2023-05-12 07:11:34
The first case of natural pregnancy after hadrontherapy of the pelvis for chondrosarcoma of the rectum. The baby is five months old and doing well. Therapies studied and performed by a group of specialists from the Cnao and the San Matteo Polyclinic
Angelica went from despair to the greatest joy, from the discovery that she had cancer become a mother for the first timeafter so much fear and a long metaphorical and real journey, which took her from the province of Avellino to Pavia. The birth of Federica it is not only the happy ending hoped for by her father and mother, who at the age of only 27 receives the diagnosis of a very rare type of cancer, but it represents a hope for young women who, despite a neoplasm, can aspire to become mothers : it will not be an achievable goal for everyone, but the progress made by science is many. Today the strategies to preserve fertility are many and more and more tested. This, then, is an “exciting” story from a medical point of view because behind Federica’s arrival there is the collaboration of many different specialists, each with a fundamental role, who have come together to find a solution never attempted before. So they arrived at first case in the world of natural pregnancy after hadrontherapy of the pelvisthe result of the cooperation between two structures of excellence: the National Center for Oncological Hadrontherapy (Cnao) and the Irccs Policlinico San Matteo Foundation, both in Pavia.
The discovery of the disease: the symptoms
Angelica begins to suffer from pain in the lumbar area in 2018, when he is 26 years old. She works in the family business and has already been engaged for quite a while to Carmine, her boyfriend who will be by her side until the end of this story. Each of her home to her, however, that they are still young. «I was doing a course in the gym, I thought of a tear or a hernia – she says – her. After a few months the suffering didn’t go away, I had even suspended physical activity, I decided to do it an MRI. It was September 2018, I wasn’t particularly worried, when you’re young you certainly don’t think about cancer ». The precise diagnosis arrives in February 2019after another resonance (with contrast medium) which highlights the mass, followed by Pet and then biopsy: grade 1 chondrosarcoma of the sacrum, very close to the rectum, uterus and ovaries. The symptoms of the disease are pain in the sacrum with sciatica to which constipation is sometimes added due to the compression of the tumor mass. «Diagnosis is a shock, followed by inevitable anxiety, fear, confusion, fatigue – Angelica recalls -. If you live in a small town and you come across a rare tumour, then the difficulties multiply, between the search for expert doctors and travelling. I wasn’t alone, though. Having Carmine and my family next to me was my first cure».
A cancer that is very difficult to cure
Chondrosarcoma of the sacrum is a rare tumor which, when possible, can be surgically removed. The operation can be more or less destructive depending on the size, location and stage of the tumor in each patient. “In this case the mass was technically removablebut the size of the tumor would have led to an “important” intervention with disabling side effects for anyone and even more for a young girl like Angelica – he explains Amelia BarcelliniCnao oncologist radiotherapist —: pain, loss of sensation in the affected area and incontinence (technically “cauda equina syndrome”). The alternative in these situations is radiotherapy: however, various studies have highlighted that the traditional one (based on photons, very useful for many patients) is not very effective against chondrosarcoma, known as a “radio-resistant” tumor, i.e. although he receives radiation damage, it is capable of self-repairing over time and therefore generating a recurrence, a return of the disease. Hadrontherapy (which uses hadrons, in particular carbon ions), has instead shown greater efficacy in drastically reducing the self-repair capacity of these tumours, increasing the possibility of long-term local control. The Cnao of Pavia is one of only six Centers in the world capable of delivering beams of protons and carbon ions». For this Angelica, from Campania, faced the journey to the Lombard capital, where she spends the summer of 2019 from June to August, is first subjected to theintervention to preserve fertility and then to 16 hadrontherapy sessionsfour a week.
Protect your fertility from side effects
“Hadrotherapy here is a well-tolerated treatment, there may be an initial increase in pain, a slight erythema, some intestinal disorder – he clarifies Maria Rosaria Fiore, Cnao radio oncologist and referent of bone sarcomas -. In Angelica’s case, however, it was very important to protect the nearby organs, all delicate because they are very sensitive to radiation (rectum, intestine, uterus and ovaries). Then, to distance them from the area to be hit with radiation (the sacrum), we used a silicone device, called “spacer”. It had to then move the ovaries because if they had been left in place they would have received a radiation dose such as to make them hormonally inactive, also causing a radio-induced menopause. And since any operation on the ovaries is not risk-free, Angelica also underwent oocyte cryopreservation, one of the standard techniques for preserving fertility. An option that must be offered to all young people who fall ill with cancerto allow them to become parents in the future.
