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Case History

image A 31-year-old woman conceived a pregnancy naturally. She was fit and well and her only past medical history was sarcoidosis which was identified following biopsy of a skin lesion 2 years previously. A computerised tomography (CT) scan performed at that time showed hilar lymph nodes and she underwent an endobronchial ultrasound and biopsy, the results of which were consistent with sarcoidosis. Her 12-week scan showed a twin pregnancy but only one viable fetus, and her pregnancy continued with usual care. At approximately 15 weeks gestation she developed left sided chest pain and after a further 2 weeks noted worsening pain, a dry cough and hoarse voice.

The patient attended the emergency department and had a chest X-ray and CT pulmonary angiogram. This demonstrated a left upper lobe cavitating mass, pleural effusion and hilar and supraclavicular lymphadenopathy, there was no pulmonary embolism.

The patient underwent an ultrasound and aspiration of pleural fluid and cytology confirmed metastatic adenocarcinoma of lung origin with a primary epidermal growth factor receptor (EGFR) exon 19 mutation. At this time the patient was 19 weeks pregnant.

The patient had a combined consultation with an oncologist and obstetrician where a detailed and frank discussion was held including the following options; termination of pregnancy to allow cancer treatment, cancer treatment and continuation of pregnancy or a period of surveillance (given that this is frequently a relatively slowgrowing cancer) to try and allow the pregnancy to continue to a viable gestation,but at the risk of disease progression and increasing symptoms. The patient opted for surveillance with an early repeat CT scan planned to check for rate of progression.

At 25 weeks gestation, a CT scan showed significant disease progression with new chest wall invasion, and so the patient commenced on primary therapy with the EGFR tyrosine kinase inhibitor gefitinib. After 3 weeks, the patient experienced significant clinical deterioration with development of new liver and brain metastases.

The patient underwent an emergency C-section at 29 weeks gestation with delivery of a healthy baby.

Further testing on pleural cytology showed a primary T790M resistance mutation. The patient was commenced on osimertinib (an EGFR tyrosine kinase inhibitor licenced for second-line treatment in the presence of T790M resistance mutations), with excellent response. Repeat imaging showed near total resolution of brain metastases, and significant reduction of other sites of disease.

What investigations are safe during pregnancy?

What would be the safest anti-cancer treatment for this lady?

When would have been the optimal time for delivery?

What investigations are safe during pregnancy?

Investigations during pregnancy which use ionizing radiation may cause some anxiety in both clinicians and in patients due to an assumed risk of harm. However, risks of investigations are relatively low, and must be balanced with the potential risks of missing or delaying the diagnosis of a significant condition. Imaging with ionizing radiation is considered low-risk if it involves a dose of <10 mGy ...

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