EASO2011 PanArab 3 Peccatori

655 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
655
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

EASO2011 PanArab 3 Peccatori

  1. 1. Hematological malignancies in pregnancy <ul><li>Fedro Peccatori, MD PhD </li></ul><ul><li>European Institute of Oncology </li></ul><ul><li>Milan, Italy </li></ul>
  2. 2. Age specific cancer incidence US Ries LAG et al. SEER Cancer Statistics Review, 1975-2003, Available from: http://seer.cancer.gov/csr/1975_2003/
  3. 3. Pregnancy and cancer: incidence Pentheroudakis et al 2008, Annals of Oncology
  4. 4. Pregnancy and cancer: incidence Pentheroudakis et al 2008, Annals of Oncology
  5. 5. Cancer and pregnancy: incidence Berry DL et al, JCO 1999
  6. 6. Most frequent lymphoma during pregnancy Does pregnancy affects the prognosis of HL patients ? <ul><li>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 </li></ul><ul><li>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 </li></ul>Hodgkin lymphoma during pregnancy: issues
  7. 7. Hodgkin lymphoma during pregnancy: treatment What is the standard treatment outside pregnancy ? <ul><li>Early Favorable : Stage I-II without Risk- Factors * </li></ul><ul><li>Early Unfavorable: Stage I-II with Risk Factors * </li></ul><ul><li>Advanced : Stage III-IV , IIB LMM </li></ul><ul><li>* Risk Factors: B-symptoms; High ESR; Bulky tumor ; >3 lymph node areas; Extranodal disease </li></ul>
  8. 8. Hodgkin lymphoma during pregnancy: treatment What is the standard treatment outside pregnancy ? <ul><li>Early Favorable : Stage I-II without Risk- Factors * </li></ul><ul><li>Early Unfavorable: Stage I-II with Risk Factors * </li></ul><ul><li>Advanced : Stage III-IV , IIB LMM </li></ul><ul><li>* Risk Factors: B-symptoms; High ESR; Bulky tumor ; >3 lymph node areas; Extranodal disease </li></ul>Early Favorable : 2 ABVD -> 20 Gy IFRT Early Unfavourable : 2 escBEACOPP -> 2ABVD -> IFRT 30Gy Advanced : 8 escBEACOPP +/- IFRT
  9. 9. 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
  10. 10. Hodgkin lymphoma during pregnancy: treatment Treatment can be started during pregnancy and continued after delivery, or postponed after delivery according to the clinical situation
  11. 11. 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
  12. 12. Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010 Hodgkin lymphoma during pregnancy: treatment
  13. 13. 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 !!
  14. 14. <ul><li>High rate of Burkitt‘s lymphoma with poor outcome </li></ul><ul><li>High incidence of breast, uterine, cervical and ovarian involvement </li></ul> Dhedin & Coiffier, 1998 Non Hodgkin lymphoma during pregnancy: issues
  15. 15. <ul><li>Most NHL in pregnancy are disseminated at diagnosis </li></ul><ul><li>Symptoms of pregnancy may mimic symptoms of lymphoma (asthenia, vomitig, loss of weight, breast enlargement, abdominal pain) </li></ul><ul><li>Fear of radiologic investigations </li></ul>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%
  16. 16. <ul><li>In the past, poor outcome was common: only 13 survivors in a series of 42 patients, but most were undertreated (only 16 received chemotherapy) </li></ul><ul><li> Ward & Weiss, 1989 </li></ul><ul><li>in another series of 96 patients 47 died at a median of 6 months post-delivery Pohlman & Macklis, 2000 </li></ul><ul><li>Modern treatments applied early in the course of the disease may result in response rates quite similar to those of non-pregnant women </li></ul><ul><li> Traullé & Coiffier, 2006 </li></ul>NHL during pregnancy: outcome
  17. 17. NHL during pregnancy: systemic treatment Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
  18. 18. What about Rituximab ? NHL during pregnancy: systemic treatment
  19. 20. Rituximab during pregnancy Azim HA Jr, Azim A, Peccatori FA. Expert Rev Clin Immunol 2010
  20. 21. Rituximab during pregnancy Azim HA Jr, Azim A, Peccatori FA. Expert Rev Clin Immunol 2010
  21. 22. Rituximab during pregnancy Birte et al. Hematologica 2006
  22. 23. NHL during pregnancy: radiation treatment Peccatori FA, Azim HA Jr, Pruneri G et al, JCO 2009
  23. 24. 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
  24. 25. 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
  25. 26. Leukemia during pregnancy : incidence Pentheroudakis et al 2008, Annals of Oncology
  26. 27. Leukemia during pregnancy : treatment <ul><li>Acute leukemias </li></ul><ul><ul><ul><ul><ul><li>AML </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>ALL </li></ul></ul></ul></ul></ul><ul><li>Chronic leukemias </li></ul><ul><ul><ul><ul><li>CML </li></ul></ul></ul></ul><ul><ul><ul><ul><li>USUALLY A PROMPT TREATMENT IS NEEDED FOR ALL LEUKEMIAS DURING PREGNANCY ! </li></ul></ul></ul></ul>
  27. 28. 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.
  28. 29. 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.
  29. 31. Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
  30. 32. ALL during pregnancy : treatment Azim HA Jr, Pavlidis N, Peccatori FA . Cancer Treat Rev 2010
  31. 33. Chronic myeloid leukemia (CML) 15% of adult leukemias Continuous Imatinib administration revolutionized treatment and prognosis
  32. 39. Omphalocele
  33. 40. 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
  34. 41. 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
  35. 42. Cancer and Pregnancy [email_address] Thank you ! 11 th Pan Arab Cancer Congress, Casablanca, Morocco

×