T cell non-hodgkins lymphoma in pregnancy

1. T Cell Non- Hodgkin’s
Lymphoma in Pregnancy
DR PEREZ SEPENU
FETO-MATERNAL UNIT- KBTH

2. OUTLINE
• BACKGROUND
• HISTORY
• EXAMINATION
• INVESTIGATIONS
• DIAGNOSIS
• MANAGEMENT SO FAR
• FOLLOW UP UPDATES
• MDT DISCUSSION POINTERS

3. BACKGROUND
• NAME: Madam G. T.
• Age: 34 years
• Parity: G4P1A +2SA
• GA: 26W5D
• EDD: 22/07/2022
• Diagnosis: T-Cell Non-Hodgkin’s Lymphoma in Pregnancy
• Occupation- Student Nurse
• Marital Status- Married to a Teacher

4. HISTORY
• First seen on 23/02/22
• Referred from General Surgery o/a Anterior Neck Swelling
(Histopathology Report suggestive of Non- Hodgkin’s Lymphoma)
• Anterior neck swelling -5/12
• No known chronic medical condition. Swelling started off as small and
painless. Gradually increased in size. Went to a herbal clinic, was
given herbs to drink and rub on the site.
• She noticed a discharge, reported to Korlebu Polyclinic, was referred
to surgical unit, biopsy was done and referred to haematology clinic
with the histopathology report.

5. HISTORY cont’d
• Direct Questioning- Fever-, chills-, chest pain+, constant, non-
radiating, odynophagia-, dyspnea-, nausea-, vomiting-, weight loss-,
bleeding episodes-,bone pain-, joint pain-.
• PMHx- Chronic Medical conditions-,Surgeries-, Previous Admissions-,
Previous Transfusions-

6. Past Obstetric and Gynaecological History
• Past Gynae and Obs Hx- Mernache @12 years, regular 28 days cycle, flows
for 5 days.
• First pregnancy(2015),planned and wanted ended in a miscarriage at 5
weeks.
• Second Pregnancy (2016), planned and wanted, delivered at term via SVD
to a live female, child currently alive and well
• Third Pregnancy (2018), not planned but wanted, ended in a miscarriage at
7 weeks
• Index Pregnancy: Not planned but wanted. Booked at 10 weeks after a
scan was done. So far uneventful. Anomaly scan done a week ago at the
MFM unit was grossly normal

7. HISTORY cont’d
• Drug Hx- Herbal Medications+, Folic Acid+, Allergies-
• Family Hx- Both parents are deceased. Cause of death unknown.
HPT+, No other chronic medical condition.
• Social Hx -Married for 7 years with a 6 year old child. Lives at Kasoa
with husband and brother. Studying at NTC Krobo Odumasi
(Community Health Nurse). Alcohol-, Smoking-,NHIS+
• Husband is a teacher

8. EXAMINATION FINDINGS
• Young lady not acutely ill looking. P-, J-, Hydration satisfactory, pedal
odema-, peripheral lymphadenopathy-
• Has an anterior neck swelling extending to the chest( 15cm x13cm),
not attached to skin, does not move with swallowing or with
protrusion of the tongue, differential warmth-, superficial veins on
the upper chest-
• CVS- HR-100bpm, RGV, BP-102/74mmhg, S1+,S2+, M-

9. EXAMINATION FINDINGS cont’d
• Resp-RR-16cpm. Vesicular Breath sounds. Air entry adequate
bilaterally+
• ABD- Uniformly enlarged, MWR, soft , L-, S-, 2K-, Uterus-26/52. Bowel
sounds- present and normal
• CNS- Conscious and alert.

10. Investigations
• Histopathology Report (27/01/22)
CD 45- Positive
EMA- Negative. No nuclear or cytoplasmic staining
AE1- AE3- Negative
Ki-67- Other form of interpretation >60%
Diagnosis-Suggestive of Non Hodgkin’s Lymphoma
Recommendation- To do immunohistochemistry for typing

11. INVESTIGATIONS CONT’D
FBC (21/02/22) BUE, CR (21/02/22)
Hb- 10.0g/dl HBsAg- Neg HIV1/2- Neg Na+- 137.4
WBC- 8.81 HBsAb-Neg Uric Acid- 168.15 K+- 4.12
Neut- 6.75 HBeAb/ Ag -Neg Urine RE- Normal Cl- 105.5mmol/L
Eos- 0.36 HBcAb- Neg Stool RE- Normal Cr-51.05
Plt-294 HBcIgM- Neg eGFR-122ml/min
LFT (21/02/22)
Total bil- 7.58 Abdominopelvic USG@ 20W1D- Normal
Indirect- 1.64
Direct- 5.9
AST-12
ALT-12
GGT-9U/L
Total Protein-80g/dl
Albumin-46g/dl
Globulin-33.73g/dl
Normal sized liver 14.74cm, with no focal lesions, no
intrahepatic ductal dilatation.
Kidneys are normal in size. No organomegaly.
Incidental findings-Noted at the supraclavicular and
parasternal regions with tortuous superficial veins
and lymph nodes.
Single intra uterine pregnancy. Placenta- Anterior, not
low lying. Fetal Heart Present @ 161bpm.
Longitudinal lie, Cephalic Presentation. No sign of
IUGR

12. INVESTIGATIONS cont’d
Immunohistochemistry (26/2/22) MRI of the neck( 05/01/22)
CD3: Positive. Diffuse strong,
nuclear cytoplasmic staining.
CD20: No nuclear or cytoplasmic
staining.
Ki-67 > 60%
T Cell NHL
LDH (03/03/22)-659.53 Normal MRI of the neck. No signs
of cervical lymphadenopathy.
Normal cervical spine position.
Normal cervical spine soft tissues.

13. DIAGNOSIS
• T- Cell NHL in pregnancy (at least Stage 2A)

14. MANAGEMENT SO FAR
• Patient and husband counselled about the disease, prognosis and
treatment options:-
• Whether to go ahead with the treatment, disregarding the pregnancy?
• Referred to KBTH maternity MFM unit for a multidisciplinary team
management approach ( Putting the pregnancy into consideration)
• Possibility of deferring her studies so as to focus on the treatment
• Treatment goal discussed with her- Ideally would have loved us to achieve
remission, but urgently she would want us to relieve her of her pain and to
reduce the size of the mass
• If can afford, to do CD 52 for Alentuzimab for a more targeted treatment.

15. MANAGEMENT SO FAR
• BMA done- awaiting results
• To start with EPOCH, whiles deciding if they can afford Alentuzimab.
• To have about 3 cycles and progress assessment done.
• Counselled on the need to hasten decisions about starting treatment
since tumor is an aggressive type

16. FOLLOW UP UPDATES
• Reproductive wishes- she would love to have four children but has
been counselled on the possibility of loosing this pregnancy if therapy
is started
• She has decided not to defer the course until 2 weeks time when this
current semester will be over
• She would like to start therapy in two weeks instead by which time
she would be done with her end of semester exams.

17. MDT DISCUSSION POINTERS
• 1. Prognosis for mother in NHL
• 2. Timing for start of definitive treatment for mother
• 3. Prognosis for baby if definitive treatment is started for mother
• 4. Mode and timing of delivery
• 5. Family planning and future fertility wishes
• 6. Main counselling points

18. THANK YOU!