Neoplastic Disease

A.J. Bautista,MD
INTRODUCTION
Incidence
 0.94/1000 live births (2003,US)
 1.2 to 1.9/1000 live births (2012, Australia)
o May be due to the rise of older mothers
 Common cancers noted (1st three are commonly found in pregnant
women):
o Breast
o Thyroid
o Cervical cancer
o Lymphoma
o Melanoma
 Neoplasms are commonly found in pregnant women, most of
which are benign
 Most frequently encountered during pregnancy
o Uterine leiomyomas
o Ovarian Cyst

Basic principles of cancer Treatment in Pregnancy

 “Pregnant women should not be penalized because she is pregnant.
Treatment should be individualized and include consideration of:
o The type and stage of cancer
o Desire to continue w/ pregnancy
o Risk of modifying or delaying treatment
 Indicated for:
o Diagnostics
o Staging
o Therapeutic

“Even if the mother has cancer, and doesn’t want to have treatment due
to it harming her baby, you cannot do anything”

SURGERY
 Delaying surgery until 12-14 weeks AOG
o First trimester – organs are being formed. Increase in rate of
abortion, and physician / procedure might be blamed for the
abortion.
o The surgery must be done regardless of AOG if the
mother is in danger
 Risk: venous thromboembolism
 Use: Mechanical Prophylaxis compression
o Pneumatic Stockings
o LMW Heparin

DIAGNOSTIC IMAGING
 Sonography
o Preferred tool when appropriate
o Most diagnostic radiographic procedures have very low x-ray
exposure and should not be delayed.

 CT scan
o Useful for imaging extra abdominal mass
o Abdominal shielding helps to decrease fetal exposure

 MRI
o Not recommended
o Preferentially after 1st trimester if needed

 Gadolinium Contrast w/ MR
o Crosses the placenta -> high fetal conc.
o Should NOT be used in the 1st trimester

 PET Scan
o NOT performed during pregnancy

 F-FDG (Fludeoyglucose)
o Concentrated in both breast tissue and milk
o Breastfeeding should be discontinued for 72 hours ff the
procedure.
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Trans by: Ampuan, Baluyot, Caraveo Edited By: Ilano
  Radiation therapy PLACENTAL METASTASIS
o Diagnostic x-ray must not be delayed  Most common
o Most susceptible period is organogenesis o Melanoma
o Can be used if lesion is “supradiaphragmatic” o Leukemia
o Contraindicated in pregnancy o Lymphoma
o Effects of therapeutic radiation on pregnancy: o Breast CA
 Microcephaly  Melanoma
 Mental retardation o Most common FETAL MESTASTASIS
 IUGR – late exposure  Liver and subq
 Brain damage – Late exposure  80 % mortality rate
(In cervical CA, 1st trimester disregard the pregnancy. For later stages
than Stage Ib, do radiotx even if mom is pregnant. The baby will die most REPRODUCTIVE TRACT NEOPLASM
of the time and then, do D&C and continue radiation. Sometimes, baby Benign (mc)
will not die and will be born with the preceding complications).  Leiomyomas
o Depends on  Ovarian neoplasm
 Dose of radiation  Endocervical polyps
 Tumor location
 Field size Malignant
o No gestational age is safe for therapeutic radiation.  Cervical CA (mc) -70%
 Ovary -23%
 Chemotherapy  Uterus, vulva, vagina – 4 %
o Wait until 2nd trimester or for organogenesis to finish
PREGNANCY IN CANCER SURVIORS:
 Fetal effects:  3 fold chance of developing chronic disease
o Malformations o 2nd malignancy (common are Blood CA)
o Growth restrictions o Heart failure (Doxorubicin)
o Mental retardation o Cranial radio-therapy related:
o Risk of future malignancies  Cognitive dysfunction
 Risks are dependent on:  Growth hormone deficiency
o Fetal age at exposure  Obesity
o Most agents are detrimental on 1st tri “Organogenesis”  Pregnancy outcome after:
 But still depends on time of exposure o Inc. preterm birth
 Caution: exposure to pregnant health workers o Inc. postpartum hemorrhage
 Contraindicated in Breastfeeding
Note: after organogenesis most neoplastic drugs are w/o immediate
COMMON CANCERS IN PREGNANCY
sequelae. Some recommend that chemotheraphy be held 3 weeks
 Breast cancer- MC
before delivery because of neutropenia or pancytopenia -> maternal
hemorrhage.  Lymphoid cell malignancies
 Malignant melanoma
 Molecular therapy  Reproductive tract neoplasia
o Drugs designed for (+) hematopoiesis.  Gastrointestinal tract cancer
o G-CSF (Filgrastim)(Pegfilgrastim)  Renal neoplasm
o Erythropoietin alfa (Procrit)  Other tumors

