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MALIGNANT BREAST TUMORS AND PREGNANCY
Among malignant neoplasms in women, breast cancer is one of the first places. In recent years, the incidence of a combination of pregnancy and cancer has increased.
There are two aspects of this problem: cancer among pregnant women and pregnancy with cancer. Breast cancer in pregnant women occurs in 0.03-0.3% of cases, pregnancy with breast cancer - in 0.78-3.8%, and in some reports this figure reaches 14%.
According to experimental data, changes in the organism of rats associated with pregnancy, in general, inhibit the formation of breast tumors, increase the differentiation of tumors and reduce the degree of malignancy.
In breast tumors diagnosed during pregnancy, deviations in hormonal homeostasis are characterized by hyperestrogenization, irregular menstrual rhythm with the appearance of an unusual peak in the physiological norm of LH excretion in the follicular phase and low FSH level in patients after abortion, hyperestrogenization in combination with hyperprolactinemia in patients mammary gland, diagnosed with lactation, hypercorticism in some patients.
Among the clinical forms of breast cancer, inflammatory ones predominate (in 15% of cases), rapidly metastasizing undifferentiated forms, and less often differentiated ones. A characteristic feature of the combination of pregnancy and breast cancer is the detection of the latter in patients with many pregnancies and childbirth of the late reproductive period (35–44 years), who have a significant (5 years or more) break between pregnancies.
Another characteristic feature is the predominance of lobular forms among the morphological structures of the mammary gland and the severity of intracanalicular and myoepithelial proliferation in the tissues surrounding the tumor. There is a high frequency of previous hyperplastic and proliferative processes in the tissues of the gland, a high level of E3 and progesterone.
Upon detection of a malignant breast tumor, confirmed morphologically, abortion is indicated. After this, treatment is carried out according to the stage of the tumor.
¦ Extragenital malignant tumors and pregnancy
Skin melanoma and pregnancy. It is well known that skin melanoma in the structure of cancer is from 1 to 3%. Her combination with pregnancy is even less common. There is evidence of the effect of hormonal status altered by pregnancy on the pigment system, which in some cases manifests itself in the activation of pigment nevus. It has been established that in the cytoplasm of melanoma cells there are special receptors for estrogens, and also rapid growth of the tumor and metastases with estrogen are reported. This indicates an unfavorable, tumor-stimulating effect of pregnancy on melanoma. Clinical observations show that a combination of pregnancy and melanoma in most cases worsens the prognosis.
The prognosis for skin melanoma largely depends on the location of the primary focus. Adverse is the localization of the primary focus on the trunk, in the head and neck. The localization of melanoma in the region of the upper and lower extremities is prognostically more favorable. Survival of patients depends mainly on the stage of melanoma.
At the clinical stage I of melanoma, the 3-year survival rate of pregnant women is 65.2 ± 5.8%, non-pregnant - 70.9 ± 2.2%; 5-year-old - 44.4 ± 6.7% and 53.6 + 2.6%; 10-year-old - 26 + 7.4% and 43 ± 2.8%, respectively. Therefore, with a combination of clinical stage I melanoma and pregnancy, long-term treatment outcomes worsen.
In the II and III clinical stages of the disease, the pregnancy factor does not significantly affect the prognosis of life.
A comparison of the survival of patients with stage I, in whom the clinical manifestations of melanoma occurred in the first half of pregnancy, with those in whom they occurred in the second half and lactation, showed that the course of the disease is significantly complicated if melanoma occurred in the second half of pregnancy. Perhaps a high level of estrogen and STH, which is observed precisely in this period of pregnancy, matters.
The above main patterns of combination of skin melanoma and pregnancy allow you to develop the following therapeutic tactics. In the first half of pregnancy in patients with stage I of the disease, with a favorable individual prognosis of life, abortion can not be performed. Under anesthesia (preferably neuroleptanalgesia), skin melanoma is widely excised according to the accepted technique. The obtained morphological data and their analysis allow us to give more informed judgments about the prognosis of the disease. The patient and relatives should be configured to maintain pregnancy.
With an unfavorable prognosis of life, established by a combination of clinical and morphological characters, the decision to maintain pregnancy is made individually. You should not insist on the preservation of pregnancy or abortion. The decision should be made by the woman herself or her relatives. Information for relatives should not be dramatized, limited to the fact that the course of any oncological process is completely unpredictable, and the disease poses a certain danger to the patient’s life. Pregnancy itself does not affect the course of the disease.
In the clinical stage II of melanoma in the first half of pregnancy, at the first stage of treatment, it is necessary to put medical indications for abortion, and then carry out treatment for melanoma of the skin with metastases to the lymph nodes. This tactic is based on the fact that with an abortion, the result of treatment is somewhat better; in addition, it creates the opportunity for additional treatment in the postoperative period.
