Case report
Lung cancer during pregnancy: An unusual case
Cancro do pulmão durante a gravidez: um caso incomum
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Few more than 40 cases have been reported in the literature, 77% were non-small cell carcinoma (NSCLC) and most of them were adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the majority of cases, patients were diagnosed with advanced disease not amenable to resection and requiring systemic treatment.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> Post-partum maternal median survival is generally poor and the majority was known to have died within 1 year after delivery.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Metastatic transmission to the products of conception is a rare phenomenon, but 11 cases of placental metastases and 3 cases of fetal metastases were reported secondary to maternal lung cancer.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is not enough information to establish a conclusion about the security of chemotherapy or targeted agents during pregnancy. There have been frequent reports of anticipation of delivery, especially in women with advanced disease and poor prognosis.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">EML4-ALK mutation in NSCLC</span><p id="par0025" class="elsevierStylePara elsevierViewall">The EML4-ALK fusion oncogene represents one of the newest molecular targets in NSCLC and defines a new molecular subset with distinct clinical and pathologic features.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> The patients most likely to harbor EML4-ALK are young, never/light smokers with adenocarcinoma.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a> These patients share many of the clinical features of NSCLC patients likely to harbor EGFR mutation. However, apart from rare exceptions, EML4-ALK and EGFR mutation are mutually exclusive.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 36-year-old light-smoking pregnant woman was admitted to hospital at 27 weeks gestation in August 2010 with a history of malaise, fatigue, exertional dyspnea, dry cough and left pleuritic chest pain since the second trimester of the gestation. No regular medication was reported. On physical examination, she appeared to have poor performance status (PS 3). Pulmonary auscultation revealed reduction of the breath sounds in the left lung field. Chest X-ray showed total left lung opacity with contralateral mediastinal deviation, suggestive of pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). A thoracocentesis and pleural biopsy were performed revealing the diagnosis of pleural invasion by lung adenocarcinoma. The immunohistochemical study showed CK7, CK8/18 and was napsin positive and negative for CK20, estrogens and progesterone receptors. The test for EGFR mutation (direct DNA sequencing) was negative.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">After a multidisciplinary meeting (Pulmonology, Obstetrics and Neonatology), the decision was made to start fetal lung maturation and cesarean section at 29 weeks gestation. The female newborn had an Apgar index 8/9 and weighed about 1.2<span class="elsevierStyleHsp" style=""></span>kg. Placental pathological examination showed no malignancy involvement. The newborn was discharged home from Neonatology Department by the 47th day and nowadays she is a healthy female child.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After delivery, the patient underwent a thoracoabdominal CT which depicted a large left hilar mass with no plane of cleavage with vascular structures, multiple implants on mediastinal pleura, and a large volume of left pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), and multiple bone and liver metastases. First line chemotherapy with carboplatin plus oral vinorelbine (AUC 5 and 60<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>, respectively) was started on September 2010. Intravenous zoledronic acid was also prescribed. After 4 sessions of chemotherapy, despite some clinical improvement, there was progression of the disease with the spreading of bone disease and neurological symptoms of paraplegia and sphincter disruption (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Subsequently, the patient underwent second line chemotherapy with pemetrexed (500<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>), and thoracic spine (T4–T10) radiotherapy (30<span class="elsevierStyleHsp" style=""></span>Gy/12 sessions), but without clinical efficacy.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">An EML4-ALK translocation (FISH method) was then identified in an additional genetic test and crizotinib 250<span class="elsevierStyleHsp" style=""></span>mg BID was started on March 2011. The patient showed global symptom relief and improvement of neurological signs, and also partial radiological response (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) based on RECIST criteria. She showed only mildly elevated hepatic transaminases, without other adverse effects. Her progression-free survival was 9 months and she died 19 months after diagnosis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">There are only a few cases in the literature describing the diagnosis of lung cancer during the course of a pregnancy. The median diagnosis onset age reported is around 34–36 years, with a median gestational age at diagnosis of 27–29 weeks. Although the clinical picture of lung cancer is similar in pregnant and non-pregnant patients, a pregnant woman is more likely to be diagnosed with more advanced or metastatic disease.