Successful Pregnancy in a 29-Year-Old G3P2 Shortly After Unilateral Pneumonectomy and Systemic Chemotherapy for Lung Cancer: A Case Report

Background

Lung cancer is a common cause of cancer-related death worldwide among females [1]. Its occurrence is rare (about <5%) among females who are less than 40 to 45 years old [1]. Adenocarcinoma is the most common histological type of lung cancer among females [2]. The prevalence of lung cancer during pregnancy is exceedingly rare, and it is estimated to affect about 0.1% of all pregnancies [3,4]. The most recent review in 2016 by Mitrou et al reported a total of 70 cases of lung cancer during pregnancy [4]. Generally speaking, lung resection is the standard surgical treatment for lung cancer, and postoperative chemotherapy has been demonstrated to prolong overall survival [5].

Pneumonectomy is a surgical procedure that involves the removal of 1 entire lung, and it is different from lobectomy and other related procedures. The indications of pneumonectomy are numerous and include trauma, infection (eg, tuberculosis), and malignancy (eg, non-small cell lung cancer). There are several published reports of concurrent pneumonectomy for progressive pulmonary tuberculosis [6] and invasive chondrosarcoma of the rib [7] during pregnancy, which were followed by a normal birth during the same course of pregnancy. Moreover, several investigations have documented favorable maternal-fetal outcomes for later pregnancies after pneumonectomy due to non-cancer-related causes, most of which were secondary to progressive pulmonary tuberculosis [8–10]. However, very little is known about maternal-fetal outcomes for future conceptions after pneumonectomy due to cancer-related causes (eg, squamous cell carcinoma) and subsequent chemotherapy regimens. This is an important knowledge gap in the literature that needs to be filled.

Herein, we report the maternal-fetal outcomes of a 29-year-old Saudi woman who conceived after unilateral pneumonectomy and adjuvant chemotherapy.

Case Report

A 29-year-old Saudi woman, G3P2, at 11 weeks of a spontaneous singleton pregnancy, presented to our maternal-fetal medicine clinic for routine follow-up. She was a known case of adenocarcinoma of the left lung 2 years ago, which was discovered during her second pregnancy at 28 weeks of gestation after an episode of hemoptysis. During the work-up, a lung mass was found and a biopsy confirmed lung adenocarcinoma. She underwent an urgent lower-segment transverse cesarean section at 30 weeks due to the urgent need for lung surgery. She immediately underwent left pneumonectomy, and 4 weeks later after surgery she received 6 cycles of adjuvant chemotherapy (cisplatin and pemetrexed), which was completed over 7 months. The histopathology of her left lung revealed poorly-differentiated invasive adenocarcinoma, grade III. At the molecular level, the malignant cells were wild-type for epidermal growth factor receptor (EGFR), but stained positive (60%) for programmed cell death ligand 1 (PD-L1). The patient was not planning on conceiving and she was not on proper contraception, as she believed that her fertility would automatically decline during chemotherapy. Nevertheless, she was incidentally found to be pregnant at 11 weeks of gestation at the time of attendance to the obstetric clinic (roughly 5 months after the completion of her adjuvant chemotherapy cycles). Hence, the conception was estimated to have happened roughly 2 months after the completion of her chemotherapy cycles.

At presentation to the clinic, she was asymptomatic. The obstetric history was remarkable for a previous cesarean delivery secondary to her condition of lung cancer 2 years ago; otherwise, she had 1 term uncomplicated normal vaginal delivery. Her family history and social history were unremarkable. The patient and her husband were both non-smokers. Her menarche began at 13 years old, with subsequent regular cycles.

An ultrasound examination showed a single viable intrauterine pregnancy corresponding to 11+4 weeks and normal nuchal translucency of 1.2 mm (37%). A multidisciplinary approach was introduced, with contributions from maternal-fetal medicine, medical oncology, and pulmonary teams to plan her management. Following a discussion of the benefits and risks, it was decided to keep her pregnancy because there was no clear medical reason to terminate it as the patient had stage II-B adenocarcinoma and had recently completed the full proper treatment. However, as the 5-year recurrence rate for this specific tumor is high, the management team recommended close monitoring and regular follow-up of the patient with different teams.

The baseline computed tomography (CT) chest and abdomen without contrast displayed complete opacification of the left hemithorax with a shift of the cardiac silhouette towards the left side. The right lung was clear with no sizable right effusion.

