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Definitely a very challenging case with no easy answers. I would approach this case as follows:
1. How rapid is the symptomatic change? If not too rapid, I would consider waiting to get the pregnancy to a point where fetal viability is not an issue, deliver the baby and then approach the management of the tumor. These tumors are generally slow growing and so that should be a possible option.
2. If you must intervene, from an efficacy perspective, there are 2 strategies; chemotherapy and radiotherapy. In children, chemotherapy has been used as first line with visual stabilization plus improvement in the long-run in just over half the patients. A number of chemo regimens have been employed, but most use a platinoid backbone; I will let Drs. Wen and Ahluwalia address the pregnancy-related chemotherapy issues.
3. From a radiotherapeutic perspective, there are long standing data showing significant long-term tumor control and visual stabilization in such tumors. The challenge would be to deliver RT during pregnancy, and the first option would be do so postpartum. However, if clinical circumstances force your hand, a few caveats:
A. You are past the first trimester, which greatly reduces teratogenicity from RT.
B. RT techniques that avoid vertex beams with greater downward interval scatter toward the fetus can be designed and used and in fact these can be modeled from a dosimetry perspective.
C. You could avoid planning CT altogether and do an MR-based plan, including an abdominal MR to compute fetal dose.
D. Consider using proton therapy with minimal exit.
E. During RT, avoid radiation-based set-up verification approaches….you could rely almost exclusively on surface gating.
Pending Moderator approval.
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