Chemotherapy of ovarian cancer in pregnancy
- Carolyn D Runowicz, MD
Carolyn D Runowicz, MD
- Executive Associate Dean for Academic Affairs
- Professor of Obstetrics and Gynecology
- Florida International University
- Herbert Wertheim College of Medicine
- Molly Brewer, DVM, MD, MS
Molly Brewer, DVM, MD, MS
- Division of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- Carole and Ray Neag Comprehensive Cancer Center
- University of Connecticut Health Center
- Section Editors
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Professor of Gynecologic Oncology
- University of Washington
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Clinical Co-Director, Gynecologic Oncology
- Founder and Director, The Oncology Sexual Health Clinic
- Massachusetts General Hospital Cancer Center
- Associate Professor of Medicine
- Harvard Medical School
- Deputy Editors
- Sadhna R Vora, MD
Sadhna R Vora, MD
- Deputy Editor — Oncology
- Instructor in Medicine
- Harvard Medical School
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
A gynecologic malignancy is estimated to complicate four to eight of every 100,000 pregnancies [1-4]. Unfortunately, the data on the effects of antineoplastic drugs administered during pregnancy have largely been derived from case reports, small case series, and collected reviews of pregnant women treated for a variety of cancers. There are even less data on long-term outcomes in offspring.
This topic will address the administration of chemotherapy for women diagnosed with ovarian cancer in pregnancy. In order to optimize treatment outcomes, a pregnant woman with a diagnosis of ovarian cancer should be managed by a multidisciplinary team that includes experts in the fields of maternal-fetal medicine, gynecologic oncology, pediatrics, and pathology.
The clinical manifestations and diagnosis of ovarian cancer in pregnancy and surgical management of this disease are reviewed separately. (See "Adnexal mass in pregnancy".)
Concerns about the administration of cytotoxic chemotherapy during pregnancy arise because chemotherapy preferentially kills rapidly proliferating cells, and the fetus represents a rapidly proliferating cell mass. All chemotherapy agents used in the treatment of epithelial and nonepithelial ovarian cancers are pregnancy category D, meaning that fetal exposure to individual chemotherapeutic agents have resulted in adverse effects including intrauterine growth restriction, prematurity, and low birth weight in the infants . Chemotherapy may also cause fetal toxicities similar to those observed in the mother (eg, bone marrow suppression).
The risks of spontaneous abortion, fetal death, and major malformations vary depending on the agent used and the trimester of pregnancy. These risks must be weighed against the benefits of immediate versus delayed (ie, postdelivery) chemotherapy for the mother. Ethical considerations of treatment during pregnancy have emphasized the role of patient autonomy and the concept of beneficence and nonmaleficence for both the mother and fetus .
- Amant F, Brepoels L, Halaska MJ, et al. Gynaecologic cancer complicating pregnancy: an overview. Best Pract Res Clin Obstet Gynaecol 2010; 24:61.
- Zhao XY, Huang HF, Lian LJ, Lang JH. Ovarian cancer in pregnancy: a clinicopathologic analysis of 22 cases and review of the literature. Int J Gynecol Cancer 2006; 16:8.
- Behtash N, Karimi Zarchi M, Modares Gilani M, et al. Ovarian carcinoma associated with pregnancy: a clinicopathologic analysis of 23 cases and review of the literature. BMC Pregnancy Childbirth 2008; 8:3.
- Whitecar MP, Turner S, Higby MK. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999; 181:19.
- Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol 2004; 5:283.
- Theriault R, Hahn K. Management of breast cancer in pregnancy. Curr Oncol Rep 2007; 9:17.
- Leslie KK, Koil C, Rayburn WF. Chemotherapeutic drugs in pregnancy. Obstet Gynecol Clin North Am 2005; 32:627.
- Selig BP, Furr JR, Huey RW, et al. Cancer chemotherapeutic agents as human teratogens. Birth Defects Res A Clin Mol Teratol 2012; 94:626.
- Boulay R, Podczaski E. Ovarian cancer complicating pregnancy. Obstet Gynecol Clin North Am 1998; 25:385.
- Zagouri F, Sergentanis TN, Chrysikos D, et al. Taxanes for ovarian cancer during pregnancy: a systematic review. Oncology 2012; 83:234.
- Mir O, Berveiller P, Goffinet F, et al. Taxanes for breast cancer during pregnancy: a systematic review. Ann Oncol 2010; 21:425.
- Cardonick E, Bhat A, Gilmandyar D, Somer R. Maternal and fetal outcomes of taxane chemotherapy in breast and ovarian cancer during pregnancy: case series and review of the literature. Ann Oncol 2012; 23:3016.
- Méndez LE, Mueller A, Salom E, González-Quintero VH. Paclitaxel and carboplatin chemotherapy administered during pregnancy for advanced epithelial ovarian cancer. Obstet Gynecol 2003; 102:1200.
- Picone O, Lhommé C, Tournaire M, et al. Preservation of pregnancy in a patient with a stage IIIB ovarian epithelial carcinoma diagnosed at 22 weeks of gestation and treated with initial chemotherapy: case report and literature review. Gynecol Oncol 2004; 94:600.
- Sood AK, Shahin MS, Sorosky JI. Paclitaxel and platinum chemotherapy for ovarian carcinoma during pregnancy. Gynecol Oncol 2001; 83:599.
- Ferrandina G, Distefano M, Testa A, et al. Management of an advanced ovarian cancer at 15 weeks of gestation: case report and literature review. Gynecol Oncol 2005; 97:693.
- Tomlinson MW, Treadwell MC, Deppe G. Platinum based chemotherapy to treat recurrent Sertoli-Leydig cell ovarian carcinoma during pregnancy. Eur J Gynaecol Oncol 1997; 18:44.
