Classical Hodgkins (BSH 2013 & 2014)

CD30+, CD15+

CD45-, CD20-, CD3-

 

Intro

 

Annual Incidence 2.7 / 100,000 in UK

Two peaks at 20-34 and >70

 

Histology

 

Four subtypes – Nodular sclerosis, mixed cellularity, lymphocyte-rich and lymphocyte-depleted

No difference in outcomes

 

Staging

 

PET-CT or CT N-P (No BM required if PET used)

 

Early (Stage I/II)

  • Favourable (GHSG) requires:

    • No large mediastinal mass

    • ESR <50 without B symptoms or ESR <30 with B symptoms

    • No extranodal disease

    • 1-2 lymph nodes involved.

  • (Or Favourable (EORTC) requires:

    • No large mediastinal mass

    • ESR <50 without B symptoms or ESR <30 with B symptoms

    • Age 50 years or younger

    • 1-3 lymph nodes involved.)

  • Unfavourable – Not meeting the favourable criteria

 

Advanced (Stage III/IV)

 

Prognostic Scores

Advanced stage patients should have Hasenclever/IPS calculated.

Hogkin IPS, one point for each of:

  • Serum albumin <40g/l

  • Hb <105g/l

  • Male sex

  • Ann Arbor Stage IV

  • Age 45 years or greater

  • WBC 15x10e9/l or above

  • Lymphocyte count 0.6x10e9/l or below

Hodgkin IPS 5-yr OS, by No. of risk factors

  • 0 - 89%

  • 1 - 90%

  • 2 - 81%

  • 3 - 78%

  • 4 - 61%

  • 5 or more - 56%

first line treatment

 

Pre-Treatment Measures

  • Sperm cryopreservation

  • Referral to fertility clinic for female patients

 

1st Line Treatment

 

ABVD – Doxorubicin, Bleomycin, Vinblastine, Dacarbazine

escBEACOPP – Bleomycin, Etoposide,Doxorubicin, Cyclophosphamide,Vincristine, Procarbazine, Pred

(In escBEACOPP, patients start on the full ‘escalated’ dose, and may be reduced based on tolerance of the previous cycle - see here)

 

In advanced disease:

  • ABVD                       PFS 73%,        OS 82-90%    Fertility >30 y.o. 94%

  • escBEACOPP          PFS 89%,        OS 95%          Fertility >30 y.o. 45%

  • 2/3 of BEACOPP patients have grade 3-4 infections and increased hospital admissions

 

HIV-related Hodgkins

  • ABVD + Anti-retroviral therapy

  • No data for BEACOPP

 

Pregnancy

  • Prioritise health of mother

  • Alternative imaging – USS / MRI

  • ABVD can be used in all 3 trimesters based on retrospective data

  • Excellent outcomes reported

 

Elderly

  • 21% TRM with BEACOPP – not advised

  • Use standardized assessment tool

  • ?VEPEMB or COPP/ABVD

 

1st Line Treatment Summary

 

Hodgkin treatment.jpg

 

Relapse / Refractory treatment

 

1o Resistant

  • Progression or non-response during induction treatment or within 90 days of completion

 

Relapse

  • Occurring >90 days from completion of induction treatment (early <12 mo, late >12 mo)

 

Poor outcomes

  • Resistant worse than relapse

  • Limited prognostic models – PET-CT probably the most informative

  • Salvage followed by Autograft if fit patients (about 1/3 of patients make it to transplant)

 

Palliative regimens

  • Single agent – vinblastine, etoposide, gemcitabine

  • Multi-agent – PECC, ChlVPP

 

Novel Therapies

  • Brentuximab – Anti-CD30 + Anti-microtubulin agent.

    • Current NICE approval for relapse after 2 prior therapies or relapse after autograft (as of April 2019)

  • Pembrolizumab & Nivolumab – Anti-programmed death 1 (PD-1) pathway antibodies

    • Pembrolizumab - via cancer drugs fund

    • Nivolumab - Current NICE approval for relapse post autograft + brentuximab (as of April 2019)

 

 

Long-term Follow-Up

 

2-5 years

Irradiated blood products for life

No role for routine radiological surveillance

Increased lifetime risk of secondary cancer, CVS and respiratory disease, infertility

Women treated with mediastinal RT <35 y.o. should be offered entry into National Notification Risk Assessment and Screening Programme (NRASP)

Lifestyle advice

Regular thyroid function tests if head and neck radiotherapy