This month, David Straus, MD, discusses treatment options for a young woman with stage 2a Hodgkin lymphoma and fertility concerns.
And don’t forget to check out next month’s clinical dilemma – send in your responses for a chance to win an ASH Clinical News-themed prize!
I have a 22-year-old female patient with stage 2a lymphocyte-predominant Hodgkin lymphoma involving lymph nodes in the pelvis. She presented while pregnant. (She has since delivered a healthy child.) Her disease is progressing slowly, but a recent CT scan showed slightly increasing nodes, so she needs to begin therapy. The radiation oncologist does not want to treat her because it may affect future fertility. I sent her to a fertility clinic that recommended harvesting eggs, but the patient refused and "will let God decide" whether she has children. I have presented her case at our lymphoma rounds and the recommendation was for six cycles of R-CHOP rather than an ABVD regimen. What would you do? If R-CHOP is the right approach, would you add an LHRH agonist?
I don't know the clinical details on this patient, but a slight increase in adenopathy would often not be a reason to treat unless transformation is documented by biopsy. I am very conservative with patients with this diagnosis because they usually have an excellent outcome regardless of whether they are treated. I would try to defer treatment if possible.
Sven Borchmann, MD, presented our experience at Memorial Sloan Kettering Cancer Center with management of nodular lymphocyte predominant Hodgkin lymphoma at the 2017 ASH annual meeting, and a manuscript is undergoing revisions for publication.1 The analysis included 163 patients seen between 1974 and 2016. The median follow-up time was 5.7 years (range = 0.3 -42.7) and 24.5 percent of patients were followed for at least 10 years. Initial management was active surveillance in 37 patients (22.7%) and active treatment – including radiation therapy only, rituximab monotherapy, chemotherapy with or without rituximab, and combined chemotherapy and radiation therapy with or without rituximab – in 126 patients (77.3%). There was no difference in 10-year overall survival (96.6%) or second progression after active treatment (92.5%) in either active surveillance or active treatment groups. Transformation to more aggressive non-Hodgkin lymphoma was approximately 1 percent/year in both groups. Treatment-related deaths exceeded deaths due to lymphoma. Bulky disease and extranodal disease were identified as possible risk factors for progression.
Borchmann S, Joffe E, Moskowitz CH, et al. Active surveillance for newly diagnosed nodular lymphocyte-predominant Hodgkin lymphoma. Blood. 2017;130(suppl 1):654.
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NEXT MONTH'S CLINICAL DILEMMA
I have a 66-year-old female patient recently diagnosed with Philadelphia chromosome–positive B-cell acute lymphocytic leukemia (ALL). Conventional cytogenetics showed hyperdiploid karyotype plus FISH/PCR positive for BCR-ABL. After four cycles of hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone) plus dasatinib, PCR is negative. Bone marrow aspirate is also negative for ALL. Should she be considered for allogeneic hematopoietic cell transplantation?
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