Pregnancy After Breast Cancer in Young BRCA Carriers: An International Hospital-Based Cohort Study

Importance

Young women with breast cancer who have germline pathogenic variants in BRCA1 or BRCA2 face unique challenges regarding fertility. Previous studies demonstrating the feasibility and safety of pregnancy in breast cancer survivors included limited data regarding BRCA carriers.

Objective

To investigate cumulative incidence of pregnancy and disease-free survival in young women who are BRCA carriers.

Design, Setting, and Participants

International, multicenter, hospital-based, retrospective cohort study conducted at 78 participating centers worldwide. The study included female participants diagnosed with invasive breast cancer at age 40 years or younger between January 2000 and December 2020 carrying germline pathogenic variants in BRCA1 and/or BRCA2. Last delivery was October 7, 2022; last follow-up was February 20, 2023.

Exposure

Pregnancy after breast cancer.

Main Outcomes and Measures

Primary end points were cumulative incidence of pregnancy after breast cancer and disease-free survival. Secondary end points were breast cancer-specific survival, overall survival, pregnancy, and fetal and obstetric outcomes.

Results

Of 4732 BRCA carriers included, 659 had at least 1 pregnancy after breast cancer and 4073 did not. Median age at diagnosis in the overall cohort was 35 years (IQR, 31-38 years). Cumulative incidence of pregnancy at 10 years was 22% (95% CI, 21%-24%), with a median time from breast cancer diagnosis to conception of 3.5 years (IQR, 2.2-5.3 years). Among the 659 patients who had a pregnancy, 45 (6.9%) and 63 (9.7%) had an induced abortion or a miscarriage, respectively. Of the 517 patients (79.7%) with a completed pregnancy, 406 (91.0%) delivered at term (≥37 weeks) and 54 (10.4%) had twins. Among the 470 infants born with known information on pregnancy complications, 4 (0.9%) had documented congenital anomalies. Median follow-up was 7.8 years (IQR, 4.5-12.6 years). No significant difference in disease-free survival was observed between patients with or without a pregnancy after breast cancer (adjusted hazard ratio, 0.99; 95% CI, 0.81-1.20). Patients who had a pregnancy had significantly better breast cancer-specific survival and overall survival.

Conclusions and Relevance

In this global study, 1 in 5 young BRCA carriers conceived within 10 years after breast cancer diagnosis. Pregnancy following breast cancer in BRCA carriers was not associated with decreased disease-free survival.

Trial Registration

ClinicalTrials.gov Identifier: NCT03673306.

Maternal deaths among patients with cancer in the United States

Our objective was to characterize the risks of maternal deaths in cancer patients compared to the general population using a large population-based cohort.Female patients with a cancer first diagnosed at ages 15 to 39 years between 2000 and 2016 (N = 240,561) from the surveillance, epidemiology, and end results database were extracted, among which 165 maternal deaths were observed.We found Hispanic ethnic groups, advanced cancer stage, receiving chemotherapy were associated with a higher risk of maternal deaths compared to the general the United States population. Patients with cancers of the respiratory system were at the highest risk of maternal deaths, followed by cancers of the digestive system, and hematological malignancies.

Pregnancy Does not Affect the Prognoses of Differentiated Thyroid Cancer Patients With Lung Metastases

CONTEXT

Pregnancy-related hormones may stimulate thyroid cancer growth, but whether pregnancy affects the prognoses of patients with lung metastases from differentiated thyroid cancer (DTC-LM) after surgery and radioiodine therapy is unclear.

OBJECTIVE

To assess the impact of pregnancy on DTC-LM through the comparison of prognoses between female patients with DTC-LM who did and did not become pregnant after surgery and radioiodine therapy.

METHODS

We retrospectively analyzed the records of 124 female patients aged 16 to 35 years who underwent surgery and radioiodine therapy for DTC-LM. These patients were divided into pregnancy group (n = 37) and nonpregnancy group (n = 87) according to whether they became pregnant after surgery and radioiodine therapy, regardless of whether they had a pregnant history before treatment.

RESULTS

The 5- and 10-year progression-free survival rates were 94.52% and 63.22% in pregnancy group versus 89.82% and 58.13% in nonpregnancy group. The 5- and 10-year cumulative overall survival rates of pregnancy group were 97.30% and 85.77% versus 93.50% and 81.95% in nonpregnancy group (all P > 0.05). The median time of follow-up in the pregnancy and nonpregnancy groups was 82 months (25-136 months) and 68 months (13-133 months), respectively. Non-radioiodine-avid LM and primary tumors needing repeated resection were independent predictors of poor progression-free survival for patients in pregnancy group.

CONCLUSION

Pregnancy does not affect the prognoses of patients with DTC-LM after surgery and radioiodine therapy. Non-radioiodine-avid LM and repeated primary tumor surgeries are independent risk factors for poor prognoses of pregnant patients.

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.

Renal and Bladder Cancer During Pregnancy: A Review of 47 Cases and Literature-based Recommendations for Management

OBJECTIVE

To provide contemporary gestational age-specific recommendations for management, a retrospective series of patients with renal or bladder cancer during pregnancy is reported.

METHODS

Obstetric and oncological data of pregnant patients with a diagnosis of renal or bladder cancer were selected from the worldwide registry of the International Network of Cancer, Infertility and Pregnancy. In addition, the literature was reviewed for recent case reports since last reviews in 2014 for renal cancer and 2004 for bladder cancer.

RESULTS

International Network of Cancer, Infertility and Pregnancy registered 22 cases (14 renal cancer and 8 bladder cancer), diagnosed between 1999 and 2017, and the literature reported 15 cases with renal cancer and 10 cases with bladder cancer between 2004 and 2019. Most common symptoms for renal and bladder cancer were pain (28%) and hematuria (66%), respectively. In more than half of the patients, surgical treatment was performed during pregnancy. Preterm deliveries were mostly medically induced (12 of 17, 71%) and all patients with a planned delivery before 34 weeks had advanced cancer. For renal and bladder cancer respectively, 79% and 87% of patients obtained complete remission. Advanced cancer stages had worse prognosis; 3 of 7 patients with known follow-up deceased within 15 months after diagnosis.

CONCLUSION

Gestational age at diagnosis determines further management of renal and bladder cancers during pregnancy. Advanced stages challenge decision-making. The maternal needs for immediate treatment, and the neonatal risks including the impact of a preterm delivery should be discussed in a multidisciplinary setting while respecting the patient's autonomy.

Prognosis of pregnancy-associated breast cancer: a meta-analysis

BACKGROUND

Pregnancy-associated breast cancer (PABC) is defined as breast cancer that is diagnosed during pregnancy and/or the postpartum period. Definitions of the duration of the postpartum period have been controversial, and this variability may lead to diverse results regarding prognosis. Moreover, evidence on the dose-response association between the time from the last pregnancy to breast cancer diagnosis and overall mortality has not been synthesized.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library for observational studies on the prognosis of PABC published up to June 1, 2019. We estimated summary-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs). Subgroup analyses based on diagnosis time, PABC definition, geographic region, year of publication and estimation procedure for HR were performed. Additionally, dose-response analysis was conducted by using the variance weighted least-squares regression (VWLS) trend estimation.

