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Cancer in Pregnancy: Hodgkin's Disease in Pregnancy

Introduction
Since the peak incidence of Hodgkin's disease (HD) is in the age range of 20 to 40 years, its association with pregnancy is not uncommon, occurring in 1:1000-1:6000 deliveries 1. To date, the majority of published studies have been case reports of small series due to the relative rareness of the combination of HD and pregnancy. Therefore, the guidelines for evaluation and treatment of HD in pregnancy are not well established.

Diagnosis
Since tomographic scans and istotope studies are not recommended during pregnancy and since the current trend is to administer chemotherapy initially even in early stages (stage I,II) of Hodgkin's disease, a limited initial staging workup is suggested.

It should include history, physical examination, routine blood tests, bone marrow biopsies, chest x-ray with abdominal shielding, abdominal ultrasound and possibly MRI 2. The clinical behavior of HD during pregnancy does not appear to differ from that outside of this setting and pregnant women are not more likely to present at a higher stage than women of reproductive agein general 3,4. Also, the histologic subtypes of HD in pregnancy are not different from that of non-pregnant women younger than 40 years 3.

Treatment
>Due to the limited availability of treatment information it is not feasible to make specific recommendations regarding patient management. In general, it is recommended to avoid chemotherapy during the first 12 to 16 weeks of pregnancy if possible and to postpone radiotherapy until after the delivery 2,3. If combination chemotherapy is considered, probably the recommended protocol is ABVD: adriamycin, bleomycin, vinblastine, dacarbazine.

Prognosis and fetal consequences
There is no effect of pregnancy on survival of women with HD 3,4. Infants born to women with HD during pregnancy do not have a higher risk for prematurity or intrauterine growth retardation4. In the cases reported by Anselmo et al5, pregnant women affected by HD safely carried their pregnancies to term and gave birth to healthy children. The association of HD with pregnancy is not, on its own, an indication for a therapeutic abortion. Recommendations regarding abortion should be individualized based on potential harm of staging procedures, chemotherapy or radiotherapy to the fetus 6.

Induction of labor should be performed when there is a viable fetus and mother's blood counts are not compromised by a recent cytotoxic treatment. Breast feeding is contraindicated during active treatment of Hodgkin's disease 7. There are no reports of HD metastatic to the placenta or to the fetus.

References

  1. Morgan OS, Hall SE, Gibbs WN: Hodgkin's disease in pregnancy. A report of 3 cases. West Indiana Med. I. 25:121-124,1976.
  2. Ward FT, Weiss RB: Lymphoma and pregnancy. Sem. Oncol 16:397-409,1989.
  3. Gelb AB, Van de Rijn M, Warnke RA, Kamel OW: Pregnancy associated lymphomas: A clinicopathological study. Cancer 78:304-310,1996.
  4. Lishner M, Zemlickis D, Degendrofer P, Panzarella T, Sutcliffe SB, Koren G: Maternal and fetal outcome following Hodgkin's disease in pregnancy. Br. J. Cancer 65:114-117,1992.
  5. Anselmo AP, Cavalieri E, Maurizi Enrici R, Pascarmona E et al: Hodgkin's disease during pregnancy: Diagnostic and therapeutic management. Fetal Diagnosis and Therapy Mar-Apr: 14(2):102-5, 1999.
  6. Koren G, Weiner L, Lishner M, Zemlicikis D, Finegen J: Cancer in Pregnancy: Identification of unanswered questions on maternal and fetal risks. Obstet Gynecol Surv 45:519-514, 1990.
  7. Doll DC, Ringenberg QS, Yarbro JW: Antineoplastic agents and pregnancy. Sem. Oncol 16:337-346,1989.
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