Neuro-Oncology

Neuro-Oncology 16(9), 1289 1294, 2014

doi:10.1093/neuonc/nou019
Advance Access date 9 March 2014

Pregnancy and glial brain tumors

Shlomit Yust-Katz, John F. de Groot, Diane Liu, Jimin Wu, Ying Yuan, Mark D. Anderson, Charles A. Conrad,
Andrea Milbourne, Mark R. Gilbert and Terri S. Armstrong
Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas (S.Y.-K., J.F.d.G., M.D.A., C.A.C., M.R.G.,
T.S.A.); Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas (D.L., J.W., Y.Y.); Department of
Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
(A.M.)
Corresponding Author: Shlomit Yust-Katz, MD, Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe
Blvd., Unit 431, Houston, Texas, 77030 (syust@mdanderson.org).

Background. Improvements in brain tumor treatments have led to an increase in the number of young women with brain tumors who
are now considering pregnancy. The aim of this study is to evaluate the influence of pregnancy on brain tumor biology.
Methods. In this institutional review board-approved retrospective study, we searched the institutions database for patients with glial
brain tumors who were pregnant at the time of diagnosis or became pregnant during the course of their illness. We identified 34 such
patients and reviewed their charts to determine each patients clinical course and pregnancy outcome.
Results. Fifteen patients were diagnosed with a primary brain tumor during pregnancy: 3 with glioblastomas, 6 with grade III gliomas,
and 6 with grade II gliomas. Pregnancy was terminated in only 2 of these patients, and the remainder delivered healthy babies.
Twenty-three patients became pregnant after diagnosis (4 patients were pregnant at diagnosis and again after diagnosis). Of the
patients who became pregnant after diagnosis, the 5 with grade I tumors had stable disease during and after pregnancy. However,
of the 18 patients with grade II or III gliomas, 8 (44%) had confirmed tumor progression during pregnancy or within 8 weeks of
delivery.
Conclusions. In contrast to grade I gliomas, the tumor biology of grades II and III gliomas may be altered during pregnancy, leading to
an increased risk of tumor progression. These findings support the need for increased tumor surveillance and patient counseling and
for additional data collection to further refine these results.
Keywords: brain tumors, pregnancy.

The annual incidence of primary malignant brain tumors in

women in the United States is 2.6 per 100 000; glioma is the
most prevalent histological type.1 The reported incidence of primary brain tumors in pregnant women is slightly lower, but the
relative frequencies of each brain tumor type appear to be similar
for pregnant and nonpregnant women.2 Overall improvements in
brain tumor treatments, particularly for the lower-grade gliomas,
have resulted in overall better prognosis for patients with these
tumors.3 As a result, a higher percentage of patients, particularly
young adults, have sustained periods of disease control. This has
led to an increase in the number of young women with brain
tumors who are now considering pregnancy. Unfortunately,
only small case series and a limited number of reports have
addressed the impact of pregnancy on brain tumor growth.4 9

In 2 retrospective case series of patients with grade II glioma,

one study suggested that tumor growth accelerated during pregnancy. The increased growth rate was associated with a higher
frequency of seizures.4 In the second case series, clinical worsening and increases in tumor growth and grade were seen in 6 of 8
pregnant patients.5 These small case series provided insight into
the potential impact of pregnancy on gliomal growth and transformation to higher-grade tumors. An additional retrospective
study evaluated the outcomes of pregnancy in patients with
brain tumors and concluded that the tumors adversely affected
pregnancy outcomes; for example, the patients had a higher rate
of cesarean delivery than expected.8 This study also included
patients with meningiomas and pituitary tumors, potentially limiting the applicability of these conclusions to patients with

Received 11 November 2013; accepted 27 January 2014

# The Author(s) 2014. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com.

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Yust-Katz et al.: Pregnancy and brain tumors

malignant gliomas. In another study, pregnancy was shown to

accelerate tumor growth in patients with meningiomas.10
The concern that pregnancy may affect tumor biology stems
from the observation that multiple hormones and growth factors
produced during pregnancy and fetal development also enhance
tumor growth. For example, fetal development requires the production of angiogenic factors such as placental growth factor, a
well-established angiogenic factor in gliomas.
The aim of this retrospective review was to provide additional
information about the influence of pregnancy on outcomes in
patients with primary brain tumors.

