Cancer Treatment and Immunotherapy during Pregnancy

Biology, care, and outcomes of gestational breast cancers: a review

PURPOSE

The incidence of gestational breast cancers, breast cancers diagnosed during pregnancy, is increasing. There is a critical need to understand the pathophysiology, treatment recommendations, and remaining questions regarding care and therapeutics for this complex condition.

METHODS

Here, we review existing data regarding evaluation and management of gestational breast cancer, including safe imaging modalities, timing and choice of chemotherapy, evidence regarding targeted therapies during pregnancy. We highlight the importance of multidisciplinary care including oncologic, obstetric, and psychosocial care.

RESULTS

Gestational breast cancers are associated with unique biologic and clinicopathologic features that are impacted by physiologic changes of pregnancy such as upregulation of target genes associated with cell proliferation and immune regulation. Patients with gestational breast cancers more often present at advanced stages, are more likely to have aggressive tumor subtypes (i.e., triple negative or HER2 positive), and overall have worse prognoses than patients with non-gestational breast cancers. In this review, we synthesize recommendations for treatment strategies based on pregnancy trimester, optimal timing and choice of surgery, chemotherapy, targeted therapies, and psychosocial support.

CONCLUSION

Developing a framework for clinical care and treatment of patients with gestational breast cancers is integral to improving outcomes for patients with gestational breast cancers. Optimal treatment includes collaborative management with a multidisciplinary team dedicated to both maternal and fetal care.

Sustained Immunotherapy Response in Metastatic Brain Melanoma Through 2 Pregnancies

BACKGROUND Metastatic brain melanoma is a deadly form of cancer with a high mortality rate and short overall survival. Immunotherapy with immune checkpoint inhibitors is the first treatment option for BRAF wild-type patients. Pregnancy is the exclusion criterion for immunotherapy and may promote the progression of melanoma. This report shows the long-lasting response of a patient with metastasis in multiple locations, including the brain, to immunotherapy and radiotherapy, who delivered 2 healthy boys during the disease. CASE REPORT A 39-year-old woman was diagnosed with BRAF(-)/NRAS(+) skin melanoma, pT2bN2aM0 (IIIB). Due to pregnancy, she did not receive adjuvant therapy. Upon delivery, the disease manifested with multiple extracranial and symptomatic brain metastasis. She was treated with whole-brain radiation and immunotherapy with ipilimumab and nivolumab followed by nivolumab. A partial response of the brain metastases and an extracranial complete response were observed. During the immunotherapy, she became pregnant and the therapy was discontinued. She was under regular medical surveillance, during which she delivered a healthy boy. The last CT scan and magnetic resonance brain examination showed a maintenance response for 43 months after initiation of immunotherapy and 31 months after therapy completion. CONCLUSIONS A long-lasting response to radiotherapy and interrupted immunotherapy is possible in the case of symptomatic metastatic brain melanoma developing during pregnancy, and healthy deliveries are possible despite the mother's progressive melanoma or exposure of the fetus to nivolumab (first trimester).

Evaluation of anticancer potential of tetracene-5,12-dione (A01) and pyrimidine-2,4-dione (A02) via caspase 3 and lactate dehydrogenase cytotoxicity investigations

Cancer stands as a significant global cause of mortality, predominantly arising from the dysregulation of key enzymes and DNA. One strategic avenue in developing new anticancer agents involves targeting specific proteins within the cancer pathway. Amidst ongoing efforts to enhance the efficacy of anticancer drugs, a range of crucial medications currently interact with DNA at the molecular level, exerting profound biological effects. Our study is driven by the objective to comprehensively explore the potential of two compounds: (7S,9S)-7-[(2R,4S,5S,6S)-4-amino-5-hydroxy-6-methyloxan-2-yl]oxy-6,9,11-trihydroxy-9-(2-hydroxyacetyl)-4-methoxy-8,10-dihydro-7H-tetracene-5,12-dione (A01) and 5-fluoro-1H-pyrimidine-2,4-dione (A02). These compounds have demonstrated marked efficacy against breast and cervical cancer cell lines, positioning them as promising anticancer candidates. In our investigation, A01 has emerged as a particularly potent candidate, with its potential bolstered by corroborative evidence from lactate dehydrogenase release and caspase-3 activity assays. On the other hand, A02 has exhibited remarkable anticancer potential. To further elucidate their molecular mechanisms and interactions, we employed computational techniques, including molecular docking and molecular dynamics simulations. Notably, our computational analyses suggest that the A01-DNA complex predominantly interacts via the minor groove, imparting significant insights into its mechanism of action. While earlier studies have also highlighted the anticancer activity of A01, our research contributes by providing a deeper understanding of its binding mechanisms through computational investigations. This knowledge holds potential for designing more effective drugs that target cancer-associated proteins. These findings lay a robust groundwork for future inquiries and propose that derivatives of A01 could be synthesized as potent bioactive agents for cancer treatment. By elucidating the distinctive aspects of our study's outcomes, we address the concern of distinguishing our findings from those of prior research.

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.

Cancer and Pregnancy in the Post-Roe v. Wade Era: A Comprehensive Review

Cancer during pregnancy, affecting 1 in 1000 pregnancies, is rising in incidence due to delayed childbearing and improved detection. Common types include breast cancer, melanoma and cervical cancer and Hodgkin's Lymphoma. There are several physiological changes that occur during pregnancy that make its management a challenge to clinicians. Managing it requires multidisciplinary approaches and cautious test interpretation due to overlapping symptoms. To minimize fetal radiation exposure, non-ionizing imaging is preferred, and the interpretation of tumor markers is challenging due to inflammation and pregnancy effects. In terms of treatment, chemotherapy is avoided in the first trimester but may be considered later. Immunotherapy's safety is under investigation, and surgery depends on gestational age and cancer type. Ethical and legal concerns are growing, especially with changes in U.S. abortion laws. Access to abortion for medical reasons is vital for pregnant cancer patients needing urgent treatment. Maternal outcomes may depend on the type of cancer as well as chemotherapy received but, in general, they are similar to the non-pregnant population. Fetal outcomes are usually the same as the general population with treatment exposure from the second trimester onwards. Fertility preservation may be an important component of the treatment discussion depending on the patient's wishes, age and type of treatment. This article addresses the complicated nature of a diagnosis of cancer in pregnancy, touching upon the known medical literature as well as the ethical-legal implications of such a diagnosis, whose importance has increased in the light of recent judicial developments.

Developmental Toxicity Studies: The Path towards Humanized 3D Stem Cell-Based Models

Today, it is recognized that medicines will eventually be needed during pregnancy to help prevent to, ameliorate or treat an illness, either due to gestation-related medical conditions or pre-existing diseases. Adding to that, the rate of drug prescription to pregnant women has increased over the past few years, in accordance with the increasing trend to postpone childbirth to a later age. However, in spite of these trends, information regarding teratogenic risk in humans is often missing for most of the purchased drugs. So far, animal models have been the gold standard to obtain teratogenic data, but inter-species differences have limited the suitability of those models to predict human-specific outcomes, contributing to misidentified human teratogenicity. Therefore, the development of physiologically relevant in vitro humanized models can be the key to surpassing this limitation. In this context, this review describes the pathway towards the introduction of human pluripotent stem cell-derived models in developmental toxicity studies. Moreover, as an illustration of their relevance, a particular emphasis will be placed on those models that recapitulate two very important early developmental stages, namely gastrulation and cardiac specification.