First time in the world
The dislocation (aka moving) of the ovaries is within the guidelines and has already been done many times, in Italy and in the world, but it is the entire procedure performed for Angelica that represents a novelty in the scientific literature. “Specifically,” he explains Lorenzo Cobianchisurgeon of the San Matteo Polyclinic who performed the surgery to dislocate the organs close to the tumor — the ovaries were brought forward, fixed to the abdominal wall, after dislocating the rectum and uterus with a spacer in order to protect these structures from the particle beam. The novelty consists in the insertion of the spacer in the site of dislocation of the ovaries and in having also partially displaced the uterus». There are no studies documenting pregnancies after pelvic hadrontherapy and indicating how to proceed, so doctors have relied on the information available on traditional radiotherapy. Once the treatment is over, Angelica returns home and follows the scheduled checks: «In general, a periodic MRI is performed for 10 years, with a CAT scan or a PET, it depends on the cases – says Barcellini -. Once the therapy is over, Angelica does not experience any particular toxicity, the rectum was not damaged, the ovaries and uterus received virtually no radiation dosemenstruation is regular, the ovaries are functional on ultrasound, the oncological follow-up is always negative”. For this type of tumor it is still risky to speak of a complete cure. «We are rather confident in a local control of the disease and, in the specific case, with limited long-term side effects, with a good quality of life – specifies Fiore -. Therefore Angelica will be periodically monitored over a fairly long period of time with clinical-radiological checks, the same as she would have done if she had undergone surgery”.
The pregnancy
Then, a year ago, the surprise. «I found out I was pregnant on Mother’s Day last year – says Angelica -. We didn’t live together, we hadn’t planned it. After the therapies I had undergone, I didn’t expect it to happen naturally or to have a pregnancy where everything was really perfect. At first I was very scared, I had a thousand doubts, no one knew how my body would react. This is why I decided to have them follow me where they had been able to treat my cancer and knew my story well. Pavia had given me back my life and the possibility of giving life: my little girl had to be born there. Dr. Barcellini and Dr. Cassani took me by the hand and from that moment on I felt safe, I found serenity again. So much so that in the last month of pregnancy I moved to Pavia, to be sure that, even in the event of a premature birth, I would be assisted by them». Instead, everything went smoothly until the end and Federica was born on December 23, 2022, with a planned caesarean section.
Childbirth
«In spring 2022 Angelica informed us that she was pregnant: we were all very happy, equally surprised, ready to take up this new challenge – she recalls Clare Cassani, oncologist gynecologist of the San Matteo Polyclinic -. Since there are no specific literature data on pregnancy after hadrontherapy, we felt that any risks could be similar to those reported for conventional radiotherapy with X-rays (i.e. increased chances of miscarriage, pre-term delivery, fetal growth retardation and major bleeding due to placental abnormalities). If these problems are recognized early, the pregnancy can be managed better, therefore starting from the twentieth week, we subjected Angelica to monthly ultrasounds to monitor the functioning of the placenta and the correct growth of the baby». But Angelica’s gestation went smoothly, without problems, Federica grew regularly. “Because of the radiation, the risk of sacral fractures during a natural birth was high and we feared heavy bleeding so, out of caution, we planned a cesarean – adds Cassani -. However, there were no complications: on Boxing Day, Angelica and Federica went home perfectly healthy. And, if the mother wants it, there is no medical reason not to think about another baby».
A group to solve problems
Success is due to many specialists, to their skills, but also to the mental approach to this “scientific primacy”: to face a new adventure you need to build on previous research and think about the possible dangers to prevent them. This is the case of the anesthesia in Angelica’s birth, for which an important doubt was posed: will it have an effect, given that her nerve roots had received a high dose of hadrontherapy? It’s the turn of Maria Paola Delmonte and Federica Brogliaanesthesiologist at the San Matteo Polyclinic, who have to evaluate the possible consequences for the sensitivity to the anesthetics commonly used during obstetric procedures: «Even after the third trimester observation Angelica was in a perfectly normal situation, without any haemodynamic repercussions, , walking or sensitivity – they explain -. If we hadn’t known her story, we wouldn’t have distinguished her from so many other mothers about to give birth. After several evaluations, together with the patient and with the whole team that was following her case, we focused on epidural anesthesia which, acting locally, is the safest one for mother and child. And everything went well.” So good that while tightening Federica, who is about to turn 5 months old, the new mother is already going a little further: «I’m 31 years old, I look to the future with confidence, I hope to be able to have a second child soon. It will be my first Mother’s Day and it will be beautiful, like a rainbow after a storm.”
May 12, 2023 (change May 12, 2023 | 07:08)
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