Cassidy Tigner

Dec. 9, 2016
Radiobiology & Protection
Protecting the Fetus during Radiation Treatments
Introduction

One of the most harmful things you can expose a fetus to is radiation. Radiation to the

fetus can cause defects to its development, higher risk for malignancy in their lifetime and can

lead to their death in the womb. Unfortunately, for some women, radiation therapy is crucial to

their survival and prognosis from the cancer they have been diagnosed with. If a woman is

pregnant before they are treated, many times they only have two options: their life, or their

childs life. It is very important to spare the fetus as much as possible if the mother does decide

to be treated with radiation. Also, determining the type of treatment for this patient will be highly

dependent on type of cancer, stage, and gestational age. Another important detail for a mother to

decide that radiotherapy is right for her, is to be well educated; she cannot make an informed

decision if she does not know the repercussions that come with the treatment. In the event that

the mother decides to receive treatments, this paper will discuss different options on how to treat

the patient while sparing the fetus.

Body

The first article discusses the approximate dose a fetus would receive if its mother had a

Mantle field radiation treatment using 6 MV photons1. This study was to determine the estimated

amount of shielding it would require to save the fetus, in which they used the Monte Carlo

calculation. No actual patients were used for this study, because it would be an unethical study to

possibly kill the fetus knowing you may not achieve results you are aiming for. Instead of

patients, they used phantoms that emulated the first, second and third trimester in a pregnant

woman. Through this experiment they found that a 5 cm thickness of lead was needed to have

the most accurate reduction of scatter radiation from the collimator and head of the machine, to

the fetus. It was also shown that the fetus could only be shielded from the external scatter coming
from the head of the machine. The other type of scatter the fetus received was from the

megavoltage beam interacting in the mothers tissue, which cannot be shielded internally for the

fetus. One problem of the study is that they did not use physical people and could only use

phantoms. This is a problem because a phantom is not precisely tissue equivalent compared to

an actual person and their fetus. Without humans being tested, you cannot truly obtain an

indicator of how the patient and fetus would react to the radiation.

The second article discusses more options for cancer treatment while pregnant,

specifically with breast cancer treatments2. The authors explain that there can be fetal

malformations, impaired development or death if exceeding 0.1-0.2 Gy. One way to limit

ionizing radiation dose is by using an MRI to determine if there is metastasis in the diagnostic

work-up. This study also shows that for each trimester of pregnancy, there are differences in the

approach and treatment of the patient. If diagnosed during the second or third trimester of

pregnancy, the authors presented a flow chart that demonstrated the patient having surgery to

remove the breast cancer lump and sentinel lymph node biopsy while also receiving

chemotherapy (with approved cytotoxic drugs) at fetal maturity, and then deliver the baby at 35-

37 weeks. After the delivery, the patient can then begin standard treatment of radiotherapy. If

diagnosed during the first trimester of pregnancy, the authors demonstrated the patient receiving

chemotherapy after the fetus is 14 weeks of gestation, delivering the baby at 35-37 weeks and

then following with standard treatment for cancer treatment. Unfortunately, this article does not

discuss much of the complications with the fetus after receiving the chemotherapy drugs in the

womb, nor does it discuss the outcomes of the patients survival and prognosis.

In source three, the authors discuss the treatment options for patients diagnosed with

cervical cancer while pregnant3. If the cancer is noninvasive, the decision is easy and the
treatment can wait until the baby is born. Starting at FIGO stage I, the options are to wait until

the pregnancy is over, or the patient could have a procedure called a vaginal radical

trachelectomy (VRT). A VRT is a laparoscopic procedure that removes most, if not all of the

cervix, and also includes a lymphadenopathy4. This is one option a patient could use instead of

radiation therapy. Later stages begin to bring in chemo therapy, and also the termination of the

fetus in order to treat the patient as effectively as possible. Unfortunately, this article only spoke

of chemo and surgery to use in replacement of radiation therapy, and did not discuss what would

happen if the patient did have radiation therapy or brachytherapy. If the patient were to get

radiation therapy, they would first have to terminate the pregnancy, or wait until they deliver the

baby. The problem with waiting until the pregnancy is over, is that it could be too late to save

themselves from the disease.

Discussion

The first study showed that the fetus can be majorly shielded from the scatter of the head

of the machine, but could not be blocked from the scatter of the interactions in the patients body.

The second article presented the idea of delaying radiation treatments until after the patient

delivers the baby, while still attacking the cancer with chemotherapy or surgery. Once the patient

delivers the baby, they can then continue with standard radiotherapy treatment. The third source

mostly only discussed treatment options besides radiation therapy, and did not discuss how they

could use radiation with the fetus intact. In order for cervical patients to receive radiation, they

would have to initially terminate the pregnancy or they would have to wait until the fetus is born

to preserve its life. There is still very much to learn about treating a pregnant cancer patient with

radiation while keeping the pregnancy viable. Women being treated for radiation therapy while

pregnant only accounts for 0.1% of cancer treatments. Therefore, more research must be done in
order for patients and doctors to feel comfortable beginning the treatment with the fetus still

being intrauterine. Due to ethical issues, it is hard to perform more research on the matter.

Finally, it was difficult to find many substantial sources that covered the area of concern for this

literature review because not much research has been done.

Bibliography
1: Mazonakis M, Tzedakis A, Varveris C, Damilakis J. Radiotherapy for supradiaphragmatic
Hodgkins disease: Determination of the proper fetal shielding conditions using Monte Carlo
methodology. Physica Medica. 2011;27(4):181-187.
2: Amant DF, Loibl S, Neven P, Van Calsteren K. Breast cancer in pregnancy. The Lancet.
2012;379(9815):570-579.
3: Koren G, Lishner M. Cancer in Pregnancy and Lactation: the Motherisk Guide. Cambridge,
UK: Cambridge University Press; 2011. Chapter 3: Cervical cancer during pregnancy
4: Beiner ME, Covens A. Surgery Insight: radical vaginal trachelectomy as a method of fertility
preservation for cervical cancer. Nature Clinical Practice Oncology. 2007;4(6):353-361.
doi:10.1038/ncponc0822.
This figure below does not have any significance in my paper, I just thought it was very cool to
see the fetus inside the uterus in this CT slice. I found this as I was searching for a worthy
source. Thought I would share it with you.