Materials and Methods

After securing institutional board review approval (protocol
PA12-0992), we queried The University of Texas MD Anderson
Cancer Center Department of Neuro-Oncology Longitudinal Patient Database for patients diagnosed with gliomas between
1995 and 2012 who were pregnant at some point during the
course of their illness.
Data collected included demographic characteristics (date of
birth, race, date of death, age), tumor characteristics (histologic
type, WHO grade, location, results of imaging studies), cancer
treatments (including extent of surgery, radiation, and chemotherapy administered), and clinical characteristics (comorbid conditions, concomitant medications, pregnancy date and outcome,
clinical course during the pregnancy, and date of disease progression, death, or last follow-up).
Patients were classified into 2 groups: those who were pregnant at the time of the brain tumor diagnosis (ie, onset of presenting symptoms during pregnancy or within 2 weeks after
delivery) and those who became pregnant after diagnosis.

Statistical Analysis
Data were summarized using standard descriptive statistics and
frequency tabulation. The time-to-event endpoints, including
overall survival, were estimated using the KaplanMeier method.11
All computations were carried out using SAS 9.2 (SAS Institute) and
R 3.0.1 (http://www.r-project.org) software.

Results
We identified records for 34 women with glial brain tumors who
were pregnant at some point during the course of their illness. An
additional 2 patient records had incomplete data and were not
included in the analysis. Six of the 34 patients were pregnant
twice during the course of their illness (4 were pregnant at the
time of their tumor diagnosis and afterwards). Therefore, a
total of 40 pregnancies were evaluated.

Patients Pregnant at Time of Diagnosis

Fifteen patients presented with a brain tumor while they were
pregnant or immediately afterward. Three of these tumors were
diagnosed as glioblastoma multiforme (GBM), 6 as grade III glioma, and 6 as grade II glioma (Table 1 and Supplemental
Table 1). The most common presenting symptom related to the
tumor was seizures. The presenting symptom occurred at a median 13 weeks of pregnancy. The time at which the presenting

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Table 1. Characteristics of patients who were pregnant at the time of

brain tumor diagnosis
Characteristic

No. patients (n 15)

Median age (range), y

Tumor grade
II
III
IV
Treatment during pregnancy
Surgery
Biopsy only
Radiation
No treatment
Delivery method
Cesarean section
Vaginal
Abortion
Unknown
Outcome of pregnancy
Healthy infant
Malformations
Unknown
Patient vital status
Dead
Alive
Median follow-up (range), y

30 (24 38)
6
6
3
10 (3 biopsies)
3
1
5
7
3
2
3
12
0
1
5
10
4.7 (0.2 8.1)

symptom occurred ranged from 0 weeks of pregnancy to 4

weeks after delivery. (The lower range was 0 because one patient
had a seizure before pregnancy; however, her symptoms progressed, and she was diagnosed while she was pregnant.)
These patients underwent surgery and pathological diagnosis at
a median 17 weeks of pregnancy; this time ranged from 4 weeks
of pregnancy to a year after delivery).
Ten patients underwent surgery during pregnancy, and 3 of
these patients underwent brain biopsy. One patient diagnosed
with GBM had an urgent surgery. One patient with GBM received
radiation therapy during pregnancy, and none were treated with
chemotherapy.
Two patients (one with GBM and one with a grade III anaplastic astrocytoma) terminated their pregnancy; the rest delivered
healthy babies. Of the 15 women diagnosed with brain tumors
during pregnancy, 7 underwent cesarean sections, 3 had vaginal
deliveries, and the method of delivery was unknown for 3. Of the
3 patients who underwent vaginal delivery, 2 underwent tumor
resection before delivery, and the third was diagnosed only
after delivery. Of the patients who underwent cesarean section,
one patient with GBM underwent surgery and radiation therapy
during pregnancy, 2 underwent biopsy, and 3 had no treatment
during pregnancy. Six of the 7 cesarean sections were performed
at term. One patient, who had GBM, underwent cesarean section
at 32 weeks gestation because the fetus developed intrauterine
growth retardation.
Four women had a second pregnancy during the course of
their illness. The mean time between first and second pregnancies was 2.5 years (median, 1.25y). Three of these patients

Yust-Katz et al.: Pregnancy and brain tumors

disease progressed after the second pregnancy, and one patient

whose disease progressed died. The fourth patient was alive with
stable disease at the time of analysis.
At the time of this analysis, 5 patients had died, and 10
remained alive. The estimated median overall survival for patients
who were diagnosed while pregnant varied by tumor grade. For
patients with grade II tumors, the median overall survival could
not be determined because 5 of the 6 patients were still alive
(95% CI, 6.1y not applicable [NA]; range, 1.8y 8.1y). The median
overall survival durations were 4.7 years (95% CI, 1.9 y NA;
range, 0.2y 10.9y) for patients with grade III tumors and 4.6
years (95% CI, 2.0y NA; range, 0.27y 9y) for patients with GBM.

