Kamath S*, Daigawane M**, Bharti S***,Samant PY****
(* Third year resident, ** Assistant Professor, *** First Year Resident, **** Additional Professor. Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)
We present a case of a primigravid woman who presented to us at 26 weeks gestation with osteosarcoma of the upper end of the right femur. She underwent right hip disarticulation surgery followed by chemotherapy during pregnancy. She continued to receive antenatal care and delivered vaginally at term gestation without difficulty.
Cancer reportedly occurs in around 1 in every 1000 pregnant women.[1,2,3] As women tend to conceive at older ages today, it is likely that the incidence of cancer during pregnancy will also rise. It has been found that the most common malignancy in pregnancy is that of the breast. The incidence of musculoskeletal tumors during pregnancy is very less and only a few studies are available so far.
A 22 year old primigravida with 26 weeks gestation, was referred for newly diagnosed osteosarcoma of the right femur. Osteosarcoma was diagnosed during investigation for a rapidly growing swelling of the right hip. The diagnosis was confirmed on bone biopsy and chemotherapy was initiated. She then came for antenatal registration. Anomaly scan done at 26 weeks revealed no fetal anomalies. She and her relatives were explained about the risks of chemotherapy in pregnancy, and effect on the fetus. As she was unresponsive to her first cycle of neoadjuvant chemotherapy, right hip disarticulation was performed followed by three cycles of adjuvant chemotherapy with Carboplatin and Adriamycin. She was treated in an oncology center and referred for antenatal registration to our center. Her serological and biochemical investigations including blood sugars, thyroid function test and hemogram were found to be normal. There were no features of agranulocytosis. However, she developed alopecia. On ultrasonography (USG) at 27 weeks gestation, there was severe intrauterine growth restriction, probably attributable to chemotherapy. She was given antenatal corticosteroids for fetal lung maturation. Obstetric doppler ultrasonography was found to be normal. At term, the estimated baby weight was around 1.5 kg. She and her relatives did not want any intervention for fetal indication. She was reviewed by the anesthesiologists for anesthesia risk. At 41 weeks, non stress test was reactive, preinduction cervical ripening with dinoprostone gel was done in view of prolonged pregnancy. Labor was uneventful and bearing down was helped by providing bedside stirrups for support. The patient delivered normally a child of 1.5 kg with an Apgar score of 9/10. The baby was observed in neonatal ICU for weight gain and developmental problems if any. The mother and the baby were discharged after adequate weight gain. Mother was advised to breastfeed until chemotherapy was started. Postpartum chemotherapy is being planned for the patient. Contraceptive counseling was done and the couple was advised male barrier method of contraception. Advise regarding prosthesis was to be provided by the treating oncologist.
Osteosarcoma during pregnancy is a rare occurrence and is likely to be undiagnosed as there are numerous musculoskeletal symptoms in pregnancy that may confound the diagnosis. There could also be a delay in diagnosis during pregnancy due to clinical misdiagnosis, patients’ apprehension and refusal for medical intervention. Treating doctors may try to avoid radiographs due to concern of radiation hazard to the fetus.
Since the year 1977, a total of 24 cases of different types of osteosarcomas’ during pregnancy have been reported; these include osteoblastic, chondroblastic, fibroblastic, parosteal or high grade osteosarcomas. The most common primary site of malignancy was found to be in the femur, followed by humerus and other sites. The most common presenting symptoms were pain, mass and pathological fracture. Most of these patients were surgically treated either during pregnancy or in the postpartum period. Some also received adjuvant chemotherapy in the postpartum period. Survival outcomes were found to be similar to their non pregnant counterparts.[5,6,7]
X- ray and computerized tomography (CT) scan pose ionizing radiation hazards and hence are contraindicated in pregnancy. Although abdominal shields are used in these procedures, considerable exposure still occurs due to scattered radiation within the patient. Magnetic resonance imaging (MRI) is a relatively safe diagnostic modality frequently used in pregnant women at any gestation depending on the need. Only a few studies are available on the surgical management of musculoskeletal tumors during pregnancy. Limb salvage surgeries can be performed according to Enneking’s grading. Pregnancy is a hypercoagulable state and various hemodynamic changes including increase in cardiac workload occur. A careful preoperative anesthetic assessment is necessary. After 20 weeks of gestation, aortocaval compression by the gravid uterus is to be avoided. After 24 weeks of gestation, the fetal viability must be documented pre and post procedure and intraoperative fetal monitoring is recommended. Tocolysis needs to be given if the patient goes into preterm labor postoperatively. Prophylactic tocolysis can be considered in patients undergoing lower abdominal or pelvic surgeries for inflammatory conditions in the third trimester of pregnancy. However, its efficacy during non obstetric surgeries is not proven and its use is controversial due to maternal side effects.
