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Malignant tumors of the breast and pregnancy
Among the malignant tumors in women, breast cancer is one of the first places. In recent years, the frequency of combinations of pregnancy and cancer has increased.
Two aspects of this problem are distinguished: cancer among pregnant women and pregnancy in cancer. Breast cancer in pregnant women occurs in 0.03–0.3% of cases, pregnancy in breast cancer is 0.78–3.8%, and in some reports, this figure reaches 14%.
According to experimental data, changes in the body of rats associated with pregnancy, in general, inhibit the appearance of breast tumors, increase the differentiation of tumors and reduce the degree of malignancy.
In breast tumors diagnosed during pregnancy, abnormalities in hormonal homeostasis are characterized by hyperestrogenization, disruption of the rhythm of the menstrual cycle with the appearance of an extraordinary physiological norm peak of PH release in the follicular phase and low FSH levels in patients after abortion, hyperestrogenization in combination with hyperprolactinemia in patients with abortion, hyperaestrogenization combined with hyperprolactinemia in patients with abortion, in patients with abortion, hyperestrogenization in combination with hyperprolactinemia in patients with abortion, sick with abortion, combined with hyperprolactinemia mammary gland, diagnosed on the background of lactation, hypercortisolism in some patients.
Among the clinical forms of breast cancer, inflammatory (in 15% of cases) prevail, often fast metastatic undifferentiated forms, less often differentiated. A characteristic feature of the combination of pregnancy and breast cancer is the discovery of the latter in patients with many pregnancies and childbirths of the late reproductive period (35-44 years) with a significant (5 years or more) break between pregnancies.
Another characteristic feature is the prevalence 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 tumor of the breast, confirmed morphologically, abortion is indicated. After that, the treatment is carried out according to the tumor stage.
¦ Extragenital malignant tumors and pregnancy
Melanoma of the skin and pregnancy. It is well known that melanoma of the skin in the structure of oncological diseases ranges from 1 to 3%. Even less often is its combination with pregnancy. There is evidence of the effect of the hormonal status of a modified pregnancy on the pigment system, in some cases manifested in the activation of pigment nevus. It has been established that there are special estrogen receptors in the cytoplasm of melanoma cells, as well as a rapid growth of the tumor and metastases during estrogen administration. This indicates an adverse, stimulating tumor growth effect of pregnancy on melanoma. Clinical observations show that the combination of pregnancy and melanoma in most cases worsens the prognosis.
The prognosis for melanoma of the skin depends largely on the localization of the primary focus. Unfavorable is the localization of the primary focus on the body, in the head and neck. Localization of melanoma in the upper and lower extremities is prognostically more favorable. Survival of patients depends mainly on the stage of melanoma.
In 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%; The 10-year-old is 26 + 7.4% and 43 ± 2.8%, respectively. Consequently, with a combination of melanoma of clinical stage I and pregnancy, the long-term results of treatment worsen.
In the II and III clinical stages of the disease, the factor of pregnancy does not significantly affect the prognosis of life.
Comparison of 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 appeared in the second half and in the lactation period, showed that the course of the disease is significantly complicated if the melanoma occurred in the second half of pregnancy. Perhaps it is the high level of estrogen and growth hormone that is observed during this period of pregnancy.
The above basic patterns of combination of skin melanoma and pregnancy make it possible to work out the following treatment tactics. In the first half of pregnancy in patients with stage I disease, with a favorable individual prognosis of life, abortion can be avoided. Under anesthesia (preferably neuroleptic algesia), skin melanoma is widely excised according to an accepted technique. The obtained morphological data and their analysis allow us to give more reasonable judgments about the prognosis of the disease. Sick and relatives should be configured to maintain pregnancy.
With an unfavorable prognosis of life, established on the basis of a combination of clinical and morphological signs, the decision on the preservation of pregnancy is made individually. One should not insist on preserving pregnancy or abortion. The decision must be made by the woman herself or her family. Information for relatives should not be dramatized, limiting itself to the fact that the course of any oncological process is completely unpredictable, and the disease poses a certain danger to the life of the patient. By itself, pregnancy does not affect the course of the disease.
In stage II of melanoma, in the first half of pregnancy, at the first stage of treatment, it is necessary to set the medical indications for abortion, and then treat melanoma of the skin with metastases to the lymph nodes. This tactic is based on the fact that if an pregnancy is interrupted, the result of treatment is somewhat better; in addition, it creates the opportunity for additional treatment in the postoperative period.
At the third clinical stage, the first stage of treatment consists in conducting a medical abortion. It should be noted that the preservation of pregnancy is the possibility of transplacental metastasis and the manifestation of the teratogenic action of chemotherapy drugs.
In the second half of pregnancy, at any stage of the disease, in the interests of the child, all measures should be taken to nurturing the fetus.
Surgical treatment in the volume generally accepted in stage I and II is carried out under anesthesia (neurolepticalgesia). Additional treatment can be initiated in the postpartum period if artificial feeding of the child. In necessary cases according to indications make Cesarean section.
Currently, there is no direct data to establish the effect of pregnancy on the fate of patients after radical treatment for melanoma of the skin. 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, we should not recommend abortion.
Patients with stage I with a poor prognosis and stage II disease can be allowed to have a child after experiencing a “critical” period of 6 years. In case of pregnancy that occurred earlier, it is possible to establish medical indications for abortion, and only a strong desire to have a baby and the second half of pregnancy serve as 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 Hodgkin's disease for more than 2 years from the end of treatment, the issue of pregnancy can be resolved positively.
Among women with lymphogranulomatosis, pregnant women account for 24.7%. Lymphogranulomatosis most often affects women of childbearing age in 72%, and pregnancy occurs in 15-30% of patients.
