Radiotherapy and Pregnancy: Together or Alone?

Abstract

Organ malformations and mental retardation (the sensitivity is high from 2 to 8 weeks, and 8 to 25 weeks after conception, respectively) are the most serious results of fetal exposure to radiation that are observed after birth and probably arise above a threshold dose of 0.1–0.2 Gy. This threshold dose is not generally reached with curative radiotherapy during pregnancy, because most of the tumors are located sufficiently far from the fetus and that precautions have been taken to protect the unborn child against leakage radiation and collimator scatter. Generally, pregnant women with malignant diseases are advised to delay the radiotherapy until after delivery. If a pregnant patient necessitates radiotherapy the physician should inform the risk of the fetus and the benefits of the mother. Subjects like week of pregnancy, stage of the disease and radiation safety must be discussed in details and the final decision should be taken by the patient. In this review, patients who were exposed to radiation during pregnancy because of radiotherapy and their fetal exposure were discussed. Key words: Radiotherapy; Pregnancy; Fetal Exposure.

Keywords

• Radiotherapy; Pregnancy; Fetal Exposure.

Radyoterapi ve Hamilelik: Birlikte ya da Tek Başına?

Öz

Organ kusurları ve zeka gelişim bozukluğu (döllenmeden sonra sırasıyla 2-8. ve 8-25. haftalarda duyarlılık yüksektir) doğumdan sonra fetal radyasyon maruziyetine bağlı görülen en ciddi sorunlardır ve muhtemelen 0.1-0.2 Gy'lik eşik dozun üzerinde ortaya çıkar. Bu eşik doza hamilelik sırasında küratif radyoterapi ile genellikle ulaşılmaz çünkü tümörlerin çoğu fetüsten yeterince uzakta yerleşiktir ve doğmamış çocuğu korumak için sızıntı radyasyona ve kolimatör saçılmalarına karşı önlemler alınmıştır. Genellikle malign hastalığı olan hamile kadınlara radyoterapinin doğum sonrasına ertelenmesi tavsiye edilir. Eğer hamile bir hastaya radyoterapi zorunluluğu olursa hekim fetüsün riskleri ve annenin faydaları konusunda bilgilendirmek zorundadır. Hamilelik haftası, hastalığın evresi ve radyasyon güvenliği gibi konular detaylı bir şekilde tartışılmalı ve son karar hasta tarafından verilmelidir. Bu derlemede hamilelik sırasında radyoterapi sırasında radyasyona maruz kalan hastalar ve fetal maruziyetleri tartışılmıştır. Anahtar kelimeler: Radyoterapi; Hamilelik; Fetal Maruziyet.

Anahtar Kelimeler

• Radyoterapi; Hamilelik; Fetal Maruziyet.

References

1. Pavlidis NA. Coexistence of pregnancy and malignancy. Oncologist 2002; 7: 279-87. DOI: 10.1634/theoncologist.7-6-573
2. White TT. Carcinoma of the breast and pregnancy; analysis of 920 cases collected from the literature and 22 new cases. Ann Surg 1954; 139: 9-18. DOI: 10.1097/00000658-195401000-00002
3. Peete CH, Honeycutt HC, Cherny WB. Cancer of the breast in pregnancy. NC Med J 1966; 27: 514-20.
4. Anderson JM. Mammary cancers and pregnancy. Br Med J 1979; 1: 1124-7. DOI: 10.1136/bmj.1.6171.1124
5. Lishner M, Zemlickis D, Degendorfer P, Panzarella T, Sutcliffe SB, Koren G. Maternal and foetal outcome following Hodgkin’s disease in pregnancy. Br J Cancer 1992; 65: 114-7. DOI: 10.1038/bjc.1992.21
6. Hacker NF, Berek JS, Lagasse LD, Charles EH, Savage EW, Moore JG. Carcinoma of the cervix associated with pregnancy. Obstet Gynecol 1982; 59: 735-46.
7. Gwyn KM, Theriault RL. Breast cancer during pregnancy. Curr Treat Options Oncol 2000; 1: 239-43. DOI: 10.1007/s11864-000-0035-8
8. Petrek JA. Breast cancer and pregnancy. J Natl Cancer Inst Monogr 1994; 16: 113-21.