- Sayedur Rahman M, Al-Sibai MH, Rahman J, et al. Ovarian carcinoma associated with pregnancy. A review of 9 cases. Acta Obstet Gynecol Scand 2002; 81:260.
- Huang HP, Fang CN, Kan YY. Chemotherapy for ovarian mucinous cystadenocarcinoma during pregnancy: a case report. Eur J Gynaecol Oncol 2004; 25:635.
- Raffles A, Williams J, Costeloe K, Clark P. Transplacental effects of maternal cancer chemotherapy. Case report. Br J Obstet Gynaecol 1989; 96:1099.
- Henderson CE, Elia G, Garfinkel D, et al. Platinum chemotherapy during pregnancy for serous cystadenocarcinoma of the ovary. Gynecol Oncol 1993; 49:92.
- Modares Gilani M, Karimi Zarchi M, Behtash N, et al. Preservation of pregnancy in a patient with advanced ovarian cancer at 20 weeks of gestation: case report and literature review. Int J Gynecol Cancer 2007; 17:1140.
- Tabata T, Nishiura K, Tanida K, et al. Carboplatin chemotherapy in a pregnant patient with undifferentiated ovarian carcinoma: case report and review of the literature. Int J Gynecol Cancer 2008; 18:181.
- Mir O, Berveiller P, Ropert S, et al. Use of platinum derivatives during pregnancy. Cancer 2008; 113:3069.
- Doi D, Boh Y, Konishi H, et al. Combined chemotherapy with paclitaxel and carboplatin for mucinous cystadenocarcinoma of the ovary during pregnancy. Arch Gynecol Obstet 2009; 280:633.
- Machado F, Vegas C, Leon J, et al. Ovarian cancer during pregnancy: analysis of 15 cases. Gynecol Oncol 2007; 105:446.
- Geijteman EC, Wensveen CW, Duvekot JJ, van Zuylen L. A child with severe hearing loss associated with maternal cisplatin treatment during pregnancy. Obstet Gynecol 2014; 124:454.
- Fruscio R, de Haan J, Van Calsteren K, et al. Ovarian cancer in pregnancy. Best Pract Res Clin Obstet Gynaecol 2016.
- Smith ER, Borowsky ME, Jain VD. Intraperitoneal chemotherapy in a pregnant woman with ovarian cancer. Obstet Gynecol 2013; 122:481.
- Bolis G, Colombo N, Pecorelli S, et al. Adjuvant treatment for early epithelial ovarian cancer: results of two randomised clinical trials comparing cisplatin to no further treatment or chromic phosphate (32P). G.I.C.O.G.: Gruppo Interregionale Collaborativo in Ginecologia Oncologica. Ann Oncol 1995; 6:887.
- Katsumata N, Yasuda M, Takahashi F, et al. Dose-dense paclitaxel once a week in combination with carboplatin every 3 weeks for advanced ovarian cancer: a phase 3, open-label, randomised controlled trial. Lancet 2009; 374:1331.
- van der Burg ME, Onstenk W, Boere IA, et al. Long-term results of a randomised phase III trial of weekly versus three-weekly paclitaxel/platinum induction therapy followed by standard or extended three-weekly paclitaxel/platinum in European patients with advanced epithelial ovarian cancer. Eur J Cancer 2014; 50:2592.
- Hubalek M, Smekal-Schindelwig C, Zeimet AG, et al. Chemotherapeutic treatment of a pregnant patient with ovarian dysgerminoma. Arch Gynecol Obstet 2007; 276:179.
- Elit L, Bocking A, Kenyon C, Natale R. An endodermal sinus tumor diagnosed in pregnancy: case report and review of the literature. Gynecol Oncol 1999; 72:123.
- Robova H, Rob L, Hrehorcak M, et al. Endodermal sinus tumor diagnosed in pregnancy: a case report. Int J Gynecol Cancer 2007; 17:914.
- Amant F, Halaska MJ, Fumagalli M, et al. Gynecologic cancers in pregnancy: guidelines of a second international consensus meeting. Int J Gynecol Cancer 2014; 24:394.
- Shimizu Y, Komiyama S, Kobayashi T, et al. Successful management of endodermal sinus tumor of the ovary associated with pregnancy. Gynecol Oncol 2003; 88:447.
- Aoki Y, Higashino M, Ishii S, Tanaka K. Yolk sac tumor of the ovary during pregnancy: a case report. Gynecol Oncol 2005; 99:497.
- Rajendran S, Hollingworth J, Scudamore I. Endodermal sinus tumour of the ovary in pregnancy. Eur J Gynaecol Oncol 1999; 20:272.
- Morice P, Uzan C, Gouy S, et al. Gynaecological cancers in pregnancy. Lancet 2012; 379:558.
- Egan PC, Costanza ME, Dodion P, et al. Doxorubicin and cisplatin excretion into human milk. Cancer Treat Rep 1985; 69:1387.
- American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108:776.
- World Health Organization. Acceptable medical reasons for use of breast-milk substitutes. WHO Press 2009. http://apps.who.int/iris/bitstream/10665/69938/1/WHO_FCH_CAH_09.01_eng.pdf (Accessed on November 26, 2012).
- GENERAL PRINCIPLES
- OVARIAN CANCER DURING PREGNANCY
- EPITHELIAL OVARIAN CANCER
- - Platinum
- - Taxanes
- - Intraperitoneal (IP) therapy
- Timing of chemotherapy
- - Early-stage disease
- - Advanced-stage disease
- GERM CELL TUMORS
- Timing of chemotherapy
- TUMORS OF LOW MALIGNANT POTENTIAL
- SEX CORD-STROMAL TUMORS
- SUMMARY AND RECOMMENDATIONS