Gebelikte Jinekolojik Olmayan Kanserlerlere Genel Yaklaşım
Özet
Gebelikte jinekolojik olmayan kanserlerin insidansı yaklaşık 1/1000 olup en sık meme, tiroid ve serviks kanserleri görülmektedir. Gebelikteki fizyolojik değişiklikler tanı gecikmelerine yol açabileceğinden semptomların dikkatli incelenmesi ve tedavinin multidisipliner bir ekiple bireyselleştirilmesi gerekir. Tanıda ultrasonografi ve MR güvenle kullanılırken, gadolinyum ilk trimesterde önerilmez ve yüksek radyasyonlu BT tercih edilmez. Kemoterapi, fetal organogenez nedeniyle ilk trimesterde yüksek risk taşır; ancak ikinci trimesterden itibaren antrasiklin bazlı rejimler gibi belirli ajanlar uygun dozlarda güvenle uygulanabilir. Terapötik radyoterapi ciddi fetal riskler (mikrosefali, zihinsel gerilik) doğurduğundan gebelikte kontrendikedir ve doğum sonrasına ertelenmelidir. Meme kanseri yönetiminde cerrahi minimal riskle uygulanabilirken, trastuzumab fetal böbrek yetmezliği riski nedeniyle kontrendikedir. Tiroid kanserleri genellikle yavaş ilerler ve cerrahi doğum sonrasına ertelenebilir; ancak agresif tiplerde ikinci trimesterde müdahale edilir ve radyoaktif iyot gebelikte tamamen kontrendikedir. Hodgkin lenfomada stabil hastaların tedavisi ertelenebilirken, agresif olgularda ilk trimesterde tedaviye başlanır. Akut lösemi ise hem anne hem de fetus için yüksek mortalite riski taşıdığından hızla tedavi edilmelidir; ilk trimesterde teratojenik ilaç kısıtlamaları nedeniyle gebeliğin sonlandırılması bir seçenek olabilir. Genel olarak gebeliğin sonlandırılması kanser prognozunu iyileştirmez ve doğum zamanlaması neonatal riskler azaltılarak planlanmalıdır.
The incidence of non-gynecological cancers during pregnancy is approximately 1/1000, with breast, thyroid, and cervical cancers being the most common. Since physiological changes during pregnancy can cause diagnostic delays, careful evaluation of symptoms and a multidisciplinary, individualized treatment approach are essential. Ultrasonography and MRI are safely used for diagnosis, whereas gadolinium is avoided in the first trimester, and CT is generally restricted due to high radiation. Chemotherapy carries significant fetal risks during the first trimester due to organogenesis; however, specific agents like anthracycline-based regimens can be safely administered from the second trimester onward. Therapeutic radiotherapy is contraindicated during pregnancy due to severe fetal risks, such as microcephaly and mental retardation, and must be postponed postpartum. For breast cancer, surgery carries minimal fetal risk, while trastuzumab is contraindicated due to fetal renal failure risks. Thyroid cancers are usually slow-growing, allowing surgery to be delayed postpartum; yet, aggressive types require second-trimester intervention, and radioactive iodine is strictly contraindicated. In Hodgkin lymphoma, treatment for stable patients can be delayed, but aggressive cases require immediate first-trimester therapy. Conversely, acute leukemia demands urgent intervention due to high maternal and fetal mortality, and pregnancy termination may be considered in the first trimester due to the teratogenicity of crucial drugs. Overall, termination does not improve cancer prognosis, and delivery timing should be carefully planned to minimize neonatal morbidity.
Referanslar
Parazzini F, Franchi M, Tavani A, et al. Frequency of Pregnancy Related Cancer: A Population Based Linkage Study in Lombardy, Italy. Int J Gynecol Cancer. 2017;27:613-619.
Donegan WL. Cancer and pregnancy. CA Cancer J Clin. 1983;33:194-214.
Eibye S, Kjær SK, Mellemkjær L. Incidence of pregnancy-associated cancer in Denmark, 1977-2006. Obstet Gynecol. 2013;122:608-617.