Thus, there are two options for a combination of lymphogranulomatosis and pregnancy: a disease is possible during pregnancy or if it occurs in a woman who has lymphogranulomatosis. The menstrual and reproductive functions in these patients may be impaired.
Irradiation of para-aortic and inguinal-iliac lymph nodes leads to loss of ovarian function and amenorrhea in almost all young women. Ovarian transposition is performed to preserve ovarian function in young women and girls. Subsequently, when irradiated, the ovaries are protected by a lead block 10 cm thick. Using this technique allows you to save ovarian function in 60%.
Lymphogranulomatosis during pregnancy is more often diagnosed in the second and third trimester.
Diagnosis of Hodgkin's disease during pregnancy is difficult, because the subjective symptoms of the disease (pruritus, low-grade fever, increased fatigue) are interpreted by doctors as complications of pregnancy.
If malignant lymphoma is suspected, the volume of diagnostic procedures is determined depending on the duration of pregnancy.
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 duration of pregnancy and the patient's condition. Radiographic studies are contraindicated.
The opinion that pregnancy has a negative effect on the course of Hodgkin's disease is not currently supported by most authors. The number of spontaneous abortions, stillbirths and pathological childbirth observed with this combination is the same as among healthy women.
Medical tactics in relation to pregnancy in patients with lymphogranulomatosis requires strict individualization. When addressing 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. When pregnancy is detected in patients who have not yet undergone treatment, or the simultaneous development of the disease and pregnancy in the first trimester, a medical abortion is advisable, which will make it possible to carry out a full examination of the patient and begin treatment.
In the acute course of the disease, including recurrence, in the second and third trimesters of pregnancy, the beginning of treatment during pregnancy, termination of pregnancy by caesarean section or birth stimulation at 7-8 months are shown. It is necessary to take into account the fact that intensive polychemotherapy or irradiation of para-aortic and inguinal-iliac regions has an adverse effect on the fetus. Chemotherapy with cytostatics should be carried out extremely carefully.
In patients with stage I-II of Hodgkin's disease, who are in a state of complete clinical remission for 3 years or more, pregnancy can be saved.
Patients with III — IV stage of the disease, it is preferable not to save 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 stop it in a timely manner.
Adverse effect of lactation on the course of Hodgkin's disease is not installed. However, given the heavy load on the body of a nursing mother, especially in cases where she is to undergo specific treatment, it is advisable to abstain from breastfeeding.
Thyroid cancer and pregnancy. Currently, thyroid cancer accounts for about 6% of all human malignant diseases. The increase in the incidence of thyroid cancer was due to women, and mostly young. According to literary data, thyroid hormones play an important role in the occurrence and preservation of pregnancy. Any dysfunction of the thyroid gland has an adverse effect on pregnancy. In turn, it leads to significant changes in the thyroid gland: its volume increases, the proliferation of thyroid hormones in the blood increases. Pregnancy can provoke the development of thyrotoxicosis and nodular 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, repeated pregnancies and childbirth occur in women, they breastfeed and only later do they recognize a malignant tumor of the thyroid gland.
Ten-year survival in papillary carcinoma 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%. In medullary squamous cell carcinoma, the prognosis is extremely poor.
The following treatment strategy is recommended for differentiated tumors of the thyroid gland, combined with pregnancy.
If differentiated thyroid cancer is diagnosed during pregnancy and a radical surgery is possible, then the pregnancy can be saved. At the same time, in the first and second trimesters one should begin with an operative intervention, and in the third one - to 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 genera. 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 causing sodium and water retention in the body and an increase in intracranial pressure. There is also evidence that pregnancy may even stimulate the growth of meningiomas and glial tumors.
Vascular tumors should be referred to as the tumors that are most susceptible to a rapid progressive course during pregnancy.
Brain tumors are contraindications for preserving pregnancy. If a brain tumor is removed, then the question of preserving 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 a combination of leukemia and pregnancy is explained by leukemic infiltration of the ovaries and tubes and functional amenorrhea.
There is a prevalence of a combination of pregnancy with chronic leukemia, mainly myeloid. According to most authors, pregnancy in patients with chronic leukemia does not adversely affect its course. There is also the opinion that pregnancy improves leukemia due to increased release of ACTH. Some authors draw attention to the fact that pregnancy with acute leukemia often ends in preterm labor, less often with fetal death, spontaneous abortion, or death of patients before delivery.
In some cases, the course of pregnancy in acute leukemia is not disturbed, and it ends with urgent childbirth. The cause of uncomplicated acute leukemia during pregnancy and terminal exacerbation in the postpartum period is explained by the fact that the fetal bone marrow compensates for the mother’s hematopoiesis, while others explain the hyperfunction of the anterior pituitary and adrenal cortex in pregnant women.
In chronic leukemia, the prognosis for the mother is slightly better than for acute ones. Chronic leukemia should be treated the same way as in the absence of pregnancy. The exception is the I trimester. The appointment of chemotherapy in this period can cause significant impairment in the development of the fetus. In this situation, pregnancy is better to abort.
Malignant tumors of the urinary system and pregnancy. In women of childbearing age, tumors of the urinary system are extremely rare. The most common tumors of the kidneys, among which the prevailing hypernephromas.
The diagnosis is established equally often in the II, III trimesters of pregnancy and in the postpartum period (26, 29, 26%, respectively). The most frequent clinical symptoms are pain in the lumbar region (64%) and hematuria (36%). If the tumor process proceeds without significant complications, you should strive to bring the pregnancy to the date of birth, when the fetus becomes viable, and produce a cesarean section and nephrectomy. If serious complications arise that require emergency intervention, the pregnancy is interrupted and a nephrectomy is performed (the optimal period for the latter is the interval between the 12th and 36th week of pregnancy).
Malignant adrenal tumors 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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Malignant tumors of the breast and pregnancy
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