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Cancer in Pregnancy: Brain Tumor in Pregnancy

Introduction
The occurence of primary intracranial tumors in pregnancy is an extremely rare event1. Symptoms and physical findings are not different from those of the non-pregnant population, although pregnancy may occasionally delay diagnosis.

Diagnosis
Careful history, physical examination, computerized tomography, and magnetic resonance imaging are essential diagnostic procedures2. Clinically significant vascular lesions may be missed on CT scan. MRI is probably the diagnostic imaging procedure of choice and should be performed when a brain tumor is suspected and when seizures appear during pregnancy3. Estrogen and progesterone receptors were found in cases of meningioma and astrocytoma during pregnancy and a possible association between pregnancy hormones and rate of tumor growth was suggested2,4.The association is especially true of meningiomas which occur predominantly in females, and have accelerated growth during the luteal phase of the menstrual cycle, as well as during the pregnancy4. Presence of these type of receptors was also established in almost all craniopharyngeomas and ameloblastomas5. However, a population-based evaluation did not find that intracranial tumors present more often during pregnancy 1.

Treatment
Management of brain tumors should be tailored to the individual patient. Surgery and radiotherapy are the main therapeutic procedures. Fetal dose during brain radiotherapy can be estimated based on gestational age, field size, and distance from field isocenter. Determination of fetal dose allows for the selection of the irradiation technique that will achieve the greatest patient benefit with the least risk to the fetus6. Dosimetric results in one study indicated that special shielding equipment over the patient's abdomen is not a prerequisite for treating brain malignancies during pregnancy, since conceptus dose never exceeded 100mGy. Nevertheless it should be used whenever possible7.

Anticonvulsants and steroids should be used according to acceptable medical indications. Emergency delivery as a result of maternal deterioration should be anticipated. To minimize temporal lobe or cerebellar herniation in neurologicaly unstable patients, consideration should be given to Caesarean delivery with the patient under general anesthesia followed by immediate neurosurgical decompression8. If symptoms are amenable to pharmacological control, delivery is recommended in the early third trimester after documentation of fetal pulmonary maturity.

In case of nonendocrine pituitary tumor such as craniopharingeoma, vaginal delivery is a viable option for some patients with operative treatment being postponed until after delivery. If essential, the transsphenoidal approach seems to be a safe procedure5.

The enlargement of preexisting pituitary adenomas during pregnancy is well documented. Hyperprolactinemia due to micro, macro or idiopathic prolactinoma should be treated medically in the vast majority of cases. Bromocriptine has been shown to be safe and remains the drug of choice during pregnancy 9,10,11. In case of bromocriptine intolerance, cabergoline and quinagolide (both dopamine agonists), were shown by some authors to be better tolerated and more effective. However their safety during pregnancy has not yet been established 12,13,14. In one study, treatment with cabergoline during pregnancy (only 27 cases) was not shown to cause structural abnormalities15.

Use of somatostatin analog octreotide in the treatment of growth hormone or thyroid stimulating hormone-secreting macroadenomas during pregnancy has been described in the literature. A limited number of case reports indicate that somatostatin did not cause any fetal malformations or alterations of postnatal development 16,17.

Prognosis
Most reported women delivered normal babies 2,6,13.

