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Oishi T, Kogelschatz CJ, Young NP, Hoffmann EM, Staff NP, Visscher SL, Borah BJ, Krauss WE, Arumaithurai K, Shelly S, Ansell SM, Klein CJ. Expanded neuromuscular morbidity in Hodgkin lymphoma after radiotherapy. Brain Commun 2020; 2:fcaa050. [PMID: 32954302 PMCID: PMC7425393 DOI: 10.1093/braincomms/fcaa050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/30/2022] Open
Abstract
Our study aims to quantitate neuromuscular morbidity from radiotherapy in Hodgkin lymphoma including: (i) frequency and (ii) time of onsets for neurological localizations; (iii) degree of disabilities and (iv) number of clinical visits compared to cardiopulmonary Hodgkin lymphoma-radiation complications. Medical records from Mayo Health systems were retrieved; identifying neuromuscular radiation treated Hodgkin lymphoma-complications from 1 January 1994 to 31 December 2016. Of an estimated 4100 post-radiotherapy Hodgkin lymphoma patients, 4.6% (189) were identified with complications. Mean latency to physician visit for symptoms was 23.7 years (range: 1-50). Most commonly identified complications included: head drop 10% (19) with or without myopathy, myopathy 39% (73), plexopathy 29% (54), myelopathy 27% (51) and polyradiculopathy 13% (24). Other findings included benign and malignant nerve sheath tumours 5% (9), phrenic and long thoracic mononeuropathies 7% (14) and compressive spinal meningioma 2% (4). Patients frequently had multiple coexisting complications (single = 76% [144], double = 17% [33], triple = 4% [8], quadruple = 2% [4]). Cardiac 28% (53) and pulmonary 15% (29) complications were also seen in these patients. History of Hodgkin lymphoma was initially overlooked by neurologists (14.3%, 48/336 clinical notes). Hospital and outpatient visits for complications were frequent: neuromuscular 19% (77/411) versus cardiopulmonary 30% (125/411). Testing was largely exclusionary, except when imaging identified secondary malignancy. Modified Rankin score at diagnosis varied: 0-1 (55.8%), 2-3 (5.8%) and 4-5 (38.3%). Neuromuscular complications among post-radiation Hodgkin lymphoma are diverse, occurring in ∼1 of 20 having markedly delayed onsets often eluding diagnosis. Frequent care visits and major morbidity are common. Survivorship recommendations should recognize the diverse neurological complications.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Cory J Kogelschatz
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.,Intermountain Neurosciences Institute, Murray, UT 84107, USA
| | - Nathan P Young
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Nathan P Staff
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Sue L Visscher
- Center of the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Bijan J Borah
- Center of the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - William E Krauss
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
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Tomaszewski JM, Crook S, Wan K, Scott L, Foroudi F. A case study evaluating deep inspiration breath-hold and intensity-modulated radiotherapy to minimise long-term toxicity in a young patient with bulky mediastinal Hodgkin lymphoma. J Med Radiat Sci 2017; 64:69-75. [PMID: 28188697 PMCID: PMC5355368 DOI: 10.1002/jmrs.219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/09/2016] [Accepted: 01/01/2017] [Indexed: 12/20/2022] Open
Abstract
Radiotherapy plays an important role in the treatment of early-stage Hodgkin lymphoma, but late toxicities such as cardiovascular disease and second malignancy are a major concern. Our aim was to evaluate the potential of deep inspiration breath-hold (DIBH) and intensity-modulated radiotherapy (IMRT) to reduce cardiac dose from mediastinal radiotherapy. A 24 year-old male with early-stage bulky mediastinal Hodgkin lymphoma received involved-site radiotherapy as part of a combined modality programme. Simulation was performed in free breathing (FB) and DIBH. The target and organs at risk were contoured on both datasets. Free breathing-3D conformal (FB-3DCRT), DIBH-3DCRT, FB-IMRT and DIBH-IMRT were compared with respect to target coverage and doses to organs at risk. A 'butterfly' IMRT technique was used to minimise the low-dose bath. In our patient, both DIBH (regardless of mode of delivery) and IMRT (in both FB and DIBH) achieved reductions in mean heart dose. DIBH improved all lung parameters. IMRT reduced high dose (V20), but increased low dose (V5) to lung. DIBH-IMRT was chosen for treatment delivery. Advanced radiotherapy techniques have the potential to further optimise the therapeutic ratio in patients with mediastinal lymphoma. Benefits should be assessed on an individualised basis.