RESULTS

A total of 54 articles (76 studies) were included in our study. PABC was associated with poor prognosis for overall survival (OS), disease-free survival (DFS) and cause-specific survival (CSS), and the pooled HRs with 95% CIs were 1.45 (1.30-1.63), 1.39 (1.25-1.54) and 1.40 (1.17-1.68), respectively. The corresponding reference category was non-PABC patients. According to subgroup analyses, the varied definition of PABC led to diverse results. The dose-response analysis indicated a nonlinear association between the time from the last delivery to breast cancer diagnosis and the HR of overall mortality (P < 0.001). Compared to nulliparous women, the mortality was almost 60% higher in women with PABC diagnosed at 12 months after the last delivery (HR = 1.59, 95% CI 1.30-1.82), and the mortality was not significantly different at 70 months after the last delivery (HR = 1.14, 95% CI 0.99-1.25). This finding suggests that the definition of PABC should be extended to include patients diagnosed up to approximately 6 years postpartum (70 months after the last delivery) to capture the increased risk.

CONCLUSION

This meta-analysis suggests that PABC is associated with poor prognosis, and the definition of PABC should be extended to include patients diagnosed up to approximately 6 years postpartum.

Clinico-pathologic features, treatment and outcomes of breast cancer during pregnancy or the post-partum period

PURPOSE

Breast cancer during pregnancy (BC-P) or the first year post-partum (BC-PP) is rare and whether it differs from breast cancer (BC) in young women not associated with pregnancy is uncertain.

METHODS

We queried our institutional database for BC-P and BC-PP cases and matched controls with BC not associated with pregnancy diagnosed between January 1, 1985 and December 31, 2013. We performed two parallel retrospective cohort studies evaluating clinico-pathologic features, treatment and outcomes for BC-P and BC-PP cases compared to their controls.

RESULTS

In our population of 65 BC-P cases, 135 controls for BC-P cases, 75 BC-PP cases and 145 controls for BC-PP cases, high grade and estrogen receptor-negativity were more frequent in both case groups than their controls. Among those with stage I-III BC, patterns of local therapy were similar for both case groups and their controls, with the majority undergoing surgery and radiation. Over three-fourths of those with stage I-III BC received chemotherapy. BC-P cases tolerated chemotherapy well, with the majority receiving doxorubicin/cyclophosphamide every 3 weeks. On multivariate analyses of those with stage I-III BC, BC-P cases had non-significantly higher hazards of recurrence and death compared to their controls, while BC-PP cases had non-significantly lower hazards of recurrence and death compared to their controls.

CONCLUSION

BC-P and BC-PP were associated with adverse clinic-pathologic features in our population. However, we did not observe inferior outcomes for BC-P or BC-PP compared to controls, likely due to receipt of aggressive multi-modality therapy.

[Maternal deaths in Sweden: Diagnostics and clinical management could be improved]

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.

Breast Cancer and Pregnancy

The diagnosis of breast cancer during pregnancy is a rare event, but the young age of the patient together with the emotional impact for both the family and the doctors make therapeutic choices usually very difficult. Until recently, the occurrence of pregnancy associated breast cancer was thought to hold a grave prognosis and therapeutic abortion was very often advised in common practice. The hormonal environment with the increase in estrogens and progesterone was the main factor for the fear of tumor stimulation. The course of breast cancer, however, does not appear to be adversely affected by continuation of pregnancy. In the last years it was realized that potentially curative therapies can be administered even when pregnancy is continued. Of course in the medical literature there is no randomized clinical trial helping in taking decision in this setting; however, a significant experience already exists in some institutions and can guide management in these difficult cases.

The aim of our review is to give an answer to questions usually coming from various specialists who collaborate with the oncologists in treating these patients and furthermore to try and find some basic guidelines which can be used in the information of the patients regarding previous experience in this field.

The problem of a pregnancy after treatment for breast cancer is also analyzed, as this aspect is an emerging issue in clinical oncology. The decision should be evaluated for each single patient, taking into account the prognosis of the patient and her desire of pregnancy.

Long-term Safety of Pregnancy Following Breast Cancer According to Estrogen Receptor Status

Safety of pregnancy in women with history of estrogen receptor (ER)-positive breast cancer remains controversial. In this multicenter case-control study, 333 patients with pregnancy after breast cancer were matched (1:3) to 874 nonpregnant patients of similar characteristics, adjusting for guaranteed time bias. Survival estimates were calculated using the Kaplan-Meier analysis; groups were compared with the log-rank test. All reported P values were two-sided. At a median follow-up of 7.2 years after pregnancy, no difference in disease-free survival was observed between pregnant and nonpregnant patients with ER-positive (hazard ratio [HR] = 0.94, 95% confidence interval [CI] = 0.70 to 1.26, P = .68) or ER-negative (HR = 0.75, 95% CI = 0.53 to 1.06, P = .10) disease. No overall survival (OS) difference was observed in ER-positive patients (HR = 0.84, 95% CI = 0.60 to 1.18, P = .32); ER-negative patients in the pregnant cohort had better OS (HR = 0.57, 95% CI = 0.36 to 0.90, P = .01). Abortion, time to pregnancy, breastfeeding, and type of adjuvant therapy had no impact on patients' outcomes. This study provides reassuring evidence on the long-term safety of pregnancy in breast cancer survivors, including those with ER-positive disease.

Cancer during pregnancy: what is the role of maternal serum and placental biomarkers? A review and commentary

Cancer during pregnancy, referred to as gestational cancer (GC), is infrequent but can occur in 1.0% of pregnant women. Hepatocellular carcinoma (HCC) is often lethal and is the fifth most common cancer worldwide, while breast adenocarcinoma (breast cancer) is the most common cancer seen during pregnancy. Liver and breast carcinomas are two examples of cancer types that present challenges to the obstetrician due to late and/or delayed diagnosis during pregnancy. Delays in diagnosis limit choices available to physicians regarding surgery, radiation, and chemotherapy. In view of such clinical situations, a role for maternal serum and placental biomarker (MSPB) screening results contributing to cancer diagnosis should be recognized; overlooking such data in GC could result from a lack of knowledge and understanding of MSPB biology, chemistry, and physiology. In this report, obstetricians and perinatologists seeking a diagnosis are urged to take advantage of available results from MSPB screening programs obtained from first- and second-trimester patient data. Using liver and breast cancer as examples, the present review and commentary seeks to demonstrate that MSPB levels, profiles, patterns, and cellular responses could provide foundational data in planning invasive or noninvasive methods and procedures (biopsy, imaging, scans, surgery) to attain a diagnosis as soon as possible in pregnancy. Finally, MSPB epidemiological and cancer risk studies could aid in providing baseline information for decisions regarding GC diagnosis from knowledge of their proposed roles in reducing lifetime risk of malignancies such as breast cancer.

Biological and pathological features in pregnancy-associated breast cancer: a matched case-control study

BACKGROUND

The prognosis for breast cancer has been considered to be worsened by the coexistence of pregnancy. However, to date, significant controversy still exists regarding the pathological tumor features and prognosis of patients diagnosed with pregnancy-associated breast cancer (PABC). The aim of the present study was to analyze the different prognostic factors and outcome in PABC subset versus a non-PABC control group matched for age and year of diagnosis.

