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Maternal Medicine - RANZCOG Q > Cancer in pregnancy > Flashcards

Cancer in pregnancy Flashcards

1
Q

Characteristics of breast ca in pregnancy

A

Typically more advanced:

  • larger tumour
  • node positive
  • poorer outcomes

Likely due to delayed diagnosis as:
- Symptoms less noticable (to pt and physician) due to physiological changes of breast in pregnancy (therefore skin change, mass, abnormal discharge may be thought to be normal)

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2
Q

Investigations for breast ca in pregnancy

A
  • History and examination by specialist
  • Breast USS first line
  • mammography to check for bilateral/multifocal disease
  • Core biopsy of breast lump (FNA has high risk of false pos and false neg due to proliferative breast changes in pregnancy)
  • Try to minimise unnecessary fetal radiation exposure
  • Staging: CXR, liver USS, MRI bones
  • (or radionucear bone scan with IDC and IVF to minimise accumulation of contrast, if MRI unavailable or further info needed)

All women should have genetic testing due to young age at diagnosis

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3
Q

Obstetric considerations in management of breast ca pregnancy

A
  • No evidence for better outcomes with TOP - personal choice based on woman’s situation
  • May be more likely to consider TOP if <10/40
  • Chemotherapy shouldn’t start until >14/40 (after 10/40 when organogenesis complete then wait 4 weeks after)
  • Detailed anatomy scan prior to treatment to ensure no prior congenital abnormalities
  • Growth scans due to increased risk of FGR
  • Steroids can be given for obstetric indications
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4
Q

Pregnancy related risks if breast ca

A

Increased risk of:

  • FGR
  • Preterm birth
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5
Q

Surgical management of breast ca in pregnancy

A
  • Surgery safe
  • Anaesthesia- be mindful of risk of preterm labour
  • Consider FHR monitoring intraoperatively or after and monitor for contractions that may be masked by analgesia
  • Optimise analgesia as pain may stimulate PTB

Anaesthesia/surgical team aim to minimise risk of:

  • hypoxia,
  • hypotension,
  • hypoglycaemia,
  • fever,
  • pain,
  • infections,
  • thrombosis
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6
Q

Chemotherapy options in breast ca

A
  • Avoid MXT, trastuzumab and tamoxifen
  • Recommended regime:
    —– fluorouracil and epirubicin
    —–doxorubicin plus cyclophosphamide
    —–epirubicin or doxorubicin plus cyclophosphamide and taxanes (paclitaxel weekly to
    every 3 weeks or docetaxel every 3 weeks)

Evidence re chemotherapy in pregnancy after 1st trimester suggests a higher rate of FGR, preterm birth, haemopoietic suppression and possible fetal/neonatal death but outcomes thought to be better for chemotherapy agents used in breast ca.

Minimal evidence re long term outcomes doesn’t suggest any long term physical/congential/emotional/behavioural adverse effects from chemo for breast ca

Risks of prematurity thought to outweigh risks of chemotherapy

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7
Q

Timing of delivery of a woman with breast ca

A

If preterm, can treat whilst pregnant- outcomes likely to be better as PTB increases likelihood of complications related to prematurity

If 35/40 at time of diagnosis then deliver and arrange staging and treatment following delivery

Overall aim of delivery 35-37/40

Ideally don’t perform chemo within 3 weeks of delivery due to fetal risk of neutropenia at birth

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8
Q

Mode of delivery with breast ca and pregnancy

A

Can have NVD- if NVD achieved can restart chemo the next day

If CS- can start chemo usually 1/52 later

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9
Q

Radiotherapy for breast ca in pregnancy?

A

Individualised decision with rad onc physician due to fetal risks of radiation exposure
Risks aren’t clear - likely a small increased risk of long term adverse health outcomes including malignancies
Ideally wait till after delivery

If needed

  • shield fetus
  • minimise field of exposure
  • Increase distance of beam from field of exposure
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10
Q

Most common type of breast ca in pregnancy

A

infiltrating ductal adenocarcinoma

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11
Q

Factors to take into consideration when deciding on treatment for breast ca in pregnancy

A
  • Tumour biology
  • Tumour stage
  • Gestational age
  • Patient and family’s wishes- including ethical/psychlogical/religious issues
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12
Q

Who should be involved in the MDT for treatment of women with breast ca in pregnancy?

A 
Breast surgeons
Med Oncology 
Rad Oncology
Obstetrics 
Neonatologist 
Radiologist 
Pathologist
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13
Q

What is the broad approach to management of breast cancer outside pregnancy?

A
  • Surgery first-line at most stages unless palliation recommended; in advanced stage cancer neoadjuvant chemo may be given prior to surgery
  • Breast conserving surgery OR mastectomy AND SNLB/axillary node clearance
  • Adjuvant radiotherapy (for all BCS, advanced grade/stage and LN involvement)
  • Adjuvant chemotherapy (if tumour >1cm, receptor neg, high stage or other poor prognostic criteria)
  • Adjuvant Tamoxifen / letrozole for 5 years (if ER/PR pos)
  • Adjuvant Trastazumab (herceptin) for 1 year (if HER2 receptor positive)
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14
Q

Treatment of locally advanced breast ca in pregnancy?

