HomeRadioGraphicsRecently Published PreviousNext Obstetric and Gynecologic ImagingFree AccessInvited Commentary: Role of the Radiologist in Pregnancy-associated CancerJordyn Silverstein, Katherine Van Loon Jordyn Silverstein, Katherine Van Loon Author AffiliationsFrom the Department of Medicine (J.S., K.V.L.) and Helen Diller Family Comprehensive Cancer Center (K.V.L.), University of California, San Francisco, 550 16th St, 6th Floor, Box 3211, San Francisco, CA 94143.Address correspondence to K.V.L. (email: [email protected]).Jordyn SilversteinKatherine Van Loon Published Online:Jul 15 2022https://doi.org/10.1148/rg.220163MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractIn the article “Imaging Cancer in Pregnancy,” Jha et al (1) provide a comprehensive review of imaging modalities for diagnosis and treatment planning for pregnancy-associated cancer (PAC). The review outlines the risks and benefits of different types of imaging and emphasizes the importance of accurate diagnostic data to be able to strategically balance maternal prognosis and fetal risk. Currently, the literature around the intersection of imaging and the care of obstetric patients with cancer is sparse, and this article provides a significant contribution.As oncologists who have had the privilege of consulting and providing care for obstetric patients in the unfortunate circumstance of a concurrent pregnancy and cancer diagnosis, we cannot underscore the complexity and importance of the patient-centered multidisciplinary care coordination. In every case of PAC, we face unique challenges in balancing both the safety of the mother and the embryo or fetus. As oncologists providing direct care to the mother, we facilitate transparent discussions about the mother’s diagnosis and prognosis, an ideal treatment plan, and predictions for how any modifications in pregnancy could impact the mother’s prognosis, if indicated. These conversations are nuanced and should take into account the individual’s cultural and religious beliefs and personal values, as well as family and financial influences, if relevant. This is particularly important for those cases in which termination of the pregnancy is considered. Our aim is always to facilitate patient-centered decision-making.In arriving at a cancer diagnosis that is both efficient and accurate, radiologists provide critical insights into the relative risks to the embryo or fetus based on the imaging modality performed, radiation dose used, and timing of imaging. Imaging modalities without ionizing radiation, including US and MRI, are preferred. Gadolinium-based contrast material at MRI should not be used. PET/CT should be used judiciously and reserved for rare cases in which results will be critical for decision-making. If CT is required, intravenous and oral iodinated contrast material are considered safe. The radiation dose for each imaging modality should be determined according to the as low as reasonably achievable (ALARA) principle (2). Radiography and CT that do not include the uterus are generally considered safe during pregnancy. Decisions around the timing of diagnostic imaging should be based on whether the results will inform treatment planning and/or management of the pregnancy. For example, in a newly diagnosed rectal cancer case, FOLFOX (folinic acid, fluorouracil, and oxaliplatin) chemotherapy can be administered safely while attempting to allow a fetus to mature to full term, regardless of stage. Thus, the patient may be guided to defer completion of staging imaging until after delivery since the additional information would not directly impact the patient’s immediate care plan.Finally, accurate determination of gestational age by the radiologist is an important factor in shaping decisions, especially when the patient’s health is at risk. In particular, this informs decisions regarding the timing of delivery. While the minimum gestational age limit that is considered viable is 24 weeks, complications owing to prematurity are the primary cause of adverse neonatal outcomes in PAC, regardless of chemotherapy exposure. Moreover, the differential toxic effects of a proposed therapeutic intervention based on gestational age are important (3). During the first trimester, some therapies are associated with high risk for stillbirth, fetal growth restriction, teratogenicity, or preterm birth (4). Meanwhile, no definite teratogenic effects of chemotherapy delivered during the second and third trimester have been detected (3). Although data on the safety of cancer treatments during pregnancy is based mostly on the results of case series and small studies, the toxicity profile for some antimetabolites (fluorouracil and cytarabine; avoid methotrexate), alkylating agents, some anthracyclines (doxorubicin and epirubicin; avoid daunorubicin), vinca alkaloids, taxanes, and platinum-based agents is generally considered safe during the second and third trimesters. Newer targeted therapies and immunotherapies have much less data and are contraindicated during pregnancy owing to theoretical risks to the fetus, including trastuzumab, pertuzumab, bevacizumab, MEK inhibitors, programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors, and cytotoxic T-lymphocyte antigen-4 (CTLA-4) inhibitors. Most oncologic surgeries can be performed at centers familiar with the physiology of pregnancy. When indicated, radiation therapy can be considered for cancers that do not involve the pelvis, with supplemental shielding of the fetus.The review article by Jha et al (1) is particularly timely in the context of two historic developments that will impact these complex cases of PAC. First, the increasing use of prenatal cell-free DNA (cfDNA) (5) means that more cancers will be diagnosed at an earlier gestational age. Beginning at 9–10 weeks gestational age, cfDNA can replace conventional screening for aneuploidy. Recently, the American College of Medical Genetics endorsed the expanded use of cfDNA to provide noninvasive prenatal tests for both low- and high-risk patients (6). Aneuploidy detected by cfDNA that is discordant from fetal karyotype may indicate an unexpected diagnosis of malignancy; the prevalence of maternal malignancy can be up to 18% (7). In these cases, patients should undergo diagnostic evaluation for a potential underlying malignancy that includes blood work-up, Papanicolaou test, fecal immunochemical tests, and chest radiography. If the results are unrevealing, this work-up should be followed by a full-body MRI of the chest, abdomen, and pelvis (5). The timely availability of MRI is particularly relevant for these patients.Second, following the landmark decision by the U.S. Supreme Court to overturn Roe v Wade, patients in many states may not have the autonomy to choose to terminate a pregnancy to preserve their own health. Historically, 9%–28% of cases of PAC select to undergo a termination of pregnancy (8,9). With many states enforcing new laws banning abortions altogether or regulating later-term abortions, prompt availability of diagnostic tools and interpretation will be critical to expediting cancer diagnoses in time to avail a fully informed choice to the mother.The authors have disclosed no relevant relationships.