Occurrence of Glioma in Pregnant Patients: An Institutional Case Series and Review of the Literature

Results

Patient 1 was 32 years old when she initially presented with a seizure and was found to have a left frontal ring enhancing mass. She underwent a gross total resection (GTR) at 16 weeks gestation with pathology demonstrating the lesion to be a GBM (IDH1 R132C mutated, MGMT unmethylated). She was followed by serial non-contrast MRIs for 6 months until delivery. After delivery she completed 6 weeks of concurrent EBRT with temozolomide (TMZ) chemotherapy and 11 cycles of monthly TMZ. She is currently on surveillance and remains alive and progression free up until her last follow up in October 2019 (96 months). Her child from this pregnancy had no reported birth defects and had a second pregnancy without complications.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

MRI scans of patient 4 at initial presentation and radiographic progression. A: T2 image at initial encounter when patient presented in status epilepticus, initial images were taken without contrast. Pathology revealed to be GBM. B: T1-post contrast MRI obtained 4 months after initial presentation. Baseline MRI at 4 weeks after completion of 6-week course of concurrent radiation with TMZ; pathology confirmed radiation necrosis.

Patient 2 was 27 years old at presentation with a new onset seizure at 17 weeks gestation. She was found to have a right frontal mass on brain MRI without contrast, and surgery was initially deferred for one month. Follow-up MRI with contrast showed progressive enhancement, and a GTR was performed at 25 weeks gestation with pathology showing the lesion to be a grade 3 anaplastic astrocytoma (IDH1 R132H mutated). After resection, she deferred treatment until she underwent spontaneous vaginal delivery (SVD) 4.5 months after surgery. During that time, she was followed by contrasted MRI studies which showed an enlarging T2-FLAIR lesion near the resection cavity. After delivery she completed 6 weeks of EBRT with concurrent TMZ and subsequently 12 cycles of monthly TMZ. Patient has remained progression free at the last clinic visit before moving out of state. However, she unfortunately developed tumor progression and passed away approximately 55 months after diagnosis. Her child from this pregnancy had no birth defects.

Patient 3 was 32 years old when she initially presented with seizures at 9 weeks gestation. Brain MRI without contrast showing a left frontal mass. Subsequent brain MRI 1 month later showed further growth and GTR was achieved at 13 weeks gestation. Pathology showed grade 4 GBM (IDH1 wild type, MGMT methylated). She was followed by contrast MRIs on a monthly basis during pregnancy after her first trimester. 4 months after GTR her GBM continued to progress and she received EBRT without concurrent TMZ during her third trimester. She delivered a healthy baby girl via C-section. She then completed 12 cycles of monthly TMZ. She underwent surveillance until she progressed in September 2019 (64 months) and was restarted on monthly TMZ. Her tumor subsequently stabilized and her child continues to thrive. She continues on monthly TMZ and has been stable as of her last follow up in March 2020.

Patient 4 was 38 years old when she presented status epilepticus at 27 weeks gestation and had emergent C-section without complications. She was noted to have a right frontal mass and underwent a subtotal resection (STR) 1 week postpartum. Pathology was consistent with a grade 4 GBM (IDH1 wild type, MGMT unmethylated). One month after STR, she underwent concurrent EBRT with TMZ but developed symptoms concerning progression. She had a second resection (5 months from initial presentation) that demonstrated mostly radiation necrosis. Her neurologic symptoms improved and completed 6 cycles of monthly TMZ. However, she subsequently developed radiographic progression necessitating dosage change in TMZ. There was continued disease progression and patient passed away approximately 19 months after initial diagnosis. Her child continues to do well at last contact (Figure 1A and B).

Patient 5 initially had a grade 2 astrocytoma status post resection at age 19 prior to her pregnancy and received surveillance MRIs with contrast every 3 months. She presented with a seizure at 5 weeks gestation and MRI without contrast showed a left temporal mass. STR was performed and pathology showed grade 2 oligoastrocytoma. Treatment was deferred and the patient was monitored with contrasted MRIs monthly starting in her second trimester. The patient delivered her child uneventfully and was continued on surveillance imaging every 2 months. She developed further progression of her tumor and underwent a second resection. Pathology confirmed the lesion to have progressed to a grade 3 anaplastic astrocytoma (IDH1 R132G mutated). She completed a 6-week course of proton beam radiation with concurrent TMZ and subsequently completed 12 cycles TMZ in November 2017. She remains progression free on surveillance as of February 2020, and her child continues to do well. Table I summarizes the demographic profiles, tumor pathology and molecular findings, and Table II the treatment histories, progression-free and overall survival, and infant outcomes.