MATERIALS AND METHODS

A total of 56 PABC cases were diagnosed from 1990 to 2008, for whom 73 non-PABC patients were identified. Pathological characteristics, immunohistochemical fea- tures, and differences in overall and disease-free survival were compared between both groups.

RESULTS

Compared to non-PABC controls, PABC patients presented more advanced disease (31% vs 13%, p = 0.024) and greater lymph node involvement (53% vs 34%, p = 0.034). Pathological and tumor features tended to present poorer prognostic factors in the PABC subset. Survival was poorer in the PABC patients (five-year DFS 68% in PABC vs 86% in non-PABC, p = 0.12). However, analysing survival adjusted for stage and age, the authors did not find significant differences between both groups.

CONCLUSIONS

PABC patients tended to be diagnosed in advanced breast disease and presented tumors with adverse pathological prognostic factors. While the authors found a poorer outcome in PABC group, no significant differences were observed with stage-matched analysis. The present results may suggest that the poorer prognosis observed within PABC women could not be due to pregnancy itself, but with a delay in diagnosis and tumor subtype pathological features.

Cancer of unknown primary during pregnancy: an exceptionally rare coexistence

BACKGROUND

Cancer in pregnancy is a rare disease with breast cancer, cervical cancer, melanoma and Hodgkin's disease to be the most commonly diagnosed malignancies during gestation. Cancer of unknown primary (CUP) is a well-recognized clinical disorder where the primary site can not be identified after a standard diagnostic approach. CUP in pregnancy has rarely been described.

MATERIALS AND METHODS

We searched MEDLINE and contacted cancer Centers in Europe, United States and Australia where patients with CUP or pregnant patients with cancer were diagnosed and treated.

RESULTS

Since 1976 we identified 18 pregnant women with CUP in a median gestational age of 34 weeks. Most of these patients were diagnosed with poorly-differentiated histology, had poor response to systemic treatment and a median maternal survival of 8 months. Seventy-two percent of mothers have died, while 80% of the newborns were alive and healthy. Almost one fourth of placentas examined showed metastatic disease.

CONCLUSION

CUP during pregnancy is a very rare coexistence, usually has an aggressive disease with poor response to chemotherapy and a dismal prognosis. Both obstetricians and oncologists should be aware of this rare condition.

Feto-maternal outcomes of pregnancy complicated by ovarian sex-cord stromal tumor: a systematic review of literature

Sex-cord stromal tumors (SCSTs) are rare ovarian cancers and their behavior during pregnancy is not well understood. To evaluate the maternal and fetal outcomes of pregnancy complicated by ovarian SCST, a systematic literature search was conducted in PubMed/MEDLINE using entry key words "pregnancy" and each type of ovarian SCST ("sex cord stromal tumor," "granulosa cell tumor," "thecoma," "Sertoli-Leydig cell tumor," or "gynandroblastoma") between 1955 and 2012 that identified 46 cases eligible for the analysis. Clinical characteristics, pregnancy outcome, tumor characteristics, and survival outcomes were evaluated. Serious adverse events were defined as complications related to the SCST that resulted in severe morbidity or mortality for mother, fetus, or both. The most common histology was granulosa cell tumor (22.0%), followed by thecoma (18.6%) and Sertoli-Leydig cell tumor (8.5%). Abdomino-pelvic pain (45.7%), palpable mass (30.4%), and virilization (26.1%) were the three most common symptoms. The majority were stage I (76.1%), tumor size <15cm (64.9%), and underwent unilateral adnexectomy (80.4%). Fetal conservation surgery was seen in 54.3%. Most cases had live births (78.3%) at full term (60.9%). Among cases proceeded expectant delay of delivery (45.7%), most cases resulted in live birth (95.2%) with median expectant interval of 20.7 weeks. Maternal and/or fetal serious adverse events (SAEs) were observed in 41.3% with maternal shock/hemoperitoneum being the most common complication (13.0%). Logistic regression test identified younger age (<30 versus ≥30, 73.3% versus 26.7%, odds ratio [OR] 11.7, 95%CI 1.35-101, p=0.026), large tumor (size ≥15cm versus <15cm, 64.9% versus 35.1%, OR 10.0, 95%CI 1.29-26.2, p=0.004), and advanced-stage (stages II-IV versus I, 76.1% versus 23.9%, OR 5.82, 95%CI 2.05-48.9, p=0.022) as risk factors of increased SAE. Overall survival of patients diagnosed with ovarian SCST during pregnancy was comparable to ovarian SCST not related to pregnancy (5-year rate, stages I and II-IV, 100% and 70.0%, respectively). In conclusion, although the majority of cases resulted in live birth, ovarian SCST-complicated pregnancy falls into the category of high-risk pregnancy. Risk factors for SAE identified in our study will help to guide strategic management of pregnancy complicated by ovarian SCST.

Liver diseases in pregnancy: Diseases not unique to pregnancy

Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver. Liver disease can cause significant morbidity and mortality in both pregnant women and their infants. Few challenges arise in reaching an accurate diagnosis in light of such physiological changes. Laboratory test results should be carefully interpreted and the knowledge of what normal changes to expect is prudent to avoid clinical misjudgment. Other challenges entail the methods of treatment and their safety for both the mother and the baby. This review summarizes liver diseases that are not unique to pregnancy. We focus on viral hepatitis and its mode of transmission, diagnosis, effect on the pregnancy, the mother, the infant, treatment, and breast-feeding. Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson’s disease, Budd Chiari and portal vein thrombosis in pregnancy are also discussed. Pregnancy is rare in patients with cirrhosis because of the metabolic and hormonal changes associated with cirrhosis. Variceal bleeding can happen in up to 38% of cirrhotic pregnant women. Management of portal hypertension during pregnancy is discussed. Pregnancy increases the pathogenicity leading to an increase in the rate of gallstones. We discuss some of the interventions for gallstones in pregnancy if symptoms arise. Finally, we provide an overview of some of the options in managing hepatic adenomas and hepatocellular carcinoma during pregnancy.

Stage at diagnosis and mortality in women with pregnancy-associated breast cancer (PABC)

Converging evidence indicates that women with pregnancy-associated breast cancer (PABC) have increased mortality compared to women with breast cancer not diagnosed near pregnancy (non-PABC). Our aim was to investigate if the stage distribution differs between PABC and non-PABC and if stage at diagnosis can explain the poorer prognosis observed among women with PABC. We identified 3,282 breast cancers in women aged 15-44 years at diagnosis for whom staging data (tumor size, nodal involvement, metastasis) were available in the Swedish Cancer Register between 2002 and 2009. Information on reproductive history and vital status was obtained from the Multi-Generation Register and the Cause of Death Register. PABC was defined as breast cancers diagnosed during pregnancy and up to 2 years after delivery (n = 317). Non-PABC was defined as cases diagnosed before pregnancy or more than 2 years postpartum. Stage distributions were compared between PABC and non-PABC, and mortality rates were modeled using Cox regression. Compared to women with non-PABC, the mortality was almost 50 % higher in women with PABC [unadjusted hazard ratio (HR) 1.47 (95 % CI 1.04-2.08)], a difference which was reduced after adjustment for age and calendar year of diagnosis [HR 1.27 (95 % CI 0.88-1.83)]. Although advanced stage of breast cancer at diagnosis was more common among PABC than among non-PABC, further adjustment for stage only slightly reduced the HR [1.22 (95 % CI 0.84-1.78)]. The difference in mortality between PABC and non-PABC was more pronounced among women above 35 years and among women with PABC diagnosed within 1 year postpartum. Age, rather than stage at diagnosis, appears to act as the principal driver of the increased mortality observed in women with PABC. However, these findings do not preclude an untoward influence on mortality by pregnancy-associated factors affecting tumor aggressiveness and progression.

