Correspondence

Case 4-2008: A Pregnant Woman with a Swollen Left Breast and Dyspnea

N Engl J Med 2008; 358:2848-2849June 26, 2008

Article

To the Editor:

As reported by Shulman et al. (Jan. 31 issue),1 the first signs of a malignant condition in a young pregnant woman with lymphoma involving the mediastinum and left breast were noted at 26.1 weeks' gestation, and a live-born infant was delivered approximately 5 weeks later. Although the clinicians state that “the baby is well,” it may be too early to tell. There is an average lag time of 4.6 months between birth and the diagnosis of cancer transmitted from a mother to a child,2 and although rare, transplacental metastases of maternal leukemias, lymphomas, melanomas, and carcinomas2-4 have been described. In addition to physical examinations, it may thus seem prudent to obtain computed tomographic (CT) scans of the boy's chest, abdomen, and pelvis, and to continue surveillance with complete blood counts, a comprehensive metabolic panel, and measurement of the serum lactate dehydrogenase level during the first year of his life, especially since the mother had multiple extranodal sites of disease and there has been no documentation of the macroscopic and microscopical examination of the placenta for tumor involvement.

Jakub Tolar, M.D., Ph.D.
Joseph P. Neglia, M.D., M.P.H.
University of Minnesota School of Medicine, Minneapolis, MN 55455
tolar003@umn.edu

4 References

1. 1

   Shulman LN, Hitt RA, Ferry JA. Case Records of the Massachusetts General Hospital (Case 4-2008). N Engl J Med 2008;358:513-523
   Full Text | Web of Science | Medline

2. 2

   Tolar J, Neglia JP. Transplacental and other routes of cancer transmission between individuals. J Pediatr Hematol Oncol 2003;25:430-434
   CrossRef | Web of Science | Medline

3. 3

   Tolar J, Coad JE, Neglia JP. Transplacental transfer of small-cell carcinoma of the lung. N Engl J Med 2002;346:1501-1502
   Full Text | Web of Science | Medline

4. 4

   Catlin EA, Roberts JD Jr, Erana R, et al. Transplacental transmission of natural-killer-cell lymphoma. N Engl J Med 1999;341:85-91
   Full Text | Web of Science | Medline

Author/Editor Response

Tolar and Neglia suggest that imaging and laboratory studies should have been performed in the infant because of the risk of transplacental passage of lymphoma. Although it was not reported in the Case Record, the placenta was examined after birth, and there was no gross or microscopical evidence of lymphoma. The infant's neonatal course was uneventful; routine radiographs and ultrasound studies were normal. The baby was seen by his pediatrician monthly for the first year of life, and there were no physical findings to suggest a malignant condition. At 6 months of age, an intramuscular capillary hemangioma of the abdominal wall was resected. At the last follow-up at 18 months of age, the child was well.

Although placental involvement by maternal lymphoma has been reported, it typically involves the maternal intervillous space, not the fetal circulation or the fetus.1-3 We know of only two reported cases of maternal lymphoma with involvement of the intravillous space and engraftment of the fetus.4,5 Thus, the risk to the child of radiation exposure from CT imaging would seem to outweigh any potential benefit.

Ephraim P. Hochberg, M.D.
Massachusetts General Hospital, Boston, MA 02115

Steven J. Morgan, M.D.
72 Highland Ave., Salem, MA 01970

Judith A. Ferry, M.D.
Massachusetts General Hospital, Boston, MA 02115

5 References

1. 1

   Nishi Y, Suzuki S, Otsubo Y, et al. B-cell-type malignant lymphoma with placental involvement. J Obstet Gynaecol Res 2000;26:39-43
   CrossRef | Medline

2. 2

   Meguerian-Bedoyan Z, Lamant L, Hopfner C, Pulford K, Chittal S, Delsol G. Anaplastic large cell lymphoma of maternal origin involving the placenta: case report and literature survey. Am J Surg Pathol 1997;21:1236-1241
   CrossRef | Web of Science | Medline

3. 3

   Kurtin PJ, Gaffey TA, Habermann TM. Peripheral T-cell lymphoma involving the placenta. Cancer 1992;70:2963-2968
   CrossRef | Web of Science | Medline

4. 4

   Catlin EA, Roberts JD, Erana R, et al. Transplacental transmission of natural-killer-cell lymphoma. N Engl J Med 1999;341:85-91
   Full Text | Web of Science | Medline

5. 5

   Maruko K, Maeda T, Kamitomo M, Hatae M, Sueyoshi K. Transplacental transmission of maternal B-cell lymphoma. Am J Obstet Gynecol 2004;191:380-381
   CrossRef | Web of Science | Medline