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">During pregnancy, there is a general concern about performing the examinations required for cancer diagnosis. This fact, in addition to the nonspecific nature of the symptoms, can delay diagnosis. It is important to be aware that small biopsies can be performed during pregnancy and usually without harming the mother or fetus.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In most types of cancer the histopathological features are similar in both pregnant and non-pregnant women.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> NSCLC is the most frequent lung cancer diagnosed and adenocarcinoma the predominant histological subtype.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment decisions related to lung cancer in a pregnant woman are a complex emotional and ethical challenge. This decision can be more difficult when the cancer is at an advanced stage at diagnosis and there is no effective treatment available. Cancer diagnosis during pregnancy is a clinical challenge with conflicting views as to whether to immediately start treatment at diagnosis or terminate the pregnancy earlier.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the very limited data available regarding the safety of different chemotherapeutics and targeted therapies during pregnancy, and because of the small number of patients treated, it is very hard to establish a standardized approach to manage these cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> As soon as the pulmonary maturation of fetus is completed, it is advisable to proceed with delivery to permit the beginning of maternal chemotherapy. Although vertical transmission of cancer cell to the placenta or the fetus is exceptionally uncommon, in some cases treatment of the mother during pregnancy might also be considered.</p><p id="par0075" class="elsevierStylePara elsevierViewall">From the oncologist's point of view, termination of pregnancy would be the best choice in order to focus on the treatment of the mother. From the obstetrician's point of view, early start of the mother's treatment could prevent metastases in the fetus and provide more time for pregnancy development. A multidisciplinary approach is mandatory, as was used in the case described; all the specialists involved contributed with their experience and gave reasoned opinions about the case.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our patient the diagnosis was performed at 27 weeks gestation. Our decision to prolong pregnancy for 2 more weeks and start fetus pulmonary maturation at that point provided the possibility of avoiding the risk of starting chemotherapy during pregnancy.</p><p id="par0085" class="elsevierStylePara elsevierViewall">This treatment decision did not seem to compromise the mother's survival. Most reports of lung cancer during pregnancy described a survival rate lower than 1 year.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although it was an initial advanced stage IV disease, the patient survived 19 months after delivery. The EML4-ALK mutation testing was crucial and after starting third-line crizotinib, the patient had a progression-free survival of 9 months, similar to the median progression-free survival described in the recent phase 1 clinical trial.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Studies carried out so far show that, in patients with advanced EML4-ALK-positive NSCLC, crizotinib therapy seemed to be associated with improved survival.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15–17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion, no exact solution is possible for cases of cancer treatment during the course of pregnancy. We may help future decisions by sharing diverse perspectives and treatment managements in case reports.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres305080" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec288224" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres305079" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec288225" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "EML4-ALK mutation in NSCLC" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case report" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-18" "fechaAceptado" => "2013-06-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec288224" "palabras" => array:5 [ 0 => "Pregnancy" 1 => "Lung cancer" 2 => "Treatment" 3 => "EML4-AKL" 4 => "Crizotinib" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec288225" "palabras" => array:5 [ 0 => "Gravidez" 1 => "Cancro do pulmão" 2 => "Tratamento" 3 => "EML4-AKL" 4 => "Crizotinib" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence of pregnancy-associated cancer is relatively low, complicating only 0.02–0.1% of all pregnancies. The authors describe a case of a 36-year-old woman, a light smoker, who was admitted to the hospital at 27 weeks of pregnancy, with respiratory symptoms since second trimester. Chest <span class="elsevierStyleSmallCaps">X</span>-ray showed total left lung opacity with contralateral mediastinal deviation, suggestive of pleural effusion, and the pleural biopsy revealed invasion by lung adenocarcinoma. EGFR mutation test was negative. After a multidisciplinary meeting, it was decided to start fetal lung maturation and cesarean section at 29 weeks gestation. The patient received two lines of chemotherapy and bone metastasis radiotherapy, but there was progression of the disease. An EML4-ALK translocation was identified in an additional genetic test. Crizotinib 250<span class="elsevierStyleHsp" style=""></span>mg BID was started. The patient showed a progression-free survival of 9 months and died 19 months after lung adenocarcinoma was diagnosed.