Patients Pregnant after Diagnosis

There were 23 patients who became pregnant after their glioma
diagnosis. The median time from tumor diagnosis to pregnancy
was 12 months (range, 2mo 90mo). Two patients were pregnant
twice after diagnosis. Five patients had grade I tumors, 9 had
grade II tumors, and 9 had grade III tumors. We did not find
patients with GBM who became pregnant after diagnosis.
In the patients who became pregnant after their glioma diagnosis, the grade I tumors were ganglioglioma (n 2), pilocytic
astrocytoma (n 2), and dysembryoplastic neuroepithelial
tumor (n 1). Complete resection of the tumor was achieved in
3 of these patients before pregnancy, and partial resection with
nonenhancing residual disease was achieved before pregnancy
in 2 (one with a dysembryoplastic neuroepithelial tumor and
one with a pilocytic astrocytoma). All 5 women had stable disease when they became pregnant, and their disease remained
stable during pregnancy. One of the patients with ganglioglioma
was pregnant twice after diagnosis. At the time of this analysis, all
patients with grade I gliomas were alive and without tumor progression (median follow-up, 4y; range, 2.5y 7y). In this cohort,
the mean time from tumor diagnosis to pregnancy was 1.4
years (median, 1y; range, 0.25y22.5y).
There were 18 patients with grade II or III glioma who became
pregnant after diagnosis (Table 2, Supplementary Table 2). Eight
(44%) of these patients, 5 with grade II tumors and 3 with grade
III tumors, were found to have tumor progression either during or
immediately after pregnancy (up to 8 weeks after pregnancy).
Importantly, 4 of these 8 patients underwent surgery during
or immediately after pregnancy and were found to have a highergrade tumor (Table 2). Only one patient, whose disease
progressed during pregnancy, had tumor progression before
pregnancy (3 years before pregnancy); the rest of these patients
had stable disease before pregnancy occurred. Although there
was no association between tumor grade and likelihood of recurrence, the extent of original tumor resection corresponded with
recurrence risk. All the patients whose disease progressed during
or immediately after pregnancy had only a biopsy or partial resection at diagnosis; whereas, among the patients without disease
progression during or immediately after pregnancy, 5 had gross
total resections and 4 had subtotal resections. All patients who
underwent gross total resection remained stable during pregnancy. The extent of resection was unknown for one patient.
Six of the patients whose disease progressed during or immediately after pregnancy had significant tumor contrast enhancement on imaging after progression (3 of these had faint
enhancement before progression).

Neuro-Oncology

Table 2. Characteristics of patients who became pregnant after diagnosis

with grade II or III brain tumors
Characteristic

No. patients
(n 18)

Median age, y (range)

Tumor grade
II
III
Median interval between tumor diagnosis and
pregnancy, y (range)
Disease progression during pregnancy
Disease progression during pregnancy and upgraded
stage based on pathology
Treatment during pregnancy
Surgery
Chemotherapy
Radiation
No treatment
Outcome of pregnancy
Healthy infant
Malformations
Abortion
Patient vital status
Alive
Dead
Median follow-up, y (range)

28 (24 36)
9
9
1 (0.2 7.5)
8
4

2
4
1
12
11
1
6
11
7
8.15 (1.9 19.4)

There was no difference (P .7901) in the median time from

diagnosis to pregnancy between patients whose disease progressed during or immediately after pregnancy (median, 12mo;
range, 2mo 90mo) and those whose disease remained stable
(median, 18mo; range, 3mo 72mo).
Neurological symptoms indicated disease progression in 5 of
the 8 patients with disease progression during or immediately
after pregnancy. In the other 3 patients, disease progression
was found on surveillance imaging. None of the patients with
stable grade II or grade III tumors experienced any new neurological symptoms.

