Management of classical Hodgkin lymphoma during pregnancy – an overview

This study reviewed evidence on treatment options for classical Hodgkin lymphoma during pregnancy. Authors concluded that standard chemotherapy during the second and third trimester is generally considered safe and effective. However, more high-quality evidence is needed.

Hodgkin lymphoma (HL) is a cancer of the lymph system. Classical HL is the most common form and considered very treatable. It mostly occurs in young adults aged 20 to 34 years. Since this is the most common age for childbearing, some women may be diagnosed with HL while pregnant. It has been estimated that classical Hodgkin lymphoma is present in approximately 1 in 1,000 to 1 in 6,000 of deliveries. The management of pregnant patients with HL is usually dependent on the disease stage, the trimester of the pregnancy, and the patient’s wishes.

The aim of this study was to review evidence on the management of classical HL during pregnancy.

The goal of treatment during pregnancy is curative. There is increasing evidence that the use of standard-of-care chemotherapy during the second and third trimester is safe. This usually involves 2 or 3 cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine).

One study involving 17 pregnant patients reported that all delivered healthy babies after being treated with ABVD during the second or third trimester. Another study involving 40 pregnant patients compared those treated with chemotherapy during pregnancy and those that delayed treatment until after delivery. There were similar rates of premature births, cesarean sections, and infants with low birth weight between the two groups. One long-term study reported that all 9 infants included in the study were developing normally at 5 years. Another study included 19 infants who had been exposed to ABVD in the second trimester. All were developing normally from birth to 10 years.

Management of classical HL during the first trimester is controversial. It may include delaying treatment until the next trimester or termination of the pregnancy followed by immediate start of treatment. ABVD during the first trimester is less commonly recommended. However, the authors found no published cases of abnormal development due to ABVD during the first trimester. One study followed 15,750 patients with blood cancer over a period of 40 years. This included 54 cases of mothers treated with chemotherapy during the first trimester. All infants had a normal birth weight. All were alive after an average follow-up of 25.3 years with normal physical and mental development. No secondary cancers were observed in the children. 89% of mothers were progression-free after 20 years.

There are currently no studies to guide the safe use of other chemotherapies during pregnancy. This includes regular and escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone). There is also little data on the treatment of relapsed HL during pregnancy.

Radiation therapy should be avoided in the first trimester. In the second and third trimester the risk of pregnancy loss is lower and the harm to the fetus is dependent on the dose of radiation given. Most studies accept dosage levels below 200 mGy as safe. One study described 7 cases of radiation during the second or third trimester. The radiation dose to the fetus ranged from 20 to 500 mGy. The children were reported to be healthy at 6 to 11 years of age. In most cases, though, radiation may be able to be delayed until after delivery, or other options should be considered.

Authors advised that more high-quality evidence is needed examining treatment options of classical HL during pregnancy. Overall, ABVD chemotherapy during the second and third trimester is safe and effective. The authors suggested that radiation therapy during pregnancy should not be a first-line treatment option.