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A incidência de neoplasia associada à gravidez é relativamente baixa, podendo atingir cerca de 0,02-0,1% de todas as gestações. Os autores descrevem o caso de uma gestante de 36 anos de idade, fumadora, admitida no hospital às 27 semanas de gestação com sintomas respiratórios desde o segundo trimestre. A telerradiografia do tórax mostrou opacidade total do pulmão esquerdo, com desvio contralateral do mediastino, sugestiva de derrame pleural e a biópsia pleural revelou invasão por adenocarcinoma pulmonar. A pesquisa da mutação EGFR foi negativa. Após reunião multidisciplinar, decidiu-se iniciar a maturação pulmonar fetal e cesariana às 29 semanas de gestação. A doente realizou 2 linhas de quimioterapia bem como radioterapia óssea paliativa, verificando-se progressão da doença. A translocação EML4-ALK foi identificada num teste genético adicional. Foi iniciado crizotinib 250<span class="elsevierStyleHsp" style=""></span>mg 2x dia. A doente apresentou uma sobrevida livre de progressão de 9 meses e faleceu 19 meses após o diagnóstico.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Neves I, Mota PC, Hespanhol VP. Cancro do pulmão durante a gravidez: um caso incomum. Rev Port Pneumol. 2014;20:46–49.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 958 "Ancho" => 1300 "Tamanyo" => 112062 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray showing total left lung opacity with contralateral mediastinal deviation. (B) Chest CT showing large mass in the left pulmonary hilum involving the pulmonary artery and the left main bronchus, as well as large left pleural effusion with pleural thickening.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1017 "Ancho" => 700 "Tamanyo" => 91818 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Spine magnetic resonance imaging showing secondary involvement of the vertebrae C7 and T1–T10 (arrows), and intramedular metastasis extending from T3 to T7.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 624 "Ancho" => 1300 "Tamanyo" => 77003 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-ray when patient started crizotinib. (B) Chest X-ray after 8 months of treatment with crizotinib.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer Statistics, 2010" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Jemal" 1 => "R. Siegel" 2 => "J. Xu" 3 => "E. Ward" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "CA Cancer J Clin" "fecha" => "2011" "volumen" => "61" "paginaInicial" => "133" "paginaFinal" => "134" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Annual Report to the Nation on the Status of Cancer, 1975–2005. Featuring trends in lung cancer, tobacco use, and tobacco control" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Jemal" 1 => "M.J. Thun" 2 => "L.A. Ries" 3 => "H.L. Howe" 4 => "H.K. Weir" 5 => "M.M. Center" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/jnci/djn389" "Revista" => array:6 [ "tituloSerie" => "J Natl Cancer Inst" "fecha" => "2008" "volumen" => "100" "paginaInicial" => "1672" "paginaFinal" => "1694" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19033571" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung cancer during pregnancy: an emerging issue" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Pavlidis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.lungcan.2007.10.010" "Revista" => array:6 [ "tituloSerie" => "Lung Cancer" "fecha" => "2008" "volumen" => "59" "paginaInicial" => "279" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18022730" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer in pregnancy: gaps, challenges and solutions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Pereg" 1 => "G. Koren" 2 => "M. Lishner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ctrv.2008.01.002" "Revista" => array:6 [ "tituloSerie" => "Cancer Treat Rev" "fecha" => "2008" "volumen" => "34" "paginaInicial" => "302" "paginaFinal" => "312" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18291591" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung cancer in the pregnant woman: to treat or not to treat, that is the question" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.A. Azim Jr." 1 => "F.A. Peccatori" 2 => "N. Pavlidis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.lungcan.2009.10.006" "Revista" => array:6 [ "tituloSerie" => "Lung Cancer" "fecha" => "2010" "volumen" => "67" "paginaInicial" => "251" "paginaFinal" => "256" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19896236" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung cancer during pregnancy involving the products of conception and a review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Jackisch" 1 => "F. Louwen" 2 => "A. Schwenkhagen" 3 => "B. Karbowski" 4 => "K.W. Schmid" 5 => "H.P. Schneider" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00404-002-0356-x" "Revista" => array:6 [ "tituloSerie" => "Arch Gynecol Obstet" "fecha" => "2003" "volumen" => "268" "paginaInicial" => "69" "paginaFinal" => "77" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12768292" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prolonged survival of a woman with lung cancer diagnosed and treated with chemotherapy during pregnancy. Review of cases reported" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Garrido" 1 => "J. Clavero" 2 => "A. Huete" 3 => "C. Sánchez" 4 => "A. Solar" 5 => "M. Alvarez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.lungcan.2007.09.019" "Revista" => array:6 [ "tituloSerie" => "Lung Cancer" "fecha" => "2008" "volumen" => "60" "paginaInicial" => "285" "paginaFinal" => "290" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17996977" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of the pregnant mother with cancer: a systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part I: solid tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.A. Azim Jr." 1 => "F.A. Peccatori" 