 Immunotherapy BREAST CARCINOMA

o Use of antibodies against tumor-specific antigens – NOT used  Most common cancer in all age group
in pregnant women  Risk factors:
o IMATINIB o Delay in childbearing
 Tyrosine kinase (-) o Breast cancer gene mutation
o DEA exposure in utero
 Probable teratogenic effect
o BRCA 1 and BRCA 2
 Pregnancy termination – No influence on course or prognosis
FERTILITY AFTER CANCER TREATMENT  Most cases show RLN has microscopic metastasis
 May be diminished o 60% have (+) axillary node
 May cause:
 1-2 months delay in assessment, diagnosis and treatment due to
o Azoospermia in men:
breast change in pregnancy and lactation.
o In women:
 Placental metastases
 Decreased follicular maturation o Occasionally found
 Follicular destruction o But confined to intervillous space
 Ovarian fibrosis o No reported fetal disease
 Fertility effect is age and dose dependent
 Prepubertal ovary more resistant  Diagnosis:
 Embryo myopreservation – standard and widely available o Does not differ from non pregnant women
 Abdominopelvic radiation impairs subsequent reproductive fxn o “Triple test”
 Fetuses who were born to women who underwent pelvic radiation  Self-Breast Examination / (Clinical)
were more likely to have birthweight <2500g  Imaging
 Radiotheraphy (not chemo) at young age irreversibly reduces  Biopsy
uterine volume o Mammography is allowed
 Although women who were treated w/ radiotherapy during o Once diagnosed a limited search for metastasis is done
childhood did not have significant increase risk for congenital o CT scan of bone and liver NOT done
malformation. o MRI – may be an alternative for liver scan

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  Treatment
o Multidisciplinary (Obstetrician, Oncologist, Surgeon)
o Surgical treatment may be definitive
 Wide excision
 Modified radical mastectomy
 Total mastectomy w/ lymph node
 Breast reconstruction- until after delivery
o Chemotherapy
 For LN (+) remote from term
 In advance disease termination may be considered
 Delayed until 2nd trimester of pregnancy
 Adjuvant is withheld until after delivery
o Immunotherapy NOT done due to association with
Oligohydramnios
 Infertile due to chemotherapy
 Lactation not adversely affected
 Future pregnancy:
o Delay for 2-3 years
o Birth outcome not affected

LYMPOID MALIGNANCY
HODGKIN DISEASE
 Most common malignant lymphoma in childbearing age
 70% painless LN enlargement above the diaphragm.
 Neck and supraclavicular nodes
 Treatment tenet:
o Careful staging
o Local radiotherapy or
o Systemic chemo is indicated
o BUT still treatment is individualized
o Stage of pregnancy
o Pregnancy duration
 Chemotherapy best AVOIDED during the first trimester
 Pregnancy does not affect the survival of the patients
 Long term prognosis:
o Menstruation recurred after chemotherapy
o No birth defects seen in studied women
o Risk for breast can increase esp. In radio therapy
o Other complications:
 Hypothyroidism
 MI
 Pulmonary fibrosis
 Bone marrow suppression

NON-HODGKIN LYMPHOMA
 More aggressive
 Associated with viral infections:
o HIV
o Epstein-barr virus
o Hep. C virus
o Human herpes simplex virus B
 5-10% are HIV infected
 Rare in pregnancy
 Management:
o Stage 1- chemotherapy
o Stage II, III and IV – chemo and immunotherapy

LEUKEMIAS
 Classified as
o Acute lymphoblastic
o Acute/chronic myelogenous leukemia
o Acute/chronic lymphocytic leukemia
 Remission is common in pregnancy with chemotherapy
 Usual fetal effect are the same
 But no evidence termination improves prognosis
 Perinatal outcomes:
o Dilated cardiomyopathy
o Transient oligohydramnios

