Hodgkin’s Lymphoma During Pregnancy

Key Points for This Section

  • Hodgkin’s lymphoma during pregnancy is a disease in which malignant (cancer) cells form in the lymph system of a pregnant woman.
  • Age and Epstein-Barr infection can affect the risk of developing Hodgkin's lymphoma during pregnancy.
  • Possible signs of Hodgkin's lymphoma include swollen lymph nodes, fever, and night sweats.
  • Tests that examine the lymph nodes are used to detect (find) and diagnose Hodgkin's lymphoma during pregnancy.
  • Certain factors affect prognosis (chance of recovery) and treatment options.

Hodgkin’s lymphoma during pregnancy is a disease in which malignant (cancer) cells form in the lymph system of a pregnant woman.

Hodgkin’s lymphoma is a cancer that develops in the lymph system, part of the body’s immune system. The lymph system is made up of the following:

  • Lymph: Colorless, watery fluid that travels through the lymph system and carries white blood cells called lymphocytes. Lymphocytes protect the body against infection and the growth of tumours.
  • Lymph vessels: A network of thin tubes that collect lymph from different parts of the body and return it to the bloodstream.
  • Lymph nodes: Small, bean-shaped structures that filter substances in lymph and help fight infection and disease. Lymph nodes are located along the network of lymph vessels found throughout the body. Clusters of lymph nodes are found in the underarm, pelvis, neck, abdomen, and groin.
  • Spleen: An organ that produces lymphocytes, filters the blood, stores blood cells, and destroys old blood cells. It is located on the left side of the abdomen near the stomach.
  • Thymus: An organ in which lymphocytes grow and multiply. The thymus is in the chest behind the breastbone.
  • Tonsils: Two small masses of lymph tissue at the back of the throat. The tonsils produce lymphocytes.
  • Bone marrow: The soft, spongy tissue in the center of large bones. Bone marrow produces white blood cells, red blood cells, and platelets.

Because lymph tissue is found throughout the body, Hodgkin’s lymphoma can begin in almost any part of the body and spread to almost any tissue or organ in the body.

Lymphomas are divided into two general types: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. This summary is about Hodgkin’s lymphoma during pregnancy. Refer to the following summaries for more information:

  • Adult Non-Hodgkin’s Lymphoma Treatment
  • Non-Hodgkin's Lymphoma During Pregnancy
  • AIDS-Related Lymphoma Treatment
  • Primary CNS Lymphoma Treatment
  • Adult Hodgkin's Lymphoma Treatment

Hodgkin's lymphoma in pregnant women is the same as the disease in nonpregnant women of childbearing age. However, treatment is different for pregnant women.

Age and Epstein-Barr infection can affect the risk of developing Hodgkin's lymphoma during pregnancy.

Risk factors for Hodgkin's lymphoma include the following:

  • Being in young adulthood.
  • Being infected with the Epstein-Barr virus.
  • Having a first-degree relative (parent, brother, sister) with Hodgkin's lymphoma.

Pregnancy is not a risk factor for Hodgkin's lymphoma.

Possible signs of Hodgkin's lymphoma include swollen lymph nodes, fever, and night sweats.

These and other symptoms may be caused by Hodgkin's lymphoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems do not go away:

  • Painless, swollen lymph nodes in the neck, underarm, or groin.
  • Fevers for no known reason.
  • Drenching night sweats.
  • Weight loss for no known reason.
  • Itchy skin.
  • Feeling very tired.

Tests that examine the lymph nodes are used to detect (find) and diagnose Hodgkin's lymphoma during pregnancy.

The following tests and procedures may be used:

  • Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
    • o The number of red blood cells, white blood cells, and platelets.
    o The amount of haemoglobin (the protein that carries oxygen) in the red blood cells.
    o The portion of the blood sample made up of red blood cells.
  • Sedimentation rate: A procedure in which a sample of blood is drawn and checked for the rate at which the red blood cells settle to the bottom of the test tube.
  • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it.
  • Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells. One of the following types of biopsies may be done:
    • o Excisional biopsy: The removal of an entire lymph node.
    o Incisional biopsy or core biopsy: The removal of part of a lymph node.
    o Needle biopsy or fine-needle aspiration: The removal of a sample of tissue from a lymph node, with a needle.
  • Immunophenotyping: A test in which the cells in a sample of blood or bone marrow are looked at under a microscope to find out if malignant lymphocytes (cancer) began from the B lymphocytes or the T lymphocytes.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on the stage of the cancer (the number of lymph node groups affected and the number of places outside of the lymph nodes to which the cancer has spread). Most pregnant patients with newly diagnosed Hodgkin’s lymphoma can be cured.

Treatment options depend on the following:

  • The stage of the cancer.
  • The patient’s symptoms and general health.
  • The wishes of the patient.
  • The age of the foetus.

Stages of Hodgkin’s Lymphoma During Pregnancy

Key Points for This Section

  • After Hodgkin’s lymphoma during pregnancy has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.
  • Stages of Hodgkin’s lymphoma during pregnancy may include A, B, E, and S.
  • The following stages are used for Hodgkin's lymphoma during pregnancy:
    • o Stage I
    o Stage II
    o Stage III
    o Stage IV

    After Hodgkin’s lymphoma during pregnancy has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.

