Hodgkin lymphoma Clinical presentation and treatment
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?
Differences Hodgkin and non-Hodgkin lymphomas (NHL) • Age distribution • NHL : > 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
Hodgkin lymphoma Clinicalpresentation 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 (> 10% within 6 months)
Hodgkin lymphoma Clinical Staging • History/ Physical examination • CT scan neck, thorax, abdomen • 18FDG-PET scan • Bone marrow biopsy
Hodgkin lymphoma Standard therapy in 2012 • Stage I/II • Favorable (2-)3 x ABVD + 30 Gy IN-RT • Unfavorable4 x ABVD + 30 Gy IN-RT • Stage III/IV 8 x ABVD
Role of radiotherapy in stage III/IV Hodgkin lymphoma • CR after adequate chemotherapy no radiotherapy • PR after adequate chemotherapy radiotherapy
Survival after Hodgkin lymphoma Radiotherapy and/or chemotherapy radiotherapy No therapy From H.S. Kaplan, 1981
Long term survival of Hodgkin lymphoma EORTC/GELA Fraction survival Favier et al, Cancer 2009;115:1680-1691
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)?
“Early” interim FDG-PET predicts prognosis M Hutchings et al, Blood 2006;107:52-9
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?
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?)
The reverse of the success Successfull treatment of HL Long term survival Late effects of treatment
m Hodgkin: Late Toxicity of Treatment Excess mortality secondary malignancies cardiac disease Excess morbidity / decreased Q.O.L cardiac disease pulmonary disease infertility fatigue
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
m.Hodgkin : Late Toxicity of TreatmentRisk Factors for Cardiac Disease Mediastinal RT dose > 30 Gy Orthovolt RT (before 1967) Adriamycine containing CT Age at RT < 20 yr Hypertension
Veranderingen bestralingsgebied H9 CT+RT klierregio Klassiek mantelveld H10 CT+RT klier Dank aan: R vd Maazen
Treatment of Hodgkin lymphoma • Progress can only be made by including patients in clinical studies!!