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The Cancer in Pregnancy ForumArchived Questions and Answers
This Forum has been the centre of an exceptional exchange of knowledge diagnosis, treatment, symptoms and other effects of cancer during pregnancy and lactation. All are welcome to review the Questions and Answers posted here, provided that they acknowledge and accept the important proviso and disclaimer below.
La paziente di anni 30, nel marzo 2001,al sesto mese di gravidanza, si Ŕ accorta della presenza di un neo sul gluteo destro, risultato poi all'escissione chirurgica avvenuta um mese dopo il parto,nell'agosto del 2001, essere un melanoma nodulare di mm.2 di spessore.
Melanoma a ,cellule epitelioidi,pigmentate, infilatrante il derma reticolare.
Spessore di Breslow: 2mm.
Livello di Clark: IV.
Numero di mitosi per mm:7.
Infiltrato linfocitario intratumorale: assente.
Infilatrato linfociatario peritumorale: assente.
EXERESI DEL LINFONODO SENTINELLA
Diagnosi Istopatologica:Istiocitosi dei seni nei linfonodi esaminati,focale presenza di pigmento melanico. Dall'ottobre 2001 ha iniziato una terapia con Interferone alfa 2b ricombinante, consigliato dall'Istituto Europeo di Oncologia Di Milano . Le dosi sono: 1.200.000 U.i al giorno in due sommistarazioni tutti i giorni per tre anni. In data odierna la paziente Ŕ alla settima settimana di gestazione; gestazione cominciata sotto cura terferonica.
Le problematiche che si pone la paziente sono:
1) quanto la gravidanza nel suo stato di immuno soppressione e di attiva proliferazione tessutale pu˛ indurre l'anticipo di una eventuale recidiva da melanoma;
2) l'esistenza di eventuale terapia che tratti la recidiva in corso di gravidanza;
3) danno diretto di recidive placentari sul feto;
4) possibilitÓ di recidive sul feto stesso;
5) danni sul feto dell'interferone.
CCoPE was asked to consider a series of questions regarding a 30 yr old woman being treated for melanoma with IFN-alfa during conception, and through to at least 7 weeks gestation:
1) In a pregnancy, under a state of immunosuppression, and in a time of active cellular proliferation, can one anticipate a relapse of the melanoma?
There is no known increased risk for relapse in pregnancy.
2) Is there any therapy to treat remission, that is safe for use in pregnancy?
There has been no therapy epidemiologically proven to be safe for use in pregnancy.
3) Will the relapse cross the placenta to the fetus?
There have been rare descriptions of fetal metastases.
4) Could the fetus get the cancer?
5) What effects does IFN-alfa have on the fetus?
There have been reports of IFN-a use in pregnancy. There is evidence that interferons may not cross the placenta (Pons et al. 1995; Dumas et al. 1993; Waysbort et al. 1993) supporting their use in pregnancy. The use of IFN-a in human pregnancy-to-date will be reviewed.
There have been 31 cases of pregnancy in patients treated with IFN-a for various conditions. The doses of IFN-a ranged from 1 mU to 6.4 mU administered at a frequency of two times a week to every day. Of the 31 reported cases, one case did not document the gestational period of exposure. Of the remaining 30, 18 had exposure to IFN- a in the first trimester. There were no malformations documented in any of these infants. Premature delivery occurred in 2(11%)women and low birth weight (LBW) occurred in 3 (17%) infants. There were 26 exposures in the second or third trimester, one of which resulted in the birth of a child with multiple malformations (Perez-Encinas et al. 1994). This woman was, however, receiving treatment for essential thrombocythemia in the form of hydroxyurea and ASA when conception occurred, and it was not documented when this therapy was stopped. It is currently unknown whether hydroxyurea administration in the first trimester of pregnancy is associated with an increased risk for giving birth to a baby with congenital malformations. ASA administration in the first trimester is not associated with any increased risk for malformation. Premature delivery occurred in 6 (23%) women exposed in the second or third trimesters, and LBW occurred in 7 (27%) infants. Overall, considering exposure in any trimester of pregnancy, there were 7 (23%) cases of prematurity and 8 (26%) mothers who had LBW babies. In two of the cases of IUGR, the pregnancy was complicated with preeclampsia. In these cases it is difficult to distinguish whether the growth restriction occurred due to the anti-proliferative effect of IFN- a or due to the placental pathology,which occurs with preeclampsia. Additionally, five of the mothers with LBW babies, and four of the mothers who had premature deliveries, had a diagnosis of essential thrombocythemia, both of which have been associated with the condition itself in pregnancy (Griesshammer et al. 1996). There have been 31 reported cases of IFN- a exposure during pregnancy and they all resulted in viable births. There was one case of congenital malformation out of 31 exposures (3.2%). These results, combined with the studies looking at placental transfer suggest that IFN- a administration during pregnancy may not be harmful to fetal growth. This would support the use of IFN- a during pregnancy for the treatment of indicated conditions and, in a situation of inadvertent pregnancy while being treated with IFN- a , these findings support the continuation of that pregnancy. Epidemiological studies looking at congenital anomalies among infants born to women treated with IFN- a are still needed.