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Trans by: Ampuan, Baluyot, Caraveo Edited By: Ilano
MALIGNANT MELANOMA o HSIL (HIGH-GRADE SQUAMOUS
 Little interaction INTRAEPITHELIAL LESION)
 Usually arises from pre existing nevus  Colposcopy by experienced MD
 Changes in the nevus warrants a biopsy:  Suspicious lesions – biopsy
o Contour  If unsatisfactory (Transformation zone can’t be seen)
o Surface elevation  Transformation zone is inverted inside. But in
o Discoloration pregnancy there is physiologic evertion (in
o Itchiness 12weeks) – repeat in Colposcopy in 2 months
o Bleeding  After delivery – repeat colposcopy and biopsy, 6
o Ulceration
weeks postpartum
 Female genital area – more common
 Palms and sole, pressure area moles – more prone malignancy o AGC (ATYPICAL GLANDULAR CELLS)
 Deeper involvement or higher Clark’s stage – poorer prognosis  Initial evaluation = non pregnant
 Staging melanoma  Colposcopy is recommended
o Based on clinical findings
 Stage I no palpable LN  Endocervical currettage NOT done, might rupture
 Stage II palpable LN membranes
 Stage III distant metastasis
Colposcopy and Biopsy
o Tumor thickness single most important predictor of survival.  Colposcopy - easier to perform, due to cervical evertion
 Survival not affected if diagnosed during pregnancy  Biopsy is liberally performed
 But a change in the nevi during pregnancy was a risk for melanoma o May bleed profusely but controlled w/
 Prognosis depends on stage, but melanoma itself pregnant or not is  Monsel’s solution
very poor in prognosis due to wide spread metastasis  Silver nitrate
o Deep invasion / (+) LN = poorer prognosis  Vaginal packing
 Therapeutic abortion does not improve survival  Suture
 Treatment
o Determined by stage LEEP and Cone Biopsy
o Surgery  LEEP (loop electro-excision procedure)
 Primary treatment o Dangerous due to bleeding
 Wide local resection  Conization avoided in pregnancy due to
 W/ or w/o LN dissection o Hemorrhage
o Chemotherapy o Abortion
 Usually avoided because it is NOT proven o Preterm labor
 But still given if indicated by the stage and maternal  Conization in pregnancy is less satisfactory due to:
prognosis o The epithelium and underlying stroma within the
o Pregnancy not recommended 3-5 years after initial therapy endocervical canal cannot be excised extensively due to risk
o Subsequent pregnancy no adverse effects on survival of membrane rupture
o OCP appears to be safe o Blood loss is common
 Accounts for 1/3 of cases of metastasis to the placenta
Management with CIN
REPRODUCTIVE TRACT NEOPLASIA  CIN I – mild dysplasia
 Cervical neoplasia o Reevaluate postpartum (6wks after delivery)
 Endometrial carcinoma  CIN 2/3 – high risk
 Ovarian cancer  You have to rule out if invasive disease/advance pregnancy
 Vulvar cancer o Additional colposcopic and cytological exams no frequent
 Uterine leiomyomas than 12weeks
o Repeat biopsy only if lesion worsens or suggestive of
CERVICAL NEOPLASIA invasive disease
Routine Papsmear should be done in pregnant women. o Deferring evaluation at least 6 weeks postpartum is also
-preinvasive disease, not cancer yet acceptable
 Guidelines:  Treatment antepartum NOT recommended
o ASCUS (ATYPICAL SQUAMOUS CELL OF
UNDETERMINED SIGNIFICANCE) INVASIVE CERVICAL CANCER
 Same as non pregnant but acceptable to defer colposcopy Staging is Clinical, Gynecologist should do IE
 Do IE
until 6 weeks postpartum
 Cannot determine if ascus came from infection, cin,etc ..  Palpate cervix (size of lesion)
 Do rectovaginal exam
 Other choices: repeat papsmear, do colposcopy with
o Assess parametria (of size of cervix,
biopsy, HPV DNA testing)  If + for nodulation –stage IIB.
 Extending to pelvic side wall – Stage IIIB
o LSIL (LOW-GRADE SQUAMOUS INTRAEPITHELIAL  Staging is underestimated in pregnancy – due cervix and
LESION) parametria is both soft
 Colposcopy for non adolescent; more conservative for  Limited use of CT scan
adolescent
 MRI useful as adjunct to:
 But acceptable to defer colposcopy until 6 weeks
o Disease extent
postpartum
o UTI
 Additional colposcopic and cytological exams NOT
o Lymph node involvement
encouraged in advance disease unless there is change  Cystoscopy and sigmoidoscopy – if rectal and bladder involvement
(monitor patient)
is suspected

