Letter to the Editor
Treatment adapted to pregnancy in a patient with Burkitt lymphoma
Tratamiento adaptado a la gestación en una paciente con linfoma de Burkitt
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The treatment seeks to cure the neoplasm while trying to avoid undesirable effects for the foetus and the mother. This challenge is particularly important in highly curable malignancies, such as Burkitt's lymphoma. We report the case of a woman diagnosed with Burkitt lymphoma during the second trimester of pregnancy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">36-Year-old female 21-week pregnant by third <span class="elsevierStyleItalic">in vitro</span> fertilization, who presented with a nodule in the left parotid region and another in the right breast. Biopsy of the breast lesion was diagnostic of Burkitt lymphoma, with translocation of the MYC gene by fluorescent <span class="elsevierStyleItalic">in situ</span> hybridization (FISH), without detection of Epstein-Barr virus DNA and with a proliferation index (Ki-67) higher than 95%. Central nervous system (CNS) and bone marrow invasion was not demonstrated. The extension study with magnetic resonance imaging (MRI) did not show any other lesions than those known in breast and parotid region, and therefore it was considered stage IV.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Given the intensity of the standard Burkitt lymphoma treatment and the patient's express desire to continue with her pregnancy at all costs, which had been very difficult to achieve, it was decided to start chemotherapy with R-CHOP (rituximab, cyclophosphamide, adriamycin, vincristine and prednisone) and triple intrathecal therapy with methotrexate, cytarabine and hydrocortisone, of which she received three cycles. At 31 weeks of pregnancy, an elective caesarean section was performed, resulting in a healthy child, after which 3 cycles of R-EPOCH infusion chemotherapy (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and anthracycline) interspersed with high-dose intravenous methotrexate were administered (3<span class="elsevierStyleHsp" style=""></span>g/m<span class="elsevierStyleSup">2</span>) after the second and third cycles as CNS infiltration prophylaxis. Currently, the patient is in complete metabolic response one year after diagnosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnosis of cancer during pregnancy occurs in one out of every 1000 pregnancies, and haematological malignancies are the second in frequency. Non-Hodgkin's lymphomas represent 5% of all cancers diagnosed during pregnancy and are characterized by being more aggressive, developing at more advanced stages and often affecting the reproductive organs.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Treating these patients is challenging in several ways. Initially, at the diagnostic level, this may be delayed by an overlap of symptoms between lymphoma and pregnancy. At the same time, there are also limitations regarding the use of certain imaging tests, such as computed tomography (CT) or positron emission tomography (PET), due to their teratogenic effect, so it is recommended to use alternative tests such as MRI. Regarding treatment, it should be considered that physiological changes occur during pregnancy, affecting drug pharmacokinetics. In addition, between the second and eighth week of pregnancy there is a high risk of developing teratogenic effects, so if the patient requires urgent treatment, termination of pregnancy is recommended.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> On the other hand, from the second and third trimesters the risk of congenital malformations is lower, the main problem being low birth weight, delayed intrauterine growth and prematurity, and in these cases, treatment could be started without the need to terminate the pregnancy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although there is little scientific evidence, anthracyclines, alkylating agents, and rituximab are considered safe during the second and third trimesters of pregnancy.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> However, systemic methotrexate, considered an essential part of Burkitt lymphoma treatment for its efficacy both systemically and in CNS infiltration prophylaxis, must be reserved for the postpartum period given its teratogenic effects.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> For this reason, it was decided in the patient reported here to carry out treatment with R-CHOP, even knowing that it is not the treatment of choice in Burkitt lymphoma, and to reserve the administration of intravenous methotrexate combined with R-EPOCH<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> until after delivery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary, it is essential to individualize the treatment of each patient according to the type of malignancy, the urgent need for treatment and the time of pregnancy, prioritizing the survival of the mother while trying to minimize the toxic effects on the foetus. The low frequency of these cases prevents systematizing the little scientific evidence, since most of the information comes from retrospective studies and short case series.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">Partially financed with PI14/01971 <span class="elsevierStyleGrantSponsor" id="gs1">FIS</span> grants, Carlos III INSTITUTE, CERCA Program, Generalitat de Catalunya SGR 288 (GRC) and Fundació “La Caixa”.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Comes M, Batlle M, Ribera J-M. Tratamiento adaptado a la gestación en una paciente con linfoma de Burkitt. Med Clin (Barc). 2020;154:470–471.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The management of lymphoma in the setting of pregnancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.C. Pinnix" 1 => "T.Y. Andraos" 2 => "S. 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Grant" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1308392" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "369" "paginaInicial" => "1915" "paginaFinal" => "1925" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24224624" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000011/v1_202006060744/S2387020620301807/v1_202006060744/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000011/v1_202006060744/S2387020620301807/v1_202006060744/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620301807?idApp=UINPBA00004N" ]
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