Cancer with pregnancy, of course, is a challenging topic because it involves two lives, the lives of a mother and a growing fetus, and the aim would always be the well-being, maternal well-being, but the concern of safeguarding the fetus is also there. So when two lives are there, the treatment should be compatible to both as far as possible. And cancer with pregnancy, the incidence will gradually rise as the marital age, and there is a delay in opting for pregnancy as well. So later on in reproductive life, there are chances of developing malignancy with pregnancy as well. And this issue, this is a challenging issue because there is issues of medical issues, ethical issues, psychological, familial, and religious concerns. And this issue poses a lot of dilemma, dilemma in pregnant women and her family side, and treating team as well. So the aim in situation dealing with cancer in pregnancy would be to offer cure to the pregnant woman, not to compromise her treatment, but at the same time, protect the fetus and the newborn from possible harms as far as possible. And it is also very important to retain the woman's reproductive system for future fertility as well. So these would be the aim while dealing with cancer in pregnancy. And it is often a big challenge. And this challenge requires a multidisciplinary team approach, as in our case, like the patient and her family have to be actively involved in decision making. And for diagnosis, of course, oncologists and radiologists, pathologists have important role. And for the delivery and safety of the baby, of course, obstetricians, neonatologists would be able to contribute a lot. And as this entity requires a lot of information, a lot of counseling, a lot of preparation, so psychologists, psychiatrists, and nurses, and sometimes even religious leaders could be of great help as a team. Cancer with pregnancy often poses a lot of difficulties because during pregnancy, there are other symptoms and anatomical and physiological changes as well. And there is always a limitation of radiology, I mean, workup of the cases, like in the case that was presented this morning, like radiological workup may be limited to non-ionizing with methods like ultrasound and MRI, though x-ray could be safe with SILT. And tumor markers may not be very reassuring because tumor markers like CA-125, alpha-beta-protein, and beta-ACV are elevated during pregnancy. And treatment often is based on type of cancer, the aggressiveness of the cancer, stage, and gestational age. Well, it could be a little bit difficult to stage the patient. Regarding the epidemiology, it is estimated that there is one per thousand pregnancy occurrence of cancer with pregnancy, which corresponds to less than 1% of all malignant tumors. And cancer during pregnancy are those ones that are more commonly seen in younger ladies, like breast cancer, melanoma, Hodgkin's disease. And talking about the management, treatment of cancer, chemotherapy is one of the main modality. But when it comes to the use of chemotherapy in managing cancer with pregnancy, it is noteworthy that most of the chemotherapeutic agents cross placental barrier, so they could adversely affect the growing fetus. And it is more hazardous when chemotherapy is used in first trimester, because we know that period of organogenesis is mostly between two to nine weeks. So during this time, there is chances that fetus exposed to chemotherapy could develop, could have neural defect or cardiovascular system defect, limb defect, and several congenital anomalies. And as said earlier, like all our known phenomena does occur in first trimester when women are exposed to chemo and when they are getting early pregnancy. But in second trimester onwards, chemotherapy seems to be fairly safe. But concerns of some defects occurring in ears, eyes, teeth, and growth and mental development are some of the issues. So chemotherapy better avoided in first trimester, especially the combination ones. But in second and third trimester, until 34 weeks, it could be relatively safe. And there are several case reports and case series on this. However, breastfeeding is contraindicated. 34 weeks, again, taken as a cutoff point, because plan of delivery happens after 34 weeks, and we would not like to have the mother in neutropenic state when delivery is being planned, which could again, which could carry the potential of postpartum hemorrhage and sepsis. Now, we did have a study, retrospective study done in B.P. Koirala Memorial Cancer Hospital. And this was 11-year-old, I mean, long study, where we had around 19 patients. And it was done between 2011 to 2012. And one question asked to the pregnant women regarding their choice of treatment, whether they wanted termination of pregnancy before they could be given definitive treatment for cancer, or whether they wanted to defer treatment until delivery in the interest of fetus, or accept treatment, again, in the interest of our own interest and fetal interest as well. And the response was mixed. 