Emergency Fertility Preservation in a Young Woman With Non-Hodgkin Lymphoma.

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From: Oncology(Vol. 35, Issue 6)
Publisher: Intellisphere, LLC
Document Type: Article
Length: 1,720 words
Lexile Measure: 1660L

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THE CASE

A nulliparous woman, age 25 years, had received a diagnosis of non-Hodgkin lymphoma (NHL) and now presented with stage IIA diffuse large B-cell lymphom a (DLBCL). According to her hematological oncologist's treatment plan, chemotherapy had to start immediately (within 1 week), with the patient receiving 6 courses of the standard R-CHOEP21 regimen (rituximab 375 mg/[m.sup.2], cyclophosphamide 750 mg/[m.sup.2], hydroxydaunorubicin 50 mg/[m.sup.2], vincristine 1.4 mg/[m.sup.2], etoposide 100 mg/[m.sup.2], prednisone 40 mg/[m.sup.2]).

Due to potential risks of chemotherapy-induced gonadotoxicity and subsequent iatrogenic premature ovarian failure (POF) and fertility loss, the patient was referred to the reproductive medicine department for fertility preservation counseling and further management.

Discussion

NHL is the most common type of lymphoma, representing 88% of lymphoma cases, and typically occurs in adolescents and young adults more than in children. (1-3) In this patient, several challenges are raised regarding fertility preservation, including that:

(1) the patient is a young adult who wants to have children in the future. Overall survival (OS) in NHL has increased dramatically in recent years, especially in young adults (5-year OS, 69%; 10-year OS, 64%), giving the patient reason to look forward to her survivorship and possible parenthood. Still, OS is not 100%;

(2) the chemotherapy regimen R-CHO-EP21 includes the alkylating agent cyclophosphamide. Cumulative doses of aggressive alkylating agents can lead to gonadotoxicity and subsequent iatrogenic POF and fertility loss in most cases;

(3) if the patient's disease becomes relapsed or refractory, hematopoietic stem cell transplant (HSCT) may be indicated, in which case pre-HSCT myeloablative conditioning regimens will be used to induce immunosuppression. These regimens, including total body irradiation (TBI) and/or high-dose alkylating chemotherapy, lead to severe gonadotoxicity and subsequent iatrogenic POF and fertility loss in almost 100% of cases;

(4) DLBCL, the most aggressive (and most common) form of NHL, requires immediate chemotherapy initiation, leaving not enough time to apply several fertility preservation options;

(5) the traditional options of embryo cryopreservation and oocyte cryopreservation (answer choices A & B) need prior ovarian stimulation for some weeks to retrieve mature oocytes that are ready for in vitro fertilization, and that is not feasible in this patient due to lack of time;

(6) the innovative option of ovarian tissue cryopreservation and further autotransplantation (answer choice C) is suitable for emergency fertility preservation, but it is also risky due to possible contamination of ovarian tissue with lymphoma cells; and

(7) ovarian protection options (answer choice D), which include oophoropexy, pelvic shielding, and gonadotropin-releasing hormone (GnRH) analogues, are not reliable. Oophoropexy and pelvic shielding do not protect ovaries when systemic chemotherapy is used, while GnRH analogues have not been proven to protect the ovaries in...

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Gale Document Number: GALE|A677572504