Single-Agent Rituximab for Primary CNS Lymphoma During Pregnancy As a Bridge to Definitive Management

Abstract

A 30-year-old female at 22 weeks gestation with her third child presented in February 2008 with a 10-day history of episodic imbalance with left-sided tonic-clonic activity without loss of consciousness. The episodes were followed by a progressive frontal headache. Initial exam was unremarkable, but a noncontrast magnetic resonance imaging (MRI) of the head demonstrated a large region of T2 hyperintensity in the white matter extending from the anterior right lateral ventricle to the right frontal lobe. A second region of T2 hyperintensity with mild mass effect extended from the superior-posterior right ventricle to the right frontal lobe ( Fig 1A). As the evaluation was ongoing, the patient developed new weakness of the left arm and leg. A biopsy of the right frontal lobe demonstrated a CD20-positive diffuse large B-cell lymphoma that was Epstein-Barr virus negative (Figs 2A and 2B).Dexamethasone 4 mg three times daily was initiated after biopsy at week 24, but the patient developed progressive weakness after 4 days. Exam demonstrated 1 of 5 (with 5 being normal) strength of the left hip and knee flexors, 2 of 5 of the left lower extremity dorsiflexors and plantar flexors, and 2 of 5 of the left deltoids. She was unable to ambulate. It was clear that there was tumor progression despite steroids and that alternative therapy for her primary CNS lymphoma (PCNSL) was urgently needed. A comprehensive multidisciplinary discussion was held with the patient and her family regarding the risks and potential benefits of high-dose methotrexate to her and the 25-week-old fetus. The patient was offered the choice of terminating pregnancy or proceeding with treatment for her PCNSL. Ultimately, the patient elected to continue the pregnancy and attempt to control her disease with the anti-CD20 monoclonal antibody rituximab as the fetus matured to viability. The plan was to initiate high-dose chemotherapy with methotrexate (HD-MTX) if there was any evidence of progression or even lack of response to rituximab.Rituximab 375 mg/m 2 was initiated at week 25, and dexamethasone 4 mg three times daily was continued. Within 12 hours, the weakness in her left upper extremity had resolved, and the weakness in

Preeclampsia: long-term consequences for vascular health

“…In recent years, a number of small studies or cases have been published that suggest use of the monoclonal antibody, rituximab, for the treatment of lymphoma or autoimmune disease is safe during pregnancy. 153 – 159 However, these same groups performed follow-up studies that identified the drug within the nasal cavity of newborns born to pregnant macaques treated during pregnancy. Therefore, this avenue of treatment may prove to be deleterious for the immune development during the first few months of life of the newborn.…”

Primary central nervous system germinal center B-like diffuse large B-cell lymphoma: a case report

“…Patients of PCNSL with administration of corticosteroid present with clinical improvement and regression which may be interpreted as a steroid-induced remission from an exacerbation of MS (4), often times, the white matter on neuroimaging studies shows abnormal signals in both PCNSL and MS, even brain biopsies may fail to detect tumor cells and show only demyelination because of different sites of sampling (5), radiographic improvement of PCNSL is not a consequence of restoring an impaired blood-brain barrier like MS, but is due to cytolytic effects of corticosteroid drugs on malignant lymphocytes (6). In some cases, repeated brain biopsy may, therefore, be necessary to provide.…”

The Management of Lymphoma in the Setting of Pregnancy

“…This population of patients with autoimmune disease likely have baseline elevated risks during pregnancy due to disease related factors as well as receipt of other potentially teratogenic medications. While rituximab is not approved for use during pregnancy, there are case reports of successful treatment of lymphoma with rituximab in pregnant patients with good fetal outcomes and thus the lack of formal approval needs to weighed against the potential benefit particularly for aggressive B-cell NHLs [22, 23]. For newer targeted therapies including brentuximab vedotin and others, administration during pregnancy is not recommended given lack of fetus safety data for this therapy available to date.…”