Question: Dr. Chiragbhai, thank you for explaining in last part about Hodgkin Disease. Now can you tell us how to treat this disease?
Answer: Hodgkin Lymphoma is treated with chemotherapy regimen ABVD in most cases. After several years of research and comparison with various new regimens, ABVD still remains the most effective and safest regimen, also much easier to use.
Earlier treatment included regimens like MOPP and large doses of radiotherapy, with less cure rates and serious long term side effects.
Que: What are the advances in management?
Ans: As discussed, ABVD remains the standard, with few other regimens in selected cases as option e.g. Stanford V, BEACOPP.
However, most important advance is the knowledge that early stage patients, stage 1, 2 do not need all six cycles of chemotherapy. They can be treated with 2-4 cycles, followed by low dose radiotherapy. PET scan has further improved accuracy of this decision making i.e. patients who achieve normal PET scan after 2 cycles do not need further chemotherapy. Only 20 Gy radiotherapy added is sufficient, and that too, only for involved field, not extended field as in the past. This has made treatment much easier and safer for many patients. Such a combination of few cycles of chemotherapy with low dose radiotherapy reduces risks of both therapies for short term and long term, and yet preserves long term control rates over 90%.
Stage 3, 4 continue to receive six cycles of chemotherapy.
Another new understanding is identification of a Hodgkin subtype called LPHL – lymphocyte predominant Hodgkin lymphoma. This type has more indolent course, better prognosis and has more options for therapy. These patients can be treated with ABVD, CHOP, CVP, or even single agent Rituximab (without any chemotherapy). They may also be treated with only Radiotherapy for localized disease.
Que: Are there options for those who relapse or have resistant disease?
Ans: Yes. These patients can be frequently cured by Autologus Stem Cell Transplant. Non transplant candidates may be treated with Radiotherapy in selected cases, or with second line chemotherapy regimens, such as gemcitabine, carboplatin, vinorelbine based.
Brentuximab vedotin is a recently approved drug for use in relapsed cases, an anti CD 30 monoclonal antibody with a drug conjugate.
Que: What are the follow up needs for long term survivors?
Ans: Long term survivors are at risk for several health concerns, especially those treated in past with alkylating agents, or full dose radiotherapy. Concerns include risk of secondary cancers, such as breast cancer or lung cancer for those radiated to chest or breast region. They need examination, mammography, breast MRI, chest imaging from a young age, 10 years after radiotherapy or by 40 years age. Mediastinal radiation and anthracycline based chemotherapy at young age increase risk of cardiovascular disease. Patients need aggressive control of cardiovascular risk factors, such as smoking, hypertension, obesity and others, and monitoring by tests like ECHO and others. Hypothyroidism is common in patients who receive Radiotherapy to neck. Pulmonary toxicity, related to bleomycin is an important concern during and after therapy, especially patients over age 40. Any suspicion of lung toxicity, bleomycin should be stopped, as it can be fatal.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com