Classical Hodgkins (cHL) (2014)

CD30+, CD15+

CD45-, CD20-, CD3-

 

Intro

 

-       Annual Incidence 2.7 / 100,000 in UK

-       Peak 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:

o   No large mediastinal mass

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

o   No extranodal disease

o    1-2 lymph nodes involved.

-       Unfavourable – Not meeting the favourable criteria

 

Advanced (Stage III/IV)

 

Prognostic Scores

Advanced stage patients should have Hasenclever/IPS calculated

hodkin ips.png
hodgkin ips 2.png

 

treatment

 

Pre-Treatment Measures

- Sperm cryopreservation

- Referral to fertility clinic for female patients

 

1st Line Treatment

 

ABVD – Doxorubicin, Bleomycin, Vinblastine, Dacarbazine

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

 

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

 

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

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

 

 

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