For advanced-stage disease, chemotherapy is recommended regardless of gestational age. Before 20 weeks, therapeutic abortion is a consideration, but if termination is unacceptable, then treatment with vinblastine followed by multi agent therapy in the second trimester can be used (Eyre, 2015). For most advancedstage disease after the irst trimester, cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine are given, and radiotherapy can be added postpartum (Cohen, 2011). In general, postponement of therapy until fetal maturity is achieved seems justiiable only when the diagnosis is made late in pregnancy.
Women with Hodgkin lymphoma have a higher incidence of VTE (El-Messidi, 2015; Horowitz, 2016). lso, in our experiences, pregnant women with Hodgkin disease-even after they arer" cured" -are inordinately susceptible to infection and sepsis. Active antineoplastic therapy only increases this vulnerability.
The overall prognosis with Hodgkin lymphoma is good, and survival rates exceed 70 percent. Pregnancy does not adversely afect the cancer course or pregnancy outcomes in women with this lymphoma. Speciically, neither chemotherapy after the first trimester nor mediastinal and neck irradiation has adverse fetal efects (Brenner, 2012; El-v1essidi, 2015; Pinnix, 2016). For women with disease in remission, pregnancy does not stimulate a relapse (Weibull, 2016).
lthough usually B-cell tumors, non-Hodgkin lymphomas can also be T-cell or natural-killer-cell neoplasms. heir biology, classification, and treatment are complex (Longo, 2015; O'Gara, 2009). hey are associated with viral infections, and indeed, their incidence has risen sharply at least pardy because 5 to 10 percent of HIV-infected persons develop lymphoma. Other associated viruses include Epstein-Barr virus, hepatitis C virus, and human herpes virus 8. Some of these lymphomas are aggressive, and survival rates vary with the type of cell line involved (Longo, 2015).
Non-Hodgkin lymphomas are infrequent during pregnancy (Brenner, 2012; Pinnix, 2016). They are also staged according to the Ann Arbor system. If diagnosed in the irst trimester, pregnancy termination followed by multiagent chemotherapy is recommended for all but indolent or very early disease. These less aggressive forms may either be observed or be temporized with focal supradiaphragmatic radiotherapy and then full treatment in the second trimester. If one of these lymphomas is diagnosed after the irst trimester, chemotherapy and immunotherapy
TABLE 63-2. Ann Arbor Staging System for Hodgkin and Other Lymphomas
I Involvement in a single lymph node region or lymphoid site-e.g., spleen or thymus
II Involvement of two or more lymph node groups on the same side of the diaphragm-the mediastinum is a single site
III Involvement of lymph nodes on both sides of the diaphragm 1.
Limited to spleen or splenic hilar, celiac, or portal nodes 2.
Includes paraaortic, iliac, or nodes plus those in III
IV Extralymphatic involvement-e.g., liver or bone marrow
Substage A = no symptoms; substage B = fever, sweats, or weight loss; substage E = extralymphatic involvement excluding liver and bone marrow.