Lymphoma in pregnancy: generally favourable outcomes

Blood cancers

By Mardi Chapman

16 Mar 2023

pregnancyStandard chemotherapy regimens can be successfully delivered to the majority of women diagnosed with lymphoma in pregnancy (LIP), according to Australian and New Zealand data representing one of the largest cohorts of LIP.

A retrospective study, published in the British Journal of Haematology [link here], reported on the features, management, and outcomes of lymphoma, diagnosed between 2009 and 2020 either during pregnancy or within the first 12 months following delivery at 16 sites in Australia and New Zealand.

The cohort comprised 73 patients, 41 diagnosed during pregnancy and 32 postnatally, with a median age of 32 years.

The study, from the Australasian Lymphoma Alliance, said the postnatal patients were included to capture lymphomas developing prior to delivery, but not diagnosed until afterwards “typically due to both the symptom obfuscation and diagnostic delays associated with pregnancy”.

The most common diagnoses were Hodgkin lymphoma (n=40), DLBCL (n=11), indolent B-cell non-Hodgkin lymphoma (n=7), and primary mediastinal B-cell lymphoma (n=6).

Collectively, LIP is the second most prevalent cancer diagnosed in pregnancy following breast cancer.

All but two patients received chemotherapy with or without rituximab and the majority (94%) received the full number of planned chemotherapy cycles.

About half (52%) also received granulocyte colony-stimulating factor support as either primary or secondary prophylaxis for febrile neutropenia.

The study said that 80% of the antenatal cohort received active treatment such as ABVD, R-CHOP or CHOP during pregnancy. Most patients had immediate treatment, four patients were deferred until later in their pregnancy, and seven patients deferred until the postnatal period.

The 2- and 5-year overall survival (OS) for all patients combined were 92% and 79% respectively, with no significant difference between the antenatal and postnatal groups.

“Seven patients died in the study period: three due to lymphoma, one due to complications of later allogeneic haematopoietic cell transplant and two due to infection, including one secondary to neutropenic sepsis during pregnancy.”

There was one foetal death occurring in the second trimester, concurrent with the maternal death due to neutropenic sepsis.

In neonatal outcomes, mean gestational age at delivery was 36.8 weeks and shorter in the antenatal group compared to the postnatal group (35.8 v 38.4 weeks) mostly due to elective induction of labour.

Of the premature deliveries, 18% had in-utero exposure to chemotherapy however in-utero exposure was not associated with an increased likelihood of a small-for-gestational-age neonate.

The investigators said the published evidence describes avoidance of preterm birth as the most important determinant for neonatal wellbeing and normal neurocognitive development, and not in-utero chemotherapy exposure.

“The optimal timing for induction of labour in LIP should take this into account,” they said.

There were only two elective terminations of pregnancy “in keeping with expert recommendations that elective termination is rarely required beyond the first trimester”.

The study noted that only 47% of the patients had documented evidence of counselling regarding future fertility, including fertility preservation if applicable.

“Although fertility preservation is not always prioritised in this setting, a recent cohort study on the lived experiences of patients with LIP [link here] identified this as an area of unmet need for these women and expert guidelines stress the importance of fertility counselling and psychosocial support for women with LIP.” [link here]

In other areas of suggested improvement regarding the management of LIP, the investigators noted the lack of a standardised approach to staging.

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