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Trans by: Ampuan, Baluyot, Caraveo Edited By: Ilano
  Survival rate same with non pregnant  Management:
o Depends on:
 Stage
 Age of gestation
 Desire to continue pregnancy
o Microinvasive
 Continue pregnancy
 Vaginal delivery
 Definitive treatment reserved until postpartum
o Invasive cancer
 1st half of pregnancy
 Immediate treatment same but depends on
decision to continue pregnancy
 Like radical hysterectomy with fetus in situ, or
radiotheraphy
 First 20wks
 Disregard pregnancy and do radical
hysterectomy
 Second Half of pregnancy
 Wait until the baby is viable
 Stage IB
 CS
 Radical hysterectomy after CS
2nd Half of Pregnancy
 Immediate treatment but may opt to wait for fetal viability before
initiation of treatment
 Preferred treatment:
o Stage I and early stage IIA lesion <3cm
 Before 20 weeks- hysterectomy in situ
o Age of viability
 Hysterotomy before radical hysterectomy (Do CS,
30wks above)
o Cure rate:
 Surgery=radiation
o Radical trachelectomy (get wide parametria) = for fertility
preservation for stage IB1 and IB2 (big tumors, radiotx)
o Radiotherapy for extensive disease, big tumors
 Delivery: controversial

Most prefer abdominal delivery to prevent:

 Tearing and possible spread
 Excessive bleeding
 Recurrence in the episiotomy scar
 Classical CS is preferred
 Prognosis is similar to non pregnant women

ENDOMETRIAL CARCINOMA:
 Rarely seen in pregnancy
 Usually well differentiated adenocarcinomas
 Management:
o Depends on age of gestation
o Usual management: TAHBSO

OVARIAN CANCER
 4th most common cause of death in women
 Incidence in pregnancy in accurate
 Most adnexal masses seen are:
o Dermoids
o Benign cystadenomas
 Pregnancy does not alter prognosis
 May cause maternal virilization during pregnancy
 Management:
o Similar to non pregnant women
o But would depend on age of gestation
If diagnosed, open right away, might be life saving. Remove ovaries, but
do not remove uterus (if with baby inside). In early pregnancy give extra
progesterone to support pregnancy.

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Trans by: Ampuan, Baluyot, Caraveo Edited By: Ilano
VULVAR CANCER
 Rare in pregnancy
 But suspicious vulvar lesion still has to be biopsied
 Treatment is individualized
 But radical vulvectomy is feasible during pregnancy

UTERINE LEIOMYOMAS
 Common in older pregnant women
 Seldom are malignant
 If autopsy is done in all women; 25% will have myoma.
 May cause tumor previa – blocking the passage way of the baby
 Unpredictatble in pregnancy; may increase in size (due to
hormones), some may not, some may become smaller

GASTROINTESTINAL CANCER
COLORECTAL CARCINOMA
 2nd most common cancer
 Rare in pregnancy
 Common symptoms:
o Abdominal pain
o Distension
o Nausea and vomitting
o Constipation
o Rectal bleeding
 Diagnosis may be delayed in pregnancy

 Examinations
o Digital rectal exam
o Occult blood
o Sigmoidoscopy
o Colonoscopy

 Treatment
o Same as in non pregnant women
o In advance disease
 1st half of pregnancy hysterectomy NOT done
 2nd half delay treatment may be considered
o Delivery: NSVD/CS
 Pregnancy may not influence course of the disease

Other Gestational Neoplasms

 Seldom seen in neoplasms
o Gastric cancer
o Zollinger-ellison syndrome
o Carcinoid tumors
o Pancreatic cancer
o Primary hepatocellular cancer
 Clotting factors are involved, that may predispose to
torrential bleeding.
o Krukenberg tumor
 Ovarian involvement of the primary GIT CA through
seeding

Renal Neoplasm
 May present with
o A palpable abdominal mass
o Pain
o Hematuria
 Treatment: Same in non pregnant women

Other tumors
THYROID CANCER
 Most common endocrine malignancy
 Diagnose: fine needle biopsy
 Treatment: Surgery 2nd half of pregnancy or after delivery

SOFT TISSUE/BONE TUMORS

 Successful surgery during pregnancy reported

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Trans by: Ampuan, Baluyot, Caraveo Edited By: Ilano