Management of hematological malignancies during pregnancy

Rizack, Tina; Mega, Anthony; Legare, Robert D.; Castillo, Jorge J.

doi:10.1002/ajh.21547

Cited by 89 publications

(65 citation statements)

References 160 publications

(227 reference statements)

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“…It can be extremely difficult during early stages to differentiate pregnancy-related physiologic changes from the subtle, early signs of an evolving acute malignancy, and this mimicry may delay a cancer diagnosis. 1,[8][9][10][11][12][13] Interestingly, a recent systematic review of nonHodgkin lymphoma (NHL) in pregnancy observed that aggressive forms of NHL exhibit unique clinical and biological features during pregnancy, including frequent involvement of the reproductive organs (breast, ovary, uterus, and placenta).…”

Section: Discussionmentioning

confidence: 99%

“…Exercise extreme caution; use where benefit to mother clearly outweighs risk to fetus. Vincristine 1,11,16,45 No congenital anomalies or neurotoxicity documented.…”

Section: 28mentioning

confidence: 99%

“…68 The overall risk of teratogenicity during the first trimester is considered to be 10-20%; 1,8 the risk is 10% after the use of a single chemotherapeutic agent and 15-25% after combination chemotherapy. 8,9,11,12,23 The greatest risks are from alkylating agents and antimetabolites; vincristine poses the lowest risk. 11 However, in a prospective study by Aviles and Niz of 20 children exposed in utero to intensive ALL chemotherapy between 1963 and 1981 (11 of which were exposed during the first trimester), none showed any congenital malformation, chromosomal abnormality, or late-onset cardiac or neurologic toxicity during follow-up periods ranging from 4 to 22 years.…”

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confidence: 99%

“…8,9,11,12,23 The greatest risks are from alkylating agents and antimetabolites; vincristine poses the lowest risk. 11 However, in a prospective study by Aviles and Niz of 20 children exposed in utero to intensive ALL chemotherapy between 1963 and 1981 (11 of which were exposed during the first trimester), none showed any congenital malformation, chromosomal abnormality, or late-onset cardiac or neurologic toxicity during follow-up periods ranging from 4 to 22 years. 24 The most commonly reported outcomes of cytotoxic insult during the first trimester are intrauterine fetal demise or spontaneous abortion, 8,12,25 as in our first case illustration.…”

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confidence: 99%

“…After the first trimester, the risk of congenital malformation falls to approximately 3%, similar to the risk in the general population. 11,25 During this period the fetus acquires functional maturity; therefore, cytotoxicity during this time has implications for functional-rather than anatomic-defects. The organs at functional risk during this phase are the central nervous system, hematopoietic system, eyes, and ears.…”

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confidence: 99%

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Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature

Zaidi

Johnson

Church

et al. 2014

Journal of Adolescent and Young Adult Oncology

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The usual age range of acute lymphoblastic malignancies (acute lymphoblastic leukemia and advanced-stage lymphoblastic lymphoma) includes teenagers and young adults (<22 years of age) and coincides with the age of fertility. Concurrence of acute lymphoblastic malignancy with pregnancy is therefore most likely to happen during the younger childbearing ages. However, the therapeutic challenges posed by the dual diagnosis of lymphoblastic malignancy and pregnancy have not specifically been studied in the context of age, and management guidelines for pregnant young patients are lacking. Inconsistency in defining the legal decision-making rights of pregnant teenaged patients adds a further level of complexity in this age group. Management of this challenging combination in the young patient therefore entails unique ethical considerations. Here we present two illustrative cases of teenage pregnancy complicated by acute lymphoblastic malignancy, review the available literature, and offer suggestions for the therapeutic management of such cases in adolescent and young adult patients. Importantly, practical management recommendations are provided in the context of clinical ethics principles that are universally applicable, including in developing countries, where the highest incidence of adolescent pregnancies has been documented.