Treatment During Pregnancy for Grades II III Tumors

and Pregnancy Outcomes
Two patients whose disease progressed during or immediately
after pregnancy underwent tumor resection, and another
received temozolomide. The patient who received temozolomide
terminated her pregnancy. Three of the patients whose disease
remained stable during and immediately after pregnancy were
undergoing treatment (chemoradiation in one, temozolomide in
one, PCV [procarbazine, CCNU, vincristine] in one) when they were
found to be pregnant. Once aware, 2 of those patients terminated
their pregnancies. The third patient, who was receiving temozolomide and valproic acid, had these medications stopped and
decided to continue with the pregnancy. Unfortunately, the
child was born with a neural tube defect and cerebral palsy.
The rest of the patients who had disease progression while pregnant were treated after delivery.

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Yust-Katz et al.: Pregnancy and brain tumors

Of the 8 patients whose disease progressed during or immediately after pregnancy, one had a spontaneous abortion, and 3
terminated their pregnancies. The rest delivered healthy babies.
Of the 10 patients with stable tumors, 2 terminated their pregnancies. The other 8 patients delivered healthy babies.

Survival Analysis
Four of the 8 patients with grade II or III tumors that progressed
during or immediately after pregnancy died of their disease, with
an average follow-up period of 7 years. Three patients died within
2 years of delivery, and the fourth patient died 9 years after
delivery.
The majority of patients (7 of 10) with grade II or III tumors
who remained stable while they were pregnant continued to
have stable disease during the follow-up period (median, 8.2y;
range, 2.6y 19.4y). The other 3 patients had disease progression
and died 4, 10, and 14 years after delivery.
Among patients who became pregnant after their tumor diagnosis, the median overall survival from the time of tumor diagnosis was 19.4 years (95% CI, 4.97y NA; range, 1.8y 19y) for those
with grade II tumors and 18.2 years (95% CI, 1.89y NA; range,
1.9y 18.2y) for those with grade III tumors. Overall survival
from delivery was 14.7 years (95% CI, 1.0y NA; range, 1.4y
14.7y) for patients with grade II tumors and 13.8 years (95%
CI, 0.33y NA; range, 0.8y 13.8y) for patients with grade III
tumors. For the patients whose disease progressed during or immediately after pregnancy, the estimated overall survival from
delivery was 2.7 years (95% CI, NA; range, 0.3y 8.9y). For those
whose disease remained stable during or immediately after pregnancy, the estimated overall survival was 13.81 years (95% CI,
9.17y 14.72y). For women who were pregnant twice, survival
from delivery was calculated from the first delivery.

Discussion
In this study, we present a case series of 34 women with glial
tumors who were pregnant at some point during the course of
their illness. These women had a total of 40 pregnancies. Nearly
half the patients with grades II III glial tumors who became
pregnant after diagnosis experienced disease progression during
or immediately after pregnancy.
This finding is in accordance with previous case series describing patients with grade II glial brain tumors.4,5 Together, these
reports raise important concerns related to the potential negative
impact of pregnancy on tumor progression and have important
implications for the frequency of patient evaluations and
counseling.
Several theories have been proposed to explain the progression of brain tumors during pregnancy. Reports suggest that hormonal changes and increases in the levels of growth factors and
angiogenic factors during pregnancy influence the rate of growth
of brain tumors.6,10 Increased levels of vascular endothelial
growth factor (VEGF) and placental growth factor are wellestablished angiogenic factors in glioblastoma.12 Moreover, placental growth factor is considered one means of promoting
angiogenesis when VEGF is inhibited by bevacizumab or other
antiangiogenic agents, and the level of placental growth factor
has been shown to increase in response to anti-VEGF treatment.13,14 Furthermore, the increase in maternal blood volume

