Angelica, just over 30 years old, holds her daughter Federica, almost 5 months old, in her arms. A natural pregnancy that has no precedent in scientific literature, because before becoming a mother the young woman had been ‘target’ by carbon ion beams aimed at the pelvic area to treat a rare tumor of the sacrum. A radical treatment that would have prevented her from conceiving a child forever, if the doctors hadn’t ‘moved’ the young woman’s uterus and ovaries to protect them from radiation.
“An entirely new procedure”, the “first case in the world”, announce from Pavia the National Center for Oncological Hadrontherapy (Cnao) and the Irccs Policlinico San Matteo Foundation which together allowed Angelica to enter the history of medicine. On the eve of Mother’s Day, her story is meant to be “a message of strength and hope for many women”.
It was May 2019 – reconstructed from the two Pavia centers – when Angelica, then 27 years old, arrives at the Cnao from Campania with a diagnosis of grade 1 chondrosarcoma of the sacrum, a rare inoperable cancer and very close to the rectum, uterus and ovaries. The young woman is treated with a cycle of hadrontherapy on the pelvis with carbon ions, the most advanced form of radiotherapy, preceded by “a completely unusual operation involving the simultaneous dislocation of the rectum, uterus and ovaries – explains a note – to place these structures safe from the radiation beam and be able to deliver a radical dose on the tumor”. A “completely unpublished procedure in the literature”, which together with the “good control of the disease” determined by hadrontherapy has also made possible a “little great miracle”: the hormonal functionality remains intact and Angelica becomes pregnant spontaneously. An all-female multidisciplinary task force, of doctors from Cnao and San Matteo, supported by the surgeon Lorenzo Cobianchi, accompanied her on her journey.
“I found out I got pregnant during Mother’s Day weekend last year – says Angelica – After the therapies I had undergone, I didn’t expect it to happen naturally, nor 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. That’s why I decided to have them follow me where they had been able to treat my cancer and knew my story well. Pavia he had given me back my life and the possibility of giving life: my baby had to be born there Dr. Amelia Barcellini of the Cnao and Dr. Chiara Cassani of the San Matteo Polyclinic took my hand and from that moment 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 ‘my’ doctors”.
‘Pink’ gowns which first of all had to defeat Angelica’s tumor: “Excluding the surgical approach – reports Barcellini, radio oncologist at CNAO – to treat it, a radical, therefore high, dose of hadrontherapy was needed, not compatible with that tolerated by the organs risk, in particular the rectum and, given Angelica’s young age, the uterus and ovaries. To distance the rectum and uterus we used a silicone device called a ‘spacer’. If the ovaries had been left in place, they would have received a radiation dose such as to make them inactive from a hormonal point of view, also causing a radio-induced menopause. To prevent this from happening, it was necessary to displace them so that they would not be affected even by a possible minimal dose of radiation. Since” however “every operation on the ovaries it is not risk-free”, to be sure “Angelica also underwent oocyte cryopreservation”. Subsequently, “we followed its hormonal functionality during all checks, without ever highlighting any alterations”.
Reports Cobianchi, surgeon of the San Matteo Polyclinic who performed the surgery to dislocate the organs close to the tumor: “The ovaries” of Angelica “were made anterior by fixing them to the abdominal wall, after dislocating the rectum and uterus with a spacer in so as to spare these structures from the particle beam”. Maria Rosaria Fiore, CNAO radio oncologist and referent for the treatment of bone sarcomas, specifies that “to our knowledge it is the first time in the world that a treatment with carbon ions has been performed on the pelvis preceded by a procedure of this type to protect the fertility. The sessions were held in the summer of 2019” and “in the spring of 2022 Angelica informed us that she was pregnant”.
After the anti-cancer therapy – they still retrace from Pavia – the young woman did not experience any particular toxicity; her rectum was undamaged, her ovaries and uterus received virtually no radiation dose, and her menses remained regular. Ultrasound the ovaries were functional and the oncological follow-up was always negative, but “the fact that Angelica managed to become pregnant spontaneously immediately assumes the contours of an exceptional story”, assure the doctors.
“Starting from the twentieth week of gestation – explains Cassani, gynecologist oncologist of the San Matteo Polyclinic, who gave birth to little Federica – we subjected Angelica to monthly ultrasounds to monitor the functioning of the placenta and the correct growth of the baby. specific literature on pregnancy after hadrontherapy, we felt that any risks could be similar to those reported for conventional radiotherapy with X-rays, primarily the risk of fetal growth retardation. A risk averted, because the pregnancy did not cause any problems and Federica is grown regularly. Last December 23, a protective caesarean section was planned”, because “due to radiation, the risk of a sacral fracture during a natural birth was high. Again on the basis of data on photon radiotherapy, however with higher doses low compared to those delivered to Angelica, there was a risk of bleeding at birth that concerned us. But even these clouds cleared, the birth took place without complications and on Boxing Day Angelica and her baby were already at home, perfectly healthy “.
Also crucial to the success of the delivery was the choice of anesthesia: which would be most suitable for Angelica, whose nerve roots had been exposed to radiation, with possible consequences on sensitivity to the anesthetics usually used during obstetric procedures? “To decide – remember Maria Paola Delmonte and Federica Broglia, anesthesiologists at the San Matteo Polyclinic – we wanted to observe the changes in the third trimester. We examined Angelica: she was in a perfectly normal situation, without any haemodynamic, stability, ambulation or sensitivity. If we hadn’t known her story, we wouldn’t have distinguished her from many other mothers about to give birth. After several evaluations made together with the patient and discussions with the whole team that was following her case, we aimed on epidural anesthesia which, acting locally, is the safest for mother and child. And everything went for the best”.
Angelica’s “is more than a story – comment from Cnao and San Matteo – It tells of a young woman who faces a rare tumor, managing to become a mother against all odds, but also bears witness to the results achieved by two excellent structures that join forces in a multidisciplinary collaboration. And it is also the story of a group of female doctors who throw their hearts over the obstacle and put themselves to the test in a path whose outcome is anything but obvious”. All together they clarify that, “given the many unknowns that surrounded this pregnancy, it would have been more ‘convenient’ for us to have it terminated as soon as possible, by having the baby born at the 36th week with a small prematurity. Instead we believed it all the way, staring at the due date two days before Christmas, so that Federica would remain for as long as necessary in her mother’s belly. And it was our precise choice. Patients already have the weight of the disease to bear on their shoulders, there are times when it must be the doctor who has the courage to make decisions, with all the load of responsibility that these entail”.
After the birth – concludes the note – a histological examination of the placenta did not reveal any sign of the radiation treatment. Today, between one checkup and another, Angelica tries not to think about the tumor and to concentrate on her life, her family, Federica and the second child she hopes to have. Looking back, she knows she was the protagonist of a small miracle and wishes that her story “can give hope to so many other women.”
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