Lymphoma During Pregnancy Can Be Safely Managed
Published Online: Monday, March 12, 2012
Andrew M. Evens, DO, MS
In the United States, approximately 3500 new cases of cancer are diagnosed each year in pregnant women, and about 20% are hematologic. What we know about lymphoma during pregnancy comes primarily from case reports, explained lead author Andrew M. Evens, DO, MS, University of Massachusetts Medical School, Worcester. Therefore, a retrospective analysis of cases of lymphoma during pregnancy was undertaken at 9 large academic centers over a 13-year period.
“To our knowledge, this represents one of the largest experiences reported of lymphoma during pregnancy,” Evens said.
The vast majority of cases were co-managed with high-risk maternal fetal medicine. From 1998 to 2011, 90 cases of lymphoma were identified, and 82 were evaluable. Median age was 31 years, about 38% were nulliparous, and lymphoma was diagnosed at a median of 24 weeks gestation (range, 5-40); 15% during the first trimester, 46% during the second trimester, 35% during the third trimester, and 4% was pre-existing.
For patients with NHL, 33% had B symptoms, 38% had elevated lactic dehydrogenase, 10% had bone marrow involvement, and 45% had other extranodal involvement (eg, lung, vaginal, liver, breast, kidney, central nervous system). For patients with Hodgkin lymphoma (HL), 24% had B symptoms and 11% had other extranodal symptoms. Median weight gain was 3.1%. Almost two-thirds (63%) of NHL patients had advanced-stage disease, and 46% of those with HL were in advanced stage; 25% of HL patients had stage IIB.
Six patients (4 NHL, 2 HL) terminated pregnancy so as to initiate chemotherapy (5 in the first trimester and 1 in the early second trimester). Chemotherapy for NHL patients was mainly CHOP- or R-CHOP-based, and ABVDbased for HL patients. Therapy was deferred in 34% of patients (n = 28).
Seventy-two percent of patients had vaginal delivery. Among 48 patients who received chemotherapy during pregnancy, full-term gestation occurred in 73% (85% delivered at 35- wk gestation or longer). Among 28 patients who deferred chemotherapy, delivery was at a median of 38 weeks, and 86% of pregnancies were carried full-term.
Patients with low-risk lymphomas, such as indolent non-Hodgkin lymphoma and/or diagnosis late in gestation can safely defer treatment until after giving birth.Most common preterm complications were induction of labor (45%), pre-eclampsia (8%), spontaneous rupture of membranes (5%), and diabetes mellitus (4%). No difference in events was observed between patients treated during pregnancy and those who deferred treatment. One stillbirth occurred in an NHL patient treated with 1 cycle of R-CHOP.
Fetal outcomes were evaluable in 76 live births. No difference was seen in median birth weight (2427 g) between chemotherapy-treated patients and those who deferred therapy. The only fetal malformation identified was 1 case of microcephaly in a patient with NHL treated with 4 cycles of CHOP.
For all patients, 3-year progression-free survival (PFS) and overall survival (OS) were 79% and 89%, respectively; for patients with B-cell NHL, 73% and 82%, respectively; for T-cell NHL, 50% and 90%, respectively; for HL, 90% and 95%, respectively. Among the 6 patients who terminated pregnancy, 3-year PFS and OS was 100.
A univariate analysis found the following 3 significant prognostic factors: HL versus aggressive B-cell lymphoma, performance status 2-4, and bone marrow involvement.
Evens AM, Advani R, Lossos IS, et al. Lymphoma in pregnancy: excellent fetal outcomes and maternal survival in a large multicenter analysis. Blood. (ASH Annual Meeting Abstracts) 2011;118(21, abstr 94).
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