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EASO2011 PanArab 3 Peccatori
 

EASO2011 PanArab 3 Peccatori

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    EASO2011 PanArab 3 Peccatori EASO2011 PanArab 3 Peccatori Presentation Transcript

    • Hematological malignancies in pregnancy
      • Fedro Peccatori, MD PhD
      • European Institute of Oncology
      • Milan, Italy
    • Age specific cancer incidence US Ries LAG et al. SEER Cancer Statistics Review, 1975-2003, Available from: http://seer.cancer.gov/csr/1975_2003/
    • Pregnancy and cancer: incidence Pentheroudakis et al 2008, Annals of Oncology
    • Pregnancy and cancer: incidence Pentheroudakis et al 2008, Annals of Oncology
    • Cancer and pregnancy: incidence Berry DL et al, JCO 1999
    • Most frequent lymphoma during pregnancy Does pregnancy affects the prognosis of HL patients ?
      • In a review of 112 pregnancies among 374 women of childbearing age with HL, pregnancy did not exacerbate HL and did not affect the outcome Barry et al 1962
      • A review of 21 pregnant women among 155 patients with HL confirmed that survival is similar despite a slightly higher incidence of advanced stage in pregnant patients Gobbi et al, 1984
      Hodgkin lymphoma during pregnancy: issues
    • Hodgkin lymphoma during pregnancy: treatment What is the standard treatment outside pregnancy ?
      • Early Favorable : Stage I-II without Risk- Factors *
      • Early Unfavorable: Stage I-II with Risk Factors *
      • Advanced : Stage III-IV , IIB LMM
      • * Risk Factors: B-symptoms; High ESR; Bulky tumor ; >3 lymph node areas; Extranodal disease
    • Hodgkin lymphoma during pregnancy: treatment What is the standard treatment outside pregnancy ?
      • Early Favorable : Stage I-II without Risk- Factors *
      • Early Unfavorable: Stage I-II with Risk Factors *
      • Advanced : Stage III-IV , IIB LMM
      • * Risk Factors: B-symptoms; High ESR; Bulky tumor ; >3 lymph node areas; Extranodal disease
      Early Favorable : 2 ABVD -> 20 Gy IFRT Early Unfavourable : 2 escBEACOPP -> 2ABVD -> IFRT 30Gy Advanced : 8 escBEACOPP +/- IFRT
    • Hodgkin lymphoma: treatment Stratification according to response, evaluated by PET “ Start soft, hit hard when needed” “ Hit hard and early, then adjust, if needed” Prof Volker Diehl
    • Hodgkin lymphoma during pregnancy: treatment Treatment can be started during pregnancy and continued after delivery, or postponed after delivery according to the clinical situation
    • Is immediate treatment necessary ? During 1 st trimester pregnancy termination might be considered because of higher risk of congenital anomalies. Starting from 2 nd trimester combination chemotherapy is feasible and safe. Patients close to term are good candidates to delivery anticipation. Hodgkin lymphoma during pregnancy: treatment
    • Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010 Hodgkin lymphoma during pregnancy: treatment
    • Non Hodgkin lymphoma during pregnancy: issues Different approaches according to pathology subtypes ! Watchful waiting is safe in most indolent lymphoma patients (low grade follicular lymphoma, marginal zone lymphoma, lymphocytic lymphoma) BUT MOST PREGNANT PATIENTS WITH NON HODGKIN LYMPHOMAS HAVE AGGRESSIVE HISTOLOGIES !!
      • High rate of Burkitt‘s lymphoma with poor outcome
      • High incidence of breast, uterine, cervical and ovarian involvement
      Dhedin & Coiffier, 1998 Non Hodgkin lymphoma during pregnancy: issues
      • Most NHL in pregnancy are disseminated at diagnosis
      • Symptoms of pregnancy may mimic symptoms of lymphoma (asthenia, vomitig, loss of weight, breast enlargement, abdominal pain)
      • Fear of radiologic investigations
      NHL during pregnancy: clinical presentation Dehdin and Coiffier, 1998 73 patients Stage IV 67% Stage III 12% Stage II 5% Stage I 16% Moore and Taslimi, 1992 37 patients Frequent diagnostic delay for >3 weeks in 40% for >3 month in 20%
      • In the past, poor outcome was common: only 13 survivors in a series of 42 patients, but most were undertreated (only 16 received chemotherapy)
      • Ward & Weiss, 1989
      • in another series of 96 patients 47 died at a median of 6 months post-delivery Pohlman & Macklis, 2000
      • Modern treatments applied early in the course of the disease may result in response rates quite similar to those of non-pregnant women
      • Traullé & Coiffier, 2006
      NHL during pregnancy: outcome
    • NHL during pregnancy: systemic treatment Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
    • What about Rituximab ? NHL during pregnancy: systemic treatment
    •  
    • Rituximab during pregnancy Azim HA Jr, Azim A, Peccatori FA. Expert Rev Clin Immunol 2010
    • Rituximab during pregnancy Azim HA Jr, Azim A, Peccatori FA. Expert Rev Clin Immunol 2010
    • Rituximab during pregnancy Birte et al. Hematologica 2006
    • NHL during pregnancy: radiation treatment Peccatori FA, Azim HA Jr, Pruneri G et al, JCO 2009
    • NHL during pregnancy: radiation treatment Peccatori FA, Azim HA Jr, Pruneri G et al, JCO 2009 CD3 CD30 NPM-ALK t(2;5)(q23;q35) H/E BM
    • NHL during pregnancy: radiation treatment Peccatori FA, Azim HA Jr, Pruneri G et al, JCO 2009 20 weeks pregnant, Stage Ia 10x10 cm field LINAC 6MeV 36 Gy in 18 fractions Max estimated fetal dose: 0.0004 Gy Mother & baby alive and well 4 years after diagnosis
    • Leukemia during pregnancy : incidence Pentheroudakis et al 2008, Annals of Oncology
    • Leukemia during pregnancy : treatment
      • Acute leukemias
              • AML
              • ALL
      • Chronic leukemias
            • CML
            • USUALLY A PROMPT TREATMENT IS NEEDED FOR ALL LEUKEMIAS DURING PREGNANCY !
    • Leukemia during pregnancy : treatment During 1 st trimester pregnancy termination might be considered because of higher risk of congenital anomalies. Starting from 2 nd trimester combination chemotherapy is feasible, with some caveats. Patients close to term are good candidates to delivery anticipation.
    • Leukemia during pregnancy : treatment During 1 st trimester pregnancy termination might be considered because of higher risk of congenital anomalies. Starting from 2 nd trimester combination chemotherapy is feasible, with some caveats. Patients close to term are good candidates to delivery anticipation.
    •  
    • Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
    • ALL during pregnancy : treatment Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
    • Chronic myeloid leukemia (CML) 15% of adult leukemias Continuous Imatinib administration revolutionized treatment and prognosis
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    • Omphalocele
    • Imatinib during 1 st trimester has a considerable risk of congenital anomalies and spontaneous abortion; but several uneventful pregnancies reported Interferon-alpha can be safely administered throughout the course of pregnancy Shift from Imatinib to IFN (or nothing) before conceiving? CML during pregnancy
    • Haematological malignancies in pregnancy are rare and difficult to treat Treatment individualized according to: patient willing gestational age disease histology and stage Chemotherapy always administered after the first trimester, when needed Doxorubicin or Epirubicin safer than Daunorubicin or Idarubicin Conclusions
    • Cancer and Pregnancy [email_address] Thank you ! 11 th Pan Arab Cancer Congress, Casablanca, Morocco