Lymphoma Occurring during Pregnancy: Obstetric Outcome and Overall Survival in a Series of 19 Patients

INTRODUCTION AND BACKGROUND: Lymphoma during pregnancy is a rare and highly challenging condition. Recent evidences show that chemotherapy can be safely administered during pregnancy, however the effects on obstetric and neonatal outcomes are still largely unknown. Aim of this study is to illustrate the oncologic management and to investigate the obstetric, neonatal and maternal outcomes in a series of cases diagnosed with lymphomas during pregnancy.

PATIENTS AND METHODS: A retrospective analysis has been conducted in a cohort of pregnant patients diagnosed with Hodgkin lymphoma (HL) and non-Hodgkin Lymphoma (NHL) between 2006 and 2019. Data were collected from the clinical databases and medical records at Istituto Europeo di Oncologia and IRCCS Policlinico di Milano (Milano, Italy). Data on maternal disease, treatments, obstetric complications, fetal and maternal outcomes were analyzed.

RESULTS: We identified 19 pregnant patients diagnosed with HL and NHL. Their median age at diagnosis was 29 years (range 23-39). Nodular sclerosis HL was the most common histological subtype (9 patients); primary Mediastinal B-cell lymphoma (PMBCL) was diagnosed in 4 patients, Diffuse Large B Cell NHL in 2 patients, whereas Burkitt lymphoma, Anaplastic Large Cell Lymphoma (ALCL), Follicular NHL and primary cutaneous ALCL were diagnosed in one patient for each of these subtypes. Seven women were diagnosed with advanced disease, with bulky presentation in 5 of them and B symptoms in 3 patients. The median gestational age at diagnosis was 22 weeks (range 7-30). Three patients were diagnosed in the first trimester of pregnancy. Two of them opted for a termination of pregnancy in order to initiate immediate treatment. The remaining 17 pregnancies ended in a live birth. Overall, 8 pregnant women received antenatal chemotherapy, started at a median gestational age of 23 weeks (range 23-33). Treatment included ABVD in 4 patients, CEOP in 3 patients, CHOP in 1 patient (rituximab delayed after delivery in 4 patients). One additional patient received radiotherapy on cutaneous lesion delivered at 33 weeks (primary cutaneous ALCL). Seven out of 9 patients treated during pregnancy obtained a complete response (CR). In eight patients treatment was postponed (due to indolent histology or asymptomatic and non-bulky disease). Obstetric complications occurred during chemotherapy at week 33 in 1 patient with intrauterine growth restriction (IUGR) and oligohydramnios. After a median follow up of 32 months, 13/19 patients are alive and free of disease, 1 patient relapsed 6 y after diagnosis of HL and she is presently undergoing salvage treatment, 1 patient non yet evaluable, 4 patients lost at follow-up.

CONCLUSIONS: Treating lymphomas during pregnancy is feasible, however the management of a pregnant patient with lymphoma requires multidisciplinary approach. In case of low risk disease and/or disease occurring in late gestational phase, therapy can be deferred to post-partum. If required, standard chemotherapeutic regimens can be administered during the 2^nd and 3^rd trimester, with minimal maternal or fetal complications. Starting treatment during pregnancy does not imply an adverse long-term outcome.