Lung cancer

Lung cancer

Epidemiology

Lung cancer during pregnancy is rare. However, the number of cases may be growing due to the combined effects of increased cigarette consumption in young women and delayed child bearing.

Diagnosis

The presenting signs and symptoms associated with lung cancer and pregnancy are similar to the non pregnant state and depend mainly on the stage of the lung cancer. Symptoms related to the growth of the tumor, such as blood-streaked sputum, persistent cough or change in cough pattern, wheezing, decreased appetite with poor weight gain during pregnancy, along with other loco-regional symptoms (with or without a detectable pleural effusion) are commonly seen. Delays in the diagnosis may occur due to reasons such as low index of suspicion, tendency to attribute symptoms such as fatigue and dyspnea on the pregnant state and physician reluctance to order a chest radiograph during pregnancy.

A detailed history and accurate physical examination remain the most important in the evaluation of these patients. Plain anteroposterior and lateral chest radiographs are the most valuable tools in the diagnosis of lung cancer (Nicklas Semin Oncol 2000). Ultrasound and MRI studies are probably appropriate for metastatic work-up, especially in subdiaphragmatic sites (Vincent Cancer 1997).

Histologic confirmation is achieved by sputum cytology, percutaneous fine needle aspiration, bronchoscopy with biopsy or by bronchoalveolar lavage (or by biopsy of metastatic sites). Decisions regarding the further investigations that are necessary for staging and metastatic workup is determined by the presenting signs and symptoms, the histological subtype (small cell vs non-small cell), and by the fetal age and possible radiation exposure.

Treatment

Non-Small Cell

The treatment of choice in early stage non-small cell lung cancer is curative surgical resection. In more advanced stages, the treatment of these patients depends on the size and location of the primary tumor and the extent of nodal involvement. Treatment options in non-pregnant patients may include different combinations of surgery, chemotherapy and radiotherapy.

Small Cell

Small cell lung cancer is characterized by an aggressive clinical course and relatively good (although short lived) response to chemo/radiotherapy compared to other types of lung cancer. Treatment during pregnancy must balance the toxicity of treatment to mother and fetus against the morbidity of untreated disease. None of the case reports of small cell lung cancer involved treatment during pregnancy. Patients received postpartum chemotherapy or radiotherapy or supportive treatment only. (Stark Radiologe 1985, Barr J Obstet Gynaecol Br Emp 1953, Hesketh J Obstet Gynaecol Br Comm 1962, Jones BMJ 1969, Delevire Arch Pathol Lab Med 1989)
Cisplatin and vinorelbine are considered a standard regimen against which future investigational regimens should be measured, since this combination proved superior to the single agent (Vincent Cancer 1997).

Prognosis

There is no evidence that pregnancy alters the prognosis of lung cancer. Maternal outcome for both small cell and non-small cell lung cancer has been poor and is a reflection of the advanced stage at diagnosis. This may be due in part, to misinterpretation of respiratory symptoms and physician's reluctance to perform radiologic imaging studies during pregnancy (Hesketh J Obstet Gynaecol Br Comm 1962).

There is no evidence that fetal outcome is adversely affected by maternal lung cancer, provided that adequate supportive treatment is provided to the mother. Metastatic involvement of the placenta has been reported in the majority of the reported cases. In contrast, there were no reports of fetal involvement (Nicklas Sem Oncol 2000).

References

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  • Bitar R. J., Melillo N. and Pesin J. L. Lung cancer during pregnancy. (Letter). Mayo Clin Proc., 70: 1130, 1995.
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  • Hesketh J. A case of carcinoma of the lung with secondary deposits in the placenta. J Obstet Gynaecol Br Comm., 69: 514, 1962.
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  • Nicklas A, Baker M. Imaging strategies in the pregnant cancer patient. Seminars in Oncology:Vol 27, No 6, December, 2000.
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  • Van Winter J. T., Wilkowske M. A., Shaw E. G., Ogburn P. L. and Pritchard D. J. Lung cancer complicating pregnancy: case report and review of literature. Mayo Clin Proc., 70: 384-387, 1995.
  • Vincent T, Devita JR, Hellman S, Rosenberg SA. Cancer. Principles & Practice of Oncology. 5th Ed. Lippincott-Raven Publishers. 1997.
  • Watanabe M, Tomita K, Burioka N, Yajima H et al. Mucoepidermoid carcinoma of the trachea with airway hyperresponsiveness. Anticancer Research 20:1995-1998, 2000.