1 / 45

Cancer in Pregnancy

Cancer in Pregnancy. Jeffrey L. Stern, M.D. Physician Reaction. Ob/Gyn: Oh No! She has cancer! Med Onc: Oh No! She’s pregnant! Surgeon/Primary Care: Oh No! She’s pregnant and has cancer! Get a Gyn/Onc involved!. Incidence. 1/1000 – 1/1500 term pregnancies

verne
Download Presentation

Cancer in Pregnancy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Cancer in Pregnancy Jeffrey L. Stern, M.D.

  2. Physician Reaction • Ob/Gyn: Oh No! She has cancer! • Med Onc: Oh No! She’s pregnant! • Surgeon/Primary Care: Oh No! She’s pregnant and has cancer! • Get a Gyn/Onc involved!

  3. Incidence • 1/1000 – 1/1500 term pregnancies • Incidence increasing: delayed childbearing

  4. What’s Different About Pregnancy? • Hormones • Metabolic Changes • Hemodynamics • Immunology • Increased vascularity • Age • Few cases – anecdotal experience • Inherent bias – breast, ovarian cancer

  5. General Considerations • Pregnancy does not have a proven negative effect on any cancer • Maintaining pregnancy after diagnosis • Delay of treatment (assume delivery at 34th week) • First trimester diagnosis: up to 28 week delay • Second trimester diagnosis: up to 22 week delay • Third trimester diagnosis: up to 10 week delay

  6. General Considerations • Surgery • Wait until 16-18 weeks for abdominal surgery: Spontaneous Abortion: 40%  3% • Don’t remove corpus luteum if possible until 14th week (progesterone supp. 50mg BID) • Deliver at maturity (at around 34 weeks) • No proven teratogenic effects of anesthesia

  7. General Considerations • Chemotherapy • First trimester (organogenesis ends at 12th week) • Increase incidence of anomalies and abortion; drug dependent i.e. antimetabolites (MTX) • IUGR and preterm labor are common • Second and Third trimester • Delay chemotherapy if possible until 16th week • end of the rapid growth phase • No increase in incidence of abortion • IUGR and preterm labor are common • Delay chemotherapy if possible until 16th week • end of the rapid growth phase

  8. General Considerations • Chemotherapy and Breastfeeding • Generally not recommended • Long-term effects of chemotherapy on children exposed in utero • Aviles, et.al. 43 cases with f/u for 3-19 yrs.

  9. General Considerations • Radiation Exposure • Diagnostic Radiation • Avoid “unnecessary” diagnostic pelvic x-rays • Use MRI when possible • CXR/Mammogram – little risk with shielding • Therapeutic Radiation • High incidence of abortion and anomalies -Dose and trimester dependent

  10. General Considerations • Obstetrical Considerations • First trimester SONO: if dates? • Level 2 SONO at 20 weeks • Chromosome analysis • Amnio: 15 weeks • CVS: Transcervical (except cervix ca) or transabdominal at 10-12 weeks • Deliver when mature • L/S ratio at 34 weeks • Betamethasone

  11. Epidemiology of Genital HPV/SIL/Cancer in Pregnancy • Up to 40% of reproductive age women have HPV • 2.0-6.5% cases of CIN/SIL occur in pregnant women • 13,500 cases of cervical cancer & 4,000 deaths/ year in U.S. • 25% of women with cervical cancer are < 36 years old • 1-13 cases of cervical cancer for every 10,000 pregnancy • 1.9% of microinvasive cervical ca. occurs in pregnancy • Stage for stage – prognosis is not effected by pregnancy

  12. Screening for Cervical Cancer/SIL • Symptoms of cancer similar to physiologic changes of pregnancy • Often a delay in diagnosis (fear of biopsies) • Pap smear at registration and 8 weeks postpartum • Ectocervical scrape • Endocervical swab / brush – risky • Reflex HPV typing • Pap less accurate in pregnancy: • increased false negative rate • Blood, inflammation • Failure to sample SCJ • Concern about bleeding • Difficult to see cervix: put CONDOM over speculum • Absence of endocervical cells

  13. Absence of Endocervical Cells

  14. Diagnosis of SIL and Cervical Cancer • Careful palpation of cervix: no induration or enlargement • Biopsy all suspicious lesions: even if Pap/HPV are neg. • Abnormal Pap: • ASCUS/LSIL and HPV negative – repeat post partum • ASCUS/LSIL and HPV positive: colposcopy • ASCH: Colposcopy - HSIL: Colposcopy • Don’t defer biopsy because of fear of bleeding or preterm labor. First trimester easiest. • Control bleeding with: • Pressure • Monsel’s solution (Ferric subsulfate) • Silver nitrate

