Case 57 – summary

Thankyou for all your input with this case!

This week we looked at classical Hodgkin’s disease. Our patient was initially diagnosed with stage 2B early unfavourable Hodgkin’s disease. Following 4 cycles of ABVD and radiotherapy he was in remission. 

Unfortunately 2 years later he relapsed with stage 4 disease. He was treated with IVE chemotherapy and an end of treatment PET CT was PET negative. He then underwent an autologous stem cell transplant and is again in remission.

When a patient presents with classical HD it is important that they are appropriately staged upfront as this can significantly alter treatment. Initial staging with a CT followed by a PET CT should be done.

It is essential that all patients have an ESR, fbc, u&e, LFT, bone profile.

All patients should have their HIV status established.

There remains debate as to the best treatment strategies for patients with classical HD.

The German Hodgkin’s study group stratified patients into early favourable/unfavourable and advanced.
Patients should also have there IPI calculated using the hasenclever score. 
Clinical trials should be offered to patients where available.
In the HD11 trial patients with early unfavourable disease treated with X4ABVD and involved field radiotherapy demonstrated a 95% OS at 8 years. 

Team discussion and discussion with the patient should be had upfront regarding radiotherapy. Ideally this should be done with a specialist in radiotherapy. Some patients may want to avoid radiotherapy and treatment may be tried with chemotherapy alone with an early end of treatment PET CT scan to ensure remission. The RAPID trial looked at patients with early disease, stage 1 and 2A with a PET CT after 3 cycles of ABVD. Those patients who were PET positive went on to have a 4th cycle of ABVD and radiotherapy, and those who were pet negative were randomly assigned to no further treatment or involved field radiotherapy. For those patients who received radiotherapy the 3 year PFS was 94.6%, and for those who received no radiotherapy was 90.8%. This approach can give good PFS rates although disease control is poorer without radiotherapy. If a patient/the treating team wish to avoid radiotherapy in a patient who could tolerate salvage treatment this approach could be considered.

In patients with advanced disease can be considered for treatment with either ABVD or upfront BEACOPP. Several factors may influence this decision including IPI, age and co-morbidities. Using the RATHL approach those patients with advanced disease who are initially treated with ABVD should have a PET after 2 cycles of treatment to help guide if escalation of treatment is required.
PET CT positivity at the end of treatment should be viewed with caution and a repeat biopsy should be considered prior to salvage treatment.

In elderly patients with classical HD AVD can be considered in a fit population (bleomycin should be used with caution in patients aged over 60). Treatment will be guided by age and co-morbidities, other, less intensive regimes may be considered in frailer patients. 

If the patient is treated with bleomycin pulmonary function tests should be performed and this should reevaluated if there is any change in symptoms. Risk factors for bleomycin associated pneumonitis include pre existing lung disease, smoking and impaired renal function.

If a patient represents with symptoms suspicious of a relapse it is essential to arrange a biopsy for diagnosis. If the patient is fit then treatment with salvage chemotherapy eg IVE/DHAP followed by an autologous transplant should be considered. If the patient is pet negative following 1st line salvage chemotherapy they can have an event free survival of >80% following auto. (moskowitz et al blood 2010)In patients who relapse following an AUTO or in those who remain PET positive following 2 lines of salvage chemotherapy an ALLO SCT can be considered.

Late effects is an area which may be overlooked in the care of patients with Hodgkin’s. All patients should be advised that they have an increased risk of secondary neoplasms, cardiovascular disease and pulmonary disease. Women who have had mediastinal radiotherapy should be considered for early enrolment onto a breast screening programme. Patients who have head and neck radiotherapy have an increased rush of thyroid problems and should have regular thyroid tests – hypothyroidism an occur up to 30years after radiotherapy. There is also an increased risk of osteoporosis in up to 10% of patients.

Patients should be given lifestyle advice to modify future risks eg smoking cessation, control BP/diabetes

All patients with a diagnosis of Hodgkin’s lymphoma should have life long irradiated blood products

Again thankyou for your input. Any questions/comments?! Is Hodgkin’s disease treated differently in your local centre?

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