Breast cancer is one of the most frequent malignant neoplasms in women, and 2-2.5% of patients with a newly established diagnosis are pregnant. Pregnancy adversely affects the course of breast cancer and in most cases accelerates its development. This applies to those variants of breast tumors in which there is a large expression of estrogen receptors of the tumor itself. Diagnosis during pregnancy and after childbirth is very difficult due to physiological proliferation with an increase in mammary glands, hypervascularization and local compaction of the parenchyma. All these changes are accepted by doctors for the manifestation of pregnancy, and cases of breast cancer are often overlooked. Often, women themselves find a disease.
Diagnosis of breast cancer includes:
- Ultrasound, Doppler study;
- mammography with a puncture biopsy of the identified node (with a maximum dose of 10 rad; with adequate protection of the fetus, it decreases to 50 mrad for the fetus);
- MRI with amplification is not used.
Management tactics depend on the stage of the disease and gestational age. The basic approach to choosing a treatment method is as follows: the patient should receive the necessary therapy in full (as outside of pregnancy), and its beginning should not be delayed. Abortion is not indicated, as it does not increase survival. Radical mastectomy during pregnancy is tolerated normally. The question of a sentinel lymph node biopsy has not been finally resolved since the opinions of experts are contradictory. It is believed that this is possible since the maximum dose is 4.3 mg, i.e. this is the permissible load. It was found that the long-term prognosis in pregnant women with breast cancer is generally worse than in non-pregnant women.
When conducting chemotherapy, the frequency of intrauterine growth retardation and prematurity is significantly increased. In all cases of breast cancer detected during pregnancy, lactation is not recommended. After successful treatment of the disease, subsequent pregnancies do not increase the risk of relapse and therefore are not contraindicated. Both adjuvant and neoadjuvant chemotherapy tactics using primarily anthracyclines are possible.
Recommended treatment regimens for breast cancer:
- 5-fluorouracil + doxorubicin + cyclophosphamide;
- 5-fluorouracil + epirubicin + cyclophosphamide;
- epirubicin + cyclophosphamide.
The use of drugs of the taxane group during pregnancy is not recommended, although the described cases did not indicate obvious harm to the fetus. After the 32nd week of gestation before chemotherapy, it is advisable to carry out delivery through the natural birth canal, as this is considered a period of confident viability of the fetus.
It is known that pregnancy does not increase the risk of recurrence of breast cancer treated before pregnancy, and, therefore, is not contraindicated in patients with this pathology. It is necessary to observe women, giving birth on time, through the natural birth canal. However, lactation is not recommended.
Lymphomas are the second most common tumor in pregnant women (1: 2-6 thousand births). Most (70-75%) cases are Hodgkin’s disease, significantly less often (25-30%) in pregnant women is non-Hodgkin’s lymphoma. In our clinics, this figure is even lower – approximately 10%. The course of the disease during pregnancy does not change, i.e. pregnancy does not stimulate the development of this disease. Damage to the fetus is extremely rare.
As with other malignant tumor diseases, if lymphoma is found in the first trimester, it is recommended to terminate the pregnancy. It is also advisable to do the same if pregnancy has occurred against the background of ongoing chemo- or radiation therapy. If this disease is detected in the second or third trimester, chemotherapy and radiation therapy are justified (only for health reasons, if the focus is above the diaphragm). Delivery is preferable through the birth canal for periods ≥ of 37 weeks.
Women treated in the past for lymphomas should use contraception for 2 years. This recommendation is based on the fact that 85% of relapses occur within the first 2 years after achieving remission. There is no evidence that subsequent pregnancy increases the risk of relapse. The prognosis of the further course of Hodgkin’s disease and non-Hodgkin’s lymphoma differs little from those who are sick during pregnancy from non-pregnant, i.e. those who became pregnant and gave birth after the onset of remission, and those who were not pregnant. Life expectancy is exactly the same.
Leukemia. Among leukemia detected during pregnancy, the vast majority (> 80%) are acute, among which myeloblastic and lymphoblastic are significantly predominant. Chronic leukemia accounts for <20%. Although there is no convincing evidence that pregnancy negatively affects the course of acute leukemia, the risk of maternal and perinatal death due to the severity of the disease itself with this combination is very high. Rare cases of the transition of leukemic cells to the fetus and very frequent cases of the formation of leukemic infiltrate in the placenta are described.
The earlier acute leukemia developed, the worse the prognosis of the outcome of this pregnancy for the mother and fetus. The best tactic in the first trimester is the termination of pregnancy. At a later date, the question of interruption is subject to collegial discussion by the obstetrician-gynecologist and hematologist with the mandatory participation of a woman. Treatment cannot be delayed since the life expectancy in acute myeloid leukemia without therapy is 2-2.5 months. Therapy should be aggressive and aim to achieve a remission of the disease. Even in cases of late (i.e., in the third trimester) onset of acute leukemia, the patient often dies. A woman can die during childbirth from uterine bleeding, but more often – in the postpartum period from infectious complications, bleeding of various localization or multiple organ failure. Neither late termination of pregnancy nor early delivery significantly affects the outcome. Cesarean section is considered a more dangerous method of delivery and should be performed only on urgent obstetric indications.
