PREGNANCY IN A PATIENT WITH NON-HODGKIN LYMPHOMA

Habib F.A.
Obstetrics and Gynecology Department, King Khalid University Hospital Riyadh, Saudi Arabia

Introduction:

The overall incidence of lymphoma during pregnancy has not been established accurately. Hodgkin’s disease is the fourth most frequently diagnosed cancer in pregnancy (1 in 1000 to 1 in 6000 pregnancies)(1). In contrast, the incidence of non- Hodgkin lymphoma during pregnancy is rare, with fewer than one hundred cases reported(2). A case of small intestinal lymphoma in association with pregnancy is presented, with emphasis on the major clinical issues involved in the approach to the management of such cases.

Case Report:

In May 1998 a 32-year-old woman, gravida four, para three, in her 29th week of pregnancy, was admitted with a two month history of abdominal pain, vomiting and distension. Signs of malabsorption were marked. Examination revealed the presence of an epigastric mass with evidence of intestinal obstruction. Fine needle aspiration of the mass revealed cells showing high grade malignancy with the possibility of the tumour being a lymphoma or sarcoma of the small intestine. Serum electrolytes, liver function tests and renal function tests were normal. Examination of blood and coagulation profiles showed moderate anaemia and a prolongation in the coagulation time.

At 30 weeks of gestation, the pregnancy was terminated by an elective lower segment caesarean section and a normal female infant weighing 1000 grams was delivered. The apgar score was 7 at 1 minute and 8 at 5 minutes. After the caesarean section a general surgeon carried out multiple resection of obstructing small bowel lymphomata, with removal of regional lymph nodes. The liver, spleen, kidneys, stomach and large bowel were normal.

Histology of the tumour revealed non-Hodgkin lymphoma, of the B-cell (Malt) type, Stage II A. Bone marrow biopsy showed no involvement with lymphoma. After complete post-operative recovery the patient received combination chemotherapy of CHOP (Cyclophosphamid, Doxorubicin, Vincristine and Prednisolone) for six cycles. She improved clinically after treatment and gained six kilograms in weight

Five months later another intestinal mass was diagnosed in the terminal ileum and biopsy showed a recurrent high grade lymphoma. The patient received chemotherapy with ESHAP Protocol (ETOPOSID VP16, Cisplatin, methylprednisolone and ephosphomide) for five cycles followed by radiotherapy, as there was no response to the chemotherapy. Four months later the patient died but the child is still in good health.

Discussion:

Malignant neoplasm of the small bowel in association with pregnancy is infrequent(4) but, on the other hand, lymphomas do occur predominantly in the ileum(3). As with other neoplastic conditions, the diagnosis of non-Hodgkins Lymphoma (NHL) in pregnancy is often delayed and the accurate assessment of the stage of lymphoma is almost impossible because of the pregnant uterus in the abdomen(4).

The diagnosis of this disease in pregnancy puts immense stress on the pregnant women, their families and on the physicians caring for them. Potential harm to the women from the delayed diagnosis, staging or therapy, and the risk to the baby from radiation or chemotherapy creates severe pressure and a need for prompt decisions as to the optimum time to deliver the baby.

The approach to treatment should be individualized according to the period of gestation, stage and localization of the disease, the presence or absence of B symptoms (fever, night sweats, and weight loss of more than 10% of the original weight six months prior to first attendance) and the progression of symptoms and signs. The nature of the histology should also be considered(5).

The treatment of NHL in pregnancy is problematic because radiotherapy and chemotherapy are potentially teratogenic(6,7). The risks and benefits of immediate and early delivery and the resultant risk of prematurity should be weighed against a delay in therapy until foetal maturity is achieved, at which stage the malignancy may have spread beyond control.

Because of the aggressive nature of this malignancy, the decision was made to begin treatment of the lymphoma immediately after surgery. In our choice of management, while the health and safety of both the mother and the foetus were considered, the priority was to treat the mother with curative intent, since she had such a large and rapidly growing tumour at the time of diagnosis and treatment could not be safely delayed until foetal maturity. Caesarean section at 30 weeks of gestation with wide local resection of the tumour was therefore followed by chemotherapy.

The response of patients to treatment varies and carries inherent risks. The patient and family should know that each cycle of most combination chemotherapies carry an inherent risk of bone marrow depression, hemorrhage and sepsis(8). They should also be aware that, should the primary treatment fail, the possibility for cure will be less despite intensive therapy (9).

The optimal management of non-Hodgkin’s lymphoma presenting in the small intestine has not been established. Attempts to improve the outcome in this patient, using combination chemotherapy and consolidation radiotherapy were not successful(10) and the experience under-scores the difficulty in treating this aggressive form of lymphoma.

Although the outcome in this case was poor, and can be attributed to the aggressive nature of the disease, it confirmed that tumour masses of non-Hodgkin’s lymphoma greater than 10 cm in size, represent a poor prognostic sign(10). This case is reported to demonstrate the diagnostic and management problems associated with this type of lymphoma, especially in pregnancy. When confronted with this problem, prompt and early therapy should be initiated.

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