a pregnant patient with a huge cerebellopontine angle meningioma

Intracranial malignancy among pregnant women is extremely rare. Neuroanaesthesia for such high-risk patients demands extreme precautions. Our patient presented with a huge right cerebellopontine angle meningioma during the first trimester of her pregnancy. We share our valuable perianaesthetic challenges in managing her tumour-debulking surgery and a brief review of intracranial neoplasm during pregnancy.

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.

Clinical management of brain tumors in pregnancy

PURPOSE OF REVIEW

We review the diagnostic tools, treatment options, and clinical management for brain tumors diagnosed in pregnancy with consideration for management approaches that are best suited to preserve maternal and fetal health.

RECENT FINDINGS

Women of child-bearing age are at risk of developing brain tumors and are at increased risk compared with male counterparts for tumors that are hormonally driven. Brain tumors are rare neoplasms, and diagnosis of brain tumors in pregnancy is uncommon, such that management guidelines and treatment recommendations are lacking for most tumor types. We discuss the standard treatment options for brain tumors and the relative risks and safety when these treatments are considered during pregnancy. We review the neoplasms most commonly affecting pregnant women and the existing literature and guidelines.

SUMMARY

Pregnancy is a unique phase of life in which hormonal, immunologic, and vascular changes may impact tumor growth and presentation. Treatment decisions should consider the symptoms and stability of the pregnant patients, the gestational age and health of the fetus, and the location and behavior of the neoplasm.