Choriocarcinoma in Enugu, South east Nigeria: a need for a shift from mortality to survival

BACKGROUND

The diagnosis of cancer in Nigeria is often translated to mean an imminent death for the patient. This contrasts the situation in some developed settings where cancer survivorship and its management have evolved. Choriocarcinoma is a rare but curable tumour so; it became necessary to review cases of this curable cancer managed at a tertiary health center in a typical resourced-constrained setting.

METHODS

A retrospective analysis of consecutive choriocarcinoma cases managed at a tertiary hospital in Enugu, South-eastern Nigeria over a five year period. Data analysis was descriptive.

RESULTS

Five non-metastatic and 10 metastatic cases of choriocarcinoma were managed. The mean age of patients was 33.6 9.1 years. All patients had vaginal bleeding with a mean duration of 4 5.19 months. The commonest predisposing factor and metastatic site were abortion (46.7%) and lungs (40.0%) respectively. The mean unit of blood transfusion during treatment was 5.3 3.8 units. Eight patients (53.3%) died on admission while 7 (46.7%) were lost to follow-up during chemotherapy 20.0% or after chemotherapy (26.7%).

CONCLUSION

The case fatality for choriocarcinoma and loss of patients to follow-up in Enugu, Nigeria were high. To shift from this situation of high mortality to that of survival, an improved follow-up of post-abortal patients and aggressive tracing of defaulters are recommended.

[Pregnancy-Associated Breast Cancer: An analytical observational study]

BACKGROUND AND OBJECTIVE

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy and up to one year postpartum.

PATIENTS AND METHOD

A retrospective, analytical, observational study comparing 56 cases of breast cancer and pregnancy (PABC) diagnosed 1976-2008 with 73 patients with breast cancer not associated with pregnancy (non-PABC) was performed. Demographic data, prognostic factors, treatment and survival were reviewed and compared.

RESULTS

The prevalence of PABC in our center is 8.3/10,000. The highest frequency (62%) appeared during the postpartum period. The stages are higher in PABC, being 31.3% advanced (EIII and EIV) in PABC versus 13.3% in non-PABC (P < .05). Regarding prognostic factors, 27.3% in PABC had a tumoral grade 3 versus 15.8% of non-PABC. Among women with PABC, 33.3% had negative estrogen receptors, 48.7% negative progesterone receptors and 34.5% positive Her2Neu compared with 22.2, 24.1 and 31%, respectively of non-PABC patients. Finally, positive lymph nodes were found in 52.8% of PABC, versus 33.8% non-PABC (P < .05). Overall and disease-free survival rate at 5 years for PABC was 63.7 and 74.2%, respectively.

CONCLUSIONS

The poorer survival observed is possibly due to the presence of adverse prognostic features such as lymph node metastases, negative hormone receptors, tumoral grade iii, as well as a delay in diagnosis with a higher rate of advanced stages.

Mortality associated with phaeochromocytoma

Two major categories of mortality are distinguished in patients with phaeochromocytoma. First, the effects of excessive circulating catecholamines may result in lethal complications if the disease is not diagnosed and/or treated timely. The second category of mortality is related to development of metastatic disease or other neoplasms. Improvements in disease recognition and diagnosis over the past few decades have reduced mortality from undiagnosed tumours. Nevertheless, many tumours remain unrecognised until they cause severe complications. Death resulting from unrecognised or untreated tumour is caused by cardiovascular complications. There are also numerous drugs and diagnostic or therapeutic manipulations that can cause fatal complications in patients with phaeochromocytoma. Previously it has been reported that operative mortality was as high as 50% in unprepared patients with phaeochromocytoma who were operated and in whom the diagnosis was unsuspected. Today mortality during surgery in medically prepared patients with the tumour is minimal. Phaeochromocytomas may be malignant at presentation or metastases may develop later, but both scenarios are associated with a potentially lethal outcome. Patients with phaeochromocytoma run an increased risk to develop other tumours, resulting in an increased mortality risk compared to the general population. Phaeochromocytoma during pregnancy represents a condition with potentially high maternal and foetal mortality. However, today phaeochromocytoma in pregnancy is recognised earlier and in conjunction with improved medical management, maternal mortality has decreased to less than 5%.

[Eight-year experience in treating aggressive mediastinal large B-cell lymphomas]

AIM

To make a differential diagnosis of diffuse large B-cell lymphoma (DLBCL) with primary involvement of the mediastinal lymph nodes (LN) and primary mediastinal large B-cell lymphoma (PMLBCL); to evaluate the efficiency of a modified NHL-BFM-90 (M-NHL-BFM-90) program in the treatment of the above nosological entities.

SUBJECTS AND METHODS

The investigation enrolled 60 patients with large B-cell lymphoma (LBCL) with primary involvement of mediastinal LN who had been treated at the Hematology Research Center, Ministry of Health of Russia, in 2004 to 2012. The diagnosis of PMLBCL and DLBCL with primary involvement of mediastinal LN was based on histological findings, the phenotype of tumor cells, and molecular evidence. Treatment was performed according to the M-NHL-BFM-90 program. Three pregnant women received predelivery polychemotherapy (PCT) according to the VACOP-B protocol and continued to have a DexaBEAM chemotherapy regimen 3-4 weeks postpartum. In case of a residual mass, all the patients underwent consolidation radiotherapy to the mediastinal area in a total focal dose of 36 Gy.

RESULTS

The diagnosis of PMLBCL was established in 39 patients: 10 men and 29 women whose ages were 18 to 60 years (median age 30 years); DLBCL with primary involvement of mediastinal LN was verified in 21 patients: 8 men and 13 women whose age was 21 to 70 years (median age 30 years). After m-NHL-BFM-90 treatment protocol, 5-year overall survival rates in the patients with DLBCL with primary involvement of mediastinal LN and in those with PMLBCL were 95+/-5 and 86+/-6% and 5-year event-free survival rates were 95+/-5 and 78+/-7%, respectively. All the pregnant women diagnosed with PMLBCL who had received the VACOP-B --> delivery--> Dexa-BEAM PCT regimen during pregnancy achieved remission. The follow-up periods were 30, 36, and 42 weeks.

CONCLUSION

The patients with new-onset LBCL and primary involvement of mediastinal LN are a heterogeneous group that includes patients having two different diagnoses: PMLBCL and DLBCL. The efficiency of high-dose PCT is different in the patients with DLBCL with primary involvement of mediastinal LN and in those with PMLBCL (in spite of their similar clinical features, similar epidemiological characteristics, and the presence of the same unfavorable prognostic factors at onset).

