The Management of Lymphoma in the Setting of Pregnancy

Paradigm Shifts in Hodgkin Lymphoma Treatment: From Frontline Therapies to Relapsed Disease

Combination chemotherapy with or without radiation has served as the primary therapeutic option for classic Hodgkin lymphoma (cHL), leading to durable remission in a majority of patients with early- and advanced-stage cHL. Patients with relapsed/refractory (RR) cHL could still be cured with salvage chemotherapy and autologous stem-cell transplantation. Brentuximab vedotin (BV) and the anti-PD-1-blocking antibodies, nivolumab and pembrolizumab, are highly effective treatments for cHL and have revolutionized the management of the disease. Recent studies incorporating BV and PD-1 blockade into salvage therapy for RR cHL and into frontline treatment regimens have changed the cHL treatment paradigm. The novel agents are also useful in the treatment of older patients who have poor outcomes with traditional therapy. This manuscript will review current strategies for approaching the management of previously untreated, RR, and challenging populations with cHL, including how to incorporate the novel agents.

Mediastinal Mass Discovered in the Second Trimester, a Rare Presentation of Hodgkin's Lymphoma in Pregnancy

Newly diagnosed malignancy during pregnancy is rare affecting approximately 1 in 1,000 pregnancies. Breast followed by hematologic malignancies are most common. Hodgkin's lymphoma (HL) is a lymphoid neoplasm which can present with lymphadenopathy or mediastinal mass and represents 6% of all malignancies diagnosed during pregnancy. Treatment involves a combination of chemotherapy with or without adjuvant radiation which poses significant challenges when diagnosed antepartum. We highlight a 28-year-old primigravida at 26 weeks gestation who presented to the emergency department in Japan with cough, dyspnea, and sore throat for 3-5 days. Initial chest radiography demonstrated a large perihilar mass with mediastinal shift. Follow-up CT chest revealed an anterior mediastinal mass measuring 8 cm × 19 cm × 16 cm with features concerning for aggressive lymphoma. The patient was subsequently transferred to a stateside tertiary care center for expedited workup. She underwent two core needle biopsies, both of which were non-diagnostic. Cardiothoracic surgery performed a cervical mediastinoscopy with excision of the enlarged right supraclavicular lymph node. Pathologic analysis revealed classical HL, nodular sclerosis subtype. Treatment was initiated with adriamycin, bleomycin, vinblastine, and dacarbazine with two cycles planned antepartum followed by additional cycles postpartum. The patient had an uncomplicated vaginal delivery at 38 weeks gestation. Diagnosis of HL in pregnancy is rare, and expedited diagnosis can be challenging as multiple diagnostic and treatment modalities may impact pregnancy. Management in pregnancy requires a multidisciplinary approach, and decisions regarding treatment and delivery timing should be weighed against risk to the fetus.

Pancreatic lymphoma during pregnancy

A 41-year-old female with 21 weeks of gestation is admitted to the hospital complaining of abdominal pain in epigastrium accompanied with pyrosis, nausea and vomit. Physical examination revealed a gravidic uterus at the level of the umbilicus and a painless epigastric mass. Laboratory test were normal. MRI showed a solid mass near the pancreatic body with dimensions of 6.4 x 6.2 x 4.8 cm compressing the stomach, duodenum and yeyunum, involving the superior third of the mesenteric vessels.

