Bone lymphoma revealed by cruralgia during pregnancy: a case report

Pregnancy complicated by Non Hodgkin lymphoma (NHL) is rare, about 100 cases have been reported. We will describe the case of a multifocal bone lymphoma revealed by a left hyperalgetic and deficient cruralgia in a female in the second trimester of pregnancy.


Introduction
Diagnosis of cancer during pregnancy is a relatively rare phenomenon with an incidence of approximately 1 in 1000-1500 pregnancies [1]. It is the second most common cause of maternal death after gestation-related vascular complications, and puts at risk the vital prognosis of the mother and the fetus. The NHL is quite exceptional during pregnancy as well as bone involvment. We will describe a case of a 40-year-old woman with multifocal bone lymphoma who was diagnosed at the 21dt week of gestation revelated by hyperalgetic and deficient cruralgia.

Discussion
Cruralgia during pregnancy is very rare. If the patient presents a neurological deficit or a disturbance of the biological check-up entail, a pelvic ultrasonography and a pelvic-spine magnetic resonance imaging (MRI) should be realized, in order to objective a compression of the femoral nerve at its origin or in the course of its path by an infectious or tumoral process [2].
Our patient was diagnosed with a Non Hodgkin's lymphoma. This haematological malignancy is very rare during pregnancy. It comes in the fourth position after cervical cancer, breast cancer and leukemia, especially the Hodgkin Lymphoma (HL) followed by Non-Hodgkin lymphoma (NHL) [3]. Its rate of occurrence is 0.8 case per 100.000 pregnant women [4] with a frequency peak between 37 and 42 years old. However ,this number is expected to rise because of the increasing age of women at conception, the observed increase in NHL incidence over the past two decades, and the growing incidence of HIV which has increased the risk 150 times more [3]. Studies have shown a large prevalence of aggressive forms [4], in young subjects, but an incidence abnormally high of extranodal involvement (breast, uterine and ovarian). Bone involvement is present in 5 to 15 % of the cases [5]. of an accessible lesion [3]. Imaging studies are needed to stage patients with non-Hodgkin lymphoma especially cervico-thoracoabdomino-pelvic scanner which should be carefully discussed so as that the total radiation dose delivered to the fetus be as low as possible [3].
Clinical data suggest a similar prognosis for pregnant and non pregnant women [4]. The treatment of pregnant women with aggressive non-Hodgkin lymphoma type diffuse large-cell B-cell lymphoma, although usually the same as that in non-pregnant women, needs to be modified according to gestational stage [3] and needs to be started early to avoid significant disease-related morbidity and mortality. The current standard of care is CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) with Page number not for citation purposes 3 rituximab. When diagnosed in the first trimester , the woman should be counselled to consider a medical interruption of pregnancy in view of potential teratogenicity, spontaneous abortion and fetal death [6]. Chemotherapy should be commenced. It seems reasonably safe to treat aggressive lymphoma presenting in the second or third trimester with CHOP with rituximab [7].
Administration of rituximab, an anti-CD20 monoclonal antibody, during pregnancy is not enough documented. However, its use during the second and third trimesters seems to be safe [8].

Conclusion
Haematological cancer in pregnancy, although rare, especially non-Hodgkin lymphoma. It poses diagnostic and therapeutic challenges.
Its management is complex, requires a multidisciplinary approach and should focus on survival of the mother, while minimising treatment-related fetal toxic effects.