The biological features and prognosis of breast cancer diagnosed during pregnancy: a case-control study

BACKGROUND

Breast cancer during pregnancy (BCP) is relatively rare and is associated with controversies about its biology and prognosis. Hence, we designed a case-control study to examine tumor features and outcome in a series of BCP patients diagnosed and treated in a single institution.

MATERIAL AND METHODS

We identified 65 patients diagnosed with BCP and for each; we selected two non-pregnant breast cancer patients, who were matched for age, year of surgery, stage, and neoadjuvant chemotherapy. We then compared the differences in pathology, immunohistochemical features (ER, PR, HER2 and ki-67), disease-free (DFS) and overall survival (OS).

RESULTS

We did not find any significant differences in tumor characteristics between the two groups. However, at a median follow-up of four years, BCP patients had an inferior DFS (HR 2.3; 95% CI 1.3-4.2), after adjustment for possible confounding covariates. No difference in OS was observed. However, upon restricting the analysis to patients who did not receive neoadjuvant chemotherapy, patients with BCP had inferior OS as well (HR 2.6; 95% CI 1.0-6.5). No association between induction of abortion and prognosis was observed.

CONCLUSIONS

While we did not observe any differences in tumor features, BCP patients have poorer prognosis compared to age and stage-matched control. Further studies should try to elucidate reasons for such poor outcome.

Previous pregnancy is a favourable prognostic factor in women with localised cutaneous melanoma

BACKGROUND

The influence of pregnancy on survival in melanoma has been a controversial issue.

OBJECTIVE

In this retrospective study we investigated whether pregnancy (overall or temporally melanoma-related) has any effect on melanoma progression or patient outcome.

METHODS

Patient data were collected from Turku University Hospital records concerning all women in fertile age (15-45 years) and diagnosed with melanoma between January 1, 1990 and December 31, 2009. We collected data on melanoma characteristics, treatment, pregnancies and patient outcomes.

RESULTS

Of the 334 patients, 248 (74%) had been pregnant in some point during their life while 55 (17%) were nulliparous. The history of pregnancies could not be verified in 31 women (9%). Progression of melanoma to advanced stage was found in 58 (17%) of these women. Altogether, 35 women (14%) with at least one pregnancy had disease progression in contrast to 14 women (26%) with no pregnancies (p =0.049). Women with at least one pregnancy had a 94% probability to survive from melanoma compared to nulliparous women of whom only 83% survived (p =0.041). In Multivariate (COX) analysis pregnancy was a favourable factor for disease-specific survival (DSS) (HR 3.75; 95% CI 1.24-11.34; p =0.019) when adjusted for age (HR 1.064; 95% CI 1.00-1.13; p =0.50), localisation and stage (p =0.040), and Breslow (HR 1.32; 95% CI 1.10-1.58; p =0.002). However, when ulceration of the primary tumour was included in the multivariate model, Breslow remained as the only independent predictor of DSS (HR 1.58; 95% CI 1.34-1.86; p =0.0001) and pregnancy was dropped from the stepwise backward model in the step preceding the last one (p =0.081).

CONCLUSION

Pregnancy is not a risk factor for disease recurrence or progression in melanoma patients, but instead can exert some favourable influence on prognosis.

Cancer during pregnancy: a review of 10 years of experience

Cancer is the second most common cause of death among women who are in reproductive ages; however it is not common during pregnancy. There are few numbers of documents concerning cancer and its related treatment outcomes and prognosis during pregnancy. The aim of this study was to review our experience about gestational cancer. In this retrospective chart review study, 25 pregnant women with any kind of diagnosed malignancy who attended hospitals in Uremia and Sanandaj city since 10 years ago were assessed. Cancer cases were verified by a pathologist using pathology and TNM system for tumors staging. Then survival duration was analyzed using Kaplan-Maier plot. From all, 10 women had gynecologic cancers and 15 had non-gynecologic cancers. Ovarian cancer was the most common malignancy. The mean of survival was 67 months for all patients (CI95%: 23.7-110.3), 67 months for gynecologic cancer group (CI95%: 40.2-93.8) and 69 months for non-gynecologic cancer group (CI95%: 0-159) (p = 0.51). According to the results, the cancer complaints and symptoms must be examined thoroughly and do not take them as pregnancy complications since delays in prognosis leads to more severe problems and makes treatment difficult. If cancer is treated carefully after three months of gestation, probably it won't have severe side effects for fetus.

Myeloproliferative disorders in pregnancy

This article reviews pregnancy outcome in women diagnosed with a myeloproliferative neoplasm (MPN), and discusses possible risk markers and the pathogenesis of poor pregnancy outcome. An outline of the key factors regarding the diagnosis and management of MPN in women of reproductive potential is followed by a description of the authors' management strategy for standard and high-risk pregnancy in MPN patients.

Prognosis for patients diagnosed with pregnancy-associated breast cancer: a paired case-control study

CONTEXT AND OBJECTIVE

Previous studies have suggested that the occurrence of pregnancy concomitantly with a diagnosis of breast cancer may affect the evolution of the neoplasia. The present study aimed to compare pregnancy-associated breast cancer (PABC) patients with non-pregnant cancer patients (controls) in relation to the time taken to diagnose the disease, tumor characteristics and mortality.

DESIGN AND SETTING

A retrospective, paired case-control study was conducted at the Hospital da Santa Casa de Misericórdia and Centro de Quimioterapia Antiblástica e Imunoterapia in Belo Horizonte, Brazil.

METHODS

The study involved 87 PABC and 252 control patients. The influence of covariables (interval between first symptoms and diagnosis, tumor histology, size of primary tumor, distant metastasis, grade of malignancy, hormone receptor status and axillary lymph node involvement) and the pregnancy variable on overall survival was investigated using univariate and multivariate analyses.

RESULTS

The median overall survival for PABC patients of 30.1 months (95% confidence interval, CI: 19.4-40.9 months) was significantly different (P = 0.005) from that of the control group (53.1 months; 95% CI: 35.1-71.0 months). The cumulative overall survivals after five and ten years were, respectively, 29.7 and 19.2% for PABC patients, and 47.3 and 34.8% for control patients (P = 0.005). Tumor size, grade of malignancy, distant metastasis and pregnancy were independent factors that significantly modified disease prognosis.

CONCLUSIONS

Pregnancy was an independent prognostic factor. The overall survival of PABC patients was shorter than that of non-pregnant patients.

Macrophages in breast cancer: do involution macrophages account for the poor prognosis of pregnancy-associated breast cancer?

Macrophage influx is associated with negative outcomes for women with breast cancer and has been demonstrated to be required for metastasis of mammary tumors in mouse models. Pregnancy-associated breast cancer is characterized by particularly poor outcomes, however the reasons remain obscure. Recently, post-pregnancy mammary involution has been characterized as having a wound healing signature. We have proposed the involution-hypothesis, which states that the wound healing microenvironment of the involuting gland is tumor promotional. Macrophage influx is one of the prominent features of the involuting gland, identifying the macrophage a potential instigator of tumor progression and a novel target for breast cancer treatment and prevention.

Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis

OBJECTIVE

To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer.

DATA SOURCES

Medline and Embase citation tracking from January 1960 to December 2007. Selection criteria Eligible studies had data on severe pregnancy outcomes for women with and without previous treatment for cervical intraepithelial neoplasia. Considered outcomes were perinatal mortality, severe preterm delivery (<32/34 weeks), extreme preterm delivery (<28/30 weeks), and low birth weight (<2000 g, <1500 g, and <1000 g). Excisional and ablative treatment procedures were distinguished.

RESULTS

One prospective cohort and 19 retrospective studies were retrieved. Cold knife conisation was associated with a significantly increased risk of perinatal mortality (relative risk 2.87, 95% confidence interval 1.42 to 5.81) and a significantly higher risk of severe preterm delivery (2.78, 1.72 to 4.51), extreme preterm delivery (5.33, 1.63 to 17.40), and low birth weight of <2000 g (2.86, 1.37 to 5.97). Laser conisation, described in only one study, was also followed by a significantly increased chance of low birth weight of <2000 g and <1500 g. Large loop excision of the transformation zone and ablative treatment with cryotherapy or laser were not associated with a significantly increased risk of serious adverse pregnancy outcomes. Ablation by radical diathermy was associated with a significantly higher frequency of perinatal mortality, severe and extreme preterm delivery, and low birth weight below 2000 g or 1500 g.

CONCLUSIONS

In the treatment of cervical intraepithelial neoplasia, cold knife conisation and probably both laser conisation and radical diathermy are associated with an increased risk of subsequent perinatal mortality and other serious pregnancy outcomes, unlike laser ablation and cryotherapy. Large loop excision of the transformation zone cannot be considered as completely free of adverse outcomes.

Melanoma and pregnancy

Herein we analyze three important issues concerning melanoma and pregnancy: 1) While initial case reports and case series predicted a grim prognosis for the woman diagnosed with melanoma during pregnancy, we summarize more recent controlled studies that suggest that pregnancy has no effect on survival in women diagnosed with localized cutaneous melanoma. 2) We review the prognosis for the fetus when a woman is diagnosed with melanoma during pregnancy. While melanoma is the most common malignancy to metastasize to the placenta, metastatic melanoma to the fetus appears to be a rare event. 3) How do we answer questions about future pregnancies and hormonal therapy when counseling women who have been diagnosed with melanoma during pregnancy or the childbearing years? Will future pregnancies worsen prognosis? Based on limited data, pregnancies subsequent to a diagnosis of localized melanoma do not appear to impact prognosis. Are oral contraceptive pills or hormonal replacement therapy contraindicated in these women? Strong epidemiologic evidence suggests that exposure to oral contraceptive pills do not increase the risk for melanoma. Although only a small number of studies have addressed the risk of hormone replacement therapy, the reports demonstrate that this also does not appear to enhance the risk for developing melanoma.

Metastatic amelanotic nodular melanoma during pregnancy

This case report presents a very aggressive course of amelanotic nodular melanoma during pregnancy resulting in death five months after delivery. A 34 year-old Caucasian woman at 19th week of the second pregnancy was diagnosed having amelanotic nodular melanoma (tumor thickness - 2.5 mm) with metastases to the regional right inguinal lymph node. Amelanotic nodular melanoma represents malignant melanocytic tumor of the skin, which clinically mimics a variety of benign and malignant skin conditions and therefore commonly leads to delayed diagnosis. Though primary tumor was excised immediately, other treatment procedures as radical lymphadenectomy and chemotherapy were delayed, and immunotherapy was not given totally. At the 29th week of pregnancy, the woman via naturalem delivered a healthy female child, and the chemotherapy was started. Since pregnancy limits the prescription of immunotherapy and chemotherapy, the prognosis for melanoma during pregnancy detected later than in the second stage is poor and can be illustrated by our reported case. Such patients seems to be at higher risk to develop metastasis of melanoma in the internal organs and occasionally even in the fetus; therefore, they should be timely informed about that.

[Management of pheochromocytoma during pregnancy: about three cases]

BACKGROUND

Pheochromocytoma is a rare disease that can be diagnosed for the first time during pregnancy. Diagnosis is difficult because it can mimic common gravid hypertension. Maternal and fetal prognosis depends on early diagnosis and adequate multidisciplinary management.

AIM

We report 3 cases of pregnant patients with pheochromocytoma.

CASES

For the first patient, diagnosis was made before pregnancy and pheochromocytoma was treated surgically at 20 weeks of pregnancy with good evolution. The second patient was hospitalized in a severe preeclampsia, acute pulmonary edema and fetal demise with fatal outcome. Pheochromocytoma was diagnosed during autopsy. The third patient had medical abortion of pregnancy because of tumor recurrence after surgical treatment. Rare association to pregnancy and clinical signs of pheochromoytoma as hypertension renders diagnosis difficult. A systematic etiology research to early hypertension during pregnancy can allow better screening of pheochromocytoma and improvement of foeto-maternal prognosis.

The complexity of management of pregnancy-associated malignant soft tissue and bone tumors

OBJECTIVE

The incidence of musculoskeletal tumors during pregnancy is very low. The aim of this study was to summarize our experience in treating a large cohort of pregnant patients diagnosed with these rare tumors.

METHODS

Women diagnosed with musculoskeletal tumors during pregnancy or immediately after delivery were identified retrospectively in our database between 1996 and 2006. Relevant maternal and neonatal data were collected.

RESULTS

Twenty patients, 8 with bone sarcomas (BS) and 12 with soft tissue sarcomas (STS) were identified. Two women were treated by wide excision of mass during pregnancy. In all other cases oncological treatment was delayed until delivery or termination of pregnancy. Vaginal delivery was possible in 9 patients, cesarean section was performed in 7, spontaneous abortion occurred in 1, and 3 underwent termination of pregnancy. Three newborns were premature, but normal growth and development were observed. Different techniques of fertility preservation were used in our patients. Five patients with BS and 5 patients with STS received preoperative chemotherapy, with different grades of toxicity. The degree of tumor necrosis tended to correlate with dose-intensity of chemotherapy. Seven patients with BS received adjuvant chemotherapy. Two patients with STS received adjuvant chemotherapy, two - radiotherapy, and four - both modalities. Median disease-free survival was 15.1 months, median overall survival - 25.4 months.

CONCLUSIONS

Musculoskeletal tumors diagnosed during pregnancy, or after delivery, do not appear to have a significant impact on the prognosis. A multidisciplinary team should tailor the oncological approach individually.