Capturing the lived experiences of women with lymphoma in pregnancy: a qualitative study

Lymphoma in pregnancy is a rare and challenging diagnosis that complicates ∼1:6000 pregnancies; posing a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. These difficulties are compounded by the paucity of real-world data on the management of LIP, and a lack of relevant support systems for women in this setting. We conducted a retrospective multicenter qualitative study, interviewing women aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020 from 13 Australasian sites. Semi-structured telephone interviews were conducted, recorded, and analyzed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. Of the 32 women interviewed, 20 (63%) were diagnosed during pregnancy (16, 34, and 13% in the 1st, 2nd, and 3rd trimesters, respectively), while 12 (37%) were diagnosed post-partum. Women recalled that their chief concerns at diagnosis were the welfare of their child (n = 13, 41%) and a fear of dying (n = 9, 28%). Perceived diagnostic delay attributed to pregnancy was reported by 41% of participants. Other key themes were communication, educational materials, psychosocial supports, and oncofertility issues. To our knowledge this is the first report capturing the lived experiences of survivors of lymphoma during pregnancy, affording a unique opportunity to consider the management, psychosocial supports, and delivery of care to meet the needs of these women.What is the NEW aspect of your work? To our knowledge, this is the first report capturing and analyzing the healthcare experiences of survivors of Lymphoma in Pregnancy (LIP).What is the CENTRAL finding of your work? Women valued clear and empathic communication, provision of tailored educational materials, access to psychosocial supports (particularly childcare and financial supports), and timely oncofertility management in their healthcare journey.What is (or could be) the SPECIFIC clinical relevance of your work? Women's personal accounts of positive and negative experiences of LIP care provide insights into their specific concerns and needs which can shape healthcare policy and development of a specific framework for managing and supporting patients with LIP (and other cancers).

Treatment of lymphoma with rituximab and chemotherapy during pregnancy

Safety of chemoimmunotherapy during pregnancy for treatment of Non-Hodgkin's lymphoma (NHL) is controversial. We review 37 cases of mothers with high grade NHL treated with rituximab and concurrent chemotherapy during pregnancy. Majority (95%) of mothers were treated in their second and third trimester, and a median of 4 cycles of combination therapy was administered. Complete remission occurred in 14/17 (82%) mothers whose disease outcomes were reported. There were 2 spontaneous abortions and 1 trimester fetal death that occurred in 3 mothers who received treatment in their first and second trimesters. Among the 34 (92%) live births, there were 6 cases of respiratory/cardiac complications requiring intervention and 5 cases of hematologic abnormalities reported. This review highlights the efficacy and safety of chemoimmunotherapy for mothers treated in second and third trimester. Further data is needed to establish recommendations for management of mothers with aggressive NHL in their first trimester of pregnancy.

Personalized treatment of malignant tumors during pregnancy

The combination of pregnancy and cancer is a challenge for the patient and a problematic clinical dilemma for the doctor. In this retrospective observational cohort study, we have tried to analyze our experience in the management of such patients. This review includes 41 patients with malignant neoplasms detected during pregnancy who received treatment at the Almazov National Medical Research Centre from 2015-2021. The majority of patients received treatment during pregnancy (n=26, 63.4%): chemotherapy - 19 (46.3%) (in 2 cases in combination with surgery), surgical treatment - 7 (17, 1%) patients. In most cases, delivery was at term (n=28, 68.3%). All children born at term were mature and had no growth restriction, regardless of whether the mothers received treatment during pregnancy or not. When detecting cancer during pregnancy, an immediate follow-up examination is required to assess the extent of the tumor and current fetal state. If pregnancy prolongation is requested, the treatment should not be postponed, except for systemic chemotherapy in the first trimester of pregnancy, pelvic radiation at any term.

Hemophagocytic lymphohistiocytosis during pregnancy: a review of the literature in epidemiology, pathogenesis, diagnosis and treatment

Hemophagocytic lymphohistiocytosis during pregnancy is rare; it is often misdiagnosed, resulting in a high maternal and foetal mortality rate. Herein, based on limited case reports including antepartum and postpartum cases, we reviewed the current studies of pregnancy-related hemophagocytic lymphohistiocytosis, and compared the epidemiology, aetiology, diagnosis and treatment of pregnancy-related hemophagocytic lymphohistiocytosis with non-pregnancy, enriching the understanding of hemophagocytic lymphohistiocytosis and its treatment in obstetrics.