American College of Obstetricians and Gynecologists' Committee on Obstetric Practice. Committee Opinion No. 656: Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Obstet Gynecol. 2016;127:e75-e80.
American College of Radiology: ACR manual on contrast media. Version 10.2.Reston, American College of Radiology, 2016.
Krishna I, Lindsay M. Breast cancer in pregnancy. Obstet Gynecol Clin North Am. 2013;40:559-571.
Woo JC, Yu T, Hurd TC. Breast cancer in pregnancy: a literature review. Arch Surg. 2003;138:91-99.
Navrozoglou I, Vrekoussis T, Kontostolis E, et al. Breast cancer during pregnancy: a mini-review. Eur J Surg Oncol. 2008;34:837-843.
Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol. 2004;5:283-291.
Abdel-Hady el-S, Hemida RA, Gamal A, et al. Cancer during pregnancy: perinatal outcome after in utero exposure to chemotherapy. Arch Gynecol Obstet. 2012;286:283-286.
Amant F, Vandenbroucke T, Verheecke M, et al. Pediatric Outcome after Maternal Cancer Diagnosed during Pregnancy. N Engl J Med. 2015;373:1824-1834.
Ring AE, Smith IE, Jones A, et al. Chemotherapy for breast cancer during pregnancy: an 18-year experience from five London teaching hospitals. J Clin Oncol. 2005;23:4192-4197.
Avilés A, Neri N. Hematological malignancies and pregnancy: a final report of 84 children who received chemotherapy in utero. Clin Lymphoma. 2001;2:173-177.
Hahn KM, Johnson PH, Gordon N, et al. Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer. 2006;107:1219-1226.
Avilés A, Neri N, Nambo MJ. Long-term evaluation of cardiac function in children who received anthracyclines during pregnancy. Ann Oncol. 2006;17:286-288.
Loibl S, Han SN, von Minckwitz G, et al. Treatment of breast cancer during pregnancy: an observational study. Lancet Oncol. 2012;13:887-896.
Amant F, Han SN, Gziri MM, et al. Management of cancer in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2015;29:741-753.
Nakagawa K, Aoki Y, Kusama T, et al. Radiotherapy during pregnancy: effects on fetuses and neonates. Clin Ther. 1997;19:770-777.
Stovall M, Blackwell CR, Cundiff J, et al. Fetal dose from radiotherapy with photon beams: report of AAPM Radiation Therapy Committee Task Group No. 36 [published correction appears in Med Phys 1995;22:1353-4.
Yonekura Y, Tsujii H, Hopewell JW, et al. ICRP Publication 127: Radiological Protection in Ion Beam Radiotherapy [published correction appears in Ann ICRP. 2014;43:5-113.
Mazzola R, Corradini S, Eidemüeller M, et al. Modern radiotherapy in cancer treatment during pregnancy. Crit Rev Oncol Hematol. 2019;136:13-19.
Antonelli NM, Dotters DJ, Katz VL, et al. Cancer in pregnancy: a review of the literature. Part I. Obstet Gynecol Surv. 1996;51:125-134.
Middleton LP, Amin M, Gwyn K, Theriault R, Sahin A. Breast carcinoma in pregnant women: assessment of clinicopathologic and immunohistochemical features. Cancer. 2003;98:1055-1060.
Elledge RM, Ciocca DR, Langone G, McGuire WL. Estrogen receptor, progesterone receptor, and HER-2/neu protein in breast cancers from pregnant patients. Cancer. 1993;71:2499-2506.
Reed W, Hannisdal E, Skovlund E, Thoresen S, Lilleng P, Nesland JM. Pregnancy and breast cancer: a population-based study. Virchows Arch. 2003;443:44-50.
Baker J, Ali A, Groch MW, et al. Bone scanning in pregnant patients with breast carcinoma. Clin Nucl Med. 1987;12:519-524.
