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Non-Hodgkin's lymphoma during pregnancy: Treatment - Patient Information [NCI PDQ]

Non-Hodgkin's Lymphoma During Pregnancy

General Information About Non-Hodgkin Lymphoma During Pregnancy

Non-Hodgkin lymphoma is a disease in which malignant (cancer) cells form in the lymph system.

The lymph system is part of the Immune system and is made up of the following:

• Lymph: Colorless, watery fluid that travels through the lymph system and carries white Blood cells called lymphocytes. Lymphocytes protect the body against Infection and the growth of tumors.
• Lymph vessels: A network of thin tubes that collect lymph from different parts of the body and return it to the bloodstream.
• Lymph nodes: Small, bean-shaped structures that filter substances in lymph and help fight infection and disease. Lymph nodes are located along the network of lymph vessels found throughout the body. Clusters of lymph nodes are found in the underarm, pelvis, neck, abdomen, and groin.
• Spleen: An organ that produces lymphocytes, filters the blood, stores blood cells, and destroys old blood cells. It is located on the left side of the abdomen near the stomach.
• Thymus: An organ in which lymphocytes grow and multiply. The thymus is in the chest behind the breastbone.
• Tonsils: Two small masses of lymph tissue at the back of the throat. The tonsils produce lymphocytes.
• Bone marrow: The soft, spongy tissue in the center of large bones. Bone marrow produces white blood cells, red blood cells, and platelets.

Because lymph tissue is found throughout the body, adult non-Hodgkin lymphoma can begin in almost any part of the body. cancer can spread to the liver and many other organs and tissues.

Lymphomas are divided into two general types: hodgkin lymphoma and non-Hodgkin lymphoma. This summary refers to the treatment of non-Hodgkin lymphoma during pregnancy. Refer to the following PDQ summaries for more information:

• Hodgkin Lymphoma During Pregnancy
• AIDS-Related Lymphoma Treatment
• Adult Hodgkin Lymphoma Treatment
• Primary CNS Lymphoma Treatment
• Adult Non-Hodgkin Lymphoma Treatment

Age and a weak immune system can affect the risk of developing non-Hodgkin lymphoma.

It is uncommon for non-Hodgkin lymphoma to occur in young Women during pregnancy. Risk factors include the following:

• Being white.
• Having one of the following medical conditions:
  • An inherited immune disorder (for example, hypogammaglobulinemia or Wiskott-Aldrich syndrome).
  • An autoimmune disease (for example, rheumatoid arthritis, psoriasis, or Sjögren syndrome).
  • HIV/AIDS.
  • Human T-lymphotrophic virus type I or Epstein-Barr virus.
  • A history of Helicobacter pylori infection.
• Taking Immunosuppressant drugs after an organ transplant.
• Being exposed to certain pesticides.
• A diet high in meats and fat.
• Past treatment for Hodgkin lymphoma.

Possible signs of non-Hodgkin lymphoma include fever, night sweats, fatigue, and weight loss.

These and other symptoms may be caused by non-Hodgkin lymphoma. Other conditions may cause the same symptoms. A Doctor should be consulted if any of the following problems occur:

• Painless Swelling of the lymph nodes in the neck, underarm, groin, or stomach.
• Fever for no known reason.
• Drenching night sweats.
• Feeling very tired.
• Weight loss for no known reason in the past 6 months.
• Skin rash or itchy skin.
• Pain in the chest, abdomen, or bones for no known reason.

Tests that examine the body and lymph system are used to help detect (find) and diagnose non-Hodgkin lymphoma during pregnancy.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • The number of red blood cells, white blood cells, and platelets.
  • The amount of hemoglobin (the Protein that carries oxygen) in the red blood cells.
  • The portion of the sample made up of red blood cells.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it.
• Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells. One of the following types of biopsies may be done:
  • Excisional biopsy: The removal of an entire lymph node.
  • Incisional biopsy: The removal of part of a lymph node.
  • Core biopsy: The removal of part of a lymph node using a wide needle.
  • Needle biopsy: The removal of part of a lymph node using a thin needle. This procedure is also called a Fine-Needle Aspiration biopsy.
• Bone marrow aspiration and biopsy: The removal of a small piece of bone and bone marrow by inserting a needle into the hipbone or breastbone. A pathologist views both the bone and bone marrow samples under a microscope to look for signs of cancer.
• Liver function tests: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. For non-Hodgkin lymphoma during pregnancy, the blood is checked for an Enzyme called lactate dehydrogenase (LDH). LDH levels help determine prognosis (chance of recovery).

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis depends on the following:

• The type and stage of the cancer.
• The amount of LDH in the blood.

The treatment options depend on the following:

• The type and stage of the cancer.
• The wishes of the patient.
• The patient's age and general health.
• Which trimester of Pregnancy the Patient is in.

Some types of non-Hodgkin lymphoma spread more quickly than others do. Most non-Hodgkin lymphomas that occur during pregnancy are aggressive. Delaying treatment of aggressive lymphoma until after the baby is born may lessen the mother's chance of survival. Immediate treatment is often recommended, even during pregnancy.

Stages of Non-Hodgkin Lymphoma During Pregnancy

After non-Hodgkin lymphoma during pregnancy has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.

