Non-Hodgkin Lymphoma Treatment During Pregnancy (PDQ®): Treatment - Health Professional Information [NCI]

General Information About Non-Hodgkin Lymphoma (NHL) During Pregnancy

Non-Hodgkin lymphoma (NHL) is more common in older patients, with a median age at diagnosis of 68 years.[1] Hodgkin lymphoma is most common in early adulthood and in patients older than 65 years.[2] This age distribution may explain why there are fewer reports of NHL in pregnant patients.[3]

References:

1. Surveillance, Epidemiology, and End Results Program: SEER Cancer Stat Facts: Non-Hodgkin Lymphoma. Bethesda, Md: National Cancer Institute, DCCPS, Surveillance Research Program. Available online. Last accessed May 26, 2023.
2. Surveillance, Epidemiology, and End Results Program: SEER Cancer Stat Facts: Hodgkin Lymphoma. Bethesda, Md: National Cancer Institute. Available online. Last accessed May 26, 2023.
3. Ward FT, Weiss RB: Lymphoma and pregnancy. Semin Oncol 16 (5): 397-409, 1989.

Stage Information for NHL During Pregnancy

To avoid exposure to ionizing radiation, magnetic resonance imaging is the preferred tool for staging evaluation.[1] For more information, see the Stage Information for B-Cell Non-Hodgkin Lymphoma section in B-Cell Non-Hodgkin Lymphoma Treatment.

References:

1. Nicklas AH, Baker ME: Imaging strategies in the pregnant cancer patient. Semin Oncol 27 (6): 623-32, 2000.

Treatment Option Overview for NHL During Pregnancy

Table 1. Treatment Options for Non-Hodgkin Lymphoma (NHL) During Pregnancy

Stage	Treatment Options
Indolent NHL During Pregnancy	Delay treatment until after delivery
Aggressive NHL During Pregnancy	Immediate therapy
	Early delivery, when feasible
	Termination of pregnancy

Treatment of Indolent NHL During Pregnancy

Treatment may be delayed for those women with an indolent non-Hodgkin lymphoma.

Treatment of Aggressive NHL During Pregnancy

Immediate Therapy

According to anecdotal case series, most non-Hodgkin lymphomas (NHLs) in pregnant patients are aggressive, and delay of therapy until after delivery appears to have poor outcomes.[1,2,3,4] Consequently, some investigators favor immediate therapy, even during pregnancy.[4] In a review of 121 patient case reports from 74 papers, one-half of the patients had very aggressive lymphomas, such as Burkitt lymphoma, and one-half of the patients had involvement of the breast, ovaries, uterus, or placenta.[5] One-half of the patients received therapy antepartum, and the 6-month survival rate was reported at 53%, with a live-birth rate of 83%.[5][Level of evidence C3]

A multicenter retrospective analysis of 50 patients described pregnancy termination in 3 patients, deferral of therapy to postpartum in 15 patients (median 30 weeks gestation), and antenatal therapy applied to the remaining 32 patients (median 21 weeks gestation, all done after the first trimester).[6] With a median follow-up of 41 months, the 3-year progression-free survival rate was 53%, and the overall survival rate was 82%, using R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) or modifications of this regimen.[6][Level of evidence C3]

Early Delivery, When Feasible

For some women, early delivery, when feasible, may minimize or avoid fetal exposure to chemotherapy or radiation therapy.

Termination of Pregnancy

Termination of pregnancy in the first trimester may allow immediate therapy for women with aggressive NHL.

Effects of Treatment on Children

Evidence (treatment effect on children exposed in utero):

• With follow-up ranging from several months to 11 years, children who were exposed to high-dose doxorubicin-containing combination chemotherapy in utero (especially during the second and third trimester) had normal growth and no evidence of congenital malformations.[4,7,8,9] For most of the chemotherapeutic agents used for the treatment of NHL, there are no data regarding long-term effects on children exposed in utero.
• In one anecdotal case, a newborn exposed to a rituximab-containing regimen in utero was born with no circulating B lymphocytes. The newborn was otherwise healthy and recovered the circulating B lymphocytes by age 6 months with no unusual or persisting intercurrent infections.[10]

References:

1. Ward FT, Weiss RB: Lymphoma and pregnancy. Semin Oncol 16 (5): 397-409, 1989.
2. Steiner-Salz D, Yahalom J, Samuelov A, et al.: Non-Hodgkin's lymphoma associated with pregnancy. A report of six cases, with a review of the literature. Cancer 56 (8): 2087-91, 1985.
3. Spitzer M, Citron M, Ilardi CF, et al.: Non-Hodgkin's lymphoma during pregnancy. Gynecol Oncol 43 (3): 309-12, 1991.
4. Gelb AB, van de Rijn M, Warnke RA, et al.: Pregnancy-associated lymphomas. A clinicopathologic study. Cancer 78 (2): 304-10, 1996.
5. Horowitz NA, Benyamini N, Wohlfart K, et al.: Reproductive organ involvement in non-Hodgkin lymphoma during pregnancy: a systematic review. Lancet Oncol 14 (7): e275-82, 2013.
6. Evens AM, Advani R, Press OW, et al.: Lymphoma occurring during pregnancy: antenatal therapy, complications, and maternal survival in a multicenter analysis. J Clin Oncol 31 (32): 4132-9, 2013.
7. Avilés A, Díaz-Maqueo JC, Torras V, et al.: Non-Hodgkin's lymphomas and pregnancy: presentation of 16 cases. Gynecol Oncol 37 (3): 335-7, 1990.
8. Moore DT, Taslimi MM: Multi-agent chemotherapy in a case of non-Hodgkin's lymphoma in second trimester of pregnancy. J Tenn Med Assoc 84 (9): 435-6, 1991.
9. Nantel S, Parboosingh J, Poon MC: Treatment of an aggressive non-Hodgkin's lymphoma during pregnancy with MACOP-B chemotherapy. Med Pediatr Oncol 18 (2): 143-5, 1990.
10. Mandal PK, Dolai TK, Bagchi B, et al.: B cell suppression in newborn following treatment of pregnant diffuse large B-cell lymphoma patient with rituximab containing regimen. Indian J Pediatr 81 (10): 1092-4, 2014.

Changes to This Summary (06 / 26 / 2023)

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.

This is a new summary.

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® Cancer Information for Health Professionals pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of non-Hodgkin lymphoma during pregnancy. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

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Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Non-Hodgkin Lymphoma Treatment During Pregnancy are:

• Eric J. Seifter, MD (Johns Hopkins University)
• Cole H. Sterling, MD (Johns Hopkins University)

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PDQ® Adult Treatment Editorial Board. PDQ Non-Hodgkin Lymphoma Treatment During Pregnancy. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/lymphoma/hp/non-hodgkin-lymphoma-treatment-during-pregnancy-pdq. Accessed <MM/DD/YYYY>.

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Last Revised: 2023-06-26