Radiation therapy in pregnancy: risk calculation and risk minimization

The benefits of radiation therapy (RT) as part of a treatment regimen for cancer must be weighed against the potential risk of harm to the patient and in the pregnant patient, the risk to the developing fetus. Information necessary for determining the potential effects of RT on the developing fetus include the gestational age, absorbed fetal dose-equivalent, and dose-rate. The risk periods in humans for RT-induced prenatal or neonatal death, congenital anomalies, severe mental retardation (SMR), temporary (TGR) or permanent growth retardation (PGR), carcinogenesis, sterility, and germ cell mutations have been elicited directly from the study of Japanese victims of the atomic bombs and unintentional medical exposures, and indirectly from animal experiments. The wide range of congenital anomalies elicited from animal studies have not occurred in the Japanese atomic bomb victims exposed in utero. The major congenital anomaly observed in the Japanese cohort has been microcephaly. The highest risk period for SMR correlates with the proliferation, differentiation, and, most importantly, migration of neurons from their proliferative zones. PGR was apparent 17 years after ionizing radiation (IR) exposure at Hiroshima in children who were within 1,500 meters of the hypocenter. Children were on average 2.25 cm shorter, 3 kg lighter, and had head diameters 1.1 cm smaller than age-matched children. The projected lifetime risk of cancer mortality in the Japanese cohort is 14% per gray. The risk of a radiation-induced hereditary disorder is reported to be approximately 1% per gray. RT plays a major role in the definitive treatment of cervical and breast carcinomas, Hodgkin's disease, and non-Hodgkin's lymphoma. With appropriate abdominal shielding in place, the estimated fetal dose can be reduced by 50% or greater in most cases. In certain clinical situations, RT may be administered during pregnancy.