The process used to find out if cancer has spread within the lymph system or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

To protect the fetus from the harms of radiation, tests that do not use radiation are used in the staging process. These include the following:

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called Nuclear magnetic resonance imaging (NMRI).
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
• Bone marrow aspiration and biopsy: The removal of a small piece of bone and bone marrow by inserting a needle into the hipbone or breastbone. A pathologist views both the bone and bone marrow samples under a microscope to look for signs of cancer.
• Lumbar puncture: A procedure used to collect cerebrospinal fluid from the spinal column. This is done by placing a needle into the spinal column. This procedure is also called an LP or spinal tap.

Stages of non-Hodgkin lymphoma during pregnancy may include E and S.

Non-Hodgkin lymphoma during pregnancy may be described as follows:

• E: "E" stands for extranodal and means the cancer is found in an area or organ other than the lymph nodes or has spread to tissues beyond, but near, the major lymphatic areas.
• S: "S" stands for spleen and means the cancer is found in the spleen.

The following stages are used for non-Hodgkin lymphoma during pregnancy:

Stage I

Stage I non-Hodgkin lymphoma during pregnancy is divided into stage I and stage IE.

• Stage I: Cancer is found in one lymph node group.
• Stage IE: Cancer is found in an area or organ other than the lymph nodes.

Stage II

Stage II non-Hodgkin lymphoma during pregnancy is divided into stage II and stage IIE.

• Stage II: Cancer is found in two or more lymph node groups on the same side of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
• Stage IIE: Cancer is found in an area or organ other than the lymph nodes and in lymph nodes near that area or organ, and may have spread to other lymph node groups on the same side of the diaphragm.

Stage III

Stage III non-Hodgkin lymphoma during pregnancy is divided into stage III, stage IIIE, stage IIIS, and stage IIIS+E.

• Stage III: Cancer is found in lymph node groups on both sides of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
• Stage IIIE: Cancer is found in lymph node groups on both sides of the diaphragm and in an area or organ other than the lymph nodes.
• Stage IIIS: Cancer is found in lymph node groups on both sides of the diaphragm and in the spleen.
• Stage IIIS+E: Cancer is found in lymph node groups on both sides of the diaphragm, in an area or organ other than the lymph nodes, and in the spleen.

Stage IV

In stage IV non-Hodgkin lymphoma during pregnancy, the cancer either:

• is found throughout one or more organs other than the lymph nodes and may be in lymph nodes near those organs; or
• is found in one organ other than the lymph nodes and has spread to lymph nodes far away from that organ.

Non-Hodgkin lymphomas during pregnancy are also described in terms of how fast they grow and the location of affected lymph nodes.

Indolent or aggressive:

• Indolent lymphomas: These tend to grow and spread slowly and have few symptoms. They are also called low-grade lymphomas.
• Aggressive lymphomas: These grow and spread quickly and have severe symptoms. Lymphoblastic lymphoma, diffuse small noncleaved Cell lymphoma/Burkitt lymphoma, and Mantle Cell Lymphoma are 3 types of aggressive adult non-Hodgkin lymphoma. Aggressive lymphomas are seen more frequently in patients who are HIV-positive (AIDS-related lymphoma). Aggressive lymphomas are also called intermediate-grade and high-grade lymphomas.

Contiguous or noncontiguous:

• Contiguous lymphomas: Lymphomas in which the lymph nodes containing cancer are next to each other.
• Noncontiguous lymphomas: Lymphomas in which the lymph nodes containing cancer are not next to each other, but are on the same side of the diaphragm.

Treatment Option Overview

There are different types of treatment for Pregnant patients with non-Hodgkin lymphoma.

Different types of treatment are available for pregnant patients with non-Hodgkin lymphoma. Treatment is carefully chosen to protect the fetus. Treatment decisions are based on the mother’s wishes, the stage of the non-Hodgkin lymphoma, and the age of the fetus. The treatment plan may change as the symptoms, cancer, and pregnancy change. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Three types of standard treatment are used:

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External Radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

To avoid any risk to the fetus, radiation therapy should be postponed until after delivery, if possible. If immediate treatment is needed, pregnant women with non-Hodgkin lymphoma may decide to continue the pregnancy and receive radiation therapy. However, lead used to shield the fetus may not protect it from scattered radiation that could possibly cause cancer in the future.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When Chemotherapy is taken by Mouth or injected into a Vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is treatment with more than one anticancer drug. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

The fetus is exposed to chemotherapy when the mother is treated and some anticancer drugs cause birth defects. Because anticancer drugs are passed to the fetus through the mother, both must be watched closely when chemotherapy is given.

Watchful waiting

Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear or change.

Treatment of Non-Hodgkin Lymphoma During Pregnancy

See the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information on the treatment of non-Hodgkin lymphoma.

Aggressive Non-Hodgkin Lymphoma During the First Trimester of Pregnancy

When aggressive non-Hodgkin lymphoma is diagnosed in the first trimester of pregnancy, medical oncologists may advise the patient to end her pregnancy so that treatment may begin. Treatment is usually chemotherapy with or without radiation therapy.

Aggressive Non-Hodgkin Lymphoma During the Second and Third Trimester of Pregnancy

When possible, treatment should be postponed until after an early delivery, so that the fetus will not be exposed to anticancer drugs or radiation therapy. However, sometimes the cancer will need to be treated immediately in order to increase the mother's chance of survival.

Indolent Non-Hodgkin Lymphoma During Pregnancy

Women who have indolent (slow-growing) non-Hodgkin lymphoma can usually delay treatment with watchful waiting.

Related Non-Hodgkin's lymphoma during pregnancy: Treatment - Patient Information [NCI PDQ]