Hodgkin's disease during pregnancy: Treatment - Health Professional Information [NCI PDQ]

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Hodgkin’s Lymphoma During Pregnancy

General Information

Note: A separate PDQ summary on Adult Hodgkin Lymphoma Treatment is also available.

Since Hodgkin lymphoma affects primarily young adults, most oncologists will eventually face the dilemma of how to provide therapy to a pregnant woman while minimizing the risk to the fetus. Treatment choice must be individualized, taking into consideration the mother’s wishes, the severity and pace of the Hodgkin lymphoma, and the length of the remaining pregnancy. Since general guidelines can never substitute for clinical judgment, oncologists should be prepared to alter the initial plans when necessary.

Stage Information

Magnetic resonance imaging is the preferred tool for staging evaluation to avoid exposure to ionizing radiation.[1] The presenting stage, clinical behavior, prognosis, and histologic subtypes of Hodgkin lymphoma during pregnancy do not differ from those of nonpregnant women during their childbearing years.[2]

References:

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

Treatment Option Overview

Hodgkin lymphoma that is diagnosed in the first trimester of pregnancy does not constitute an absolute indication for therapeutic abortion. Each patient must be looked at individually to take into account the stage and rapidity of growth of the lymphoma and the patient's wishes.[1] If the Hodgkin lymphoma presents in early stage above the diaphragm and appears to be growing slowly, patients can be followed carefully with plans to induce delivery early and proceed with definitive therapy.[2] Alternatively, these patients can receive radiation therapy with proper shielding.[3,4,5,6] Investigators at M.D. Anderson reported no congenital abnormalities in 16 babies delivered after the mothers had received supradiaphragmatic radiation while shielding the uterus with 5 half-value layers of lead.[7] Because of theoretical risks that the fetus might develop future malignancies from even minimal scattered radiation doses outside the radiation field, radiation therapy should be postponed, if possible, until after delivery.[8] Chemotherapy administered in the first trimester is associated with congenital abnormalities in as many as 33% of infants.[9,10] However, in one series, there were no adverse effects in 14 children of mothers who received mechlorethamine + vincristine + procarbazine + prednisone or doxorubicin + bleomycin + vinblastine + dacarbazine (ABVD) during gestation, 5 of whom began treatment during the first trimester.[11] Consequently, some women may opt to continue the pregnancy and agree to radiation therapy or chemotherapy if immediate treatment is required.

In the second half of pregnancy, most patients can be followed carefully and can postpone therapy until induction of delivery at 32 to 36 weeks.[9,12,13] If chemotherapy is mandatory prior to delivery, such as for patients with symptomatic advanced stage disease, vinblastine alone (given at 6 mg/m² intravenously every 2 weeks until induction of delivery) may be considered as it has never been associated with fetal abnormalities in the second half of pregnancy.[12,13] Steroids are also employed both for their antitumor effect as well as for hastening fetal pulmonary maturity. As an alternative, a short course of radiation can be used prior to delivery in cases of respiratory compromise due to a rapidly enlarging mediastinal mass. Combination chemotherapy with ABVD appears to be safe in the second half of pregnancy.[11] If chemotherapy is required after the first trimester, many clinicians prefer the combination of drugs over single-agent drugs or radiation therapy.

In one study, the 20-year survival of pregnant women with Hodgkin lymphoma was not different from nonpregnant women matched for similar stage of disease, age at diagnosis, and calendric year of treatment.[14] The long-term effects on progeny after chemotherapy in utero are unknown, though present evidence tends to be reassuring.[10,11,12,13,14]

The designations in PDQ that treatments are “standard” or “under clinical evaluation” are not to be used as a basis for reimbursement determinations.

References:

1. 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.
2. 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.
3. 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.
4. Greskovich JF Jr, Macklis RM: Radiation therapy in pregnancy: risk calculation and risk minimization. Semin Oncol 27 (6): 633-45, 2000.
5. Fisher PM, Hancock BW: Hodgkin's disease in the pregnant patient. Br J Hosp Med 56 (10): 529-32, 1996 Nov 20-Dec 10.
6. Friedman E, Jones GW: Fetal outcome after maternal radiation treatment of supradiaphragmatic Hodgkin's disease. CMAJ 149 (9): 1281-3, 1993.
7. 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.
8. Lishner M: Cancer in pregnancy. Ann Oncol 14 (Suppl 3): iii31-6, 2003.
9. Cardonick E, Iacobucci A: Use of chemotherapy during human pregnancy. Lancet Oncol 5 (5): 283-91, 2004.
10. Thomas PR, Biochem D, Peckham MJ: The investigation and management of Hodgkin's disease in the pregnant patient. Cancer 38 (3): 1443-51, 1976.
11. 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.
12. 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.
13. 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.
14. 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.

Changes to This Summary (07/17/2007)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

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Date Last Modified: 2007-07-17

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