Management of Lymphoma During Pregnancy Feasible

Although management of lymphoma during pregnancy is not well studied, a retrospective review at 10 academic centers in the United States suggests that in selected cases, lymphoma can be treated with minimal maternal and fetal complications, and that treatment can be deferred until after giving birth in patients with low-risk lymphomas. The study was presented at the 53rd Annual Meeting of the American Society of Hematology held December 2011 in San Diego, California.

“To our knowledge, this represents one of the largest experiences reported of lymphoma during pregnancy. There is not much published data in the literature to guide us. Therefore, 10 different centers came together to collect our experiences for guidance for not only ourselves, but treating oncologists across the world,” said lead author of this study, Andrew M. Evens, DO, MSc, University of Massachusetts Medical School, Worcester, Massachusetts. “The main point of our study is that the outcomes we found were consistent with non–pregnancy-associated lymphoma outcomes.”

In the United States, approximately 3500 new cases of cancer are diagnosed each year in pregnant women. Breast cancer is the most common type, and hematologic malignancies (about 20% of all cases) are the second most common. Prior to this study, knowledge about lymphoma during pregnancy came primarily from case reports, Evens explained.

The retrospective review included 82 evaluable cases of lymphoma in pregnant women over a 13-year period. Treatment of selected cases of localized disease during the second and third trimester was associated with minimal maternal and fetal risk of complications. The data suggest that treatment for lymphoma can be safely deferred until after giving birth in patients with low-risk lymphomas, such as indolent non-Hodgkin lymphoma (NHL), and/or diagnosis late in gestation. Evens said that this approach can achieve survival similar to that of non-pregnant patients with lymphoma.

Almost all of the cases of lymphoma during pregnancy were comanaged with high-risk maternal fetal medicine, with the goal of carrying the fetus to term (beyond 36 weeks’ gestation). In the 82 evaluable patients, 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 preexisting.

Of the 82 evaluable cases, 43 were NHL and 39 were Hodgkin lymphoma (HL). Median weight gain was 3.1%, which is considered low. Since lymphoma is associated with weight loss, this low weight gain makes sense, Evens noted. Almost two-thirds (63%) of NHL patients had advanced-stage disease (most of them diffuse large B-cell lymphoma), 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 to initiate chemo­therapy (5 in the first trimester and 1 in the early second trimester). Chemo­therapy was based mainly on cyclo­phosphamide, doxorubicin, vincristine, and prednisone (CHOP) or rituximab plus CHOP (R-CHOP) for NHL and doxorubicin, bleomycin, vinblastine, and dacarbazine for HL patients. Therapy was deferred in 34% of patients (n=28).

Seventy-two percent of patients had a vaginal delivery. Among 48 patients who received chemotherapy during pregnancy, full-term gestation occurred in 73% (85% delivered at 35 weeks’ gestation or longer). Among 28 patients who deferred chemotherapy, delivery was at a median of 38 weeks, and 86% of pregnancies were carried to full term. 

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 between infants of chemotherapy-treated patients and those who deferred therapy. Only 1 fetal malformation was found: microcephaly in an NHL patient 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 B-cell NHL, 73% and 82%; for T-cell NHL, 50% and 90%; and for HL, 90% and 95%, respectively. Among the 6 patients who terminated pregnancy, 3-year PFS and OS were 100%.