9. Nakagawa K, Aoki Y, Kusama T, Ban N, Nakagawa S, Sasaki Y. Clin Ther 1997; 19: 770-7. DOI: 10.1016/S0149-2918(97)80101-4
10. Brent RL. The effects of embryonic and fetal exposure to X-ray, microwaves, and ultrasound. Clin Obstet Gynecol 1983; 26: 484-510. DOI: 10.1097/00003081-198306000- 00030
11. Greer BE, Goff BA, Koh W. Cancer in the pregnant patient. In: Hoskins WJ, Perez CA, Young RC, eds. Principles and Practice of Gynecologic Oncology, 2nd edn. New York: Lippincott Raven 1997:463-70.
12. Rugh R. X-ray induced teratogenesis in the mouse and its possible significance to man. Radiology 1971; 99: 433-43.
13. Hicks SP, D’amato CJ. Effects of ionizing radiation on mammalian development. Adv Teratol 1966; 1:195-9.
14. Jablon S, Kato H. Childhood cancer in relation to prenatal exposure to atomic bomb radiation. Lancet 1970; 2: 1000- 3. DOI: 10.1016/S0140-6736(70)92813-8
15. United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). Genetic and somatic effects of ionizing radiation. United Nations, New York, 1986, 16-8, 332-4.
16. International Commission on Radiological Protection. Pregnancy and medical radiation. Ann ICRP 2000; 30: 1- 43. DOI: 10.1016/S0146-6453(00)00024-5
17. Streffer C, Shore R, Konermann G, et al. Biological effects after prenatal irradiation (embryo and fetus). A report of the International Commission on Radiological Protection. Ann ICRP 2003; 33: 5-206.
18. Pentheroudakis G, Pavlidis N. Cancer and pregnancy: poena magna, not anymore. Eur J Cancer 2006; 42: 126- 40. DOI: 10.1016/j.ejca.2005.10.014
19. UNSCEAR. Sources and effects of ionizing radiation. Annex J, developmental effects of irradiation in utero. New York: United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), 1977.
20. Otake M, Yoshimaru H, Schull WJ. Severe mental retardation among the prenatally exposed survivors of the atomic bombing of Hiroshima and Nagasaki: A comparison of the T65DR and DS86 dosimetry systems. Radiation Effects Research Foundation: Hiroshima; 1987: 16-87.
21. Schull WJ, Otake M, Yoshimura H. Effect of intelligence test score of prenatal exposure to ionizing radiation to Hiroshima and Nagasaki: a comparison of the T65DR and DS86 dosimetry systems. RERF Technical report. Hitroshima: Radiation Effects Research Foundation; 1988:3-88.
22. Otake M, Schull WJ, Lee S. Threshold for radiation- related severe mental retardation in prenatally exposed A- bomb survivors: a re-analysis. Int J Radiat Biol 1996; 70: 755-63. DOI: 10.1080/095530096144644
23. Otake M, Schull WJ. Radiation-related brain damage and growth retardation among the prenatally exposed atomic bomb survivors. Int J Radiat Biol 1998; 74: 159-71. DOI: 10.1080/095530098141555
24. Otake M, Schull WJ. Radiation-related small head sizes among prenatally exposed A-bomb survivors. Int J Radiat Oncol Biol Phys 1993; 63: 255-70.
25. Stovall M, Blackwell CR, Cundiff J, et al. Fetal dose from radiotherapy with photon beams: report of AAPM Radiation Therapy Committee Task Group No. 36. Med Phys 1995; 22: 63-82. DOI: 10.1118/1.597525
26. Kal HB, Struikmans H. Radiotherapy during pregnancy: fact and fiction. Lancet Oncol 2005; 6: 328-33. DOI: 10.1016/S1470-2045(05)70169-8
27. Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation. Br J Radiol 1997; 70: 130-9.
28. Woo SY, Fuller LM, Cundiff JH, et al. Radiotherapy during pregnancy for clinical stages IA-IIA Hodgkin's disease. Int J Radiat Oncol Biol Phys 1992; 23: 407-12. DOI: 10.1016/0360-3016(92)90761-6
29. Antypas C, Sandilos P, Kouvaris J, et al. Fetal dose evaluation during breast cancer radiotherapy. Int J Radiat Oncol Biol Phys 1998; 40(4): 995-9. DOI: 10.1016/S0360-3016(97)00909-7
30. Sharma DS, Jalali R, Tambe CM, Animesh, Deshpande DD. Effect of tertiary multileaf collimator (MLC) on foetal dose during three-dimensional conformal radiation therapy (3DCRT) of a brain tumour during pregnancy. Radiother Oncol 2004; 70: 49-54. DOI: 10.1016/j.radonc.2003.10.011
31. Mazonakis M, Varveris H, Fasoulaki M, Damilakis J. Radiotherapy of Hodgkin's disease in early pregnancy: embryo dose measurements. Radiother Oncol 2003; 66: 333-9. DOI: 10.1016/S0167-8140(02)00329-8
32. Fenig E, Mishaeli M, Kalish Y, Lishner M. Pregnancy and radiation. Cancer Treat Rev 2001; 27: 1-7. DOI: 10.1053/ctrv.2000.0193
33. Van der Giessen PH. Measurement of the peripheral dose for the tangential breast treatment technique with Co-60 gamma radiation and high energy X-rays. Radiother Oncol 1997; 42: 257-64. DOI: 10.1016/S0167- 8140(96)01884-1
34. Mazonakis M, Varveris H, Damilakis J, Theoharopoulos N, Gourtsoyiannis N. Radiation dose to conceptus resulting from tangential breast irradiation. Int J Radiat Oncol Biol Phys 2003; 55: 386-91. DOI: 10.1016/S0360- 3016(02)04206-2
35. Ngu SL, Duval P, Collins C. Foetal radiation dose in radiotherapy for breast cancer. Australas Radiol 1992; 36: 321-2. DOI: 10.1111/j.1440-1673.1992.tb03209.x
36. Nuyttens JJ, Prado KL, Jenrette JM, Williams TE. Fetal dose during radiotherapy: clinical implementation and review of the literature. Cancer Radiother 2002; 6: 352-7. DOI: 10.1016/S1278-3218(02)00249-4
37. Nisce LZ, Tome MA, He S, Lee BJ 3rd, Kutcher GJ. Management of coexisting Hodgkin's disease and pregnancy. Am J Clin Oncol 1986; 9: 146-51. DOI: 10.1097/00000421-198604000-00009
38. Cygler J, Ding GX, Kendal W, Cross P. Fetal dose for a patient undergoing mantle field irradiation for Hodgkin's disease. Med Dosim 1997; 22: 135-7. DOI: 10.1016/S0958-3947(97)00011-3
39. Mazonakis M, Lyraraki E, Varveris C, Samara E, Zourari K, Damilakis J. Conceptus dose from involved-field radiotherapy for Hodgkin's lymphoma on a linear accelerator equipped with MLCs. Strahlenther Onkol 2009; 185: 355-63. DOI: 10.1007/s00066-009-1932-9
40. Klieger-Grossmann C, Djokanovic N, Chitayat D, Koren G. In utero exposure to therapeutic radiation for Hodgkin lymphoma. Can Fam Physician 2009; 55: 988-91.
41. Schantz SP, Yu GP. Head and neck cancer incidence trends in young Americans, 1973-1997, with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg 2002; 128: 268-74.
42. Llewellyn CD, Johnson NW, Warnakulasuriya KA. Risk factors for squamous cell carcinoma of the oral cavity in young people--a comprehensive literature review. Oral Oncol 2001;37: 401-18. DOI: 10.1016/S1368- 8375(00)00135-4
