Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are both treatable and potentially curable, depending on the disease stage and cancer type as well as individual patient characteristics. However, pregnancy at the time of diagnosis can complicate treatment decisions, due to the challenges of maximizing outcomes for both the pregnant patient and the fetus.
Lymphoproliferative diseases are relatively rare during pregnancy and affect approximately 1 in 6000 pregnancies. The presence of lymphoma not only complicates disease management but also presents diagnostic challenges. Positron emission tomography-computer tomography (PET-CT) scans are typically used for diagnosis and follow-up, but PET-CT scans in pregnant patients are often avoided, which can delay a lymphoma diagnosis. In addition, symptoms related to lymphoma, including profuse sweating, fatigue, and dyspnea, are frequently mistaken for being related to the patient’s pregnancy. Nonetheless, outcomes are generally good for both patient and fetus if treatment is individually tailored.
A review published in Expert Review of Hematology discussed the current literature and optimal treatment options for HL and NHL during pregnancy.
“For the treating physicians, I would like to emphasize that lymphoproliferative diseases are potentially curable during pregnancy,” said author Anna Gurevich-Shapiro, MD, MPhil, of the division of hematology at the Tel Aviv Sourasky Medical Center in Israel, in an interview with Hematology Advisor. “Successful management starts with a timely and accurate diagnosis.”
She noted that this is often made difficult by an overlap between symptoms of pregnancy and the constitutional symptoms characteristic of lymphoma, thereby requiring special attention to the character, severity, and duration of complaints. “We also recommend that providers keep in mind that most imaging modalities are either safe in pregnancy or have a safe alternative,” Dr Gurevich-Shapiro said.
Additionally, treatments are not without adverse effects. “Nevertheless, the existing data gathered in recent years have demonstrated that with careful, individual planning, most of the adverse effects can be surmounted,” she explained.
As with any patient, treatment of pregnant patients with lymphoma will be dictated by the nature and stage of the disease, though these factors must be combined with gestational age. Terminating the pregnancy is not indicated, except when a diagnosis of aggressive disease is made during the first trimester or if the lymphoma is highly aggressive and requires intensified therapeutic regimens.
Due to their low molecular weight, most cytotoxic drugs cross the placenta, and the many physiological changes that occur during pregnancy can affect drug distribution, metabolism, and excretion. For example, the metabolism of dacarbazine, a prodrug that is part of the adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy regimen, was observed to be slower in 2 patients, which resulted in lower concentrations of dacarbazine’s active metabolites and potentially increased toxicity. There are currently no clear guidelines for adjusting chemotherapy dosages in regard to gestational age.
In general, if a diagnosis of HL is made during the first trimester and urgent treatment is not required, treatment initiation should wait until the second trimester. Vinblastine or corticosteroids can be used as a bridging therapy, and ABVD can be safely administered during the second and third trimesters.
The use of radiation is complex and should be avoided during the first trimester, particularly in weeks 1 through 8, as radiation can lead to teratogenesis and is also associated with an increased risk of childhood malignancy. Avoiding radiation therapy completely during pregnancy is preferable, but in some cases of localized supradiaphragmatic disease, it can be performed with appropriate shielding.