  15. Management of Cervical SIL On Biopsy • Satisfactory Colposcopy • LSIL / HPV+/- : Re-evaluate 6-8 weeks postpartum • HSIL / HPV+/- : F/U depends on trimester • Low grade SIL (50%) regress postpartum (Delivery route seems to matter) • High grade SIL(30%) regress postpartum • Vaginal delivery

  16. Management of Cervical SIL • Cone biopsy in pregnancy • Indications • Unsatisfactory colposcopy/ Pap: SCC, HSIL • Adenocarcinoma in situ • Microinvasive SCC • Perform at 16-18 weeks • Risks • Abortion: 5% • Hermorrhage: immediate: 9%, delayed: 4% • Technique • Local wedge resection • Shallow cone • LEEP • Circumferential figure 8 sutures at cervical-vaginal junction • Vasopressin/ local anesthetic with epinephrine

  17. Management of Cervical SIL HSIL/ HPV positive: No Lesion Visible on Colposcopy • Reinspect: Vulva, Vagina, Anus and Cervix • Lugol’s: Vagina and Cervix • Review Cytology • Consider Random Biopsies: 6 and 12:00 • Careful Follow-up: Pap and Colpo

  18. Vulvar/ Vaginal Condylomata or SIL in Pregnancy • Warts and SIL often enlarge rapidly in pregnancy • No treatment unless symptomatic • Often regresses dramatically postpartum • Treat if symptomatic or interferes with vaginal delivery - disease on perineal body or posterior fourchette • Treatment options: • Trichloroacetic Acid • Podophyllin • Aldara • 5-FU cream • Laser • Excision: scalpel; LEEP • Cryotherapy

  19. Cervical Cancer in Pregnancy • Work-up • MRI of pelvis/abdomen • Chest X-ray • Carcinoembryonic Antigen (CEA) • CBC, BUN, Creatine, LFT’s • Advanced disease • Urine cytology/ cystoscopy • Stool for occult blood/ sigmoidoscopy

  20. Cervical Cancer in Pregnancy: Treatment by Stage • Stage IA1 - <3mm invasion; < 7mm wide • 1.2% positive nodes • Cone biopsy • No further treatment necessary; simple hysterectomy • Vaginal delivery at term

  21. Cervical Cancer in Pregnancy: Treatment by Stage • Stage IA2 (3-5mm invasion, no vascular inv.): • 6.3% positive nodes • Stage IB – Disease confined to cervix • Stage IIA – vaginal extension • Vaginal delivery: increased risk of hemorrhage and cervical laceration • Depends on desire for pregnancy • First trimester: delay of up to 28 weeks – degree of risk unknown • Radical hyst. and pelvic LND at diagnosis • “Radical” cone biopsy/ trachelectomy/ cerclage and extraperitoneal pelvic and aortic LND at 16-18 weeks • C-Section and Radical hyst. and pelvic LND when mature

  22. Cervical Cancer in Pregnancy: Treatment by Stage • Stage IA2, IB, IIA • Second trimester: delay of up to 22 weeks • Depends on desire for pregnancy • Can probably safely wait until maturity • Third trimester: delay of up to 10 weeks • C-section, Radical hysterectomy and pelvic Lymph node dissection at maturity

  23. Cervical Cancer in Pregnancy: Treatment by Stage • Stage IB (bulky) or Stages IIb-IV • First trimester – delay of up to 28 weeks • Depends on desire for pregnancy • Unwanted • Whole pelvic radiation therapy/ chemotherapy • If SAB occurs before XRT is finished – proceed with cesium insertions (about 35 days) • Occasionally will need hysterotomy and pelvic LND if no SAB and then cesium insertions; or a “small” radical hyst. & pelvic LND if small residual cervical disease • Wanted • Consider chemotherapy until maturity at 34 weeks

  24. Cervical Cancer in Pregnancy: Treatment by Stage • Stage IB (bulky) or Stages IIb-IV • Second trimester – delay of up to 22 weeks • Unwanted: pregnancy – Radiation therapy as above • Spontaneous abortion at 35 days • Wanted: pregnancy – consider chemotherapy until maturity • Third trimester – delay of up to 10 weeks • C-Section at maturity/ staging lap; transpose ovaries • Start radiation therapy 2 weeks postpartum • Consider chemotherapy until maturity