Chemotherapy in second and third trimesters is offered based on maternal need.[13,14] Pelvic malignancies must not be treated with radiotherapy during pregnancy because of the proximity to the fetus.
Breastfeeding is contraindicated in women on anti neoplastic medications, especially anthracyclines like adriamycin and alkylating agents like carboplatin. These drugs are secreted in the breast milk altering its chemical constitution and microbial flora and have adverse effects on the infant like nephrotoxicity, neurotoxicity, bone marrow suppression and hypersensitivity reactions.
As these tumors are rare in occurrence, no specifications or guidelines have been issued so far. Hence it becomes very important to do more research and contribute data in this particular field of literature.
- Cardonick E, Usmani A, Ghaffar S. Perinatal outcomes of a pregnancy complicated by cancer, including neonatal follow-up after in utero exposure to chemotherapy: results of an international registry. Am J Clin Oncol. 2010;33(3):221–8
- Donegan WL. Cancer and pregnancy. CA: A Cancer Journal for Clinicians. 1983;33(4):194–214.
- Brewer M, Kueck A, Runowicz CD. Chemotherapy in pregnancy. Clin Obstet Gynecol. 2011;54(4):602–18.
- Cardonick E, Bhat A, Gilmandyar D, Somer R. Maternal and fetal outcomes of taxane chemotherapy in breast and ovarian cancer during pregnancy: case series and review of the literature. Ann Oncol. 2012;23(12):3016–23.
- Merimsky O, Le Cesne A. Soft tissue and bone sarcomas in association with pregnancy. Acta Oncol 1998; 37(7-8):721-727.
- Maxwell C, Barzilay B, Shah V, Wunder JS, Bell R, Farine D. Maternal and Neonatal outcomes in pregnancies complicated by bone and soft-tissue tumors. Obstetrics and Gynecology 2004;104(2):344-348.
- Pratt CB, Rivera G, Shanks E. Osteosarcoma during pregnancy. Obstet Gynecol.1977;50(1 Suppl):24s–26s.
- Costa J, Wesley RA, Glatstein E, Rosenberg SA. The grading of soft tissue sarcomas. Results of a clinicohistopathologic correlation in a series of 163 cases. Cancer. 1984;53(3):530-41.
- Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res. 1986;204:9-24.
- Liu LX, Arany Z. Maternal Cardiac Metabolism in Pregnancy. Cardiovasc Res. 2014;101(4):545-53.
- Cardonick E. Pregnancy-associated breast cancer: optimal treatment options. Int J Womens Health. 2014;6:935–43.
- Nejdlova M, Johnson T. Anaesthesia for non- obstetric procedures during pregnancy. Continuing Education in Anaesthesia Critical Care a& Pain, 2012;12(4):203-206.
- Triunfo S, Scambia G. Cancer in pregnancy: diagnosis, treatment and neonatal outcome. Minerva Ginecol. 2014;66(3):325–34.
- Azim HA Jr, Peccatori FA, Pavlidis N. Treatment of the pregnant mother with cancer: a systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part I: Solid tumors. Cancer Treat Rev. 2010;36(2):101–9.
- Nakagawa K, Aoki Y, Kusama T, Ban N, Nakagawa S, Sasaki Y. Radiotherapy during pregnancy: effects on fetuses and neonates. Clin Ther. 1997;19(4):770–7.
- Pistilli B, Bellettini G, Giovannetti E, Codacci-Pisanelli G, Azim HA Jr, Benedetti G, et al. Chemotherapy, targeted agents, antiemetics and growth-factors in human milk: How should we counsel cancer patients about breastfeeding? Cancer Treat Rev. 2013;39(3):207-11.
- Griffin SJ, Milla M, Baker TE, Liu T, Wang H, Hale TW. Transfer of carboplatin and paclitaxel into breast milk. J. Hum Lact.2012;28(4):457-9.
Kamath S, Daigawane M, Bharti S, Samant PY. Osteosarcoma In Pregnancy. JPGO 2018. Volume 5 No.2. Available from: http://www.jpgo.org/2018/02/osteosarcoma-in-pregnancy.html