Management of classical Hodgkin lymphoma during pregnancy
- Joachim Yahalom, MD
Joachim Yahalom, MD
- Member and Professor of Radiation Oncology
- Memorial Sloan-Kettering Cancer Center
- Cornell University Weill College of Medicine
- Steven Horwitz, MD
Steven Horwitz, MD
- Associate Attending
- Memorial Sloan-Kettering Cancer Center
- Section Editors
- Arnold S Freedman, MD
Arnold S Freedman, MD
- Section Editor — Lymphoproliferative Disorders
- Professor of Medicine
- Harvard Medical School
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Although Hodgkin lymphoma (formerly called Hodgkin's disease, HL) accounts for only 10 percent of all lymphomas, it is one of the most common lymphoma subtypes diagnosed during pregnancy, largely because the peak incidence of HL coincides with female reproductive age. However, the association between HL and pregnancy is uncommon. HL is diagnosed in approximately 1:1000 to 1:6000 pregnancies and accounts for 3 percent or fewer of all patients with HL [1-3]. (See "Epidemiology, pathologic features, and diagnosis of classical Hodgkin lymphoma", section on 'Epidemiology'.)
As a result, there are few large series that have evaluated the many issues that must be addressed in such women. This topic will review the clinical presentation and management of HL during pregnancy, the interaction of malignancy and pregnancy, and the effects of treatment on the developing fetus and delivered infant. The diagnosis and management of HL in the nonpregnant adult is discussed separately. (See "Initial evaluation and diagnosis of classical Hodgkin lymphoma in adults" and "Overview of the treatment of classical Hodgkin lymphoma in adults".)
Pregnant patients with HL present in a similar fashion to nonpregnant patients with HL (eg, painless lymphadenopathy). Of importance, some signs and symptoms due to the HL (eg, fatigue, shortness of breath, anemia, thrombocytopenia) overlap with common signs and symptoms seen during pregnancy, potentially resulting in a delay of diagnosis. (See "Thrombocytopenia in pregnancy" and "Initial evaluation and diagnosis of classical Hodgkin lymphoma in adults", section on 'Clinical presentation'.)
Retrospective case series have described the clinical presentation of pregnant women with HL, with generally similar findings [1,3-6]. One of the larger series consisted of 48 women (median age 26 years) with 50 pregnancies occurring during active HL . The diagnosis of HL was made in 12 patients before conception, in 10 during pregnancy, and in 27 within nine months after delivery or pregnancy termination. Each pregnant woman was matched with three nonpregnant HL controls. The stage at diagnosis did not differ significantly from the controls: stage I, 25 percent; stage II, 46 percent; stage III, 17 percent; and stage IV, 12 percent (table 1). (See "Initial evaluation and diagnosis of classical Hodgkin lymphoma in adults", section on 'Clinical presentation'.)
The presence of B symptoms (ie, fever, night sweats, or weight loss exceeding 10 percent of body weight) is variable. While most patients from North American series have presented without B symptoms [1,4,5,7], one report from Mexico described B symptoms in 10 of 14 patients . (See "Staging and prognosis of Hodgkin lymphoma", section on 'Criteria for B symptoms'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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 1992; 23:407.
- STEWART HL Jr, MONTO RW. Hodgkin's disease and pregnancy. Am J Obstet Gynecol 1952; 63:570.
- Lishner M, Zemlickis D, Degendorfer P, et al. Maternal and foetal outcome following Hodgkin's disease in pregnancy. Br J Cancer 1992; 65:114.
- Jacobs C, Donaldson SS, Rosenberg SA, Kaplan HS. Management of the pregnant patient with Hodgkin's disease. Ann Intern Med 1981; 95:669.
- Gelb AB, van de Rijn M, Warnke RA, Kamel OW. Pregnancy-associated lymphomas. A clinicopathologic study. Cancer 1996; 78:304.
- Evens AM, Advani R, Press OW, et al. Lymphoma occurring during pregnancy: antenatal therapy, complications, and maternal survival in a multicenter analysis. J Clin Oncol 2013; 31:4132.
- Yahalom J. Treatment Options for Hodgkin's Disease During Pregnancy. Leuk Lymphoma 1990; 2:151.
- 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 1991; 36:243.
- Cohen-Kerem R, Railton C, Oren D, et al. Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 2005; 190:467.
- Levine D, Barnes PD, Edelman RR. Obstetric MR imaging. Radiology 1999; 211:609.
- Pelsang RE. Diagnostic imaging modalities during pregnancy. Obstet Gynecol Clin North Am 1998; 25:287.
- Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol 2007; 188:1447.
- Zanotti-Fregonara P, Jan S, Taieb D, et al. Absorbed 18F-FDG dose to the fetus during early pregnancy. J Nucl Med 2010; 51:803.
- Brewer M, Kueck A, Runowicz CD. Chemotherapy in pregnancy. Clin Obstet Gynecol 2011; 54:602.
- Rizack T, Mega A, Legare R, Castillo J. Management of hematological malignancies during pregnancy. Am J Hematol 2009; 84:830.