At 19 weeks of gestation, a CT chest revealed no signs of recurrence or metastasis; however, the possibility of missing smaller metastasis spots could not be confidently excluded because the imaging investigations were done without contrast (Figure 1). Her antenatal visit was uneventful. An obstetric ultrasound exam demonstrated normal anatomy and growth scan. Laboratory work-up, including complete blood count, in addition to renal, and hepatic function tests, revealed normal results. An adult echocardiogram showed normal findings.

The lower-segment transverse cesarean section was performed at 37+4 weeks, since the patient had 1 previous cesarean section and refused vaginal birth after cesarean delivery. The baby weighed 2495 g with an Apgar score of 8 and 9 at 1 and 5 minutes, respectively. The postpartum interval was not complicated. After delivery, a CT chest and abdomen showed no signs of recurrence or metastasis. At 8-weeks follow-up, the management team inserted a non-hormonal intrauterine device (copper-based) for contraception. The patient had returned to her normal daily activities and planned follow up with medical oncology and pulmonary teams.

Discussion

The first case of lung cancer during pregnancy was reported in the early 1950s [11]. The incidence of tumors during pregnancy, generally, is very uncommon. The incidence of lung cancer during pregnancy, specifically, is exceedingly low [3,4]. In the present case report, our non-smoker, 29-year-old patient was diagnosed with adenocarcinoma of the lung during her second pregnancy and underwent urgent cesarean section to perform unilateral pneumonectomy, which was followed by adjuvant chemotherapy. In consideration of the underlying malignancy, the medical oncologist prevented the patient from using any hormonal contraception (eg, pills, patches, or hormone-based intrauterine devices) so as to not increase the potential risk of thromboembolic events. The patient was counselled about the potential problems of future conception. Also, the use of physical condoms as a method of contraception was advised and not prohibited. Nonetheless, around 5 months after the completion of the adjuvant chemotherapy cycles, the patient was found to be pregnant at 11 weeks of gestation. A recent review revealed that almost 50% of patients diagnosed with lung cancer during pregnancy were treated during the post-partum period, whereas 24% of the patients were treated during the course of the pregnancy [4]. This observation indicates that cancer treatment during pregnancy may not affect pregnancy in terms of maternal-fetal outcomes. Also, it was reported that almost all patients with lung cancer during pregnancy were found to be positive for EGFR mutation [4], which was not the case in our patient.

The patient was referred to our maternal-fetal medicine service and underwent CT without contrast. The literature suggests that CT does not appear to increase the hazard of spontaneous abortion or congenital deformities. However, CT may potentially increase the likelihood of developing pediatric malignancies [12]. Also, while intravenous gadolinium is contra-indicated during pregnancy, iodinated contrast appears to be safe during pregnancy [13]. In our case, it was decided that there was no need for any obstetric intervention, as she had completed her adjuvant therapy.

During pregnancy, several physiologic alterations happen, including increased minute ventilation, compensated respiratory alkalosis, and low expiratory reserve volume. Pregnant women with respiratory diseases other than chronic respiratory insufficiency or pulmonary hypertension can actually tolerate pregnancy very well [14]. Moreover, a large series of nearly 80 patients established that unilateral pneumonectomy can result in a normal obstetric history and life expectancy [8].

It was reported that the administration of systemic chemo-therapy during the first trimester should be avoided owing to the serious consequences to the fetus, whereas several chemotherapy or combination drugs could be safely administered during the second and third trimesters [15–17]. Our patient presented to our center at the end of the first trimester, and she had already completed her treatment cycles. This also may indicate that her combined therapy had no adverse impact on her pregnancy or fetus.

Conclusions

Pulmonary malignancy during pregnancy is rarely reported and the associated maternal-fetal outcomes after one-sided pneumonectomy and adjuvant chemotherapy are underreported. Herein, we presented a case of incidental conception shortly after performing unilateral pneumonectomy and completing adjuvant chemotherapy. Overall, her pregnancy did not seem to be adversely affected by the unilateral pneumonectomy and adjuvant chemotherapy. She carried out her pregnancy and delivered by cesarean section at 37 weeks and 4 days of gestation for an obstetric indication. Overall, conception after unilateral pneumonectomy and adjuvant chemotherapy is not strongly contraindicated, but it is not encouraged.