Living with fetus and malignancy, rare occurrence.pptx

Cancer during pregnancy is rare (1/1000 pregnancy/yr). corresponding to 0.07% to 0.1% of all malignant tumors. Common cancers during pregnancy are Breast, Thyroid, Cervical cancer, Colon, Malignant melanoma, Leukemia, Lymphomas. Melanoma, hematopoietic malignancies and lung cancer are the only cancers that have been reported to metastasize to the placenta and fetus, while melanoma accounts for almost one third of all cases.

1. Dr. Md. Rezaul Haque FCPS Part II Trainee (Radiotherapy) Dept. of Radiation Oncology National Institute of Cancer Research and Hospital Living with fetus and malignancy

2. Mousumi Begum, 37 years old married lady hailing from Madhupur, Tangail admitted into NICRH under Dept of Radiation oncology on 11 aug 24 with the complaints of abdominal pain, vomiting and abdominal swelling. According to the statement of the patient, She was reasonably well 8 months back.

3. She was 2nd gravida 26th weeks pregnant during that time. She was on regular antenatal check up. Suddenly She developed severe vomiting and abdominal pain with unusual abdominal enlargement. Pain was constant, moderate to severe, non radiating, no relation with food intake and does not relieved by vomiting or PPI but relieved by NSAID.

4. Vomiting was mild projectile, small in amount , not foul smelt, not bile or blood stained, digested and undigested food materials that she took previously. Then patient consulted with local gynecologist. Gynaecologist advised: USG of W/A reported multiple SOL in Liver. Referred to surgeon for further management.

5. FNAC from Liver SOL was done by surgeon and revealed “Presence of malignant cell possibly HCC/Metastatic adenocarcinoma/Cholangiocarcinoma’’. MRI of W/A without contrast (27.09.23): “Splenomegaly and splenic SOL (largest one 9.5 x 7.8cm) along with multiple liver SOL(Largest one 6.5 x 5.0 cm) and hepatomegaly”.

6. All other baseline reports are within normal limit including CXR. All vital signs with bowel and bladder habit was normal. Core biopsy from liver SOL and splenic SOL done as there was inconclusive result on FNAC. Core biopsy from Liver SOL revealed “ Metastatic Adenocarcinoma, Possibly primary

7. colon, GB. HCC is remote possibility.” Core biopsy from Splenic SOL revealed “ No malignancy.” Then patient was awaited upto 37 th week without any oncological management. She was on symptomatic management

8. She underwent LUCS at 37th week and gave birth a healthy baby without any postoperative complications. Then referred to oncologist for further management. She consulted with clinical oncologist at a private hospital. Oncologist advised some investigation to searched primary site.

9. Upper GI endoscopy, Colonoscopy, Chest x-ray (04.12.23), S. AFP: Normal Repeat MRI of W/A with contrast: Hepatosplenomegaly and multiple SOL in Liver (Largest one 6.3x6.0 x 6.6cm) and spleen

10. IHC for search primary from biopsy block from Liver: Metastatic adenocarcinoma, Primary could not be determined. CK7: Positive CK20, CDX2, TTF1, PAX8, Glypicans-3 : Negative

11. Then she r eceived chemotherapy with Docetaxel 100mg and Carboplatin 600 mg x 6 cycles followed by 2 cycles chemotherapy with Gemcitabine 1300 mg and Oxaliplatin 140 mg up to 07 sep 24 as a case of CUP.

12. Then patient came to NICRH due to poor financial condition. General and systemic examination done. Physical examination of Breast : NAD PVE and DRE: NAD Abdomen: Tender on epigastric, right and left hypochondriac region. Hepatosplenomegaly with irregular border.

13. After admission, CT scan of W/A with Contrast (15.08.24) : Hepatomegaly, Multiple liver SOL along with splenomegaly with Multiple splenic SOL. No lymphadenopathy. CT scan of chest with contrast (15.08.24) : Bilateral Lung mets.

14. Plan to do CEA, CA19.9, Repeat IHC but patient could not do these investigations due to poor financial condition. She got chemotherapy with Gemcitabine and cisplatin on 22.08.24. Before starting chemotherapy, patient’s P/S was 01. Baseline reports was normal except anemia (8.0 gm/dl) which was corrected by blood transfusion.

