Management and controversies of classical Hodgkin lymphoma in pregnancy

Abstract

SummaryThe goal of managing classical Hodgkin lymphoma (cHL) in pregnancy is to obtain good long-term outcomes for both the mother and fetus. Given the excellent outcomes outside of pregnancy, the goal of treatment should remain curative. There remains a tension and debate regarding the timing of chemotherapy, the curative nature of such treatment and the timing of delivery. Moreover, the aim during pregnancy should be to minimize fetal toxicity and optimize perinatal outcomes. The management of cHL within pregnancy was covered within the excellent recent British Committee for Standards in Haematology guidelines, but with necessary brevity. By reviewing the literature over the last 30 years, herein we discuss the options for management during each trimester. Critical organogenesis occurs between 2 and 8 weeks post-conception; during which time the immature fetus is vulnerable to cytotoxic exposure. We discuss the evidence for using ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and single agent vinblastine in the first trimester. cHL presenting in pregnancy raises complex and difficult ethical dilemmas that can cause anxiety for patients, families and physicians. Decision-making must be multi-disciplinary and holistic, taking into account the patient's wishes, psycho-social and religious beliefs and personal circumstances. Clear communication between the haemato-oncologist, medical obstetrician, nurse specialists, midwives and neonatologists is paramount to a successful outcome.

Treatment of Early Stages Hodgkin Lymphoma During Pregnancy

“…Table 2 show the clinical characteristics of newborns, the 4 newborns that received chemotherapy during the first trimester had low-weight: 1950 to 2100 (median: 2010) g, these fetuses began ABVD regimen at 12, 13, 16, and 16 weeks of pregnancy, but, all recovered the normal weight at a median of 7.4 weeks. 3 – 10 No congenital abnormalities were observed. Psychological, physical, neurological and cardiac tests were normal.…”

“…Treatment of advanced stages (IIB, III and IV) during pregnancy has well defined, and ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine) is considered the best therapeutic option, with a very good response and overall survival, and minimal toxicity to the fetus, 4 – 11 even administered during the first trimester. 12 However, treatment during early stages (IA and IIA) remain controversial, while some oncologist suggested that chemotherapy administration will be deferred until after delivery, 4 – 6 , 8 – 10 and suggested that the use of single agent: vinblastine, could be administered, but, no precise schedule; dose, timing, time; has been considered.…”

“… 13 , 14 RT during pregnancy remains to be controversial, some authors suggested that RT can be employed with adequate protection, 6 , 9 . 10 , 15 but, concern about late toxicities, 16 – 18 will be considered and RT has been suggested that will be administered after delivery, it is necessary. Thus, we retrospectively analyzed our cohort of pregnant patients with early stage HL that were treated with a uniform schedule, and with a longer follow-up, to observe the impact on OS in mothers and to assess the outcome of the children.…”

Maternal and Fetal Outcomes After Therapy for Hodgkin or Non-Hodgkin Lymphoma Diagnosed During Pregnancy

“…In keeping with previous reports, our practice is to consider AT during the second and third trimesters if deferring that therapy until after delivery would be expected to compromise maternal outcome. 3,8,9 Figure. Progression-Free and Overall Survival Radiation therapy was given during pregnancy to four patients.…”

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

“…protocol remains the current treatment for HL in pregnancy in North America and Europe [13,14]. Small case series and retrospective studies in pregnancies treated for HL reported that doxorubicin was safe for the fetal heart when administered during the second and third trimester [9,12,[15][16][17]. But they reported that doxorubicin in pregnancy could reduce the thickness of the left ventricular wall without causing heart defects or functional disorders [15].…”