Hodgkin Lymphoma Treatment During Pregnancy (Health Professional Version)

General Information About Hodgkin Lymphoma Treatment During Pregnancy

Hodgkin lymphoma (HL) primarily affects young women, some of whom may be pregnant. When treating a pregnant woman, an oncologist will provide therapy that minimizes risk to the fetus. Treatment choice must be individualized, taking the following into consideration:

• The mother’s wishes.
• The severity and aggressiveness of the HL.
• The trimester of the pregnancy.

Stage Information for Hodgkin Lymphoma During Pregnancy

To avoid exposing a pregnant woman to ionizing radiation, magnetic resonance imaging is the preferred method for staging evaluation.[1] The presenting stage, clinical behavior, prognosis, and histological subtypes of Hodgkin lymphoma (HL) in pregnant women do not differ from those in nonpregnant women during their childbearing years.[2] For more information, see the Stage Information for HL section in Hodgkin Lymphoma Treatment.

References

1. Nicklas AH, Baker ME: Imaging strategies in the pregnant cancer patient. Semin Oncol 27 (6): 623-32, 2000. [PUBMED Abstract]
2. Gelb AB, van de Rijn M, Warnke RA, et al.: Pregnancy-associated lymphomas. A clinicopathologic study. Cancer 78 (2): 304-10, 1996. [PUBMED Abstract]

Treatment Options for Hodgkin Lymphoma During Pregnancy

Treatment options for Hodgkin lymphoma (HL) during pregnancy include:

1. Watchful waiting.
2. Radiation therapy.
3. Chemotherapy.

In one study, the 20-year survival rate of pregnant women with HL did not differ from the 20-year survival rate of nonpregnant women who were matched for similar stage of disease, age at diagnosis, and calendar year of treatment.[1]

The long-term effects on children after chemotherapy exposure in utero are unknown.[1-5]

Based on anecdotal series, there is no evidence that a pregnancy after completion of therapy increases the relapse rate for patients in remission.[6,7]

Therapy During the First Trimester

HL that is diagnosed in the first trimester of pregnancy does not constitute an absolute indication for therapeutic abortion. Treatment options for each patient must take into account disease stage, rapidity of growth of the lymphoma, and the patient's wishes.[8]

Watchful waiting

If the HL presents in early stage above the diaphragm and is growing slowly, patients can be observed carefully, with plans to induce delivery early and proceed with definitive therapy.[9]

Radiation therapy

Alternatively, these patients can receive radiation therapy with proper shielding.[10-13] Investigators at the MD Anderson Cancer Center reported no congenital abnormalities in 16 babies delivered after the mothers had received supradiaphragmatic radiation while the uterus was shielded with five half-value layers of lead.[14] Because of theoretical risks of the fetus developing future malignancies from even minimal scattered radiation doses outside the radiation field, postponing radiation therapy—if possible, until after delivery—should be considered.[15]

Chemotherapy

Evidence (chemotherapy during the first trimester):

1. Chemotherapy that is administered during the first trimester has been associated with congenital abnormalities in as many as 33% of infants.[2,16] Consequently, some women may opt to continue the pregnancy and agree to radiation therapy or chemotherapy if immediate treatment is required after the first trimester.
2. A multicenter retrospective analysis of 40 patients described pregnancy termination in 3 patients, deferral of therapy to the postpartum period in 13 patients (median 30-week gestation), and antenatal therapy given to the remaining 24 patients (median 21-week gestation, all done after the first trimester).[17]
   • With a median follow-up of 41 months, the 3-year progression-free survival (PFS) rate was 85%, and the overall survival (OS) rate was 97%, often with the use of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine).[17][Level of evidence C3]
3. A retrospective analysis of 39 patients from the MD Anderson Cancer Center described pregnancy termination in 3 patients, deferral of therapy to the postpartum period in 12 patients, and antenatal therapy given to 24 patients.[18]
   • Two women had a miscarriage after receiving doxorubicin-based chemotherapy during the first trimester.
   • With a median follow-up of 68 months from diagnosis, the 5-year PFS rate was 75%, and the OS rate was 82%. These rates did not differ between the antenatal and postpartum timing of therapy.[18][Level of evidence C3]

Therapy Later in Pregnancy

Watchful waiting

In the second half of pregnancy, patients can be observed carefully, and therapy can be postponed until induction of delivery at 32 to 36 weeks.[4,5,16]

Radiation therapy

As an alternative, a short course of radiation therapy can be used before delivery in cases of respiratory compromise caused by a rapidly enlarging mediastinal mass.