In clinical stage III, the first stage of treatment is a medical abortion. It should be borne in mind that the preservation of pregnancy is the possibility of transplacental metastasis and the manifestation of teratogenic effects of chemotherapy.
In the second half of pregnancy at any stage of the disease, based on the interests of the child, all measures should be taken to complete the fetus.
Surgical treatment in the generally accepted volume at stage I and II is carried out under anesthesia (neuroleptanalgesia). Additional treatment can be started in the postpartum period if the baby is artificially fed. In necessary cases, according to indications, a cesarean section is performed.
Currently, there is no direct data to establish the effect of pregnancy on the fate of patients after radical treatment for skin melanoma. The previous analysis showed that pregnancy does not have a “protective” property, and therefore pregnancy should not be recommended after treatment.
After radical treatment in stage I of melanoma in patients with a favorable prognosis of life, abortion should not be recommended.
Patients with stage I with an unfavorable prognosis and stage II of the disease can be allowed to have a child after experiencing a “critical” period of 6 years. With a pregnancy that occurred in an earlier period, it is possible to establish medical indications for abortion, and only a stubborn desire to have a baby and the second half of pregnancy are an obstacle. The patient and her relatives should be warned about all possible complications that may arise in this case.
Lymphogranulomatosis and pregnancy. Little studied in the literature is the question of the interaction of lymphogranulomatosis and pregnancy. Pregnancy aggravates the prognosis of the disease, even if it is interrupted.
In the case of complete clinical and hematological remission of lymphogranulomatosis for more than 2 years from the end of treatment, the issue of gestation can be resolved positively.
Among women with lymphogranulomatosis, pregnant women account for 24.7%. Women of childbearing age are more likely to suffer from lymphogranulomatosis in 72%, and pregnancy occurs in 15-30% of patients.
Thus, two variants of the combination of lymphogranulomatosis and pregnancy are observed: a disease during pregnancy or its onset in a woman with lymphogranulomatosis is possible. Menstrual and reproductive functions in these patients may be impaired.
Irradiation of the paraaortic and inguinal-iliac lymph nodes leads to a loss of ovarian function and amenorrhea in almost all young women. To maintain ovarian function, young women and girls transpose the ovaries. Further, during irradiation, the ovaries are protected with a lead block 10 cm thick. Using this technique, the ovarian function can be maintained at 60%.
Lymphogranulomatosis during pregnancy is more often diagnosed in the II — III trimester.
Diagnosis of lymphogranulomatosis during pregnancy is difficult, because the subjective symptoms of the disease (skin itching, low-grade fever, fatigue) are interpreted by doctors as pregnancy complications.
If malignant lymphoma is suspected, the volume of diagnostic procedures is determined depending on the duration of pregnancy.
A puncture biopsy of the lymph node can be performed at any time during pregnancy. Removal of the lymph node is made taking into account the gestational age and the patient's condition. X-ray studies are contraindicated.
The opinion that pregnancy negatively affects the course of lymphogranulomatosis is currently not supported by most authors. The number of spontaneous abortions, stillbirths and pathological births observed with this combination is the same as among healthy women.
Medical tactics in relation to pregnancy in patients with lymphogranulomatosis need strict individualization. When solving this issue, it is necessary to take into account the duration of pregnancy, the nature of the course of the disease, prognostic factors and the patient’s desire. If pregnancy is detected in patients who have not yet been treated, or the simultaneous development of the disease and pregnancy in the first trimester, medical abortion is advisable, which will allow a full examination of the patient and proceed with treatment.
In the acute course of the disease, including relapse, in the II and III trimesters of pregnancy, the beginning of treatment during pregnancy, termination of pregnancy by cesarean section or rhodostimulation at the 7-8th month are indicated. It should be borne in mind that intensive polychemotherapy or irradiation of the paraaortic and inguinal-iliac regions has an adverse effect on the fetus. Chemotherapy with cytostatics should be carried out with extreme caution.
In patients with stage I – II lymphogranulomatosis, who are in a state of complete clinical remission for 3 years or more, pregnancy can be saved.
Patients with stage III-IV disease preferably do not preserve pregnancy.
The active course of the disease in the first 2 years indicates a poor prognosis, so patients are advised to abstain from pregnancy or terminate it in a timely manner.
The adverse effect of lactation on the course of lymphogranulomatosis has not been established. However, given the heavy load on the body of a nursing mother, especially in those cases when she has a specific treatment, it is advisable to refrain from breastfeeding.