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Section: Discussionmentioning

confidence: 99%

“…Exercise extreme caution; use where benefit to mother clearly outweighs risk to fetus. Vincristine 1,11,16,45 No congenital anomalies or neurotoxicity documented.…”

Section: 28mentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature

Zaidi

Johnson

Church

et al. 2014

Journal of Adolescent and Young Adult Oncology

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Hematological malignancies and pregnancy: Treat or no treat during first trimester

Avilés

Neri

Nambo

2012

Intl Journal of Cancer

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Treatment of hematological malignancies (HM) during pregnancy remain unsolved, although the use of chemotherapy during second and third trimester has been accepted because of the low rate of toxicities, the use of cytotoxic drugs during first trimester is generally forbidden. Most of the concerns are related to congenital abnormalities and development, but long-term follow-up of these children are not available. From 1975 to 2008, we diagnosed and treated 15,750 cases of HM, and 143 female patients were pregnant during this time that were treated with combined chemotherapy. In our study, we present the long-term follow-up (the median follow-up was 22.4 years with a range of 3.8-32.0 years) of 54 newborns, whose mothers received chemotherapy during the first trimester of pregnancy with an intent-to-cure HM. Physical and neurological development were carefully assessed, and cardiac and chromosomal studies were performed until the age of 20 years to evaluate late toxicities. The obstetrical development of pregnancy was normal, chemotherapy was used at doses and schedules used in normal patients. Low-weight birth was the most frequent finding. No congenital abnormalities were detected. Physical, psychological and neurological developments were normal. Education and academic degree were according to the economical and social factors. Cardiac function and chromosomal examination were normal. No neoplasm or acute leukemia has been observed in these children. Forty-three mothers are alive and disease-free and can be considered cured. The use of cytotoxic drugs during the first trimester to treat HM seems to be beneficial to both the mother and fetus, and chemotherapy during the first trimester can be considered if the cure of the patient is the goal.Cancer is the leading cause of death in women of childbearing age. However, its simultaneous occurrence during pregnancy is uncommon, with a reported incidence of 0.007%-0.2%. The coincident occurrence of pregnancy and cancer present complex therapeutics problems for the patient, oncologist, hematologist, obstetricians and pediatricians, almost legal, ethical and religious problems.The most common hematological malignancies (HM) during pregnancy are acute leukemia (AL), Hodgkin's lymphoma (HL) and non-Hodgkin's lymphoma (NHL). Several studies and recent review articles have analyzed the dilemmas of the diseases associated with pregnancy.

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Acute leukemias in pregnant women: Results of a retrospective study at a local tertiary‐care hospital in Japan

Kobayashi

Biyajima

Matsuzawa

et al. 2023

eJHaem

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Leukemia may rarely develop in a woman during pregnancy, posing clinical challenges to the patient, fetus, family, and medical staff managing malignancy and pregnancy. We retrospectively analyzed cases of pregnancy‐associated leukemia consecutively diagnosed and treated at a local tertiary‐care hospital in Nagano, Japan, over the past 20 years. Five cases were identified among 377,000 pregnancies in the area (one in every 75,000 pregnancies), all involving acute leukemia (three acute myelogenous leukemia [AML] and two acute lymphoblastic leukemia [ALL]). The cases were diagnosed in the first trimester (n = 1), second trimester (n = 3), or third trimester (n = 1). There were no apparent pregnancy‐associated delays in diagnosing and treating the cases. Three patients underwent induction chemotherapy during pregnancy, two of whom eventually delivered healthy babies. One of the five patients chose abortion before chemotherapy initiation. Two cases showing high‐risk features at the diagnosis (AML with an FLT3‐ITD mutation [n = 1] and relapsed ALL [n = 1]) eventually died despite consolidative allogeneic hematopoietic stem cell transplantation. Our results suggested that patients with pregnancy‐associated acute leukemia can be treated similarly to nonpregnant patients, although pregnancy imposes particular clinical challenges that should be resolved with multidisciplinary care.

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Management of hematological malignancies during pregnancy

Cited by 89 publications

References 160 publications

Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature

Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature

Hematological malignancies and pregnancy: Treat or no treat during first trimester

Acute leukemias in pregnant women: Results of a retrospective study at a local tertiary‐care hospital in Japan

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