Chemotherapy

If chemotherapy is mandatory before delivery—such as for patients with symptomatic advanced-stage disease—vinblastine alone, given intravenously at 6 mg/m² every 2 weeks until induction of delivery, may be considered because it has not been associated with fetal abnormalities in the second half of pregnancy.[4,5] Combination chemotherapy with ABVD appears to be safe in the second half of pregnancy.[3] If chemotherapy is required after the first trimester, many clinicians prefer the combination of drugs over single-agent drugs or radiation therapy. Steroids are used both for their antitumor effect and for hastening fetal pulmonary maturity.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

References

1. Lishner M, Zemlickis D, Degendorfer P, et al.: Maternal and foetal outcome following Hodgkin's disease in pregnancy. Br J Cancer 65 (1): 114-7, 1992. [PUBMED Abstract]
2. Thomas PR, Biochem D, Peckham MJ: The investigation and management of Hodgkin's disease in the pregnant patient. Cancer 38 (3): 1443-51, 1976. [PUBMED Abstract]
3. 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 36 (4): 243-8, 1991. [PUBMED Abstract]
4. Jacobs C, Donaldson SS, Rosenberg SA, et al.: Management of the pregnant patient with Hodgkin's disease. Ann Intern Med 95 (6): 669-75, 1981. [PUBMED Abstract]
5. Nisce LZ, Tome MA, He S, et al.: Management of coexisting Hodgkin's disease and pregnancy. Am J Clin Oncol 9 (2): 146-51, 1986. [PUBMED Abstract]
6. Weibull CE, Eloranta S, Smedby KE, et al.: Pregnancy and the Risk of Relapse in Patients Diagnosed With Hodgkin Lymphoma. J Clin Oncol 34 (4): 337-44, 2016. [PUBMED Abstract]
7. Gaudio F, Nardelli C, Masciandaro P, et al.: Pregnancy rate and outcome of pregnancies in long-term survivors of Hodgkin's lymphoma. Ann Hematol 98 (8): 1947-1952, 2019. [PUBMED Abstract]
8. Koren G, Weiner L, Lishner M, et al.: Cancer in pregnancy: identification of unanswered questions on maternal and fetal risks. Obstet Gynecol Surv 45 (8): 509-14, 1990. [PUBMED Abstract]
9. Anselmo AP, Cavalieri E, Enrici RM, et al.: Hodgkin's disease during pregnancy: diagnostic and therapeutic management. Fetal Diagn Ther 14 (2): 102-5, 1999 Mar-Apr. [PUBMED Abstract]
10. Mazonakis M, Varveris H, Fasoulaki M, et al.: Radiotherapy of Hodgkin's disease in early pregnancy: embryo dose measurements. Radiother Oncol 66 (3): 333-9, 2003. [PUBMED Abstract]
11. Greskovich JF, Macklis RM: Radiation therapy in pregnancy: risk calculation and risk minimization. Semin Oncol 27 (6): 633-45, 2000. [PUBMED Abstract]
12. Fisher PM, Hancock BW: Hodgkin's disease in the pregnant patient. Br J Hosp Med 56 (10): 529-32, 1996 Nov 20-Dec 10. [PUBMED Abstract]
13. Friedman E, Jones GW: Fetal outcome after maternal radiation treatment of supradiaphragmatic Hodgkin's disease. CMAJ 149 (9): 1281-3, 1993. [PUBMED Abstract]
14. 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 23 (2): 407-12, 1992. [PUBMED Abstract]
15. Lishner M: Cancer in pregnancy. Ann Oncol 14 (Suppl 3): iii31-6, 2003. [PUBMED Abstract]
16. Cardonick E, Iacobucci A: Use of chemotherapy during human pregnancy. Lancet Oncol 5 (5): 283-91, 2004. [PUBMED Abstract]
17. 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 31 (32): 4132-9, 2013. [PUBMED Abstract]
18. Pinnix CC, Osborne EM, Chihara D, et al.: Maternal and Fetal Outcomes After Therapy for Hodgkin or Non-Hodgkin Lymphoma Diagnosed During Pregnancy. JAMA Oncol 2 (8): 1065-9, 2016. [PUBMED Abstract]

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