- Cordon-Cardo C, O'Brien JP, Casals D, et al. Multidrug-resistance gene (P-glycoprotein) is expressed by endothelial cells at blood-brain barrier sites. Proc Natl Acad Sci U S A 1989; 86:695.
- Martin DD. Review of radiation therapy in the pregnant cancer patient. Clin Obstet Gynecol 2011; 54:591.
- Anatolian Medical Oncology Society Group, Ustaalioglu BB, Gumus M, et al. Malignancies diagnosed during pregnancy and treated with chemotherapy or other modalities (review of 27 cases): multicenter experiences. Int J Gynecol Cancer 2010; 20:698.
- Amant F, Vandenbroucke T, Verheecke M, et al. Pediatric Outcome after Maternal Cancer Diagnosed during Pregnancy. N Engl J Med 2015; 373:1824.
- Van Calsteren K, Verbesselt R, Beijnen J, et al. Transplacental transfer of anthracyclines, vinblastine, and 4-hydroxy-cyclophosphamide in a baboon model. Gynecol Oncol 2010; 119:594.
- Zucali R, Marchesini R, De Palo G. Abdominal dosimetry for supradiaphragmatic irradiation of Hodgkin's disease in pregnancy. Experimental data and clinical considerations. Tumori 1981; 67:203.
- Covington EE, Baker AS. Dosimetry of scattered radiation to the fetus. JAMA 1969; 209:414.
- Wong PS, Rosemark PJ, Wexler MC, et al. Doses to organs at risk from mantle field radiation therapy using 10 MV x-rays. Mt Sinai J Med 1985; 52:216.
- Sharma SC, Williamson JF, Khan FM, Lee CK. Measurement and calculation of ovary and fetus dose in extended field radiotherapy for 10 MV x rays. Int J Radiat Oncol Biol Phys 1981; 7:843.
- Mazonakis M, Varveris H, Fasoulaki M, Damilakis J. Radiotherapy of Hodgkin's disease in early pregnancy: embryo dose measurements. Radiother Oncol 2003; 66:333.
- Garber JE. Long-term follow-up of children exposed in utero to antineoplastic agents. Semin Oncol 1989; 16:437.
- Reynoso EE, Shepherd FA, Messner HA, et al. Acute leukemia during pregnancy: the Toronto Leukemia Study Group experience with long-term follow-up of children exposed in utero to chemotherapeutic agents. J Clin Oncol 1987; 5:1098.
- Avilés A, Neri N. Hematological malignancies and pregnancy: a final report of 84 children who received chemotherapy in utero. Clin Lymphoma 2001; 2:173.
- Eyre TA, Lau IJ, Mackillop L, Collins GP. Management and controversies of classical Hodgkin lymphoma in pregnancy. Br J Haematol 2015; 169:613.
- Connors JM. Challenging problems: coincident pregnancy, HIV infection, and older age. Hematology Am Soc Hematol Educ Program 2008; :334.
- Doll DC, Ringenberg QS, Yarbro JW. Antineoplastic agents and pregnancy. Semin Oncol 1989; 16:337.
- Bachanova V, Connors JM. How is Hodgkin lymphoma in pregnancy best treated? ASH evidence-based review 2008. Hematology Am Soc Hematol Educ Program 2008; :33.
- Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol 2004; 5:283.
- Kal HB, Struikmans H. Radiotherapy during pregnancy: fact and fiction. Lancet Oncol 2005; 6:328.
- Amant F, Van Calsteren K, Halaska MJ, et al. Long-term cognitive and cardiac outcomes after prenatal exposure to chemotherapy in children aged 18 months or older: an observational study. Lancet Oncol 2012; 13:256.
- Barnicle MM. Chemotherapy and pregnancy. Semin Oncol Nurs 1992; 8:124.
- Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 8th ed, Lippincott Williams & Wilkins, Philadelphia, PA 2008.
- Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics 2013; 132:e796.
- Durodola JI. Administration of cyclophosphamide during late pregnancy and early lactation: a case report. J Natl Med Assoc 1979; 71:165.
- HENNESSY JP, ROTTINO A. HODGKIN'S DISEASE IN PREGNANCY. Am J Obstet Gynecol 1963; 87:851.
- BARRY RM, DIAMOND HD, CRAVER LF. Influence of pregnancy on the course of Hodgkin's disease. Am J Obstet Gynecol 1962; 84:445.
- CLINICAL PRESENTATION
- STAGING DURING PREGNANCY
- EFFECTS OF TREATMENT DURING PREGNANCY ON FETAL GROWTH AND DEVELOPMENT
- First trimester
- Second and third trimesters
- Long-term outcome
- MANAGEMENT OF HL DURING PREGNANCY
- Selection of patients for deferred therapy
- - Specific regimens
- - Antiemetics
- - Effect of pregnancy on drug pharmacokinetics
- Radiation therapy
- Elective termination of pregnancy
- DELIVERY OF THE INFANT
- MANAGEMENT AFTER DELIVERY
- INFLUENCE OF PREGNANCY ON THE COURSE OF HL