4. LPHL. Nodular LPHL is characterized by its indolent nature and favorable prognosis. Nearly 80% of patients present with early stage disease. Ten-year PFS rates of 85% (stage I) and 61% (stage II) and OS rates of 94% (stage I) and 97% (stage II) were described in a single-institution study of over 100 patients treated between 1970 and 2005 (J Clin Oncol 2010;28:136). Deaths due to disease are rare with the majority of deaths being potentially treatment-related, primarily cardiac disease and second malignancies. Of note, patients with LPHL are at risk of transformation to diffuse large B-cell lymphoma, especially in the setting of intra-abdominal disease. Most physicians currently recommend either observation following resection or IFRT alone for treatment of early-stage LPHL. Because most patients are first seen with stage I disease in the neck, axilla, or groin, exposure of normal tissues is relatively limited with IFRT. Treatment for the rare patient with stage III to IV disease continues to be chemotherapy usually in combination with rituximab (Blood 2013;122:4288). While some advocate the use of standard HL regimens such as ABVD, outstanding results have been reported with R-CHOP chemotherapy.
5. Recurrent Hodgkin’s lymphoma. All patients younger than 70 years who relapse after chemotherapy or combined modality therapy should be considered for autologous hematopoietic cell transplant (HCT). Initially patients should receive one of several effective salvage regimens for two to four cycles to reduce tumor burden. Non–cross-resistant regimens such as ESHAP (etoposide, methylprednisolone, high-dose cytarabine, cisplatin) and ICE (ifosfamide, carboplatin, etoposide) are associated with response rates of 73% to 88% in relapsed HL. Treatment with GND (gemcitabine, vinorelbine, and liposomal doxorubicin) is a reasonable salvage regimen for non-transplant candidates or those not responding to platinum-based salvage regimens.
High dose chemotherapy with HCT is associated with PFS rates of 40% to 50%. Salvage therapy is most likely to be successful in patients whose initial remission is longer than 12 months, whose relapse is confined to limited sites including no bone marrow or pulmonary involvement at relapse, and who are without constitutional symptoms. The best approach for patients with favorable early-stage disease, treated with chemotherapy alone, who relapse in initial sites of disease must still be determined. Radiation or standard-dose salvage chemotherapy followed by radiation may be adequate in patients with a first remission lasting more than 12 months and relapse limited to the initial site(s) of disease with HCT reserved for second relapse.
Brentuximab vedotin, an anti-CD30 antibody conjugated to a potent microtubule inhibitor, monomethyl auristatin E (MMAE), is approved for patients with relapsed or refractory HL following at least two prior lines of treatment. In a pivotal phase II trial, brentuximab vedotin had an overall response rate of 75%, with a median PFS of 5.6 months (J Clin Oncol
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