    The process used to find out if cancer has spread within the lymph system or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

    To protect the foetus from the harms of radiation, tests that do not use radiation are used in the staging process. These include:

    • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
    • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

    Stages of Hodgkin’s lymphoma during pregnancy may include A, B, E, and S.

    Hodgkin's lymphoma during pregnancy may be described as follows:

    • A: The patient has no symptoms.
    • B: The patient has symptoms such as fever, weight loss, or night sweats.
    • E: "E" stands for extranodal and means the cancer is found in an area or organ other than the lymph nodes or has spread to tissues beyond, but near, the major lymphatic areas.
    • S: "S" stands for spleen and means the cancer is found in the spleen.

    The following stages are used for Hodgkin's lymphoma during pregnancy:

    Stage I

    Stage I is divided into stage I and stage IE:

    • Stage I: Cancer is found in one lymph node group.
    • Stage IE: Cancer is found in an area or organ other than the lymph nodes.

    Stage II

    Stage II is divided into stage II and stage IIE:

    • Stage II: Cancer is found in two or more lymph node groups on the same side of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIE: Cancer is found in an area or organ other than the lymph nodes and in lymph nodes near that area or organ, and may have spread to other lymph node groups on the same side of the diaphragm.

    Stage III

    Stage III is divided into stage III, stage IIIE, stage IIIS, and stage IIIS+E:

    • Stage III: Cancer is found in lymph node groups on both sides of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIIE: Cancer is found in lymph node groups on both sides of the diaphragm and in an area or organ other than the lymph nodes.
    • Stage IIIS: Cancer is found in lymph node groups on both sides of the diaphragm and in the spleen.
    • Stage IIIS+E: Cancer is found in lymph node groups on both sides of the diaphragm, in an area or organ other than the lymph nodes, and in the spleen.

    Stage III is also divided into stage III(1) and stage III(2) as follows:

    • Stage III(1): Cancer is found only in the upper abdomen above the renal vein.
    • Stage III(2): Cancer is found in lymph nodes in the pelvis and/or near the aorta.

    Stage IV

    In stage IV, the cancer either:

    • is found throughout one or more organs other than the lymph nodes and may be in lymph nodes near those organs; or
    • is found in one organ other than the lymph nodes and has spread to lymph nodes far away from that organ.

    Treatment Option Overview

    Key Points for This Section

    • There are different types of treatment for pregnant patients with Hodgkin's lymphoma.
    • Four types of standard treatment are used:
      • o Radiation therapy
      o Chemotherapy
      o Watchful waiting
      o Steroid therapy

      There are different types of treatment for pregnant patients with Hodgkin's lymphoma.

      Different types of treatment are available for pregnant patients with Hodgkin’s lymphoma. Treatment is carefully chosen to protect the foetus. Treatment decisions are based on the mother’s wishes, the stage of the Hodgkin’s lymphoma, and the age of the foetus. The treatment plan may change as the symptoms, cancer, and pregnancy change. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

      Four types of standard treatment are used:

      Radiation therapy

      Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

      To avoid any risk to the foetus, radiation therapy should be postponed until after delivery, if possible. If immediate treatment is needed, pregnant women with Hodgkin’s lymphoma may decide to continue the pregnancy and receive radiation therapy. However, lead used to shield the foetus may not protect it from scattered radiation that could possibly cause cancer in the future.

      Chemotherapy

      Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

      The foetus cannot be protected from being exposed to chemotherapy when the mother is treated. Some chemotherapy regimens may cause birth defects when given in the first trimester. Vinblastine is an anticancer drug that has not been linked with birth defects in the second half of pregnancy.

      Watchful waiting

      Watchful waiting is closely monitoring a patient’s condition without giving any treatment unless symptoms appear or change. Delivery may be induced when the foetus is 32 to 36 weeks old, so that the mother can begin treatment.

      Steroid therapy

      Steroids are hormones naturally produced in the body by the adrenal glands and by reproductive organs. Some types of steroids are made in a laboratory. Certain steroid drugs have been found to help chemotherapy work better and help stop the growth of cancer cells. Steroids can also help the lungs of the foetus develop faster than normal. This is important when delivery is induced early.

      Treatment of Hodgkin’s Lymphoma During Pregnancy

      Hodgkin’s Lymphoma During the First Trimester of Pregnancy

      When Hodgkin’s lymphoma is diagnosed in the first trimester of pregnancy, it does not necessarily mean that the patient will be advised to end the pregnancy. Each patient's treatment will depend on the stage of the lymphoma, how fast it is growing, and the patient's wishes. For women who choose to continue the pregnancy, treatment of Hodgkin’s lymphoma during the first trimester of pregnancy may include the following:

      • Watchful waiting when the cancer is above the diaphragm and is slow-growing. Delivery may be induced when the foetus is 32 to 36 weeks old so the mother can begin treatment.
      • Radiation therapy above the diaphragm, with the foetus shielded.
      • Systemic chemotherapy using one or more drugs.

      Hodgkin’s Lymphoma During the Second Half of Pregnancy

      When Hodgkin’s lymphoma is diagnosed in the second half of pregnancy, most patients can delay treatment until after the baby is born. Treatment of Hodgkin’s lymphoma during the second half of pregnancy may include the following:

      • Watchful waiting, with plans to induce delivery when the foetus is 32 to 36 weeks old.
      • Systemic chemotherapy using one or more drugs.
      • Steroid therapy.
      • Radiation therapy to relieve breathing problems caused by a large tumour in the chest.

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