36% wanted immediate treatment. And most of these cases were, of course, in first trimester. But other cases, like 26%, wanted to defer treatment until delivery. And they were, obviously, in, most of them were in third trimester. And 36% accepted treatment, like chemotherapy, or even surgery with fetus in utero. And most of these cases were in second and third trimester. So our experience regarding chemotherapy in pregnancy, we did have some cases of CML who underwent oral chemotherapy, imatinib, and had a successful pregnancy outcome. But we did have a sad case of acute myeloid leukemia, where induction chemotherapy was done at around 32 weeks. But unfortunately, she went into neutropenia, and returned labor and delivery. And unfortunately, we lost both mother and baby due to a mother due to postpartum hemorrhage and baby could not be rescued as well. And we did have a case of an NHL who underwent CHOP regime, and she had healthy delivery. And we did have a case of ovarian tumor, which was Yorkshire ovarian tumor, who underwent BEP regime and had, with fetus in utero, and had successful delivery and outcome. And these are some of the images taken with the consent of the patient and her family. Cancer surgery during pregnancy, well, often, this happens to be one of the main modality of treatment, especially when it comes to ovarian tumor. And this entity, like surgery during pregnancy, seems to be less controversial, because it has been regarded to be fairly safe during second and third trimester. But in first trimester, there is always risk of abortion. And in third trimester, if not managed properly, there is chances of preterm labor. But there has to be certain modifications in anesthetic agent and preparations, and surgical management. Because, again, to retain future fertility, conservative surgery is usually offered. So less aggressive, less radical surgery is probably preferred during pregnancy. Astrectomy is rarely required or indicated, unless we're dealing with a disseminated disease where we would prefer for optimal cycle reduction. I'd like to share with you a case of cervical cancer, which was referred with the diagnosis of antepartum hemorrhage at around 32 weeks of pregnancy. And ruling out, the ultrasound ruled out placental cause for the antepartum hemorrhage. On local examination, cervical mass was detected, so biopsy proved adenocarcinoma. She was referred to B.P. Corella Memorial Cancer Hospital where I was serving. And then as the baby was only around 32 weeks, we wanted to wait for another few weeks for long maturity and for a better neonatal outcome. So after discussion with the patient, her family, and multidisciplinary team, we gave dexona for long maturity, waited for two weeks. But unfortunately, again, she had second bout of heavy bleeding. Then we decided to go ahead with C-section at 36 weeks, delivering a healthy male baby. But the hemorrhage did not cease. So we went on to having caesarean astrectomy with sampling of enlarged lymph node. And it turned out to be adenocarcinoma advanced stage. And after the wound healed, she was subjected to definitive concurrent chemoRT. And the last image is of one year. But unfortunately, after almost three years, this lady had recurrence, and we lost her. But the baby is still doing well. And another case of ovarian tumor, which happened in primary gravida at around 14 weeks, she had acute pain abdomen. And she did have a twisted ovarian tumor requiring emergency laparotomy. So conservative surgery in the form of sulfingofrectomy and omental biopsy was done, as seen here. And the histopath came out to be yolk sac ovarian tumor. So in discussion with, again, the patient, patient party, medical oncology, and pediatrician, we decided on giving BEP regime with fetus in utero. And cesarean delivery was performed after 37 weeks. So we have been following the baby, and the baby seems to have normal milestone. And now he is almost seven years going to school. We did have some referral for termination of pregnancy. And I remember one of the cases was thyroid cancer diagnosed at around 16 weeks. And head and neck oncologist, oncosurgeon wanted termination prior to definitive surgery. But the family wanted to continue the pregnancy. So thyroid surgery was carried on during second trimester. And the pregnancy continued undisturbed, and there was successful delivery. And we did have another case of squamous cell carcinoma of scalp, again, diagnosed at nine weeks. Again, this family wanted to continue pregnancy. So wide localization of the scalp cancerous lesion was done. And pregnancy continued with a successful outcome. So cancer surgery during pregnancy seems to be fairly safe if done properly. Another modality of treatment is radiation therapy, which poses a lot of harm to the fetus. So it's often lethal. So not recommended