Hodgkin Lymphoma During Pregnancy
Since Hodgkin lymphoma affects primarily young adults, most oncologists will eventually face the dilemma of how to provide therapy to a pregnant woman while minimizing the risk to the fetus. Treatment choice must be individualized, taking into consideration the mother’s wishes, the severity and pace of the Hodgkin lymphoma (HL), and the length of the remaining pregnancy. Since general guidelines can never substitute for clinical judgment, oncologists should be prepared to alter the initial plans when necessary.Stage Information
To avoid exposure to ionizing radiation, magnetic resonance imaging is the preferred tool for staging evaluation. The presenting stage, clinical behavior, prognosis, and histologic subtypes of HL during pregnancy do not differ from those of nonpregnant women during their childbearing years. See the Stage Information for Adult Hodgkin Lymphoma section for more information.Treatment Option Overview
HL that is diagnosed in the first trimester of pregnancy does not constitute an absolute indication for therapeutic abortion. Each patient must be looked at individually to take into account the stage and rapidity of growth of the lymphoma and the patient's wishes. If the HL presents in early stage above the diaphragm and appears to be growing slowly, patients can be followed carefully with plans to induce delivery early and proceed with definitive therapy. Alternatively, these patients can receive radiation therapy with proper shielding.[5-8] Investigators at M.D. Anderson reported no congenital abnormalities in 16 babies delivered after the mothers had received supradiaphragmatic radiation while shielding the uterus with five half-value layers of lead. Because of theoretical risks that the fetus might develop future malignancies from even minimal scattered radiation doses outside the radiation field, radiation therapy should be postponed, if possible, until after delivery.
Chemotherapy that is administered in the first trimester has been associated with congenital abnormalities in as many as 33% of infants.[11,12] However, in one series, there were no adverse effects in 14 children of mothers who received a combination of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) during gestation, five of whom began treatment during the first trimester. Consequently, some women may opt to continue the pregnancy and agree to radiation therapy or chemotherapy if immediate treatment is required.
In the second half of pregnancy, most patients can be followed carefully and can postpone therapy until induction of delivery at 32 to 36 weeks.[11,14,15] If chemotherapy is mandatory prior to delivery, such as for patients with symptomatic advanced stage disease, vinblastine alone (given at 6 mg/m² intravenously every 2 weeks until induction of delivery) may be considered because it has never been associated with fetal abnormalities in the second half of pregnancy.[14,15] Steroids are employed both for their antitumor effect and for hastening fetal pulmonary maturity. As an alternative, a short course of radiation therapy can be used prior to delivery in cases of respiratory compromise caused by the rapidly enlarging mediastinal mass. Combination chemotherapy with ABVD appears to be safe in the second half of pregnancy. If chemotherapy is required after the first trimester, many clinicians prefer the combination of drugs over single-agent drugs or radiation therapy.
In one study, the 20-year survival rate of pregnant women with HL did not differ from the 20-year survival rate of nonpregnant women who were matched for similar stage of disease, age at diagnosis, and calendric year of treatment. The long-term effects on progeny after chemotherapy in utero are unknown, though present evidence tends to be reassuring.[12-16]References
- Nicklas AH, Baker ME: Imaging strategies in the pregnant cancer patient. Semin Oncol 27 (6): 623-32, 2000. [PUBMED Abstract]
- Gelb AB, van de Rijn M, Warnke RA, et al.: Pregnancy-associated lymphomas. A clinicopathologic study. Cancer 78 (2): 304-10, 1996. [PUBMED Abstract]
- Koren G, Weiner L, Lishner M, et al.: Cancer in pregnancy: identification of unanswered questions on maternal and fetal risks. Obstet Gynecol Surv 45 (8): 509-14, 1990. [PUBMED Abstract]
- Anselmo AP, Cavalieri E, Enrici RM, et al.: Hodgkin's disease during pregnancy: diagnostic and therapeutic management. Fetal Diagn Ther 14 (2): 102-5, 1999 Mar-Apr. [PUBMED Abstract]
- Mazonakis M, Varveris H, Fasoulaki M, et al.: Radiotherapy of Hodgkin's disease in early pregnancy: embryo dose measurements. Radiother Oncol 66 (3): 333-9, 2003. [PUBMED Abstract]
- Greskovich JF Jr, Macklis RM: Radiation therapy in pregnancy: risk calculation and risk minimization. Semin Oncol 27 (6): 633-45, 2000. [PUBMED Abstract]
- Fisher PM, Hancock BW: Hodgkin's disease in the pregnant patient. Br J Hosp Med 56 (10): 529-32, 1996 Nov 20-Dec 10. [PUBMED Abstract]
- Friedman E, Jones GW: Fetal outcome after maternal radiation treatment of supradiaphragmatic Hodgkin's disease. CMAJ 149 (9): 1281-3, 1993. [PUBMED Abstract]
- Woo SY, Fuller LM, Cundiff JH, et al.: Radiotherapy during pregnancy for clinical stages IA-IIA Hodgkin's disease. Int J Radiat Oncol Biol Phys 23 (2): 407-12, 1992. [PUBMED Abstract]
- Lishner M: Cancer in pregnancy. Ann Oncol 14 (Suppl 3): iii31-6, 2003. [PUBMED Abstract]
- Cardonick E, Iacobucci A: Use of chemotherapy during human pregnancy. Lancet Oncol 5 (5): 283-91, 2004. [PUBMED Abstract]
- Thomas PR, Biochem D, Peckham MJ: The investigation and management of Hodgkin's disease in the pregnant patient. Cancer 38 (3): 1443-51, 1976. [PUBMED Abstract]
- Avilés A, Díaz-Maqueo JC, Talavera A, et al.: Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children. Am J Hematol 36 (4): 243-8, 1991. [PUBMED Abstract]
- Jacobs C, Donaldson SS, Rosenberg SA, et al.: Management of the pregnant patient with Hodgkin's disease. Ann Intern Med 95 (6): 669-75, 1981. [PUBMED Abstract]
- Nisce LZ, Tome MA, He S, et al.: Management of coexisting Hodgkin's disease and pregnancy. Am J Clin Oncol 9 (2): 146-51, 1986. [PUBMED Abstract]
- Lishner M, Zemlickis D, Degendorfer P, et al.: Maternal and foetal outcome following Hodgkin's disease in pregnancy. Br J Cancer 65 (1): 114-7, 1992. [PUBMED Abstract]