Pushing the boundaries. Concurrent Hodgkin lymphoma and breast cancer treatment with preservation of pregnancy: A case report

Abstract

Background: Breast cancer and hematological cancers are the most commonly diagnosed malignancies during pregnancy. This case report is the first to describe the ultimate challenge to preserve a pregnancy while the expectant mother is diagnosed and treated simultaneously for two concurrent primary malignancies, a stage IIA Hodgkin lymphoma and pT2N0(Sn) breast cancer.

Clinical case: A 36-year-old pregnant primigravida underwent a routine non-invasive prenatal test at 14 weeks and 4 days of gestation. Genome-wide sequencing was used and revealed an aberrant DNA/chromosome copy number profile among which a strong 2p-gain, possibly related to a maternal malignancy. Physical examination showed an enlarged cervical lymph node and ultrasound guided biopsy confirmed the diagnosis of a nodular sclerosing classical Hodgkin lymphoma subsequently staged as an early stage, unfavorable (IIA) Hodgkin lymphoma. Whole body magnetic resonance imaging for further staging also indicated a suspicious nodule in the right breast. Further investigation resulted in the concurrent diagnosis of a pT2N0(Sn) invasive ductal adenocarcinoma. Patient underwent a mastectomy with sentinel lymph node biopsy at 15 weeks and 5 days of gestation, followed by 4-weekly chemotherapy administration, consisting of doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). Pregnancy went further relatively uncomplicated and fetal assessment was reassuring during pregnancy. Due to fever of unknown origin and preterm labor, a cesarean section was performed on a gestational age of 35 weeks and 4 days. Oncological treatment was completed after delivery with involved-field radiation therapy for the Hodgkin lymphoma. Completion of systemic treatment for breast cancer consisted of docetaxel/cyclophosphamide chemotherapy, and anti-hormonal treatment in the form of ovarian function suppression and letrozole.

Conclusion: Here we show for the first time that two concurrent primary malignancies can be treated successfully during pregnancy with respect to maternal and fetal chances. Motivated modifications of breast cancer treatment (mastectomy instead of lumpectomy, AVBD instead of epirubicin-cyclophosphamide chemotherapy), allowed treatment of both cancers during pregnancy. Final treatment was administered after delivery.

Keywords: Breast cancer; Case report; Hodgkin lymphoma; Pregnancy.

Fig. 1

Timeline of interventions during the pregnancy and postpartum.

Fig. 2

The chromosome copy number profile after NIPT analysis for chromosomes 1–22, X and Y shows several (mosaic) aberrations on several chromosomes, among which a clear chromosome 2p gain. Such a profile is highly indicative for the presence of a (maternal) malignancy.

Fig. 3

Whole body diffusion-weighted magnetic resonance (WB-DWI/MRI) in pregnant patient with aberrant noninvasive prenatal test (NIPT): (A) b1000 DWI shows enlarged and bright mediastinal lymphadenopathies (arrows) with anatomical correlate at (B) T1-weighted image indicative of lymphoma and a bright nodular lesion (dashed arrows) in de the right breast suspicious of breast cancer. (C) Corresponding apparent diffusion coefficient (ADC) map of the mediastinal lymphadenopathy (green box) shows value of 0.00089 mm²/sec confirming malignancy. Interim WB-DWI/MRI after 2 cycles of chemotherapy and right mastectomy shows (D) signal substantial loss at b1000 DWI and partial volume regression at (E) T1-weighted image of the mediastinal lymphadenopathies (arrows) corresponding to (F) a substantially increased ADC of 0.00191 mm²/sec indicating substantial necrosis induction and thus excellent response of the lymphoma.