during pregnancy. But when it comes to oncological emergencies requiring radiation therapy, like spinal cord compression, CNS meds, or SVC syndrome, then there have been some case reports of continuing and offering radiation therapy in emergency basis with abdominal cell, as shown in this picture. But this, I think, is not a universal practice, and it's not a usual treatment. In our series, we did have a cervical cancer case, which was in Gravida 3 para 2 plus 0, who presented at around 14 weeks of pregnancy. Since she had already two living issues, healthy babies, she did not want to continue this pregnancy. And she carried advanced stage cervical cancers, squamous cell carcinoma, stage 3b. So again, with this counseling, and discussing with family, and multidisciplinary team discussion, we went ahead with definitive radiation therapy, external beam radiation therapy, with fetus in utero. And she had missed abortion after 20 days of radiation therapy, after around 10 days of treatment. And after a few days, she had spontaneous expulsion, as shown here. So this was the first picture that we saw that radiation could be very harmful, could be harmful to the fetus. And this was the fibrose placenta, due to radiation. And in our series, we had 10 cases that attended remission with treatment during pregnancy, and two were living with disease. But unfortunately, we lost seven mothers. And in fetal outcome, there were nine healthy babies delivered, and 10 abortions and IUDs. And we did have some cases that presented quite late after delivery. And we assumed that they carried cancer, and during pregnancy, they had this cancer. And this was a sad case of 22-year-old lady, who had a nasty vulval lesions, squamous cell carcinoma. But she waited until the baby was delivered, and was big enough. So she came to us for treatment in postpartum period, six months later. And we offered her radical white local excision, and adjuvant radiation therapy. And this was another interesting case, which presented to us six months after delivery, vaginal delivery at home. And she did have bouts of bleeding. And on examination, she had cervical cancer, cervical lesion, which proved to be squamous cell carcinoma. And it was back in 2010. So we were still following the old Figo classification. So we offered her radical hysterectomy in her postpartum period. And we do have successful cases of ovarian cancer, distal melanoma, treated successfully with chemotherapy and conservative surgery. And after two years of being on remission, we allowed her, like they wanted to try for conception. She did conceive. And this was successful C-section delivery. And three years later, we noted that there was no sign of any residual tumor. And this was done in civil service hospital. And we have a few cases of choriocarcinoma, treated cases of choriocarcinoma. We have become pregnant later on, and have given successful delivery. And this young lady did have vaginal meds. And the excision of the vaginal meds proved to be choriocarcinoma. She was subjected to emacotherapy. And this young lady also had choriocarcinoma, and was treated with emaco. And after two years of being in remission, she was allowed for conception. She did have spontaneous conception. But during caesarean delivery, there was postpartum hemorrhage, so she had caesarean hysterectomy. And this young lady had low-risk GTN, persistent GTN. And she was subjected to single-agent methotrexate. And after, again, two years of remission, she did conceive and delivered healthy babies. So these cases were very noteworthy and very encouraging to us. So based on these cases, we can say that the cancers during pregnancies are rare, but they do occur. And fertility and successful childbirth is possible. And management of pregnancy with cancer requires multidisciplinary team approach, like involving gynecologists, gynecologists, and clinical and medical oncologists, pathologists, pediatricians, psychologists, and nurses. And regarding the prognosis, it has been noted that cancer does not cause adverse effect to pregnancy. And pregnancy does not accelerate the disease pathology as well. Somehow nature has been very kind. And pregnant patients should be offered optimal management. And of course, during management of these pregnant patients, the mother's health is important. And it is equally important to consider the fetal well-being or neonatal outcome as well. And I would like to acknowledge my team, us team from B.P. Coerella Memorial Hospital and my present team in Civil Service Hospital. And we do have such interesting cases, and probably we will be able to come up with more good series. So with prayers for happiness in all families, I would like to end my presentation. Thank you all.

cancer during pregnancy

well-being of mother and fetus

treatment options

multidisciplinary team approach

surgery as preferred option

optimal management for mother and baby