Lymphoma During Pregnancy Can Be Safely Managed

Andrew M. Evens, DO, MS

Little is known about maternal and fetal outcomes in women diagnosed with lymphoma during pregnancy. A retrospective review of 90 cases of lymphoma in pregnant women found that treatment of selected cases of localized disease during the second and third trimester was associated with minimal maternal and fetal risk of complications. The review suggested that patients with low-risk lymphomas, such as indolent non-Hodgkin lymphoma (NHL) and/or diagnosis late in gestation can safely defer treatment until after giving birth. This approach leads to survival comparable with that expected for lymphoma in a nonpregnant population. This research was presented at the 53rd Annual Meeting of ASH.

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).