2 => "N. Pavlidis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ctrv.2009.11.007" "Revista" => array:6 [ "tituloSerie" => "Cancer Treat Rev" "fecha" => "2010" "volumen" => "36" "paginaInicial" => "101" "paginaFinal" => "109" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20015593" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical features and outcome of patients with non-small-cell lung cancer who harbor EML4-ALK" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.T. Shaw" 1 => "B.Y. Yeap" 2 => "M. Mino-Kenudson" 3 => "S.R. Digumarthy" 4 => "D.B. Costa" 5 => "R.S. Heist" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2009.22.6993" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2009" "volumen" => "27" "paginaInicial" => "4247" "paginaFinal" => "4253" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19667264" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.L. Kwak" 1 => "Y.J. Bang" 2 => "D.R. Camidge" 3 => "A.T. Shaw" 4 => "B. Solomon" 5 => "R.G. Maki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1006448" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1693" "paginaFinal" => "1703" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20979469" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung cancer in never smokers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Yang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0031-1272865" "Revista" => array:6 [ "tituloSerie" => "Semin Respir Crit Care Med" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "10" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21500120" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ALK fusion gene positive lung cancer and 3 cases treated with an inhibitor for ALK kinase activity" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Kimura" 1 => "T. Nakajima" 2 => "K. Takeuchi" 3 => "M. Soda" 4 => "H. Mano" 5 => "T. Iizasa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.lungcan.2011.05.027" "Revista" => array:6 [ "tituloSerie" => "Lung Cancer" "fecha" => "2012" "volumen" => "75" "paginaInicial" => "66" "paginaFinal" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21757253" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The biology and treatment of EML4-ALK non-small cell lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Sasaki" 1 => "S.J. Rodig" 2 => "L.R. Chirieac" 3 => "P.A. Jänne" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejca.2010.04.002" "Revista" => array:6 [ "tituloSerie" => "Eur J Cancer" "fecha" => "2010" "volumen" => "46" "paginaInicial" => "1773" "paginaFinal" => "1780" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20418096" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastrointestinal, urologic and lung malignancies during pregnancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Pentheroudakis" 1 => "N. Pavlidis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Recent Results Cancer Res" "fecha" => "2008" "volumen" => "178" "paginaInicial" => "137" "paginaFinal" => "164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18080450" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Activity and safety of crizotinib in patients with ALK-positive non-small-cell lung cancer: updated results from a phase 1 study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.R. Camidge" 1 => "Y.J. Bang" 2 => "E.L. Kwak" 3 => "A.J. Iafrate" 4 => "M. Varella-Garcia" 5 => "S.B. Fox" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1470-2045(12)70344-3" "Revista" => array:6 [ "tituloSerie" => "Lancet Oncol" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "1011" "paginaFinal" => "1019" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22954507" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of ALK-positive non-small cell lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Y.J. Bang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5858/arpa.2012-0246-RA" "Revista" => array:6 [ "tituloSerie" => "Arch Pathol Lab Med" "fecha" => "2012" "volumen" => "136" "paginaInicial" => "1201" "paginaFinal" => "1204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23020724" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of crizotinib on overall survival in patients with advanced non-small-cell lung cancer harbouring ALK gene rearrangement: a retrospective analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.T. Shaw" 1 => "B.Y. Yeap" 2 => "B.J. Solomon" 3 => "G.J. Riely" 4 => "J. Gainor" 5 => "J.A. Engelman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1470-2045(11)70232-7" "Revista" => array:6 [ "tituloSerie" => "Lancet Oncol" "fecha" => "2011" "volumen" => "12" "paginaInicial" => "1004" "paginaFinal" => "1012" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21933749" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735115/0000002000000001/v1_201401230023/S2173511513000997/v1_201401230023/en/main.assets" "Apartado" => array:4 [ "identificador" => "9711" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735115/0000002000000001/v1_201401230023/S2173511513000997/v1_201401230023/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511513000997?idApp=UINPBA00004E" ]
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| 2024 August | 44 | 31 | 75 |
| 2024 July | 38 | 29 | 67 |
| 2024 June | 33 | 31 | 64 |
| 2024 May | 43 | 31 | 74 |
| 2024 April | 42 | 30 | 72 |
| 2024 March | 31 | 18 | 49 |
| 2024 February | 47 | 19 | 66 |
| 2024 January | 30 | 36 | 66 |
| 2023 December | 24 | 25 | 49 |
| 2023 November | 36 | 30 | 66 |
| 2023 October | 31 | 34 | 65 |
| 2023 September | 40 | 31 | 71 |
| 2023 August | 23 | 15 | 38 |
| 2023 July | 24 | 24 | 48 |
| 2023 June | 20 | 19 | 39 |
| 2023 May | 30 | 22 | 52 |
| 2023 April | 33 | 14 | 47 |
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