A

Neoadjuvant chemotherapy with or without surgery
until fetal maturity

Delivery 35-37/40

Completion of treatment

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15
Q

Treatment options for breast cancer if <12 weeks gestation.

A

If locally advanced:
- Consider termination, and then standard treatment

If not locally advanced:

  • Breast conserving surgery or mastectomy + SLND or axillary node clearance
  • Adjuvant chemotherapy AFTER 14 weeks
  • No radiotherapy
  • Aim delivery ≥35-37 weeks
  • Complete treatment pos partum with radiotherapy and other adjuvant treatments e.g. tamoxifen/herceptin as required
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16
Q

Treatment of breast ca that ISN’T locally advanced in pregnancy?

A

Breast-conserving surgery or mastectomy, sentinel
node procedure or axillary node dissection

Adjuvant chemotherapy until fetal maturity, with
approved cytotoxic drugs (not if >35/40- in this case deliver)

Radiotherapy is not considered after surgery and
before chemotherapy to reduce treatment methods
during pregnancy

Delivery 35-37/40

completion of treatment after delivery

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17
Q

Specific surgical considerations for breast cancer in pregnancy.

A
  • Avoid adjuvant radiotherapy - therefore consider less breast conserving surgery
  • For SNLB - technetium radioisotope is safe, but avoid blue dye due to risk of hypersensitivity reaction
  • Avoid autologous breast reconstruction surgery whilst pregnant, due to physiological changes during pregnancy
  • Ensure has LMWH VTE prophylaxis postpartum due to triple risk (pregnancy, cancer, post-op)
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18
Q

Postpartum considerations for pts with breast ca

A

Examine placenta for evidence of metastasis

Can start chemo: 1/7 after NVD, 1/52 after CS

Breastfeeding can be done if physologically possible but not if having chemo

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19
Q

Why shouldn’t trastuzumab or tamoxifen be given during pregnancy?

A

trastuzumab
- HER2 receptors expressed on fetal kidneys therefore can cause fetal renal failure/renal consequences and oligo/anhydramnios

Tamoxifen
- causes craniofacial abnormalities and ambiguous genitalia, and fetal death

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20
Q

Most common malignancies diagnosed in pregnancy?

A

Gynaecological (mainly uterine, cervical, ovarian),
Breast,
Haematological (leukaemia and lymphoma)
Skin (melanoma) cancers.

21
Q

MDT team for gynaecological cancers?

A 
gynaecological surgeon, 
medical oncologist, 
radiation oncologist (in cervical cancer), 
radiologist, 
pathologist, 
obstetrician,
neonatologist,
22
Q

4 criteria that dictate management of cervical cancer in pregnancy:

A
  • extent of local spread (ie, tumour stage and tumour size),
  • nodal status,
  • gestation of pregnancy,
  • histological subtype.
23
Q

Early stage cervical ca management

A

In early-stage cervical cancer during the first and at the beginning of the second trimester, MRI and laparoscopic lymphadenectomy are useful for planning of a potentially conservative approach.

1A (microinvasive) - close observation and delay treatment until after delivery

1B1 - Radical trachelectomy and laparoscopic LN dissection

1B2 and above - recommend termination or preterm delivery and chemoradiotherapy.

Pregnancy sparing option = neoadjuvant chemotherapy and preterm delivery, followed by surgery or radiotherapy post partum

24
Q

Management of locally advanced cervical ca

A

1B2 and above - recommend termination or preterm delivery and chemoradiotherapy.

Pregnancy sparing option = neoadjuvant chemotherapy and preterm delivery, followed by surgery or radiotherapy post partum

The management of patients with locally advanced cervical disease is controversial and should be discussed on a case-by-case basis according to the tumour size, radiological findings, the term of pregnancy, and the patient’s wishes.

25
Q

Management of ovarian ca in pregnancy

A

Diff erent histological types of malignant ovarian diseases arise during pregnancy and
their management depends on the diagnosis (histological subtypes, tumour
diff erentiation, and nodal status), the tumour stage, and the term of the pregnancy.
In patients with peritoneal spread or high-risk early-stage disease, neoadjuvant
chemotherapy with pregnancy preservation might be possible.

26
Q

What effect does pregnancy have on the outcome for cervical cancer?

A

None- outcomes the same for pregnant and non-pregnant women

27
Q

Considerations for cervical screening in pregnancy

A
  • Can be difficult to interpret in pregnancy due to: large ectropion, frequent inflammation, presence of confusing decidual cells that can be mistaken for atypia, also called an AriasStella reaction.

