Cancer+and+Pregnancy

5. International Gynecologic Cancer Society Founded in 1986 Multidisciplinary Over 1500 members in more than 80 countries

12. IGCS Workshop “ Gynecologic malignancies” 8-9 September, 2008, Ankara, Turkey Vesna Kesic Instiute of Obstetrics and Gynecology Clinical Center of Serbia Cancer and Pregnancy

14. The biggest physiological process of human reproduction and the biggest pathological process which in most cases results in death are linked in the battle fought between immortality and destruction

15. The occurrence of cancer in pregnancy is relatively rare, about 1 case per 1000 deliveries

16. Cancer in pregnancy- the cruelest dillema Does the women lose the baby to save her life or risk her life to try to save baby ?

17. Is the potential life of an unborn child more important than prolonging a life of a young woman? Whose life is of greater value? And whose decision is this anyway ? ?

18. Fetus Mother Pregnancy Risk

19. For women diagnosed with cancer waiting for 40 weeks could be a death sentence particularly with high-grade, aggressive or metastatic cancers .

20. Malignant disease in pregnancy complicates the management of both cancer and the pregnancy.

21. The diagnostic and therapeutic approach is particularly difficult because it involves two persons: the mother and the baby .

22. Obstetricians and Oncologists should offer at the same time optimal : - maternal treatment - fetal well-being

23. Treatment that may be essential for the mother may be fatal or highly damaging for the baby.

25. Management of cancer in pregnancy There are not many options and none of them are ideal

28. To treat cancer as effectively as possible while continuing the pregnancy and trying to minimize the risk for fetus Third option

30. Cancer in pregnancy if often detected later because the symptoms are masked by other, usually physiological, body changes

34. Risks of radiotherapy Radiotherapy is contraindicated in pregnancy although some specialists use it above the diaphragm with abdominal shielding particularly in later stages of pregnancy

35. Risks of radiotherapy Therapeutic doses of 5000-6000 cGy expose the fetus to 10 cGy in early pregnancy and 200 cGy or more in later pregnancy Doses over 2,5-5 cGy pose high risk for malformation early in pregnancy

36. 0 . 05 Gy is limit doses for the risk of malformations. With 1 Gy the risk is 50%

37. From conception to days 9/10 Letal effect Weeks 2-6 Malformation Growth retardation Weeks 12-16 Mental and growth retardation, microcephaly Weeks 20-25 to birth Sterility, malignancies, genetic disorders Likely effects of radiotherapy

38. Risks of chemotherapy Almost all drugs cross the placental barrier to some extent As chemotherapeutic drugs work by inhibiting cell division, they pose a risk to the developing fetus.

40. Most common drugs reported to induce the malformations or to exert teratogenic effects In « Cancer in Pregnancy », Cambridge 1996 Alkylating agents Antimetabolites Bisulfan Aminopterin Cyclophosphamide Metotrexate Chlorambucil 5-Fluorouracil Cytosine arabinoside

42. Delivery If a baby is delivered within 2 weeks of the last chemotherapy dose, there is a risk of a neutropenic baby being born to a neutropenic mother Breastfeading Breast feeding is not advisable for women who have recently been on chemotherapy Risks of chemotherapy

43. 0.07 - 0.1% of all malignant tumors are diagnosed during or shortly after the pregnancy

44. What are the most common cancers complicating pregnancy?

45. The incidence of malignant tumors in pregnancy Cervical cancer 0.17% Breast cancer 0.07% Gastric cancer 0.05% Colon cancer 0.02% Ovarian cancer 0.01%

46. Genital tumous and pregnancy Cervical cancer Ovarian tumors Endometrial cancer Vaginal cancer Vulvar cancer

47. Ries LAG, Eisner MP, Kosay CL et al., eds. SEER Cancer Statistics Review, 1975-2001. Bethesda, MD: National Cancer Institute. Available at http://seer.cancer.gov/csr/1975_2001.

49. The disease has been detected during the pregnancy or postpartum period in 1.7 to 3.1%. In reproductive age ≈10% Creasman WT et al., 1970

50. The incidence of invasive cervical cancer in pregnancy is between 0.3 to 1.6 per 1000 pregnancies

52. Screening for invasive cervical cancer should be performed during the first antenatal examination Harper DM, Roach MS. J Fam Pract, 1996; 42: 79-83

53. Normal pregnancy is not a contraindication for taking cervical smear, nor to colposcopic examination !

54. Management of abnormal cervical smear during pregnancy Abnormal cytology (5%) Colposcopy B iopsy

56. The aim of colposcopic examination during the pregnancy is to exclude the invasion !

57. Ever sion of columnar epithelium

58. Physiological metaplasia

59. Decidual rea ction

60. Decidual pol ypus

61. HPV in pregnancy

62. CIN in Pregnancy

65. The incidence of CIN in pregnancy 0.25 - 1.1 % Bokhman VJ, 1989 0.17 % Kashimura M, 1991 0.93 % Ueki M, 1995 0.3 % Chuquai R, 1994 1.15 % Kesic V, 1996 0.73 %