Breast cancer diagnosed during pregnancy

Cancer is rare during pregnancy, but breast cancer is the second most common cancer in pregnant women. Pregnancy-associated breast cancer (PABC) is defined as breast cancer that occurs during pregnancy or within one year of delivery. Five cases of PABC occurring during the second and third trimester of pregnancy managed at the University Hospital of Vienna during the year 2005/2006 are reported. A review of the available literature is also presented. Five patients were diagnosed with PABC which was detected in completely different weeks of pregnancy. In two women, the diagnosis was made during the second trimester of pregnancy and in three during the third trimester. The treatment depended, among other things, on the gestational age at diagnosis. The patients diagnosed during the second trimester received six courses of neoadjuvant chemotherapy type FEC (5-fluorouracil, epirubicin, cyclophosphamide). Locoregional radiotherapy and surgery were postponed until after delivery. The three patients diagnosed during the third trimester received adequate therapy after delivery. The mean age of the patients at the time of diagnosis was 37 years (range: 33-40 years) and all patients were diagnosed at an advanced stage. All patients were alive and free of symptoms and signs at the time of writing. All infants are healthy and no congenital malformation or stillbirth was observed. In conclusion, late diagnosis and poor prognosis of PABC are common in literature. Treatment options seem to be reduced in pregnant women and mainly depend on the patient's condition as well as on the gestational age at presentation. In a multidisciplinary approach, an optimal therapy schedule should be assessed depending on these two conditions.

Pregnancy in women with a history of breast cancer

The effect of pregnancy on survival and the best time to conceive are uncertain, so consideration of individual priorities is essential

Pregnancy after breast cancer: population based study

OBJECTIVES

To identify women who survived breast cancer and subsequently conceived and to determine the rate of pregnancy (proportion), management, outcome of the cancer, and outcome of the first subsequent pregnancy.

DESIGN

Population based descriptive study with cases identified from the Western Australian data linkage system and validated by review of medical charts. Supplementary data obtained from hospital and clinician records.

SETTING

Western Australia, 1982-2003.

PARTICIPANTS

Women aged <45 with a diagnosis of breast cancer who subsequently conceived.

MAIN OUTCOME MEASURES

Pregnancy outcome and rate, survival, time from diagnosis to pregnancy.

RESULTS

Sixty two (54%) women with a diagnosis of breast cancer who subsequently conceived did so less than two years after their diagnosis: 29 of them had an abortion, 27 had a live birth, and six miscarried. Within a proportional hazards regression model subsequent pregnancy was associated with improved overall survival (hazard ratio 0.59, 95% confidence interval 0.37 to 0.95). When the model was stratified by time from diagnosis subsequent pregnancy was associated with improved overall survival in women who waited at least 24 months to conceive (0.48, 0.27 to 0.83) and a non-significant protective effect was seen for women who waited at least six months to become pregnant.

CONCLUSIONS

Our study does not support the current medical advice given to premenopausal women with a diagnosis of with breast cancer to wait two years before attempting to conceive. This recommendation may be valid for women who are receiving treatment or have systemic disease at diagnosis, but for women with localised disease early conception, six months after completing their treatment, is unlikely to reduce survival.

Gastrointestinal graft-versus-host disease in recipients of autologous hematopoietic stem cells: incidence, risk factors, and outcome

Graft-versus-host disease (GVHD) is seen in skin, intestinal mucosa, and liver after autologous stem cell transplantation. We reviewed 681 consecutive patients to estimate the probability of gastrointestinal (GI) GVHD, response to treatment, risk factors for development, and effect on survival. GI GVHD was defined by persistent symptoms, mucosal abnormalities at endoscopy, and histology showing apoptotic crypt cells with or without lymphoid infiltrates. The proportion of patients with GI GVHD was 90/681 (13%). Nausea and vomiting occurred in 90% and diarrhea in 40%. The mean time to developing symptoms was day +15, that to histologically proven diagnosis was day +42, and that to starting prednisone treatment was day +45 after stem cell infusion. Treatment with a short course of prednisone effected durable responses in 79% of patients, and an additional 18% responded to a second course of prednisone. A multivariable logistic regression model demonstrated that the combined factor of a diagnosis of breast cancer or hematologic malignancy and female sex was statistically significantly associated with the probability of GI GVHD (P = .003). Survival in patients with GI GVHD was not statistically different than that in those without GVHD. We conclude that women with breast cancer or hematologic malignancy are more likely to develop GI GVHD after autologous transplantation, and that treatment with prednisone was effective.

The effect of pregnancy on survival in women with a history of breast cancer

Nearly 25% of individuals diagnosed with breast cancer will be pre-menopausal women. As maternal age of first birth has risen in the United States, more females are being treated for breast cancer prior to child-bearing. Although surgery and radiation therapy appear to have no impact on future fertility, young women should be aware of the impact that systemic chemotherapy may have on ovarian function, as well as on future offspring. As regards survival, despite a link between female sex hormones and mammary carcinogenesis, the fear that pregnancy subsequent to breast cancer treatment would result in activation of dormant micrometastases has not been demonstrated in the literature. Published series have, in fact, shown either no impact on survival or a slightly protective effect when women deliver after breast cancer treatment. Although these studies are retrospective in nature and may be prone to selection bias and under-reporting of the true denominator, they can at a minimum be used to reassure women that a subsequent pregnancy is unlikely to have a negative impact on her survival.

Concomitant pregnancy and breast cancer: options for systemic therapy

Breast cancers diagnosed during pregnancy and lactation typically have an aggressive phenotype and an advanced stage at presentation. The timing of treatment modalities in pregnant women is complex and requires multidisciplinary input. Alternatives which are relatively safe for both mother and fetus are available, though unforeseen risks may exist. Chemotherapy is not thought to be safe for a fetus during the first trimester; however, in women with high risk cancers, treatment should not be delayed. Thereafter, anthracycline based chemotherapy has a low incidence of fetal complications. Little evidence beyond case reports exists for taxanes or tamoxifen in pregnancy, and less is available regarding the safety of novel molecularly targeted therapeutics such as trastuzumab. The prognosis of breast cancer diagnosed during pregnancy and lactation is poor, largely because of advanced stage and aggressive phenotype; it is unclear whether pregnancy is an independent prognostic marker for poor outcome.

Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero

BACKGROUND

As women in the US delay childbearing, it has been hypothesized that the incidence of breast cancer diagnosed during pregnancy will increase. There are very little prospective data on the treatment of pregnant women with breast cancer with chemotherapy and even less data on the outcomes of their children who were exposed to chemotherapy in utero.

METHODS

Fifty-seven pregnant breast cancer patients were treated on a single-arm, multidisciplinary, institutional review board-approved protocol with FAC (5-fluorouracil, doxorubicin, cyclophosphamide) in the adjuvant (n = 32) or neoadjuvant (n = 25) setting. Parents/guardians were surveyed by mail or telephone regarding outcomes of children exposed to chemotherapy in utero.

RESULTS

Of the 57 women, 40 are alive and disease-free, 3 have recurrent breast cancer, 12 died from breast cancer, 1 died from other causes, and 1 was lost to follow-up. Of the 25 patients who received neoadjuvant FAC, 6 had a pathologic complete response, whereas 4 had no tumor response to chemotherapy and eventually died from their disease. All women who delivered had live births. One child has Down syndrome and 2 have congenital anomalies (club foot; congenital bilateral ureteral reflux). The children are healthy and those in school are doing well, although 2 have special educational needs.

CONCLUSIONS

Breast cancer can be treated with FAC chemotherapy during the second and third trimesters without significant short-term complications for the majority of children exposed to chemotherapy in utero. Longer follow-up of the children is needed to evaluate possible late side effects such as impaired cardiac function and fertility.