How I treat lymphoma in pregnancy

Lymphomas afflict all age groups of people, with certain types demonstrating a female predilection in adolescents and young adults. A proportion of lymphomas that are diagnosed in this population demographic occur in the setting of pregnancy. Most of these behave aggressively at presentation and require immediate or urgent therapy. Treatment must consider both maternal and fetal health, and management approaches are therefore influenced by gestational age at diagnosis and treatment and timing of delivery. Although there is a paucity of literature on how to treat these patients, limited retrospective reports demonstrate generally good outcomes and highlight the necessity of an experienced multidisciplinary team approach to management.

Lymphoma Occurring During Pregnancy: Current Diagnostic and Therapeutic Approaches

PURPOSE OF REVIEW

Pregnancy-associated lymphoma (PAL) is an uncommon entity that lacks detailed prospective data. It poses significant management challenges that incorporate maternal and fetal risks associated with treatment or delayed intervention. Herein, we review the current literature for the diagnosis, management, and supportive care strategies for PAL.

RECENT FINDINGS

Establishment of a multidisciplinary team, including hematology-oncology, maternal-fetal medicine, and neonatology, is critical in the management of PAL. For staging, ultrasound and MRI are preferred modalities with use of computerized tomography in select situations. Data for the safety and effectiveness of therapy for PAL is largely based on retrospective studies. The timing of lymphoma-directed antenatal systemic therapy depends on the trimester, gestational age, lymphoma subtype and aggressiveness, and patient wishes. Therapy in the first trimester is usually not advocated, while treatment in the second and third trimesters appears to result in similar outcomes for PAL compared with non-pregnant patients with lymphoma. An overarching goal in most PAL cases should be to plan for delivery at term (i.e., gestational age > 37 weeks). For supportive care, most antiemetics, including agents such as neurokinin-1 receptor antagonists, have been used safely during pregnancy. For prevention or treatment of infections, particular antibiotics (i.e., macrolides, cephalosporins, penicillins, metronidazole), antivirals (i.e., acyclovir, valacyclovir, famciclovir), and antifungals (amphotericin B) have demonstrated safety and with use of growth factors reserved for treatment of neutropenia (vs. primary prophylaxis). Therapy for PAL should be individualized with goals of care that balance maternal and fetal well-being, which should include a multidisciplinary care team and overall intent for term delivery in most cases.

Good news on the active management of pregnant cancer patients

Cancer occurs in approximately 1/1000 to 1/2000 pregnancies and presents complex medical and ethical dilemmas for patients and providers. The most common cancers diagnosed in the gestational period include breast, cervical, melanoma, and lymphomas. The majority of existing evidence regarding the treatment of cancer during pregnancy is derived from experiences with breast cancer. Other cancers often pose unique challenges given the location of the tumors and their traditional mode of treatment with pelvic surgery and radiation. Additionally, many emerging therapies for cancer target mechanisms that are necessary for fetal development, such as angiogenesis, and are contraindicated in pregnant women. Although limitations on the treatment of cancer during pregnancy currently exist, increasing evidence shows that many surgical and systemic therapies can be effective for a mother’s oncologic outcomes without significant detriment to the developing fetus. Traditional perspectives of cancer during gestation may sway providers to encourage pregnancy termination, delays in therapy, or early delivery. However, recent studies and reviews discourage such practices. Although every cancer diagnosis in pregnancy requires an individualized approach and should use the multidisciplinary perspectives of maternal–fetal medicine specialists as well as medical and surgical oncologists, providers should feel empowered to safely employ systemic, surgical, and even reserved cases of radiation therapies for their pregnant patients with cancer. The aim of this review is to highlight some of the recent advances in cancer therapies for common cancer subtypes and encourage providers to use this growing body of evidence to employ treatments with curative intent while continuing to evaluate the long-term effects of these therapies on mothers and their children.

