Diagnosis and management of cancer during pregnancy

1. Pregnancy Outcome In Cancer Patients
Medical And Surgical Management Of Cancer
During Pregnancy
Dr. Mamdouh Sabry
MD. Ain Shams, Ph.D. France
Consultant Ob. & Gyn.
EL Mataria Teaching Hospital, Nasser Institute
Cairo, Egypt

2. BETTER LIFE OF CANCER
PATIENTS REGARDING
FERTILITY, PREGNANCY
OUTCOME AND SEXUALITY IS
THE TARGET OF OUR TEAM IN
Nasser Institute, Pediatric
Oncology Gp. And Hemato-
oncology Gp.

3. What created the situation ?
The increase In :
• Malignancy among children and during age
reproductive period (EBC)…
• Technology for early detection & treatment.
• Survivors from cancer during reproductive
age and childhood.
• Technology of fertility preservation
techniques.
• Delay age of marriage & increase cancer
rate with age.

4. Data Collection
WAS NOT EASY
 Data from ASCO (am. Soc. Cl. On.)
 Up to date.com, ESMO guidelines, Medscape……
 Evaluation of more than 70 publications, obser., cohort,
case rep. and few clinical trials.
 Cochrane Collaboration Library.
 Our experience in N. In. , Hema. On. Gp., Ped. On. Gp.

5. Pregnancy and Malignancy
• Diagnosed in (1/ 1000- 2000 ) pregnancy.
• Breast, hematologic (lymphoma & leukemia),
melanoma, cervix, ovary, thyroid, bone and soft
tissue cancers.
• Newly detected cases or pregnancy detected
during cancer ttt or planned pregnancy in cancer
patient and or recurrence during pregnancy.
• Diagnostic techniques, Therapeutic options, fetal
safety, termination, mode of delivery and lactation
are all questionable and in debate ??
• Breast lump, atypical vag. Discharge, enlarging L.N
,rectal bleeding or others should attract attention.

6. DIAGNOSTIC MODALITY
( Investigations For ):
• Screening.
• Diagnosis.
• Confirmation of the diagnosis.
• Staging.
• Pre-operative.
• Excision Biopsy.

7. X-rays
-Measured in several types of units.
-Radiation-absorbed dose (rad), US measurement.
-Gray (Gy) international measurement.
-Both represent a single-time exposure and radiation
absorbed dose (as diagnostic procedures).
-The measurement units; roentgen equivalent man
(rem) and Sievert (Sv) used to quantify radiation
exposure over time and radiologic effective dose (as
environmental releases).
-1 Gy equals 100 rad & 1 Sv equals 100 rem.
-Dose calculation depends on study type, machine
type, distance from machine, organ penetrated and
method of study.

8. X-ray, follow.
-X-rays have deterministic and stochastic effects.
-Deterministic effects are usually intrauterine, involving
damage to growing cells, it has a dose response curve
and a threshold effect, either all or non, the damage
threshold begins at 0.1-o.15 Gy which causes abortion
or no implantation and extends to 1Gy, which is
associated fetal death in-utero at term.
-Stochastic effects appears in the later years of
exposed persons, not needing threshold? (0.05 Gy)
relative risk documented in multiple case-control
studies, others considered this to be theoretical.
-Dose< 5 rad not associated with fetal hazards.

9. X-ray follow.
CT scanning
-New generations more
sensitive and accurate.
-0.17-0.35 rad are fetal
exposure in abdominal or
pelvic CT.
Fluoroscopy/Angiography
-Cerebral angiography
exposes to <10 mrad
-Risk benefit ratio.
Plain Films
-In chest radiograph,
exposure for 2 views
<0.07 mrad
-To bone, ribs, skull and
lower limb deliver lower
doses due to fetal
distance from target
organ, but hip and
pelvis X-ray deliver
about 200 mrad.

10. X-ray, Conclusion
SO, Concern about possible effects of
high-dose ionizing radiation exposure
should not prevent medically indicated
diagnostic x-ray procedures from being
performed on a pregnant woman.
During pregnancy, other imaging
procedures not associated with ionizing
radiation (ultrasonography and MRI)
should be considered instead of x-rays
when appropriate.

11. X-ray, Conclusion
“Women should be counseled that x-ray
exposure from a single diagnostic procedure
does not result in harmful fetal effects.
Specifically, exposure to less than 5 rad has
not been associated with an increase in fetal
anomalies or pregnancy loss.”
American College of Obstetricians and Gynecologists,
Committee on Obstetric Practice;
Guidelines for Diagnostic Imaging During Pregnancy.
ACOG Committee Opinion No. 299.
ACOG, September 2004.

