First Documented Use of Liposomal Doxorubicin in a Pregnant Patient with Hodgkin Lymphoma

Context Hodgkin Lymphoma (HL) patients tend to be younger and may become pregnant concomitantly. We present a pregnant, heavily-pretreated HL patient who received liposomal doxorubicin (doxil) and delivered a healthy boy. Setting Patient is a 29 y/o woman diagnosed with classical HL in 2016. She completed six cycles of ABVD in October, 2016. In May 2017, she received radiation to areas of progression. She was referred to us in November 2017 with disease progression confirmed with inguinal biopsy. She received two cycles of ICE with partial response. She received brentuximab in March, April, and May 2018. In June 2018, nivolumab was added to brentuximab. The combination continued until October 2018. Given better response, she had stem cells collected. She became pregnant in October 2018. She had an abortion and proceeded to transplant November 19, 2018. PET showed remission 3 months later, and she started brentuximab maintenance. Follow-up imaging showed relapse, verified on biopsy 8/9/19. We discussed giving nivolumab, but she became pregnant again. Nivolumab and bendamustine are category D with limited to no safety in pregnancy. We offered gemcitabine, vinorelbine, and doxil (GND). After a baseline MRI and echocardiogram demonstrated ejection fraction of 59%, she started GND in the second trimester. She received three cycles of chemotherapy (January to March 2020). Results Improved lymphadenopathy was noted on exam with shrinking right inguinal mass, fewer fevers, and improved appetite. Patient developed COVID-19 in April 2020 and so discontinued further chemotherapy. She delivered a healthy boy 5/1/20 weighing 2.93 kg. Post-delivery PET-CT showed progression of disease, and palpable nodes had begun to grow again. Bendamustine started 6/3/20. Conclusions ABVD is found to be safe in pregnant HL patients starting in the second trimester. A literature search found no cases of the use of doxil in pregnancy in any malignancy setting. Experimental models, including murine, have demonstrated the potential safety of a liposomal delivery system. GND is a well-recognized chemotherapy combination for HL. While data support the use of ABVD starting in the second trimester, limited data are available for relapsed pregnant HL patients. GND may be a safe regimen in such a setting.