Thyroid Cancer and Pregnancy. Thyroid cancer currently accounts for about 6% of all human cancers. An increase in the incidence of thyroid cancer occurred at the expense of women, and mainly of a young age. According to published data, thyroid hormones play an important role in the occurrence and maintenance of pregnancy. Any violation of thyroid function has an adverse effect on pregnancy. In turn, it leads to significant changes in the thyroid gland: its volume increases, proliferation of thyroid hormones in the blood increases. Pregnancy can provoke the development of thyrotoxicosis and nodular forms of goiter.
Thyroid cancer has a number of features. Cancer of this localization, especially its highly differentiated form, is observed in women of childbearing age and is not accompanied by hormonal disorders. These forms of thyroid cancer are slow. At the same time, women have repeated pregnancies, childbirths, they breastfeed and only later they recognize a malignant tumor of the thyroid gland.
The ten-year survival rate for papillary cancer is 90%, in young patients even more than 90%. Clinical experience also indicates a relatively benign course of thyroid cancer during pregnancy, due to the fact that papillary and follicular forms of thyroid cancer, even in the presence of regional metastases, proceed favorably. Five-year survival rate is 93.3%. With medullary squamous cell carcinoma, the prognosis is extremely unfavorable.
The following treatment tactics are recommended for differentiated thyroid tumors combined with pregnancy.
If a differentiated thyroid cancer is diagnosed during pregnancy and radical surgery is possible, then pregnancy can be saved. Moreover, in the I and II trimesters, you should start with surgery, and in III - operate after delivery.
Malignant brain tumors and pregnancy. The combination of pregnancy and brain tumors is relatively rare. The frequency of this pathology ranges from 1: 1000 to 1:17 500 births. There is also evidence that in about 75% of cases of brain tumors in women of reproductive age, the first symptoms of the disease appear during pregnancy. Most reports indicate a negative effect of pregnancy on the course of brain tumors. The progression of the clinical manifestation of a brain tumor during pregnancy is explained by endocrine, electrolyte, hemodynamic and other changes that cause sodium and water retention in the body and an increase in intracranial pressure. There is also evidence that pregnancy can even stimulate the growth of meningiomas and glial tumors.
The tumors most predisposed to a rapid progressive course during pregnancy include vascular tumors.
Brain tumors are a contraindication to the preservation of pregnancy. If the brain tumor is removed, then the issue of preserving the pregnancy is decided individually, depending on the morphological type of the tumor and the state of health of the woman.
Leukemia and pregnancy. The combination of leukemia and pregnancy is relatively rare. Pregnancy is especially rare in patients with acute leukemia. The comparative rarity of the combination of leukemia and pregnancy is due to leukemic ovarian and tube infiltration and functional amenorrhea.
A predominance of a combination of pregnancy with chronic leukemia, mainly myeloid, is noted. According to most authors, pregnancy in patients with chronic leukemia does not adversely affect its course. There is also an opinion that pregnancy improves the course of leukemia due to increased release of ACTH. Some authors draw attention to the fact that pregnancy in acute leukemia often ends in premature birth, less often in utero, fetal death, spontaneous abortion or death of patients before delivery.
In some cases, the course of pregnancy with acute leukemia is not disturbed, and it ends with an urgent delivery. The reason for the uncomplicated course of acute leukemia during pregnancy and terminal exacerbation in the postpartum period is explained by the fact that the bone marrow of the fetus compensates for the blood formation of the mother, while others explain this by hyperfunction of the anterior pituitary and adrenal cortex in pregnant women.
In chronic leukemia, the prognosis for the mother is slightly better than in acute leukemia. Chronic leukemia should be treated in the same way as in the absence of pregnancy. The exception is I trimester. The appointment of chemotherapy drugs in this period can cause significant disturbances in the development of the fetus. In this situation, it is better to terminate the pregnancy.
Malignant tumors of the urinary system and pregnancy. In women of childbearing age, tumors of the urinary system are extremely rare. The most common kidney tumors, among which hypernephroma prevail.
The diagnosis is made equally often in the II, III trimesters of pregnancy and in the postpartum period (26, 29, 26%, respectively). The most common clinical symptoms are lumbar pain (64%) and hematuria (36%). If the tumor process proceeds without significant complications, one should strive to bring the pregnancy to the time of delivery, when the fetus becomes viable, and perform a cesarean section and nephrectomy. If serious complications arise that require emergency interventions, the pregnancy is terminated and a nephrectomy is performed (the optimal period for the latter is the interval between the 12th and 36th week of pregnancy).
Malignant tumors of the adrenal gland and pregnancy. Злокачественные опухоли надпочечников сочетаются с беременностью в соотношении 1:12, что составляет 8,3 % среди женщин, больных злокачественными опухолями надпочечников. Гистологический тип в половине случаев представлен аденокарциномой, а в другой половине — злокачественной феохромоцитомой. Феохромоцитома часто манифестирует в ранних сроках беременности симптомами высокой артериальной гипертензии.
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