Abstract
Cancer in pregnant women is a very difficult clinical condition that profoundly affects patients and their families, as well as the medical staff who provide their care. Diagnostic and therapeutic decisions must balance adequate treatment and fetal risk. In developed societies, cancer in pregnant women has become more common during the last 30 years because of an increase in the number of relatively older women who give birth. The most common malignancies in pregnant women are melanoma; lymphoma; leukemia; and breast, cervical, ovarian, gastrointestinal, and genitourinary cancers. Cancer of the head and neck in pregnant patients is very rare. In this article, we describe a rare case of advanced squamous cell carcinoma of the hypopharyngeal area in a young pregnant woman, and we discuss the diagnosis and treatment of cancers of the head and neck in pregnant patients.
1
Introduction
Although cancer is the second most frequent cause of death in women during their reproductive years, cancer in pregnant patients is not a common clinical problem . However, the association of cancer and pregnancy has become more common during the last 30 years in developed societies, primarily because of an increase in the number of women who give birth at an older age . In addition, smoking and alcohol consumption are increasing in young women . Although to our knowledge there are no satisfactory studies about cancer in pregnant women, that disease is estimated to occur in 1 of 1000 pregnancies in developed societies . The malignant diseases most frequently diagnosed in pregnant women are melanoma; lymphoma; leukemia; and ovarian, brain, breast, cervical, gastrointestinal, and genitourinary cancers . The most common pregnancy-associated head and neck cancers include those of the larynx and thyroid, melanoma, and lymphoma .
Malignant tumors of hypopharynx are rare. Hypopharyngeal cancer accounts for less than 1% of all cancers in and represents approximately 8% to 10% of all head and neck cancers . Cancer of the hypopharynx occurs primarily in men who are 50 to 60 years old. A review of the English literature yielded no reports of hypopharyngeal carcinoma during pregnancy.
In this article, we describe a rare case of advanced squamous cell carcinoma of the hypopharyngeal area in a young pregnant woman, and we discuss the diagnosis and treatment of cancer of the head and neck in pregnant patients.
2
Case report
A 32-year-old woman with the primary complaint of a painless mass of more than 1 month duration on the right side of her neck was accepted as a patient in our otolaryngology department. She had experienced difficulty in swallowing and a sore throat for the 2 prior weeks and hemoptysis for the 2 prior days. She was pregnant at 18 weeks gestation.
Indirect laryngoscopic examination revealed a vegetative mass in her hypopharynx ( Fig. 1 ). That mass originated in the posterior wall of the hypopharynx and obstructed the hypopharyngeal and laryngeal areas. Palpation revealed a hard, painless, fixed lymph node approximately 3 cm in diameter in the right submandibular area.
Magnetic resonance imaging (MRI) showed a mass that had infiltrated the bilateral aryepiglottic fold, bilateral sinus pyriformis, laryngeal cartilages, prevertebral muscle, tracheoesophageal junction, and upper third of the esophagus ( Fig. 2 ). A punch biopsy of the hypopharyngeal mass was performed after the patient had received a local anesthetic. The pathology report revealed squamous cell carcinoma (clinical stage T4N2M0). The cancer was considered inoperable.
The patient was referred to an obstetrician at which time (18 weeks of gestation) the fetus was found to be healthy. The patient and her husband were informed of the aggressiveness of her disease. After they had met with an oncologist and the patient’s obstetrician, chemotherapeutic treatment was selected as the therapy of choice, and the pregnancy was not terminated. Adjuvant chemotherapy, including cisplatin and docetaxel, was initiated and was administered every 21 days. At 30 weeks of gestation, amniocentesis was performed, and neither quantitative nor qualitative chromosomal anomalies were identified.
After the fifth cycle of chemotherapeutic treatment, when the fetus was viable, a healthy male infant was delivered via cesarean section at 34 weeks of gestation. He weighed 2325 g, and his Apgar score was 9/10. At that time, the patient’s laryngeal mass was smaller than its prechemotherapy size ( Fig. 3 ).
Positron emission tomography/computed tomography was performed after the patient had been delivered of her infant. There was no evidence of distant metastasis. On endoscopic hypopharyngeal examination, the lesion was again smaller. A 45-day course of radiotherapy was added to the adjuvant chemotherapy, and at the conclusion of radiotherapy, no palpable lymph nodes were detected on the patient’s neck, the larynx was edematous, and the size of the mass had decreased further ( Fig. 4 ).