Maternal ABVD chemotherapy for Hodgkin lymphoma in a dichorionic diamniotic pregnancy: a case report

Background

Hodgkin lymphoma (HL) is the most common hematological malignancy during pregnancy. The first-line treatment for HL in pregnancy is the standard ABVD regimen without any drug and/or dose adjustment. However, data on chemotherapy during twin pregnancies are sparse, and a better understanding of the mechanisms involved in exposure to and the toxic effects of anticancer drugs in the fetuses is needed.

Case presentation

A 41-year-old dichorionic diamniotic pregnant patient was given ABVD treatment for HL at a gestational age of 28 weeks and 3 days. The patient received 2 cycles of chemotherapy with a 15-day therapeutic window including an actual 25 mg/m² dose of doxorubicin per cycle. Unlike the female twin, the male twin presented four days after birth a left cardiac dysfunction. Doxorubicin cardiotoxicity in the male newborn was also supported by high blood levels of troponin. At one month of age, echocardiography findings were normal. We investigated literature data on physiological aspects of pregnancy that may influence doxorubicin pharmacokinetics, and pharmacodynamic and pharmacokinetic data on the use of doxorubicin in pregnancy. We detailed the role of the transporters in doxorubicin placenta distribution, and tried to understand why only one fetus was affected.

Conclusions

Fetal safety depends at least on maternal doxorubicin pharmacokinetics.Because of drug interactions (i.e. drug metabolism and drug transport), care should always be taken to avoid maternal pharmacokinetic variability. The toxic effects were discrepant between the dizygotic twins, suggesting additional fetus-specific pharmacokinetic/pharmacodynamic factors in doxorubicin toxicity.

Current treatment of lymphoma in pregnancy

Introduction: Lymphoproliferative diseases occurring during pregnancy present the treating physician with unique diagnostic and therapeutic challenges, aiming to achieve maternal cure without impairing fetal health, growth, and survival. Due to the rarity of this complication, there is limited data to guide clinical decision-making, especially regarding the safety of novel emerging therapies. Areas covered: The presented review describes the current practice of treatment for Hodgkin's (HL) and non-Hodgkin's (NHL) lymphoma in the pregnant patient, according to disease stage and trimester of pregnancy. Novel agents for treatment of lymphoma in the setting of pregnancy are discussed. Therapeutic dilemmas and areas of uncertainty are illuminated. Expert opinion: HL and NHL are potentially curable diseases in the pregnant patient with generally good outcomes for the mother and the offspring, when tailoring the treatment according to the individual patient. The complexity of the situation merits shared decision-making with the patient and her family, explicitly outlining the risks and benefits. The pregnant patient is best managed by a multidisciplinary team, familiar with the intricacies of the gestational period, and providing the necessary support and sensitivity. Further studies are needed regarding the safety of novel agents in pregnancy.

Dyspnea in Pregnancy: A Case Report of a Third Trimester Mediastinal Mass in Pregnancy

BACKGROUND Dyspnea in pregnancy is common and attributable to a variety of etiologies including normal physiology. The obstetric provider is challenged with distinguishing between physiologic versus pathologic dyspnea. CASE REPORT A 31-year-old G2 P1001 female at 34 weeks gestation presented with dyspnea, tachycardia, and inability to lie supine. Imaging revealed a large heterogeneous anterior mediastinal mass (14.8×11.5 cm). Multidisciplinary coordinated care led to diagnosis of B cell lymphoma, delivery via cesarean section under regional anesthesia in steep Trendelenberg position, followed by chemotherapy postpartum. CONCLUSIONS Dyspnea in pregnancy is common but might represent underlying pathology. While an obstetrician is knowledgeable of physiologic pregnancy changes, he or she should remain vigilant for underlying pathologic causes of dyspnea, including malignancy. Anterior mediastinal masses propose unique anesthetic challenges including respiratory impairment and cardiopulmonary collapse requiring collaborative care and planning.

