How is nasopharyngeal cancer treated during pregnancy?

Treatment of Nasopharyngeal Cancer During Pregnancy

Treatment of nasopharyngeal carcinoma (NPC) during pregnancy requires individualized multidisciplinary management, with decisions based on gestational age, disease stage, and careful consideration of maternal survival and fetal risks. 1

Diagnosis and Staging

• Fine needle aspiration, core needle or open excisional biopsies are safe to perform during pregnancy 1
• MRI without contrast is the preferred imaging modality, with abdominal shielding to limit fetal exposure 1
• Gadolinium contrast should be avoided, especially during the first trimester 1
• CT scans and radioisotope studies should be avoided due to radiation exposure risks 1
• Ultrasound examinations and chest X-rays with abdominal shielding can be safely performed for basic staging 1

Treatment Approach Based on Trimester

First Trimester

• Pregnancy termination should be considered if immediate treatment with chemotherapy or radiotherapy is required 1
• If the patient wishes to continue pregnancy, treatment may be delayed until the second trimester in early-stage disease 1
• For advanced disease requiring immediate treatment, careful discussion of risks and benefits is essential 1

Second and Third Trimesters

• Chemotherapy can be administered with acceptable fetal risks during the second and third trimesters 1
• There is a slightly increased risk of stillbirth, growth restriction, and premature delivery with chemotherapy during pregnancy 1
• Delivery should be planned for weeks 32-35, at least 3 weeks after the last chemotherapy cycle 1
• Radiotherapy should be deferred until after delivery due to significant fetal risks 1

Chemotherapy Considerations

• Methotrexate is absolutely contraindicated at any stage of pregnancy due to severe teratogenic effects 1
• Older-generation alkylating agents (procarbazine, busulfan), thalidomide, lenalidomide, pomalidomide, and tretinoin are also contraindicated 1
• Targeted therapies and hormonal agents should be avoided during pregnancy 1
• For NPC, platinum-based regimens are standard but must be carefully considered 1
• Supportive medications:
  • Antiemetics like ondansetron and metoclopramide can be safely administered 1
  • Corticosteroids should be used cautiously in the first trimester 1
  • Growth factors for neutropenia management have been used without significant adverse effects 1

Radiation Therapy

• Intensity-modulated radiotherapy (IMRT) is the standard of care for NPC but should be deferred until after delivery 1
• The recommended dose for NPC is 70 Gy in 33-35 fractions 1
• Radiation exposure poses significant risks to the fetus, particularly during the first trimester 1
• In rare cases when radiation is absolutely necessary during pregnancy, modified techniques with additional shielding may be considered, but this is generally not recommended 1

Multidisciplinary Approach

• Treatment decisions should involve medical oncologists, radiation oncologists, obstetricians, perinatologists, and the patient 1
• Referral to tertiary cancer centers with expertise in cancer management during pregnancy is strongly recommended 1
• Regular monitoring of both maternal disease status and fetal development is essential 1

Long-term Outcomes

• With modern treatment approaches, pregnancy itself may not negatively influence survival outcomes in patients with NPC 2
• However, pregnancy may delay NPC diagnosis, potentially affecting stage at presentation 2
• Children born to mothers who received chemotherapy during the second and third trimesters generally show normal physical and mental development 1

Follow-up

• After delivery, histological examination of the placenta should be performed, although placental/fetal metastases are extremely rare 1
• Standard follow-up protocols for NPC should be implemented after delivery 1
• Future pregnancies are not contraindicated in women who have completed treatment and are disease-free 3

The management of NPC during pregnancy presents unique challenges that require careful consideration of both maternal and fetal outcomes. Treatment decisions should prioritize maternal survival while minimizing risks to the fetus whenever possible.