CTCL and Pregnancy: Great uncertainty and an appeal for prospective clinical research
Oral presentation
The impact of pregnancy on cutaneous T-cell lymphoma (CTCL) and lymphoproliferative disorders (LPDs) is mostly unexplored territory limited to case reports and series. For patients considering pregnancy, the lack of available data and limited pregnancy-safe treatment options can be distressing.
The objective of this retrospective study was to explore relationships between CTCL/LPD and pregnancy. From our cutaneous lymphoma clinic, we identified 37 patients with a documented history of pregnancy (n=77 pregnancies). After excluding pregnancies prior to the onset of CTCL/LPD symptoms (n=40), 37 pregnancies in 22 patients were included. Demographics and medical history were extracted from patient records, then semi-structured interviews were conducted to inquire about skin changes during pregnancy. Diagnoses included mycosis fungoides (MF) (16/22, 72.7%), lymphomatoid papulosis (LyP) (4/22, 18.2%), pleomorphic small/medium T-cell LPD (1/22, 4.6%), and subcutaneous panniculitis-like T-cell lymphoma (1/22, 4.6%) (SPTCL). All patients had early-stage disease.
Overall, most patients reported their skin condition worsened or flared (21/37, 56.8%) during pregnancy. 12 patients (32.4%) reported stable disease, and 3 patients reported improvement (4/37, 10.8%). No patients developed extracutaneous involvement during pregnancy or breastfeeding. Aside from prematurity, no fetal complications were reported.
One patient had stable MF IA prior to her first pregnancy but rapidly progressed to IB in the setting of interferon alfa-2b discontinuation, requiring preterm caesarean delivery and extensive radiotherapy (RT). She continued treatment throughout her second pregnancy with adequate disease control but developed new symptomatic plaques requiring further RT in the months following delivery.
Flares were reported in 3 of 4 pregnant patients with LyP, none of whom were on systemic therapy directly before or during pregnancy. The patient with SPTCL was free of lesions during both of her pregnancies, with flares recurring 6 months postpartum. Four patients with MF experienced worsening of previously undiagnosed patches, two of whom were diagnosed 9 months postpartum. The remaining two patients were diagnosed several years after pregnancy.
Treatment options for pregnant patients with CTCL/LPD are limited due to teratogenicity. For example, methotrexate, first-line therapy for LyP, is an abortifacient with potential for causing fetal anomalies. Topical corticosteroids and phototherapy are safe throughout pregnancy, whereas treatments for advanced disease like bexarotene and acitretin are contraindicated.
The overall contribution of pregnancy-induced immunosuppression cannot be ignored. We call attention to the prevalence of disease flares during pregnancy and recommend pregnant patients remain on safe skin-directed therapy. Prospective multicenter investigations are needed to further investigate the safety of localized RT and systemic CTCL/LPD therapies during pregnancy.
The objective of this retrospective study was to explore relationships between CTCL/LPD and pregnancy. From our cutaneous lymphoma clinic, we identified 37 patients with a documented history of pregnancy (n=77 pregnancies). After excluding pregnancies prior to the onset of CTCL/LPD symptoms (n=40), 37 pregnancies in 22 patients were included. Demographics and medical history were extracted from patient records, then semi-structured interviews were conducted to inquire about skin changes during pregnancy. Diagnoses included mycosis fungoides (MF) (16/22, 72.7%), lymphomatoid papulosis (LyP) (4/22, 18.2%), pleomorphic small/medium T-cell LPD (1/22, 4.6%), and subcutaneous panniculitis-like T-cell lymphoma (1/22, 4.6%) (SPTCL). All patients had early-stage disease.
Overall, most patients reported their skin condition worsened or flared (21/37, 56.8%) during pregnancy. 12 patients (32.4%) reported stable disease, and 3 patients reported improvement (4/37, 10.8%). No patients developed extracutaneous involvement during pregnancy or breastfeeding. Aside from prematurity, no fetal complications were reported.
One patient had stable MF IA prior to her first pregnancy but rapidly progressed to IB in the setting of interferon alfa-2b discontinuation, requiring preterm caesarean delivery and extensive radiotherapy (RT). She continued treatment throughout her second pregnancy with adequate disease control but developed new symptomatic plaques requiring further RT in the months following delivery.
Flares were reported in 3 of 4 pregnant patients with LyP, none of whom were on systemic therapy directly before or during pregnancy. The patient with SPTCL was free of lesions during both of her pregnancies, with flares recurring 6 months postpartum. Four patients with MF experienced worsening of previously undiagnosed patches, two of whom were diagnosed 9 months postpartum. The remaining two patients were diagnosed several years after pregnancy.
Treatment options for pregnant patients with CTCL/LPD are limited due to teratogenicity. For example, methotrexate, first-line therapy for LyP, is an abortifacient with potential for causing fetal anomalies. Topical corticosteroids and phototherapy are safe throughout pregnancy, whereas treatments for advanced disease like bexarotene and acitretin are contraindicated.
The overall contribution of pregnancy-induced immunosuppression cannot be ignored. We call attention to the prevalence of disease flares during pregnancy and recommend pregnant patients remain on safe skin-directed therapy. Prospective multicenter investigations are needed to further investigate the safety of localized RT and systemic CTCL/LPD therapies during pregnancy.