12. Nuclear Medicine Exams
-Most of the radiopharmaceuticals used will
cross the placental barrier.
-In general, the effective dose from most
diagnostic nuclear medicine exams, other
than the radioiodines, will be less than 10
mSv (1 rem).
-The fetal absorbed dose represents the
combined effect of both external radiation
from maternal tissues and placental transfer
and fetal uptake of radiopharmaceuticals.

13. Magnetic Resonance Imaging (MRI)
“Although there have been no documented
adverse fetal effects reported, the National
Radiological Protection Board arbitrarily advises
against its use in the first trimester.”
Guidelines for Diagnostic Imaging During Pregnancy.
ACOG Committee Opinion
-USA, FDA labeling MRI devices to indicate, safety of
MRI with respect to the fetus not yet confirmed.
-Gadolinium is teratogenic in animals and does cross
the placenta.
.

14. Ultrasound Imaging
“There have been no reports of documented adverse
fetal effects for diagnostic ultrasound procedures,
including duplex Doppler imaging.”
“There are no contraindications to ultrasound
procedures during pregnancy, and this modality
has largely replaced x-ray as the primary method
of fetal imaging during pregnancy.”
American College of Obstetricians and Gynecologists,
Committee on Obstetric Practice;
Guidelines for Diagnostic Imaging During Pregnancy.
ACOG Committee Opinion No. 299.
ACOG, September, 2004.

15. TREATMENT & FOLLOW UP
AND OUTCOME

16. Cancer Diagnosed During Pregnancy
• Pregnancy does not have a proven negative effect
on any cancer.
• Termination may be done early in pregnancy to
admit proper oncologic care, risk benefit value ???.
• Surgery never postponed if crucial in ttt plan.
• Surgery is performed safely with slight increase in
miscarriage risk in 1st trimester, increase morbidity
is noticed in major pelvic and abdominal surgery.
• Laparoscopy may be performed ( experience ).
• Chemotherapy is not recommended during first
trimester, 3 weeks before delivery and during
lactation, if lactated. ( IUGR or premature delivery)

17. • Contemporary research established that, breast
cancer does not imply a worse prognosis in
women seeking pregnancy after ttt. .
• Delay ttt for few weeks (1st trimester) not affect
outcome in breast cancer or many others. (Int.
cancer in pregnancy study, German breast gp.,
Ann. Oncol. Jun. 2013, RCOG guidelines 2011)
• Chemotherapy can be introduced during
pregnancy in hematologic malignancies and
others.
• Interleukins, monoclonal antibody and immune
therapy admission are trimester dependent.

18. Pregnancy after cancer Treatment
• Decrease fertility and pregnancy rate is higher
in women, 40% less than normals , 70% less in
breast cancer. But fertility is affected early in
men with genital cancer.
• Neonatal outcome in men or women with history
of cancer is comparable to general population.
• The timing of pregnancy is considered
regarding end of treatment and risk of relapse.
• Better wait 3-6 months after ttt.
• Wait after end of hormone dependent breast
cancer.

19. Pregnancies diagnosed during anti-cancer
Therapy
• Pre-menopausal females undergoing systemic anti-
cancer therapy (i.e. chemo., hormonal, immuno or
radiotherapy) should use active contraception,
sperm DNA integrity in men ?!
• Contraception use up to 3–6 months after the last
administered dose is advised.
• It depends on cancer origin, duration of pregnancy
and type of therapy.
• Some cases of hematologic malignancy are allowed
to be pregnant during therapy.

20. TO CONCLUDE

21. Interference, staging and diagnostic
modality
• Avoid exposure to ionizing radiation.
• Ultrasound and MRI (no contrast) are
considered safe. Pet CT is unsafe.
• Chest X-ray, spiral CT and mammography
with shielding may be done during pregnancy.
• CA125, HCG, CA15,3 and Alpha feto protein
not used as markers, ESR and leucocytes
• Biopsy and surgery can be performed during
pregnancy.

22. Conclusion, cont.
- In order to provide the best possible care,
a team approach involving an obstetrician,
fetologist, oncologist, radiologist, oncology
surgeon and neonatologist is required.
- The couple also should be involved in the
decision-making.
- It is equally important to share experience
as current recommendations are often
based on case series and expert views with
little high-quality research.

23. Conclusion, cont.
• Does chemotherapy and pelvic radiation
affect gonadal function? Yes.
• Can we protect them ? Yes.
• Is pregnancy safe after Breast cancer ttt?Yes.
• Does pregnancy worsen hematologic, other
tumors or breast cancer prognosis? NO.
• Is pathologic features different from matched
non-pregnant females ? No.
• Pay attention to abnormal findings during
pregnancy, it might hide malignancy.