BUT

  • Same level of accuracy than in non-pregnant women
28
Q

Management of an abnormal smear in pregnancy

A
  • Can have colposcopic examination
  • Biopsy can be performed
  • Endocervical curettage should NOT be performed
29
Q

Management of low grade abnormal smears in pregnancy

A
  • Low grade- regression rate high and progression rate low

- Repeat postnatally

30
Q

Management of high grade abnormal smears in pregnancy with no invasion

A
  • High grade- regression rate low and progression rate high
  • High grade lesions e.g. CIN3 can be treated after pregnancy but they should have colposcopic examination very trimester to ensure they don’t develop an invasive lesion
31
Q

Management of high grade abnormal smears in pregnancy with invasion

A
  • Invasive lesions: cone/LLETZ carry risk of: bleeding, infection, preterm labour, PPROM and risks increase with gestational age.

Decision to perform LLETZ/Cone:

  • If invasive disease suspected
  • length of cx
  • Gestation and risks of above
  • Clinical team’s preference
32
Q

How does histological subtype of cervical cancer influence management?

A

Squamous-cell, adenocarcinoma, and adenosquamous lesions have similar prognosis and management

rare subtypes such as small-cell carcinoma, have a poor prognosis. In this case, pregnancy termination is mandatory and patients should be treated immediately to deliver optimum therapy

33
Q

How to stage cervical ca in pregnancy?

A

MRI - looking at locoregional spread

PET-CT- carries unacceptably high dose of radiation to fetus

Pelvic lymphadenectomy- can be performed in 1st and 2nd trimesters laparoscopically

34
Q

Treatment of stage 1 cervical ca in pregnancy

A
  • Delayed treatment until fetal maturation acceptable in 1A
  • 1B or higher recommend lymphadenectomy- if negative can delay treatment
  • Can consider radical trachelectomy: in combination with lymphadenectomy. Rate of fetal loss is high.
35
Q

Management of locally advanced cervical cancer in pregnancy

A

Either neoadjuvant chemotherapy or chemoradiotherapy

If not pregnant and:
- tumour >4cm
- nodal involvement
Normally would have chemoradiotherapy

In pregnancy this would end the pregnancy

Alternatively- neoadjuvant chemo alone has been trialled with mixed results and some women did die of advanced disease after pregnancy. None of the babies had abnormalities after birth

36
Q

Chemotherapy agents for cervical ca in pregnancy

A

Cisplatin and paclitaxel

Carboplatin can also be used and would have less renal effects

37
Q

Investigation of possible ovarian cancer

A

USS- ?features of complex mass
MRI - helpful for staging and characterising mass

CA125- elevated in 1st trimester and post partum. May be helpful in 2nd and third.

CT- contraindicated because of radiation

38
Q

Most common histological subtypes of ovarian ca in pregnancy

A

non-epithelial tumours (germ-cell and sexcord tumours),

ovarian tumours of low malignant potential,

epithelial ovarian cancers

39
Q

What should be done for lesions that are suspicious?

A
  • Laparoscopic excision- dependent on lesion either cystectomy without spilling or unilateral USO
  • Frozen section to determine further surgery
  • Washings, omental biopsy, if mucinous then appendectomy
40
Q

Management of tumours of low malignant potential in pregnancy

A

Cystectomy and removal of any macroscopic disease may be suitable providing no spill

Staging- washings, omental biopsy +/- appendectomy

Prognosis usually good

41
Q

Management of epithelial ovarian cancer in pregnancy

A

Incidence is low in pregnant patient, rare form of cancer in pregnancy

No peritoneal spread: Primary surgery is preservation of uterus with peritoneal staging. Lymph node resection based on risk-balance and surgical feasibility.

Stage 3 ca: consider termination and surgery

Neoadjuvant chemotherapy to preserve pregnancy depending on other features e.g. stage and gestation

42
Q

Incidence of cancer diagnosis in pregnancy?

A

0.1%

43
Q

Most common haematological malignancies in pregnancy?

A

Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Acute leukaemia

44
Q

Investigation of lymphoma in pregnancy?

A

Lymph node biopsy sample

Usually would do CT/PET but carries fetal risk of radiation.

Instead- can consider CXR and MRI

45
Q

Management of acute leukaemia

A

Requires early and aggressive treatment regardless of gestational age

In the first trimester typically recommend TOP due to treatment needed and likelihood of bone marrow transplant needed (can’t be done whilst pregnant)

46
Q

Obstetric complications with haematological cancer? (aside from cancer itself)

A

Thrombcytopaenia and thrombosis risk

Thrombosis risk- aside from VTE risk also increased risk of placental thrombosis leading to IUFD or FGR.

Should take clexane

47
Q

Principles of treatment for haematological malignancy in pregnancy

A

If aggressive malignancy: termination if frist trimester then treatment, if 2nd or 3rd trimester then can remain pregnant and start chemo

If not aggressive- consider watch and wait in 1st trimester then start chemo from 2nd trimester

48
Q

Reproductive counselling for women who had an acute haematological malignancy

A

Recommend waiting 2-3 years due to risks of recurrence

Should also avoid COCP due to clotting risk

49
Q

At what dose of radiation are adverse obstetric outcomes observed?

A

Deterministic effects of radiation—such as fetal death, malformations, or impaired fetal development—can arise when fetal exposure exceeds the threshold dose of 0·1–0·2 Gy.

Maternal Medicine - RANZCOG Q (5 decks)

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