How I treat acute and chronic leukemia in pregnancy

Management of Concurrent Pregnancy and Acute Lymphoblastic Malignancy in Teenaged Patients: Two Illustrative Cases and Review of the Literature

“…11 However, in a prospective study by Aviles and Niz of 20 children exposed in utero to intensive ALL chemotherapy between 1963 and 1981 (11 of which were exposed during the first trimester), none showed any congenital malformation, chromosomal abnormality, or late-onset cardiac or neurologic toxicity during follow-up periods ranging from 4 to 22 years. 24 The most commonly reported outcomes of cytotoxic insult during the first trimester are intrauterine fetal demise or spontaneous abortion, 8,12,25 as in our first case illustration. After the first trimester, the risk of congenital malformation falls to approximately 3%, similar to the risk in the general population.…”

“…It can be extremely difficult during early stages to differentiate pregnancy-related physiologic changes from the subtle, early signs of an evolving acute malignancy, and this mimicry may delay a cancer diagnosis. 1,[8][9][10][11][12][13] Interestingly, a recent systematic review of nonHodgkin lymphoma (NHL) in pregnancy observed that aggressive forms of NHL exhibit unique clinical and biological features during pregnancy, including frequent involvement of the reproductive organs (breast, ovary, uterus, and placenta).…”

“…9,20 The placenta is an inefficient barrier to cytotoxic drugs, allowing the passage of molecules < 600 kDa (including almost all cytotoxic agents). 10,12 The comparative teratogenicity of individual chemotherapeutic agents depends on their molecular weight, ionization state, lipid solubility, and binding affinity to plasma proteins; therefore, low-molecular-weight, nonionized, highly lipid-soluble, and loosely protein-bound drugs are able to cause the greatest fetal harm. 1,10,12,21 However, the most crucial determinant of teratogenicity is the gestational timing of exposure.…”

“…10,12 The comparative teratogenicity of individual chemotherapeutic agents depends on their molecular weight, ionization state, lipid solubility, and binding affinity to plasma proteins; therefore, low-molecular-weight, nonionized, highly lipid-soluble, and loosely protein-bound drugs are able to cause the greatest fetal harm. 1,10,12,21 However, the most crucial determinant of teratogenicity is the gestational timing of exposure. Exposure during the first two weeks produces an ''all or nothing'' effect, meaning either loss of pregnancy or no lasting damage.…”

“…68 The overall risk of teratogenicity during the first trimester is considered to be 10-20%; 1,8 the risk is 10% after the use of a single chemotherapeutic agent and 15-25% after combination chemotherapy. 8,9,11,12,23 The greatest risks are from alkylating agents and antimetabolites; vincristine poses the lowest risk. 11 However, in a prospective study by Aviles and Niz of 20 children exposed in utero to intensive ALL chemotherapy between 1963 and 1981 (11 of which were exposed during the first trimester), none showed any congenital malformation, chromosomal abnormality, or late-onset cardiac or neurologic toxicity during follow-up periods ranging from 4 to 22 years.…”