  25. Juvenile Laryngeal HPV • 3.5 million deliveries in U.S./year • Prevalence of HPV: 10-40% • Infected pregnant women: 350k - 1.5 million • 120 cases annually • Risk to infant (1:2,900 – 1:12,500) • VAGINAL DELIVERY

  26. Ovarian Masses in Pregancy • Overall incidence • 1:500 pregnancies • Increased incidence secondary to sonography • Incidence of true neoplasms • 1:1,000 pregancies • Incidence of ovarian cancer • 1:10,000 – 1:25,000 pregancies • Unexpected adnexal mass at C-Section • 1:700 pregnancies

  27. Ovarian Masses in Pregnancy Frequency by Type • Non-neoplastic – 33% • Corpus luteum cyst • Follicular cyst • Neoplastic – Benign – 63% • Dermoid (36%) • Serous cystadenoma (17%) • Mucinous cystadenoma (8%) • Others (2%) • Neoplastic – Malignant – 5% • Low malignant potential (3%) • Adenocarcinoma (1%) • Germ cell / Stromal tumor (1%)

  28. Management of Ovarian Masses in Pregnancy • Generalizations • Symptoms • Ultrasound/ MRI appearance • Size • Gestational age • Tumor markers • B-HCG, AFP, CA-125 all increased in pregnancy • CA-125 should be normal after 1st trimester • Fear of missing cancer or development of complications • Corpus luteum resolves by 14th week • Ovarian cysts “benign” by Ultrasound or MRI, < 6 cm, that do not change over time, do not require surgery • Cysts greater than 6-8 cm or inc. in size: “usually” operated on • Cysts which persist after 18th week are “usually” operated on • Usually operate at 18 weeks to minimize fetal loss

  29. Complications of Ovarian Masses in Pregnancy • Severe pain: 25% • Obstruction of labor: 15% – C-Section • Torsion: 10% of cases • Sudden pain, Nausea & Vomiting etc. • Most common at: • 8-16 week – rapid uterine growth (60%) • Postpartum – involution (40%) • Hemorrhage: 10% of cases • Ruptured corpus luteum • Germ cell tumor

  30. Complications of Ovarian Masses in Pregnancy • Rupture/ tumor dissemination (10%) • Anemia • Malpresentations • Necrosis • Infection • Ascites • Masculinization of female fetus • Hilar cell tumor • Luteoma of pregnancy • Sertoli-Leydig cell tumor

  31. Work-up of Ovarian Cancer • Pelvic ultrasound • MRI pelvis/ abdomen • Chest X-ray • CA-125: elevated in normal pregnancy, should normalize after 12 weeks • AFP, B-HCG, LDH – predominantly solid mass • Liver FunctionTests, BUN, Creatinine • GI studies only if clinically indicated

  32. Management of Ovarian Cancer • Prognosis not affected by pregnancy • Tumors of Low Malignant Potential – all stages (20%) • Adenocarcinoma Stage I, grade 1 or 2 (10%) • Germ cell tumors (5%) – may require chemotherapy • Gonadal stromal tumors (15%) • Surgery at 16-18 weeks if possible • Frozen section: beware of inaccuracies • Conservative ovarian surgery • Adnexectomy/ Oophorectomy/ Cystectomy • Hysterectomy not indicated • Thorough staging: • Pelvic/ aortic node disection/ Omentectomy/ peritoneal biopsies

  33. Management of Ovarian Cancer • Epithelial Ovarian Cancer Stage IC – IV • Try to delay chemotherapy until 12-16 weeks of pregnancy • Try to delay removal of corpus luteum until 14 weeks • First trimester • TAB followed by appropriate surgery and chemotherapy • Chemotherapy after FNA: • C-Section and appropriate management at maturity • Second and Third Trimester • Chemotherapy first • C-Section and appropriate surgical management at maturity

  34. Malignant Germ Cell Tumors • Dysgerminoma • 30% of Ovarian malignant neoplasms in pregnancy • Most stage IA • Average 25cm; solid • Therapy • Surgery: USO, wedge biopsy of opposite ovary, surgically stage • 25% are bilateral • Stage IA & IB: No further treatment • Advance stages • Hysterectomy not required • Chemotherapy