15. Patient complained abdominal pain from next day of chemotherapy which was being deteriorated day time to time. She developed respiratory distress 5 days after chemotherapy and worsen after 8 hours then she was shifted to ICU for better management. Unfortunately patient die on ICU after 8 hours of ICU shifting.

16. Do awaiting for termination of pregnancy progress the disease? Can malignancy metastasis to fetus? Could we start chemotherapy after diagnosis? What regimen of chemotherapy may be prescribed during pregnancy? Questions

17. Try to find out answers: Cancer during pregnancy is rare (1/1000 pregnancy/yr). corresponding to 0.07% to 0.1% of all malignant tumors. Common cancer during pregnancy are:

18. Thyroid Colon Ovary Malignant melanoma breast cancer, cervical cancer, lymphomas and leukemias

19. Melanoma, hematopoietic malignancies and lung cancer are the only cancers that have been reported to metastasize to the placenta and fetus, while melanoma accounts for almost one third of all cases.

20. Limitations cancer diagnosis during pregnancy: Changes in hormone levels during pregnancy can cause the breasts to become larger, lumpy, and/or tender. Bleeding from the rectum could be from benign hemorrhoids, which are common during pregnancy, or from colon or rectal cancer.

21. Limitations cancer diagnosis during pregnancy: Feeling tired could be from weight gain from the pregnancy or from low red blood cell counts (anemia), which can be seen during pregnancy or with cancers such as leukemias and lymphomas. The growth of the fetus and uterus can make it hard to detect ovarian tumors.

22. Investigations safe during pregnancy: Mammogram Ultrasonogram CXR with belly shield Bone scan PET CT scan MRI Thyroid Scan

23. Tumour markers : Although serum tumor markers could be useful in the diagnosis, follow-up and management of cancer patients, they lack sensitivity and specificity during pregnancy, due to significant physiological variations in serum levels. Commonly used tumor markers CA 15-3, SCC, CA 125 and AFP levels are increased in pregnancy and consequently are not reliable.

24. On the other hand, CEA, CA 19-9, LDH, AMH, and HE-4 levels are not commonly increased in pregnancy and theoretically could be of additional help. Some exceptions are inhibin B, whose levels increase in the last trimester of a normal pregnancy, and LDH, which is a marker of hypertensive abnormalities related to pregnancy.

25. Safe cancer treatment during pregnancy: Surgery Chemotherapy (2nd or 3rd trimester) Radiotherapy outside pelvic area

26. Cancer surgery during pregnancy It is generally safe during pregnancy, and it may be considered depending on where the cancer is in the body. Surgery is typically believed to be safest if done in the second or early third trimester, but it can be done any time during the pregnancy, depending on the situation.

27. Chemotherapy during pregnancy Chemo is generally not given during the first trimester of pregnancy. Because a lot of fetal development happens during this time, the safety of some chemo drugs hasn’t been studied in the first trimester. The risk of miscarriage (losing the baby) is also greatest during this time.

28. Chemo is generally not recommended after 35 weeks of pregnancy or within 3 weeks of delivery because it can lower the mother’s and baby’s blood cell counts. This could cause bleeding and increase the chances of infection during birth. Holding off on chemo for the last few weeks before delivery allows the mother’s and baby’s blood counts to return to normal before childbirth.

29. Hormone therapy and targeted drug therapy, are more likely to harm the fetus and are not usually given during pregnancy It’s not clear how much of a risk immunotherapy might pose to the fetus at this time.

30. However, rituximab, a drug used to treat certain lymphomas and leukemias, can be used with caution in the second and third trimesters. Interferon-alpha (IFN-α) is another immunotherapy drug that can be used safely during the entire pregnancy, but it is not often used for cancer treatment.

31. Tyrosine kinase inhibitors (TKIs) are known to cross the placenta, and most are not recommended during pregnancy. But one TKI, imatinib, is considered safe to use after the first trimester to treat chronic myeloid leukemia (CML).

32. Thank You