43. Bradley PJ, Raghavan U. Cancers presenting in the head and neck during pregnancy. Curr Opin Otolaryngol Head Neck Surg. 2004; 12:76-81. DOI: 10.1097/00020840- 200404000-00004
44. Dumper J, Kerr P. Recurrent squamous cell carcinoma of the tongue in pregnancy. J Otolaryngol 2005; 34: 242-3. DOI: 10.2310/7070.2005.34406
45. Haba Y, Twyman N, Thomas SJ, Overton C, Dendy P, Burnet NG. Radiotherapy for glioma during pregnancy: fetal dose estimates, risk assessment and clinical management. Clin Oncol (R Coll Radiol) 2004; 16: 210-4. DOI: 10.1016/j.clon.2004.01.009
46. Mazonakis M, Damilakis J, Theoharopoulos N, Varveris H, Gourtsoyiannis N. Brain radiotherapy during pregnancy: an analysis of conceptus dose using anthropomorphic phantoms. Br J Radiol 1999; 72: 274-8.
47. Yu C, Jozsef G, Apuzzo ML, MacPherson DM, Petrovich Z. Fetal radiation doses for model C gamma knife radiosurgery. Neurosurgery. 2003; 52: 687-93. DOI: 10.1227/01.NEU.0000048479.23069.24
48. Magné N, Marcié S, Pignol JP, Casagrande F, Lagrange JL. Radiotherapy for a solitary brain metastasis during pregnancy: a method for reducing fetal dose. Br J Radiol 2001; 74: 638-41.
49. Sneed PK, Albright NW, Wara WM, Prados MD, Wilson CB. Fetal dose estimates for radiotherapy of brain tumors during pregnancy. Int J Radiat Oncol Biol Phys 1995; 32: 823-30. DOI: 10.1016/0360-3016(94)00456-U
50. Münter MW, Wengenroth M, Fehrenbacher G, Schardt D, Nikoghosyan A, Durante M, Debus J. Heavy ion radiotherapy during pregnancy. Fertil Steril 2010;94:2329.e5-2329.e7.
51. Podgorsak MB, Meiler RJ, Kowal H, Kishel SP, Orner JB. Technical management of a pregnant patient undergoing radiation therapy to the head and neck. Med Dosim 1999; 24: 121-8. DOI: 10.1016/S0958-3947(99)00010-2
52. Ioffe V, Hudes RS, Shepard D, Simard JM, Chin LS, Yu C. Fetal and ovarian radiation dose in patients undergoing gamma knife radiosurgery. Surg Neurol 2002; 58: 32-41. DOI: 10.1016/S0090-3019(02)00742-5
53. Weisz B, Schiff E, Lishner M. Cancer in pregnancy: maternal and fetal implications. Hum Reprod Update 2001; 7: 384-93. DOI: 10.1093/humupd/7.4.384
54. Hopkins MP, Lavin JP. Cervical cancer in pregnancy. Gynecol Oncol 1996; 63: 293. DOI: 10.1006/gyno.1996.0324
55. Greer BE, Easterling TR, McLennan DA, et al. Fetal and maternal considerations in the management of stage I-B cervical cancer during pregnancy. Gynecol Oncol 1989; 34: 61-5. DOI: 10.1016/0090-8258(89)90108-X
56. Gordon AN, Jensen R, Jones HW 3rd. Squamous carcinoma of the cervix complicating pregnancy: recurrence in episiotomy after vaginal delivery. Obstet Gynecol 1989; 73: 850-2.
57. National Cancer Institute-Surveillance, Epidemiology and End Results (SEER). Cancer statistics review 1973-1991: tables and graphs. Bethesda, MD: National Cancer Institute; 1994.
58. Pavlidis N, Pentheroudakis G. The pregnant mother with breast cancer: diagnostic and therapeutic management. Cancer Treat Rev 2005; 31: 439-47. DOI: 10.1016/j.ctrv.2005.04.010
59. How to cite this review: Bakkal BH, Sayın M.
60. Radiotherapy and Pregnancy: Together or Alone? .
61. JIUMF 2012; 19(2): 120-7. DOI:
62. 7247/jiumf.19.2.13