Thyroid cancer in pregnancy

OBJECTIVE

To compare stage at diagnosis, treatment and survival among pregnant women with thyroid cancer to non-pregnant women with thyroid cancer, and to assess the impact of treatment on maternal and perinatal outcomes.

METHODS

A database containing maternal and newborn discharge records linked to the California Cancer Registry was queried to obtain information on all thyroid cancers from 1991-1999. Women with thyroid cancer occurring during pregnancy were compared to age-matched non-pregnant women with thyroid cancer.

RESULTS

595 cases of thyroid cancers were identified (129 antepartum and 466 postpartum). About 64% of thyroid cancers were diagnosed at stage 2 among pregnant women versus 58% among non-pregnant controls. The odds of thyroid cancer were 1.5 times higher among Asian/Pacific Islanders than among Non-Hispanic White women. Pregnancy had no significant effect on mortality after diagnosis of thyroid cancer. Thyroidectomy during pregnancy was not associated with adverse maternal or neonatal outcomes.

CONCLUSIONS

Thyroid cancer discovered during or after pregnancy does not appear to have a significant impact on the prognosis of the disease.

Outcome of colorectal carcinoma in patients under 40 years of age

AIMS

Colorectal carcinoma in patients under 40 years of age usually has a poor prognosis. Controversies still exist regarding the features and the prognosis of colorectal cancer in young patients.

METHODS

The records of 45 patients with histologically confirmed colorectal carcinoma treated between 1992 and 2002 at the Division of Oncology at Taipei Veterans General Hospital were reviewed. The relevance of sex, duration of symptoms, tumor site, histological type, lymph node involvement, Karnofsky performance status (KPS), carcinoembryonic antigen (CEA) and lactate dehydrogenase (LDH) levels at the diagnosis and tumor stage to overall survival (OS) were determined by univariate analysis, and their independent significance were tested by multivariate analysis.

RESULTS

Most patients presented with an advanced tumor stage (24% Dukes' C and 66% Dukes' D). Colon carcinoma constituted 76% of the colorectal tumors. Family history was present in two patients and did not affect the OS. Two patients were found to have colon carcinoma during pregnancy. The 5-year survival rate in patients with Stage B, C, and D were 25, 16 and 0%, respectively. With aggressive treatment, patients with early stage carcinoma achieved longer survival. Eleven patients received resection of metastatic carcinoma of the liver, lung and ovary. Adjuvant chemotherapy with irinotecan/5-fluorouracil-based chemotherapy seemed to improve the OS in such patients, though the OS was still poorer than in patients with early stage tumors. In univariate analysis, KPS (P = 0.0001), lymph node involvement (P = 0.0024), CEA (P = 0.0423) and LDH levels (P = 0.0126) at the diagnosis and tumor stage (P = 0.0122) proved to be significant predictors of overall survival. Multivariate analyses revealed that KPS > or =70% (P = 0.007) and normal LDH levels at diagnosis (P = 0.004) were predictive of overall survival in this population.

CONCLUSIONS

The present study shows that performance status and preoperative LDH levels were the major determinants for survival in patients with colorectal carcinoma under 40 years of age and the present series also suggests that surgical resection of metastatic colorectal carcinoma followed by adjuvant chemotherapy might be beneficial in certain patients. The data also suggests that current treatment modalities for young patients with advanced colorectal cancer might not be effective and more effective therapeutic regimens might be needed. Thus, it is important for surgeons to recognize the potential for colorectal cancer in young patients and to take an aggressive approach to the diagnosis and early treatment of the disease.

Malignant melanoma in pregnancy. A population-based evaluation

BACKGROUND

For many years, there has been controversy in the medical community regarding the correlation of female hormonal factors with the outcome of women with malignant melanoma. There have been multiple reports that women with high hormone states, such as pregnancy, had thicker tumors and/or a worse prognosis compared with a group of control women.

METHODS

The authors used a database that contained maternal and neonatal discharge records from the entire state of California from 1991 to 1999 and linked those records to the California Cancer Registry, which maintains legally mandated records of all cancers reported in California during the same time period. Four hundred twelve women with malignant melanoma diagnosed during or within 1 year after pregnancy were identified (145 antepartum, 4 at delivery, and 263 postpartum) and were compared with a group of age-matched, nonpregnant women with melanoma (controls). The database captured only pregnancies at > or = 20 weeks of gestation.

RESULTS

When comparing women who had pregnancy-associated melanoma with the control group, the authors found no difference in the distribution of disease stage (82.0% of pregnant and postpartum women had localized melanoma vs. 81.9% of control women) or the tumor thickness (mean: 0.77 mm for pregnant women, 0.90 mm for postpartum women, and 0.81 mm for the control group). In a multiple regression model that controlled for age, race, stage, and tumor thickness, pregnancy had no impact on survival in women with melanoma. Lymph node assessment and positivity of lymph nodes also were equivalent between the two groups. Maternal and neonatal outcomes did not differ between pregnant women with melanoma and control women who were pregnant and had no history of malignancy. Small numbers of women with advanced melanoma and the inability to capture melanoma that occurred in pregnancies that were lost or were terminated prior to 20 weeks limited the conclusions primarily to women with localized melanoma.

CONCLUSIONS

In this large, population-based study of pregnant women in California from 1991 to 1999 with malignant melanoma, there were no data found to support a more advanced stage, thicker tumors, increased metastases to lymph nodes, or a worsened survival. The outcome for women with localized melanoma associated with pregnancy was excellent. Maternal and neonatal outcomes also were equivalent to those of pregnant women without melanoma.

Effect of pregnancy on survival in women with cutaneous malignant melanoma

PURPOSE

An adverse influence of pregnancy on the risk of death in women with cutaneous melanoma was suggested historically by anecdotal reports. Previous studies included small numbers of women observed for short periods.

METHODS

Using data from the Swedish National and Regional Registries, we performed a retrospective cohort study of all Swedish women who were diagnosed with cutaneous melanoma during their reproductive period, from January 1, 1958, to December 31, 1999. The relationship between pregnancy status at the diagnosis of melanoma and overall survival was examined in multivariable proportional-hazards models.

RESULTS

The cohort comprised 185 women (3.3%) diagnosed with melanoma during pregnancy and 5,348 (96.7%) women of the same childbearing age diagnosed with melanoma while not pregnant. There was no statistically significant difference in overall survival between pregnant and nonpregnant groups (log-rank chi(2)1[r] = 0.84, P = .361). Pregnancy status at the time of diagnosis of melanoma was not related to survival in a multivariable Cox model in the 2,101 women (hazard ratio for death in the pregnant group was 1.08; 95% CI, 0.60 to 1.93). In the multivariable analysis, pregnancy status after diagnosis of melanoma was not a significant predictor of survival (hazard ratio for death in women who had pregnancy subsequent to the diagnosis of melanoma was 0.58; 95% CI, 0.32 to 1.05).

CONCLUSION

The survival of pregnant women with melanoma is not worse than the survival of nonpregnant women with melanoma. Pregnancy subsequent to the diagnosis of primary melanoma was not associated with an increased risk of death.