Treatment of Early Stages Hodgkin Lymphoma During Pregnancy

BACKGROUND

To assess maternal and fetal outcome of women and newborns who received chemotherapy during pregnancy to treat Hodgkin lymphoma (HL)in early stages (IA, IIA), we performed a retrospective analysis of a cohort of 44 pregnant women with HL and early stages, diagnosed and treated between 1988 to 2013, at a tertiary reference cancer center.

METHODS

We analyzed data on HL characteristics and treatment, with a particular attention to maternal and fetal complications; in children, we performed a longer follow-up to detect any anomaly in physical development, scholar performance, psychological, cardiac, neurological function, and intelligence tests.

RESULTS

Median age was 29.4 (range 21-37) years; Most patients were stage IIA (86%), had M a bulky mediastinal disease (78%) and 60% had > 3 nodal sites involved; thus these patients were considered to have a not favorable condition. Abortion was refused when it was proposed. All patients received chemotherapy during pregnancy; ABVD (adryamicin, bleomycin, vinblastine, and dacarbazine) at standard doses and schedule, even during the first trimester. Radiotherapy, when indicated, was administered after delivery in 39 patients. No obstetrical complications were observed, delivery occurred between 33 to 36 weeks in 10 cases (22%); and >37 weeks in 34 cases (87%). Four newborns were low-weight: 2012 g median (range 1750 - 2350 g). No clinical malformations were observed, and development of newborns was physiological without evidence of cardiac and neurological damage, behavior, intelligence, and scholar attendance were normal. At median follow-up range of 120.4 (48-299) months, the progression-free survival and overall survival of patients were 95% and 93%respectively.

CONCLUSION

Combined chemotherapy, as initial therapy appears to be the best approach in this setting of patients, with an excellent outcome to both mothers and children. If radiotherapy is necessary, it could be administered after delivery.

Disparities in lymphoma on the basis of race, gender, HIV status, and sexual orientation

Lymphoid malignancies account for the sixth leading cause of death in the US, and, although survival is improving overall, this trend is not applicable to all patients. In this review, we describe disparities in the initial presentation, treatment, and outcomes across a diverse group of lymphoma patients on the basis of gender, race, HIV status, and sexual orientation. Identifying these disparities will hopefully lead to improved outcomes in these groups of lymphoma patients in the future.

Pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma: A case report and literature review

RATIONALE

Hemophagocytic lymphohistiocytosis (HLH) occurs primarily in pediatric population, or secondary to malignancy, infection, or autoimmune disease. This disease is rare and prognosis is generally poor. Only a small number of cases during pregnancy have been reported in literature.

PATIENT CONCERNS

We report a case of pregnancy-associated HLH secondary to natural killer (NK)/T cells lymphoma. She was admitted at 30 weeks and 3 days of pregnancy with complaints of abdominal pain and fever as high as 39.2°C. The patient was found to have splenomegaly, pancytopenia, and acute hepatic failure.

DIAGNOSES

A subsequent bone marrow biopsy revealed focal hemophagocytosis and atypical lymphoid cells. The splenic pulp also contained a large number of tissue cells proliferating and devouring mature red blood cells, lymphocytes, and cell debris. On the basis of these findings, we diagnosed the case as pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma.

INTERVENTIONS

Treatment consisted with dexamethasone and etoposide in combination with rituximab.

OUTCOMES

Due to timely termination of pregnancy, the neonate was in good condition. However, the patient died on the 18th day postoperation due to multiorgan failure.

LESSONS

We recommend that HLH be considered as differential diagnosis in a pregnant patient complaining of persistent fever, cytopenia, or declining clinical condition despite delivery of the baby. Prompt diagnosis and treatment is essential and fetal outcomes should also be considered. The decision to terminate a pregnancy and initiate chemotherapy during pregnancy with malignancy-associated HLH (M-HLH) needs to be further investigated in a larger cohort.