In chronic myeloid leukemia, α-interferons are prescribed that are compatible with pregnancy, do not have teratogenic effects and therefore are the drugs of choice.
Drugs of other groups, such as imatinib and hydroxyurea, due to their teratogenic potential are not the means of choice during pregnancy. Leukapheresis contributes to the rapid reduction of hyperleukocytosis and maybe a temporary alternative to chemotherapy.
In chronic lymphatic leukemia, as a rule, it is possible to delay the start of therapy until delivery. Leukapheresis can be used to quickly reduce hyperleukocytosis.
Melanoma is a malignant, unfavorable rare disease. Ultrasound is recommended for diagnosis, in which the depth of tumor invasion is determined and a biopsy is performed. Therapy consists of excising the tumor, removing the sentinel lymph node, which is also possible during pregnancy, since the radiation load on the fetus is <5 mGy.
According to the data of K. Wiedermeyer, P. Mayser, with high-risk melanomas with an unfavorable prognosis, adjuvant therapy should be started within 6 weeks, which is not always possible during gestation. Pregnancy does not worsen the prognosis of the disease and is not a risk factor for the development of melanoma.
Colon and rectal cancer appear in 1 case in 50 thousand pregnancies (isolated rectal damage is> 80%; large intestine – 17%). Non-specific symptoms (diarrhea, constipation, abdominal pain, rectal bleeding, mucus) are often attributed to pregnancy. Diagnosis requires endoscopy with biopsy, computed tomography, and magnetic resonance imaging.
In the first trimester and in the early stage of the tumor, surgical treatment with preservation of pregnancy is possible. In the II and III trimesters and / or in the later stages of the disease, delivery by cesarean section is indicated when the fetus reaches viability. To select the time of delivery, the stage of the tumor and the prognosis for the patient, as well as the maturity of the fetus, should be considered. Simultaneous surgical treatment of colon cancer with a caesarean section is possible. After surgery, at stage ≥ IIB, adjuvant chemotherapy containing platinum and 5-fluorouracil preparations is necessary.
Thyroid cancer is especially relevant in Ukraine. With this disease, women do not die and perinatal losses are not observed. The number of cases of previously treated and newly diagnosed thyroid cancer in pregnant women is growing. Thyroid nodules with a diameter of <1 cm detected during pregnancy should be examined using a fine-needle puncture biopsy with cytological analysis of the material obtained. A fine needle biopsy under ultrasound guidance has advantages, reducing the possibility of inadequate material collection. If the pregnant woman has nodes in the thyroid gland ≥ 1 cm, a thick needle biopsy is also recommended, also under the supervision of ultrasound. When the nodes are found in the first trimester and are malignant with rapid growth, pregnancy should not be interrupted, but it is necessary to offer the patient to undergo surgical treatment in the second trimester. Women with papillary cancer or a follicular tumor without manifestations of disease progression who want to delay surgical treatment and give birth to a child can be reassured by the fact that the highly differentiated type of thyroid cancer is characterized by slow growth, and delaying surgery is not associated with risk. It is recommended to prescribe levothyroxine to inhibit (but not completely) the production of thyroid-stimulating hormone (TSH) in women with previously treated thyroid cancer or with suspected cancer, as well as those who wish to postpone surgical treatment for the postpartum period. Patients at higher risk get more benefit from a greater inhibition of TSH secretion compared to people at low risk. Free and total thyroxine should ideally not exceed normal rates for pregnancy.
Women who previously underwent thyroid cancer and combined treatment are recommended contraception for 9-12 months, preferably after radioiodine therapy. Pregnancy does not increase the risk of relapse or metastases, it is never contraindicated. The dose of levothyroxine, which is suppressive outside pregnancy, should be reduced to replacement during pregnancy (TSH <1.0 mIU / L). Childbirth is carried out on time through the natural birth canal.
Brain tumors. This disease is characterized by a malignant clinical course, regardless of the histological nature. There is evidence of accelerated growth of meningiomas, angiomas, and neurofibromas during pregnancy. If the disease is identified in the first trimester, it is preferable to conduct a medical or surgical abortion; in the second trimester – surgical intervention (in cases of the primary tumor); in the third trimester – observation, delivery with the viability of the fetus.
With high intracranial pressure (the risk of dislocation and wedging of brain structures), volumetric brain formation syndrome, the risk of hemorrhage or hypoperfusion, a cesarean section is necessary.