This chapter describes the diagnosis, surgical intervention, and prognosis for breast cancer in pregnancy. Estrogen receptor-negative and progesterone receptor-negative tumors, which correlate with poor prognoses, are more common among pregnant women than among age-matched controls, possibly due to receptor down-regulation in pregnancy. The rate of mastectomy among pregnant women is higher than the rate of lumpectomy due to large tumor size and avoidance of adjuvant radiation, but breast-conserving surgery is becoming more frequent. Radiation therapy administered either to complete breast-conserving surgery, as postmastectomy adjuvant treatment in high-risk patients or as a palliative treatment for metastatic cancer, is contra-indicated during pregnancy because of fetal exposure. Chemotherapy should be avoided four weeks before the anticipated delivery date to reduce the risk for infection, or hemorrhage due to pancytopenia. Comparisons between pregnant and nonpregnant women of matched age, nodal status, estrogen receptor status, and tumor histopathology and size yielded no differences in prognosis.

This chapter describes the diagnosis, treatment, and prognosis for cervical cancer in pregnancy. The majority of women with early cervical cancer are asymptomatic and are diagnosed by abnormal cytology. Patients with advanced or disseminated disease can have a wide variety of symptoms including pelvic pain, flank pain, and respiratory distress. Conization during pregnancy should be viewed as diagnostic and not therapeutic due to a high rate of positive margins and residual disease as demonstrated by E. V. Hannigan. The clinical staging may include plain film radiographs, an intravenous pyelogram (IVP), or a barium enema, but not findings at the time of surgery, computerized tomography (CT), or magnetic resonance imaging (MRI). CT scanning can be performed with minimal risk in the pregnant patient and is helpful in determining the presence of lymphadenopathy or hydronephrosis. The effect of pregnancy on prognosis is controversial, especially in the higher stages of the disease.

This chapter describes the diagnosis, treatment, and prognosis for hepatocellular carcinoma (HCC) in pregnancy. Risk factors for HCC include hepatitis B virus (HBV) or HCV infections, aflatoxin exposure, cirrhosis, alcohol abuse, metabolic liver disease, carcinogen exposure, steroids, and male gender. There is a report of association between high parity, HBsAg carriers, oral contraceptives, and HCC. Detailed medical history and the level of serum alpha-fetoprotein (AFP) may be helpful as screening tools. Liver sonography and/or magnetic resonance imaging (MRI) together with fine liver aspiration are used for definitive diagnosis during pregnancy. These imaging methods and measures are also used for staging. Partial hepatectomy is the treatment of choice. The choice of aggressive approach is based on anatomical and surgical considerations, and tumor spread. Two case reports of HCC diagnosed in the second trimester reported favorable outcomes for both mother and child.

This chapter describes the diagnosis, treatment, and prognosis for Hodgkin's lymphoma (HL) in pregnancy. The diagnosis of lymphoma requires a lymph node biopsy for pathological examination. The routine staging process for all lymphomas requires radiological evaluation usually with chest and abdominal computed tomography (CT). Abdominal and pelvic CT should be avoided during pregnancy. When magnetic resonance imaging (MRI) is available, it should be the modality of choice for the staging of lymphoma during pregnancy. Recently, positron emission tomography (PET)-CT has been increasingly used for both staging and treatment follow-up in patients with lymphoma. Although chemotherapy is currently recommended for the treatment of HL at all stages, radiotherapy can still be considered an appropriate treatment for stage 1. The most popular chemotherapy regimen for the treatment of HL is adriamycin, bleomycin, vinblastine, dacarbazine (ABVD). Adequate treatment with ABVD should be administered immediately at the beginning of the second trimester.

This chapter describes the diagnosis, treatment, and prognosis of intracranial tumors in pregnancy. Common symptoms of increased intracranial pressure, including nausea and vomiting, can potentially be confused with routine pregnancy related conditions such as hyperemesis gravidarum, thereby posing specific diagnostic challenges for physicians. Magnetic resonance imaging (MRI) is probably the diagnostic imaging procedure of choice and should be performed when a brain tumor is suspected and when seizures appear during pregnancy. Computed tomography (CT), however, is the choice of many physicians for an initial neuroimaging test because of its low cost, widespread availability, and relative short procedure duration, and is considered safe during pregnancy. Surgery and radiotherapy are the main therapeutic procedures. Bromocriptine has been shown to be safe and remains the drug of choice during pregnancy, but should only be used for symptomatic treatment.

