The radiologist's role in a multidisciplinary approach to cancer in pregnancy

Abstract

Pregnancy-associated cancer (PAC) occurs in approximately 1 in 1000 pregnancies, and the incidence is expected to rise due to delayed childbearing (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020; Woitek et al. in ESMO Open 1:e000017, 2016). Diagnosis and management of PACs are challenging and diagnosis is often delayed as symptoms may overlap with physiologic changes of pregnancy (Jha et al. in RadioGraphics 42:220005, 2022). These patients are best cared for by a multidisciplinary healthcare team composed of experts (Silverstein et al. in JCO Oncol Pract 16:545-557, 2020). Management of these patients must balance optimal maternal care with potentially harmful fetal effects. This involves honest, forthright, and sometimes difficult discussions between the care team and the patient throughout the entirety of care. Radiologists play a significant role in timely cancer diagnosis, staging and follow-up during and after pregnancy, accurate determination of gestational age, and in assessing fetal growth and well-being throughout pregnancy.

Keywords: Malignancy in pregnancy; Multidisciplinary care; Pregnancy-associated cancer; Radiology.

Fig. 1

37-year-old pregnant patient, at 28 weeks of gestation, presenting with two months of recurrent diarrhea and rectal bleeding. Initial stool microscopy was positive for Giardia and flexible sigmoidoscopy noted mild proctitis. The patient’s symptoms persisted despite completion of treatment for Giardia and she was admitted for an expedited work-up of suspected colitis. a Axial T2-weighted fat-saturated MRI through the pelvis demonstrated circumferential, long segment thickening of the sigmoid colon wall (arrow), which was favored to represent colitis. b Retrospectively, diffusion-weighted MRI sequences demonstrated reduced diffusion of the colonic wall (arrow), which should have alerted the radiologist to possible underlying malignancy. Despite extensive treatment, the patient’s symptoms worsened and biopsy was recommended. c Repeat flexible sigmoidoscopy demonstrated erythematous, friable, and ulcerated sigmoid colonic tissue. Biopsies taken from this region were positive for adenocarcinoma. The patient was started on chemotherapy at 30 weeks of gestation. During her hospital course, the patient developed worsening, unexplained abdominal pain. After a detailed risks and benefits discussion with the patient, the shared decision was made to perform a CT abdomen/pelvis. d Axial contrast-enhanced CT abdomen/pelvis demonstrated new pneumoperitoneum (arrow) and e a rim-enhancing fluid and gas collection (arrowheads) consistent with sigmoid perforation. This necessitated urgent delivery via cesarean section at which time a concomitant left colonic resection was performed. Surgical pathology confirmed adenocarcinoma. During surgery, the patient was also found to have peritoneal disease which the team is planning to treat with systemic chemotherapy, peritoneal stripping, and hyperthermic intraperitoneal chemotherapy

Fig. 2

25-year-old pregnant patient in early first trimester, presenting with a palpable left supraclavicular mass. This was evaluated by ultrasound (not shown) which revealed an enlarged and abnormal lymph node corresponding to the patient’s palpable abnormality. Subsequent evaluation with fine needle aspiration and core biopsy, under ultrasound guidance, revealed Hodgkin’s lymphoma, at which time the patient was 8 weeks pregnant. Due to concern for fetal safety, staging was performed with a whole-body non-contrast MRI, instead of a PET-CT. a Coronal T1-weighted fat-saturated MRI demonstrated supraclavicular and mediastinal adenopathy (arrow). Chemotherapy was deferred until the second trimester. Maternal fetal medicine deemed no indication for early delivery based on her malignancy diagnosis. b Coronal fused images from the follow-up PET-CT after term delivery showed no evidence of disease, compatible with remission

Fig. 3

30-year-old pregnant patient, at 32 weeks of gestation, presenting with persistent headaches and nausea. a Axial non-contrast CT demonstrated a dense mass centered in the right cerebellum with surrounding edema (arrow). b Sagittal non-contrast CT demonstrated downward cerebellar tonsillar herniation (arrow) and acute obstructive hydrocephalous (arrowhead). Emergent treatment was initiated to reduce intracranial pressure. Once the patient was stable, a multidisciplinary team discussed next best steps in management. Despite theoretical fetal risks, the decision was made to pursue an MRI with contrast. c Coronal T2-weighted MRI images demonstrated a hyperintense mass (arrow) with a peripheral rim of hemosiderin and vascular flow voids. d T1-weighted contrast-enhanced MRI axial images demonstrated a well-circumscribed, enhancing mass, (arrow) most compatible with a hemangioblastoma. e Sagittal T2-weighted MRI images demonstrated continued marked mass effect with tonsillar herniation (arrow), upper cervical cord edema, and papilledema. The patient was scheduled for urgent surgery. However, the day before her surgery, she became preeclamptic and was delivered by emergency cesarean section at 33 weeks. After delivery, the patient underwent craniotomy for tumor resection with pathology confirming hemangioblastoma. After resection, the patient reported resolution of her presenting symptoms and is being followed with serial imaging