68. Management after the histological finding in pregnancy CIN Mi cro i nvasive cancer Inva sive cancer Conization Postpone further Radi cal d i agnostic and h ysterectomy t herapeutic p rocedures or for post-partum period radiot herapy Targeted biopsy

69. Conization in pregnancy

72. The treatment of invasive cervical cancer in pregnancy should proceed without regard for the fetus, unless the lesion is diagnosed at a stage close to fetal viability

74. Cervical cancer in pregnancy I trimester: Immediate treatment III trimester: Treatment after Caesarean section II trimester ? Medical and ethical problem

75. Stage Ib/ IIa

76. Cervical cancer in pregnancy I trimester: Surgery with embryo in utero III trimester: Surgery immediately after Caesarean section II trimester ? Medical and ethical problem

77. Stage > IIb

78. Cervical cancer in pregnancy stage > II a I trimester: Start external irradiation Wait for spontaneous abortion III trimester: Caesarean section Irradiation immediately after recovery II trimester ? Medical and ethical problem

79. Inva sive cervical cancer in second trimester Before 20-24 weeks Evacuating pregnancy by hysterotomy and immediately after radical hysterectomy After 24-28 weeks Waiting for fetal maturity

82. Karolinska hospital, Stochkolm, Sweden Cervical cancer and simultaneous pregnancy Actuarial survival 1914- 1943: 30.4% 1944- 1959: 53.6% 1969- 1995: 81.5% Bjorkholm E & Pettersson F. Carcinoma of the uterine cervix and simultaneous pregnancy. Int J Gynec Cancer, 1999; 9 (suppl 1): 116

85. Most frequent types of ovarian tumors in pregnancy Benign c ystic teratom a ................. 36% Ser ous c y stadenom a ................ 25% Muci nous c yst adenom a ................. 12% Corpus luteum cyst ................. 5 . 5% Malign ant tumor s ................ 4%

88. If adnexal mass is < 6 cm, unilateral, mobile and asymptomatic: - observation and repeat U/S at 14 to 16 wks. If adnexal mass is > 6 cm, solid or of complex appearance, bilateral or persists into 2nd trimester: - laparotomy. Management of ovarian mass in pregnancy

90. Extra-genital tumous and pregnancy Breast cancer Cancer of the colon Gastric cancer Melanoma Thyroid cancer Bladder cancer Brain tumors Tumors of the hypophysis Hemoblastosis Liver tumors

91. Incidence of Breast cancer in Europe (sr per 100,000 women) Globocan 2002 … … 36.0 Belaruss 38.8 Russia 44.3 Romania 46.2 Bulgaria 52.1 Macedonija 58.9 B & H 58.9 Slovenia 62.2 Croatia 64.1 Serbia 91.9 France 92.0 Belgium

92. Breast cancer has been detected during the pregnancy or postpartum period in 3% of cases In reproductive age ≈14%

94. - Mammography sensitivity: 68% (due to increased density ) - Ultrasonography sensitivity: 93% - Open breast biopsy (FNA ±) confirms diagnosis Pregnant woman has 2.5 - fold higher risk to present with advanced disease Diagnosis of Breast Cancer in Pregnancy

100. How frequently does maternal cancer metastasize to either placenta or fetus?

102. Placenta Estimated incidence of placental involvement by cancer cells: very rare Fetus Estimated incidence of fetal involvement by cancer cells: 25% of the cases with placental involvement

103. The patient, her partner and her doctor are required to take a difficult decision without always a clear answer (rights of the fetus ≠ rights of the mother) When should therapeutic abortion be recommended?

104. Therapeutic abortion- general considerations - Absence of guidelines. - Final decision is not always easy - Issue becomes more important when cancer diagnosis is made during the first trimester Most important parameters are: - the stage - the indication for treatment - the curability of the disease.

105. Recommendations for therapeutic abortion during the first trimester 1. Primary aggressive breast cancer 2. Advanced breast cancer 3. Stage III-IV aggressive NHL or Hodgkin’s disease 4. Acute leukemia

107. 1 . Try to benefit mother’s life 2 . Try to treat curable malignant disease of pregnant women 3 . Try to protect fetus and newborn from harmful effects of cancer treatment 4. Try to retain intact mother’s reproductive system for future gestations 4 optimal gold standards to be considered

108. Obstetrician Gynec olo gist Pa tient Radiotherapist Neonatologist Medical oncologist