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
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 (> 10% within 6 months)
 Hodgkin lymphoma
Clinical Staging

History/ Physical examination

CT scan neck, thorax, abdomen

18 FDG-PET scan

Bone marrow biopsy

Hodgkin lymphoma
Ann Arbor staging
 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

Role of radiotherapy in stage III/IV
Hodgkin lymphoma
CR after adequate chemotherapy
no radiotherapy

PR after adequate chemotherapy

radiotherapy
Treatment Results ?
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 results in Hodgkin
lymphoma at 5 years
 Treatment of Hodgkin lymphoma
summary 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 lymphoma
summary 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?)
 High Dose CT + AutoSCT
in relapsed HL

PFS @ 5 yrs OS @ 5yrs

% %
Relapse 45-60 50-65

Primary 20-30 20-30

resistant
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 Treatment
Secondary Malignancies
m.Hodgkin : Late Toxicity of Treatment
Cardiac 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 Treatment
Risk 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!!