References

  1. Haas JF, Janisch W, Staneczek W: Newly diagnosed primary intracranial neoplasma in pregnant women: a population based assessment. J of Neurol, Neurosurg and Psychiatry. 49:874-880, 1986.
  2. Isla A, Alvarez F, Gonzales A, Garcia-Grande A, Perez Alvarez A, Garcia-Blazquez M. Brain tumors and pregnancy. Obstet Gynecol 89:19-23, 1997.
  3. Awada A, Watson T, Obeid T. Cavernous angioma presenting as pregnancy-related seizures. Epilepsia, 38 ( 7 ): 844-846, 1997.
  4. Carrols RS, Zhang J, Black PM. Expression of estrogen receptors alpha and beta in human meningeomas. Journal of Neuro-Oncology. 42 (2) :109-16, 1999.
  5. Aydin Y, Can SM, Gulkilik A, Turkmenoglu O, Alatli C, Ziyal I. Rapid enlargement and recurrence of a preexisting intrasellar craniopharyngioma during the course of two pregnancies. Case Report. Journal of Neurosurgery. 91(2):322-4, 1999.
  6. Mazonakis M, Damilakis J, Theoharopoulos N et al. Brain radiotherapy during pregnancy: An analysis of conceptus dose using anthropomorphic phantoms. Brit J. Radiol 72: 274-8, 1999.
  7. Mazonakis M, Damilakis J, Theoharopoulos N, Varveris H, Gourtsoyiannis N. Brain radiotherapy during pregnancy: an analysis of conceptus dose using anthropomorphic phantoms. British Journal of Radiology. 72(855): 274-8, 1999
  8. Tewari KS, Cappuccini F, Asrat T, Flamm BL, Carpenter SE, Disaia PJ, Quilligan EJ. Obstetric emergencies precipitated by malignant brain tumors. American Journal of Obstetrics & Gynecology. 182(5):1215-21, 2000.
  9. Molitch ME. Management of prolactinomas during pregnancy. Journal of Reproductive Medicine. 44 (12 Suppl):1121-6, 1999.
  10. Molitch ME. Pituitary diseases in Pregnancy. (Review). Seminars in Perinatology. 22 (6):457-70, 1998.
  11. Badawy SZ, Marziale JC, Rosenbaum AE, Chang JK, Joy SE. The long-term effects of pregnancy and bromocriptine treatment on prolactinomas-the value of radiologic studies. Early Pregnancy. 3 (4):306-11, 1997.
  12. Colao A, Lochhe S, Cappa M, Di Sarno A, Landi ML, Sarnacchiaro F, Facciolli G, Lombardi G. Prolactinomas in children and adoloscents. Clinical presentation and long-term follow-up. Journal of Clinical Endrocrinology & Metabolism. 83(8):2777-80, 1998.
  13. Muratori M, Arosio M, Gambino G, Romano C, Biella O, Faglia G. Use of cabergoline in the long-term treatment of hyperprolacinemic and acromegalic patients. Journal of Endocrinological Investigation. 20(9):537-46, 1997.
  14. Ciccarelli E, Grottoli S, Razzore P, Gaia D, Bertagna A, Cirillo S, Cammarota T, Camanni M, Camanni F. Long-term treatment with cabergoline, a new long-lasting ergoline derivate, in idiopathic or tumorous hyperprolactinaemia and outcome of drug-induced pregnancy. Journal of Endocrinological Investigation. 20(9) 547-51, 1997.
  15. Verhelst J, Abs R, Maiter D, Van den Bruel A, Vandeweghe M, Velkeniers B et al. Cabergolide in the treatment of hyperprolactinemia: a study in 455 patients. Journal of Clinical Endocrinology & Metabolism. 84(7): 2518-22,1999.
  16. Mozas J, Ocon E, Lopez de la Torre M, Suzrez AM, Miranda JA, Herruzo AJ. Successful pregnancy in a woman with acrogmegaly treated with somatostatin analog (octreotide) prior to surgical resection. International Journal of Gynaeocology & Obstetrics. 65 (1):71-3, 1999.
  17. Caron P, Buscail L, Beckers A, Esteve JP, Igout A, Hennen G, Susini C. Expression of somatostatin receptor SST4 in human placenta and absence of octreotide effect on human placental growth hormone concentration during pregnancy. Journal of Clinical Endocrinology & Metabolism. 82(11):3771-6,1997.
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The information on this website is not intended as a substitute for the advice and care of your doctor or other health-care provider. Always consult your doctor if you have any questions about exposures during pregnancy and before you take any medications.

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