1292

may lead to increased cerebral blood flow and might cause

increased edema around the tumor. The increased edema can
cause symptoms as well as changes in imaging studies.6,10
Our study suggests that early tumor progression may occur
without overt symptoms; therefore, radiographic evaluation during pregnancy should be continued. However, although most
studies evaluating MRI safety during pregnancy show no ill
effects,15 18 animal studies have shown intravenous gadolinium
to be teratogenic at high and repeated doses.19 These teratogenic
effects have not been observed in a small number of human studies in which gadolinium has been given in pregnancy.20 22 Therefore, in the absence of complete safety data, it is recommended
that gadolinium not be administered during pregnancy unless
there is an essential clinical indication.23 In our dataset, only 6
patients received gadolinium during pregnancy (5 of them had
newly diagnosed tumors); 2 of these patients subsequently terminated their pregnancies. The rest delivered healthy babies.
Our patient series showed a correlation between the extent of
tumor resection and the likelihood of tumor progression during
pregnancy. All patients who had an initial gross total resection
had disease that remained stable, whereas 62% of patients
who had a subtotal resection or underwent biopsy without
tumor resection had tumor progression. In agreement with
prior studies, this finding emphasizes the effect of tumor resection on relapse risk.24 This phenomenon may be either a consequence of hormonal effects on the larger tumor burden in
patients without gross total resection or, alternatively, a reflection of a more aggressive tumor biology that precluded extensive
primary resection. Not surprisingly, the survival durations and
pregnancy outcomes for patients in our study whose disease progressed during or immediately after pregnancy were worse compared with those whose disease remained stable.
In contrast to our observation of a high rate of disease progression during pregnancy in patients with grades II and III
tumors, grade I tumors remained stable during and after pregnancy in the cases we studied. The different tumor biology, characterized by minimal tumor infiltration and risk of malignant
transformation resulting in the possibility of cure with surgery, is
a likely explanation for the absence of tumor progression during
pregnancy. Another explanation for the stability of those tumors
is that their progression might not be angiogenesis dependent.
For example, pilocytic astrocytoma progression is not dependent
on angiogenesis, and in fact nonrecurrent tumors may display a
greater degree of VEGF expression.25 In contrast, in hemangioblastoma, which is a highly vascular tumor with high levels of
VEGF, progression related to pregnancy has been described.26 In
meningioma, the VEGF level is related to peritumoral edema and
invasiveness; accordingly, tumor progression during pregnancy
has accordingly been described in meningioma patients.10, 27
However, meningioma progression during pregnancy might be
related to hormonal changes, as up to 80% of benign meningiomas express progesterone receptor.28
Our series included 15 patients who presented with brain
tumors while they were pregnant. The rate of cesarean sections
in those patients was high, which is in accordance with a previous
study of the outcomes of hospitalization in pregnant woman with
central nervous system neoplasms.8
We believe that the decision whether to proceed with vaginal
delivery or cesarean section was influenced by the tumor burden.
Two of the 3 patients who underwent vaginal delivery had a

Yust-Katz et al.: Pregnancy and brain tumors

tumor resection during pregnancy (the third patient was diagnosed after delivery). Of the 7 patients who underwent cesarean
section, 3 had no surgery before delivery, and 2 underwent biopsy
without surgery. Despite the concurrent brain tumor diagnosis, all
but one of the cesarean sections in these patients were performed at term.
Comparison of the overall survival of the patients in this report
with tumor registry data is difficult owing to the spectrum of disease grade and the relatively young age of our patients compared
with the registry data.28 A case-control comparison could be considered, but the relatively small numbers of patients with each
tumor grade in our series and the inherent selection bias would
limit the utility of survival comparisons. The prolonged survival
of the patients with GBM who were pregnant at diagnosis might
be related to their young age and high functional status.
Although this report represents one of the largest series evaluating the effect of pregnancy on outcomes in women with grades
II-IV gliomas, several limitations of this report warrant consideration when interpreting the results. This was a retrospective study
over a prolonged period during which treatments changed and
additional diagnostic markers, such as allelic loss of chromosome
1p and 19q, were added to disease classifications. These changes
had an effect on treatment decisions.
We cannot assume that the growth rate is accelerated, but the
high rate of tumor progression and malignant transformation
during pregnancy does support prior observations and raises concerns for women with gliomas considering childbearing. Further
multi-institutional evaluation is required.

Supplementary Material
Supplementary material is available online at Neuro-Oncology
(http://neuro-oncology.oxfordjournals.org/).

Funding
None declared.

Conflict of interest statement: Shlomit Yust-Katz, Diane Liu, Jimin Wu, Ying
Yuan, and Mark D. Anderson have no disclosures; Terri S. Armstrong has
received research support from Merck and Genentech; Mark R. Gilbert
has received honoraria from and is on the advisory board of Merck, Genetech, and Abbott; John F. de Groot has an advisory relationship with Genentech, VBL Therapeutics, Novartis, and Deciphera Therapeutics and has
received an honorarium from Merck and research funding from
Sanofi-Aventis, AstraZeneca, and EMD-Serono.

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