Cardonick E, Dougherty R, Grana G, et al. Breast cancer during pregnancy: maternal and fetal outcomes. Cancer J. 2010;16:76-82.
Kupstas AR, Hoskin TL, Day CN, et al. Effect of Surgery Type on Time to Adjuvant Chemotherapy and Impact of Delay on Breast Cancer Survival: A National Cancer Database Analysis. Ann Surg Oncol. 2019;26:3240-3249.
Brewer M, Kueck A, Runowicz CD. Chemotherapy in pregnancy. Clin Obstet Gynecol. 2011;54:602-618.
Nugent P, O'Connell TX. Breast cancer and pregnancy. Arch Surg. 1985;120:1221-1224.
Cardonick E. Maternal-fetal evidence based guidelines. In Cancer. (Berghella, V. ed.) CRC Press, 2011.
Morris PC. Thyroid cancer complicating pregnancy. Obstet Gynecol Clin North Am. 1998;25:401-405.
Moosa M, Mazzaferri EL. Outcome of differentiated thyroid cancer diagnosed in pregnant women. J Clin Endocrinol Metab. 1997;82:2862-2866.
Yasmeen S, Cress R, Romano PS, et al. Thyroid cancer in pregnancy. Int J Gynaecol Obstet. 2005;91:15-20.
Nam KH, Yoon JH, Chang HS, et al. Optimal timing of surgery in well-differentiated thyroid carcinoma detected during pregnancy. J Surg Oncol. 2005;91:199-203.
Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum [published correction appears in Thyroid. Thyroid. 2017;27:315-389.
Vini L, Hyer S, Pratt B, Harmer C. Management of differentiated thyroid cancer diagnosed during pregnancy. Eur J Endocrinol. 1999;140:404-406.
Duggan B, Muderspach LI, Roman LD, et al. Cervical cancer in pregnancy: reporting on planned delay in therapy. Obstet Gynecol. 1993;82:598-602.
Zanotti-Fregonara P, Jan S, Taieb D, et al. Absorbed 18F-FDG dose to the fetus during early pregnancy. J Nucl Med. 2010;51:803-805.
El-Hemaidi I, Robinson SE. Management of haematological malignancy in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2012;26:149-160.
Eyre TA, Lau IJ, Mackillop L, Collins GP. Management and controversies of classical Hodgkin lymphoma in pregnancy. Br J Haematol. 2015;169:613-630.
Cohen JB, Blum KA. Evaluation and management of lymphoma and leukemia in pregnancy. Clin Obstet Gynecol. 2011;54:556-566.
Avilés A, Neri N. Hematological malignancies and pregnancy: a final report of 84 children who received chemotherapy in utero. Clin Lymphoma. 2001;2:173-177.
Maggen C, Dierickx D, Lugtenburg P, et al. Obstetric and maternal outcomes in patients diagnosed with Hodgkin lymphoma during pregnancy: a multicentre, retrospective, cohort study. Lancet Haematol. 2019;6:e551-e561.
Nisce LZ, Tome MA, He S, Lee BJ 3rd, Kutcher GJ. Management of coexisting Hodgkin's disease and pregnancy. Am J Clin Oncol. 1986;9:146-151.
Lishner M, Zemlickis D, Degendorfer P, Panzarella T, Sutcliffe SB, Koren G. Maternal and foetal outcome following Hodgkin's disease in pregnancy. Br J Cancer. 1992;65:114-117.
Smith LH, Danielsen B, Allen ME, et al. Cancer associated with obstetric delivery: results of linkage with the California cancer registry. Am J Obstet Gynecol. 2003;189:1128-1135.
Catanzarite VA, Ferguson JE 2nd. Acute leukemia and pregnancy: a review of management and outcome, 1972-1982. Obstet Gynecol Surv. 1984;39:663-678.
Sanz MA, Grimwade D, Tallman MS, et al. Management of acute promyelocytic leukemia: recommendations from an expert panel on behalf of the European LeukemiaNet. Blood. 2009;113:1875-1891.
