The document summarizes treatment options for cancer during pregnancy. Radiation exposure should be limited to less than 100 mGy to avoid risks to the fetus like growth restriction and malformations. Ultrasound is the preferred imaging method, while CT and PET scans should be avoided. Surgery can be done at any time, and chemotherapy is usually postponed until the second trimester to reduce fetal risks. Radiotherapy poses risks and its timing depends on fetal dose, gestational age, and tumor location. Carbon ion therapy may allow localized dose deposition while minimizing fetal exposure. Outcomes for pregnancy after cancer generally depend on cancer type.

1. Treatment of cancer during pregnancy

2. incidence
The diagnosis of cancer during pregnancy is uncommon
1 in every 1000 pregnant women
cancers are those most commonly diagnosed during pregnancy:
Breast, melanoma and cervical cancers

3.  diagnosis and biological features
Symptoms indicative of cancer:
- breast lump, atypical vaginal discharge, changing mole , enlarging
lymph node
pathological examination are usually comparable with age- and stage-
matched non-pregnant
After the diagnosis of cancer during pregnancy
- the patient should be referred to an institution with expertise
in dealing with such cases.

4.  Staging and risk assessment
Imaging procedures
- Ultrasound: is the preferred imaging modality for breast, abdomen
and pelvis
- Chest X-ray and mammography: with abdominal shielding can be
safely
- MRI: without gadolinium
- CT and PET scans: should be avoided throughout the course of
pregnancy

5.  Review : the effects of ionizing radiation
The potential biological effects of radiation exposure to a developing
fetus in utero
- prenatal death
- intrauterine growth restriction
- small head size
- mental retardation
- organ malformation
- childhood cancer

6.  Review:the effects of ionizing radiation
o The risk of each effect depends on:
- gestational age at the time of exposure
- fetal cellular repair mechanisms
- absorbed radiation dose level
o Fetal doses below 100 mGy should not be considered a reason
for terminating a pregnancy
o exposure to less than 5 rad [50 mGy] has not been associated
with an increase in fetal anomalies or pregnancy loss

7. Incidence of prenatal & neonatal death and
abnormalities

8. Biological effects of ionizing radiation

9.  Staging and risk assessment
Imaging procedures
- Ultrasound: is the preferred imaging modality for
breast, abdomen and pelvis
- Chest X-ray and mammography: with abdominal
shielding can be safely
- MRI: without gadolinium
- CT and PET scans: should be avoided throughout the
course of pregnancy

10.  Staging and risk assessment
evaluating serum tumor markers
CA125 and CA15.3 :they should not be considered in the
management of pregnant cancer patients

11.  treatments
local treatments
- Surgery
- Radiotherapy
systemic treatments
-Chemotherapy

12.  Surgery
Surgery can be safely carried out at any time during the course
of the pregnancy
- mastectomy or breast conservative surgery
- Radical hysterectomy:pregnancy termination and fetal death
Major abdominal and pelvic surgery might be associated with
increased morbidity
slightly higher risk of miscarriage has been reported during the
first trimester
careful monitoring particularly after the 25th week of gestation

13.  Radiotherapy
Several fetal adverse effects have been described after gestational
radiotherapy
- risk of childhood cancer
- intrauterine growth restriction
- mental retardation
- fetal death
critical factors
- fetal dosage
- radiation field extension
- gestational age

14.  Radiotherapy
increased risk of fetal malformation and mental retardation occurs
radiation doses >100–200 mGy
fetal doses in excess of 100mGy can result in some reduction of IQ
this dose is generally not reached with curative radiotherapy
- tumors are located sufficiently far from the uterus
- uterus adequate shielding
lower dosages might be causal in the development of childhood
cancer or sterility

15.  Radiotherapy
radiation is during the first or second trimesters; fetus dose should be
low and below the threshold for deterministic effects
adjuvant radiotherapy is never an urgent procedure postponement of
radiotherapy until delivery could result in delay of radiotherapy for
>6 months, which could increase the risk of local recurrence
Careful planning of the local management strategy should be made in
breast cancer patients diagnosed during the first trimester

16.  Radiotherapy
Heavy ion radiotherapy during pregnancy
o Carbon therapy
The difference of dose distribution by one port between carbon ion
beams and X-ray and proton

17.  Carbon therapy
Characteristics of carbon ions
- Higher biological effect; cause double-strand DNA break by one hit
- high-LET;Carbon ion beams deliver a larger mean energy per unit
length
- carbon ion beams allowing a highly localized deposition of energy
- fall-off around the target is steeper with carbon ion beams than proton
beams

18.  Carbon therapy
Characteristics of carbon ions:
- Treatment is feasible over a short period of time
- achieving precise dose localization in the target lesion
while causing minimal damage to surrounding normal
tissues
- Energy deposition of carbon ion beams increases with
penetration depth up to the sharp maximum

19. Characteristics of carbon ions

20. shielding and dosimetry uterus region

21.  Chemotherapy
should not be administered during the first trimester of gestation
starting in the second trimester do not experience significant long-
term complications
If pregnancy occurs during Chemotherapy , the patients should be
informed of the possible increased risk of fetal malformations
secondary to the first trimester exposure(while on tamoxifen)

22.  Other alternative methods of treatment
monoclonal antibodies
- trastuzumab & rituximab:did not show fetal malformations
secondary to brief first trimester exposure
Tyrosine kinase inhibitors
- imatinib for patients with CML:suggest a high risk of fetal
malformation and miscarriage following first trimester exposure

23.  pregnancy in cancer survivors
pregnancy rates are 40% lower among female cancer survivors
compared with the general population
This observation is highly dependent on the cancer type,
- in which women diagnosed with melanoma or thyroid cancer have
pregnancy rates highly comparable with the general population
women with breast cancer have the lowest chance of subsequent
pregnancy, which is nearly 70% lower compared to the general
population

24. Thank you for your attention