  35. Malignant Germ Cell Tumors • Endodermal sinus tumor • Grade 2-3 malignant teratoma • Choriocarcinoma (non-gestational) • USO and staging for early disease • All require chemotherapy regardless of stage

  36. Tumor like Ovarian Lesions Associated with Pregnancy • All resolve spontaneously after delivery • Conservative surgical approach: frozen section +/- oophorectomy • Luteoma of pregnancy - usually an incident. finding at C-Section • Microscopic. -20cm – multiple nodules • Bilateral: 1/3 of cases • 25% have increased. testosterone • Maternal masculinization. – later ½ of pregnancy • Fetal virilization – 70% of female infants • Hyperreactio Luteinalis - Bilateral multicystic theca lutein cysts • Large solitary luteinized follicular cyst of pregnancy • Hilar Cell Hyperplasia – masculinized fetus • Intrafollicular Granulosa cell proliferations • Ectopic Decidua

  37. Breast Cancer in Pregnancy (2nd most common cancer in pregnancy) • 20% of cases are in women <40 years old • 1-2% of cases are pregnant at time of diagnosis • One case/1500-3000 pregnancies • Often difficult to diagnose • Low dose mammogram with appropriate shielding of fetus is “safe” • MRI – probably best • Diagnosis often delayed • Increase incidence of positive nodes (80%) • Termination of pregnancy & proph. castration is not beneficial • No adverse effects on prognosis from subsequent pregnancies

  38. Treatment of Breast Cancer • Treatment same as non-pregnant • Lumpectomy • Sentinal node biopsy • 2.5mCi technetium 99 – 4.3 mGy at worst. Usually contraindicated. • +/- radiation • Chemotherapy • Modified radical mastectomy and nodes • Adjuvant chemotherapy after 16 weeks • CAF better than CMF in 1st trimester • Axillary or localized chest wall RXT is probably safe after the first trimester but can be difficult to shield fetus. • Prognosis:

  39. Leukemia in Pregnancy • Most abort spontaneously • Average age is 28 • Usually recommend termination of pregnancy because of aggressive chemotherapy • Prognosis – dependant on cell type

  40. Hodgkins Disease/Lymphoma in Pregnancy • Gestational Age/ Stage • <20 weeks: TAB • >20 weeks: XRT • Chest mantle first • Chemotherapy depending on stage • Abdominal XRT after delivery • 80% curable – depending on cell type

  41. Melanoma in Pregnancy • Incidence rising • 50% occur in women of child bearing age • 9% of cases occur in pregnancy • Extremities most common site • Pregnancy does not affect prognosis

  42. Ovarian Function and Chemotherapy • Dose and age related • Younger than 25: permanent amenorrhea uncommon • Older than 40: 50% permanent ovarian failure • Birth control pills may prevent ovarian failure • Risk of birth defects in offspring not increased (4%) • Wait 2-3 years after therapy to become pregnant • Allow for possible recurrent disease

  43. Ovarian Function and Fertility and Radiation Therapy • Age and dose related (<20 years old – better) • Ovaries outside radiation field (avg. dose 54 cGy): • No failure • Ovaries at edge of radiation field (avg. dose 290 cGy): • 25% failure • Start to lose function at 150 cGy • Ovaries in radiation field: • At 500 cGy most women are amenorrheic • Oophoropexy to the iliac fossa • Use clips to identify ovaries

  44. Metastases to Fetus/Placenta • Only 50 cases in literature • Melanoma (50% of reported cases) • Leukemia: 1/100 affected pregnancies • Lymphoma • Breast

  45. Reference List • Barber H.R.K., Brunschwig A: Am. J. OB/GYN, 85.156, 1963. • Baltzer J., Regenfrecht M., Kopche W., Carcinoma of the Cervix and Pregnancy Int. J. Gyneco Obstet. 31:317, 1990. • Zemlickis D., Lishner M. Degendorfer P.et.el. Maternal and fetal outcome after breast cancer pregnancy. Am.J. Obstet. Gynecol. 9: 1956, 1991. • Karlen J.R. et.al. Dysgermenoma associated with pregnancy. OB/GYN 53:330, 1979. • P.Struyk, P.S. Ovarian Masses in Pregnancy Acta.Scand. 63: 421, 1984. • Aviles, A. et.al. Growth and Development of Children of Mothers Treated with Chemotherapy during pregnancy: Current status of 43 children. Am. J. Hematology 36: 243, 1991. • Brodsky et.al. Am. J. Obstet, Gynecol. 138:1165, 1980.

More Related