Hodgkin lymphoma

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Hodgkin lymphoma

• Clinical presentation and treatment

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Hodgkin lymphoma

• Malignant cell is a B lymphocyte
• Enlarged lymph nodes important clinical sign
• Thus Confusion!
• Patients
• Students
• Q what is difference with non-Hodgkin lymphomas
  where in most cases malignant cell is also of B
  cell origin?

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Differences Hodgkin and non-Hodgkin lymphomas
(NHL)

• Age distribution
• NHL gt 60 years peak incidence
• Hodgkin bimodal
• Variabilty of clinical presentation
• Hodgkin limited stage rarely extranodal
• NHL higher stage frequently extranodal
• Treatment
• Radiotherapy very important part of treatment in
  Hodgkin's disease

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Hodgkin lymphoma Clinical presentation

• In general less complex than NHL!
• Lymphadenopathy
• Enlarged painless lymphnodes
• Supra-diaphragmatic in 90 (cervical,
  mediastinal)
• Hepato-splenomegaly initially infrequent
• B symptoms in 25-30
• Fever, often periodical classically Pel-Ebstein
• Night sweats
• Weight loss (gt 10 within 6 months)

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Hodgkin lymphoma Clinical Staging

• History/ Physical examination
• CT scan neck, thorax, abdomen
• 18FDG-PET scan
• Bone marrow biopsy

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Hodgkin lymphoma Ann Arbor staging
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Hodgkin lymphoma Standard therapy in 2012

• Stage I/II
• Favorable (2-)3 x ABVD 30 Gy IN-RT
• Unfavorable 4 x ABVD 30 Gy IN-RT
• Stage III/IV 8 x ABVD

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Role of radiotherapy in stage III/IV Hodgkin
lymphoma

• CR after adequate chemotherapy
• no radiotherapy
• PR after adequate chemotherapy
• radiotherapy

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Treatment Results ?
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Survival after Hodgkin lymphoma
Radiotherapy and/or chemotherapy
radiotherapy
No therapy
From H.S. Kaplan, 1981
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Long term survival of Hodgkin lymphoma
EORTC/GELA
Fraction survival
Favier et al, Cancer 20091151680-1691
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Treatment results in Hodgkin lymphoma at 5 years
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Treatment of Hodgkin lymphomasummary Stage I/II

• Excellent results
• Future
• maintain results
• reduce (late) toxicity
• - reduce/ omit Radiotherapy?
• - reduce Chemotherapy
• PET guided treatment (interim post Tx)?

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Early interim FDG-PET predicts prognosis
M Hutchings et al, Blood 200610752-9
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Treatment of Hodgkin lymphomasummary Stage III/IV

• Results moderate/good (cf DLBCL!)
• Future
• Improve results without increasing (late)
  toxicity
• - more intensive chemotherapy?
• PET guided treatment
• Interim escalate if positive?
• Post Tx if positive radiotherapy/ HDT AuSCT?

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Treatment for relapsed Hodgkin lymphoma

• 15-30 of all HL patients will relapse and
  require second-line treatment
• High-dose chemotherapy and autologous stem cell
  transplantation
• - superior over conventional chemotherapy
• (Linch et al., Lancet 1993, Schmitz et al.,
  Lancet 2002)
• - remains the standard of care for relapsed HL
• (except very late relapse?)

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High Dose CT AutoSCT in relapsed HL
PFS _at_ 5 yrs OS _at_ 5yrs
Relapse 45-60 50-65
Primary resistant 20-30 20-30
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The reverse of the success
Successfull treatment of HL
Long term survival
Late effects of treatment
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m Hodgkin Late Toxicity of Treatment

• Excess mortality
• secondary malignancies
• cardiac disease
• Excess morbidity / decreased Q.O.L
• cardiac disease
• pulmonary disease
• infertility
• fatigue

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m.Hodgkin Late Toxicity of TreatmentSecondary
Malignancies
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m.Hodgkin Late Toxicity of TreatmentCardiac
disease

• coronary insufficiency
• myocardial infarction RR 1.9 - 3.7
• acute cardiac arrest RR 1.9 - 3.1
• pericarditis
• cardiomyopathy RR 1.4 - 5.1
• valvular abnormalities

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m.Hodgkin Late Toxicity of TreatmentRisk
Factors for Cardiac Disease

• Mediastinal RT dose gt 30 Gy
• Orthovolt RT (before 1967)
• Adriamycine containing CT
• Age at RT lt 20 yr
• Hypertension

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Veranderingen bestralingsgebied
H9 CTRT klierregio
Klassiek mantelveld
H10 CTRT klier
Dank aan R vd Maazen
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Treatment of Hodgkin lymphoma

• Progress can only be made by including patients
  in clinical studies!!