This chapter discusses the treatment of acute and chronic leukemia during pregnancy. Leukemia occurs very rarely during pregnancy. The majority of cases are acute leukemia; of which two-thirds are myeloblastic (AML) and one-third are lymphoblastic (ALL). Chronic myeloid leukemia (CML) is found in less than 10% of leukemia cases during pregnancy, and chronic lymphocytic leukemia (CLL) is extremely rare. The treatment of CML has evolved dramatically since the introduction of tyrosine kinase inhibitors (TKI). There are several options for the treatment of CLL. When treatment is indicated, cytoreduction may be accomplished mechanically with leukapheresis. The most popular drugs are: chlorambucil, which is contra-indicated during the first trimester of pregnancy because of its teratogenicity; and fludarabine, an anti-metabolite. Corticosteroids may be used for the treatment of autoimmune complications, as in nonpregnant patients. Hairy cell leukemia is very rare during pregnancy. Interferon alpha was historically used in the treatment of this disease.

This chapter describes the diagnosis, treatment, and prognosis for lung cancer in pregnancy. The presenting signs and symptoms associated with lung cancer and pregnancy are similar to the nonpregnant state and depend mainly on the stage of the lung cancer. Lung cancer staging consists of physical examination in combination with surgical and radiologic investigations. The need for chemotherapy or radiotherapy during the early stages of pregnancy for rapidly progressive disease may lead to consideration of termination of pregnancy. The treatment of choice in early stage non-small cell lung cancer is curative surgical resection. Small cell lung cancer is characterized by an aggressive clinical course and relatively good response to chemo/radiotherapy compared to other types of lung cancer. When chemotherapy is administered during pregnancy, timing of delivery of the infant should take into account the expected bone marrow depression and potential problems such as bleeding or infections.

This chapter describes the diagnosis, treatment, and prognosis for malignant melanoma during pregnancy. Clinical staging traditionally included assessment of the local tumor site and adjacent skin, regional lymph node areas, and distant organs that are frequently the site of metastatic disease. Surgical removal of the melanoma with adequate margins remains the standard primary therapy for early melanoma. Interim Multicenter Selective Lymphadenectomy Trial (MSLT-1) results revealed similar overall 5-year survival benefit between patients who had undergone wide excision and sentinel lymph node biopsy (SLNB) with immediate lymphadenectomy and those who had wide excision and postoperative observation of regional lymph node with lymphadenectomy if nodal relapse occurred. The risk of malformations when chemotherapy is administered in the first trimester is estimated to be around 7.5%-17% for single-agent chemotherapy and 25% for combination chemotherapy. The effect of pregnancy on prognosis of melanoma is a focus of interest in the medical literature for years.

This chapter describes the diagnosis, treatment, and prognosis for non-Hodgkin's lymphoma (NHL) in pregnancy. Indolent NHL includes follicular lymphoma and chronic lymphocytic leukemia/small lymphocytic lymphoma, which are extremely rare during pregnancy. Aggressive NHL, which includes large B-cell lymphomas, mantle cell lymphoma, and mature T-cell and NK-cell neoplasms, represents the majority of NHL cases diagnosed during gestation. Due to the aggressive course of these lymphomas, most patients should be treated promptly with intensive combination chemotherapy. Aggressive NHL group includes precursor (B or T) lymphoblastic leukemia/lymphoma and Burkitt's lymphoma. Most chemotherapy regimens for very aggressive lymphomas include high-dose methotrexate, which among the currently used anticancer drugs, poses the greatest risk to the developing fetus when administered during the first trimester. Placental involvement in pregnancy associated NHL is extremely rare, but a single case of dissemination to the fetus has been reported.

This chapter describes the diagnosis, treatment, prognosis, and lactation for ovarian cancer in pregnancy. Various sonographic scoring systems of the adnexal mass may include features that have been associated with ovarian malignancies, such as bilaterality, heterogeneous solid component, papillary structure, septations, size >7 cm, low-resistance blood flow, and ascites. Improvement in Doppler ultrasound technology for evaluation of tumor vascularity has been used lately as a predictor of malignancy. Magnetic resonance imaging (MRI) may be used as an additional diagnostic imaging tool in more complex conditions, such as displacement of the ovaries up into the abdomen when the pregnant uterus is growing, or in metastatic disease, or in other diagnostic uncertainty. Most patients with ovarian cancer diagnosed during pregnancy have disease confined to the pelvis or abdomen. Paclitaxel-carboplatin chemotherapy until fetal maturity is the regimen of choice in ovarian cancer.