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Affiliation(s)
| | - Sarah Crook
- Ballarat Austin Radiation Oncology Centre, Ballarat, Victoria, Australia
| | - Kenneth Wan
- Ballarat Austin Radiation Oncology Centre, Ballarat, Victoria, Australia
| | - Lucille Scott
- Ballarat Austin Radiation Oncology Centre, Ballarat, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Austin Health, Melbourne, Victoria, Australia
- Olivia Newton-John Cancer Research Institute, Heidelberg, Victoria, Australia
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Barrington SF, Kirkwood AA, Franceschetto A, Fulham MJ, Roberts TH, Almquist H, Brun E, Hjorthaug K, Viney ZN, Pike LC, Federico M, Luminari S, Radford J, Trotman J, Fosså A, Berkahn L, Molin D, D'Amore F, Sinclair DA, Smith P, O'Doherty MJ, Stevens L, Johnson PW. PET-CT for staging and early response: results from the Response-Adapted Therapy in Advanced Hodgkin Lymphoma study. Blood 2016; 127:1531-8. [PMID: 26747247 DOI: 10.1182/blood-2015-11-679407] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 12/26/2015] [Indexed: 02/01/2023] Open
Abstract
International guidelines recommend that positron emission tomography-computed tomography (PET-CT) should replace CT in Hodgkin lymphoma (HL). The aims of this study were to compare PET-CT with CT for staging and measure agreement between expert and local readers, using a 5-point scale (Deauville criteria), to adapt treatment in a clinical trial: Response-Adapted Therapy in Advanced Hodgkin Lymphoma (RATHL). Patients were staged using clinical assessment, CT, and bone marrow biopsy (RATHL stage). PET-CT was performed at baseline (PET0) and after 2 chemotherapy cycles (PET2) in a response-adapted design. PET-CT was reported centrally by experts at 5 national core laboratories. Local readers optionally scored PET2 scans. The RATHL and PET-CT stages were compared. Agreement among experts and between expert and local readers was measured. RATHL and PET0 stage were concordant in 938 (80%) patients. PET-CT upstaged 159 (14%) and downstaged 74 (6%) patients. Upstaging by extranodal disease in bone marrow (92), lung (11), or multiple sites (12) on PET-CT accounted for most discrepancies. Follow-up of discrepant findings confirmed the PET characterization of lesions in the vast majority. Five patients were upstaged by marrow biopsy and 7 by contrast-enhanced CT in the bowel and/or liver or spleen. PET2 agreement among experts (140 scans) with a κ (95% confidence interval) of 0.84 (0.76-0.91) was very good and between experts and local readers (300 scans) at 0.77 (0.68-0.86) was good. These results confirm PET-CT as the modern standard for staging HL and that response assessment using Deauville criteria is robust, enabling translation of RATHL results into clinical practice.
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Affiliation(s)
- Sally F Barrington
- PET Imaging Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
| | - Amy A Kirkwood
- Cancer Research UK and UCL Cancer Trials Centre, London, United Kingdom
| | | | - Michael J Fulham
- Department of Molecular Imaging (PET-CT), Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Thomas H Roberts
- Cancer Research UK and UCL Cancer Trials Centre, London, United Kingdom
| | | | - Eva Brun
- Department of Oncology and Radiation Physics, Skane University Hospital, Lund University, Lund, Sweden
| | - Karin Hjorthaug
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Zaid N Viney
- Department of Radiology, Guy's and St. Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Lucy C Pike
- PET Imaging Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
| | - Massimo Federico
- Oncology Unit, Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Luminari
- Oncology Unit, Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - John Radford
- The University of Manchester and the Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Judith Trotman
- Sydney Medical School, University of Sydney, Sydney, Australia; Concord, Repatriation General Hospital, Sydney, Australia
| | - Alexander Fosså
- Department of Oncology, Norwegian Radium Hospital, Oslo, Norway
| | - Leanne Berkahn
- Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Daniel Molin
- Department of Genetics and Pathology, Experimental and Clinical Oncology, Uppsala University, Uppsala, Sweden
| | | | - Donald A Sinclair
- PET Imaging Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
| | - Paul Smith
- Cancer Research UK and UCL Cancer Trials Centre, London, United Kingdom
| | - Michael J O'Doherty
- PET Imaging Centre, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St. Thomas' Hospital, London, United Kingdom
| | - Lindsey Stevens
- Cancer Research UK and UCL Cancer Trials Centre, London, United Kingdom
| | - Peter W Johnson
- Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom
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Trends in Use of Radiation Therapy for Hodgkin Lymphoma From 2000 to 2012 on the Basis of the National Cancer Data Base. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:12-7. [DOI: 10.1016/j.clml.2015.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/12/2015] [Indexed: 11/21/2022]
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Olszewski AJ, Shrestha R, Castillo JJ. Treatment Selection and Outcomes in Early-Stage Classical Hodgkin Lymphoma: Analysis of the National Cancer Data Base. J Clin Oncol 2015; 33:625-33. [DOI: 10.1200/jco.2014.58.7543] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose The choice between combined-modality therapy (CMT) and chemotherapy alone for early-stage Hodgkin lymphoma (HL) remains controversial. Our objective was to define factors affecting treatment selection and resulting survival outcomes in the United States. Patients and Methods We identified 20,600 patients treated with CMT or chemotherapy between 2003 and 2011 from the National Cancer Data Base. Factors affecting treatment selection were studied in a mixed-effects logistic model. Survival outcomes were compared using a propensity score analysis to account for indication bias. Results Only 49.5% of patients received CMT, and this proportion steadily declined between 2003 (59.4%) and 2011 (45.2%), particularly in younger patients. Apart from classical prognostic factors (age, stage, tumor location, histology, comorbidities), treatment selection was significantly influenced by sex, black race, distance to facility, and type of insurance. Uninsured patients had the lowest odds of receiving CMT. A significant random effect related to facility-specific treatment preference was also evident. Estimated 5-year overall survival (OS) was 89.6%, and relative survival (RS) was 94.3%. After adjustment for guarantee-time and indication biases, CMT was associated with better OS (hazard ratio [HR], 0.61; 95% CI, 0.53 to 0.70) and RS (excess HR, 0.42; 95% CI, 0.33 to 0.54) than chemotherapy alone. This effect was without significant heterogeneity in subset analysis and was not sensitive to unobserved confounding. Conclusion Socioeconomic factors affect selection of curative treatments in HL. Widespread abandonment of CMT beyond circumstances sanctioned by guidelines may affect survival. Further research should focus on developing strategies that minimize toxicity and access disparities without compromising survival.
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Affiliation(s)
- Adam J. Olszewski
- Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA
| | - Rajesh Shrestha
- Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA
| | - Jorge J. Castillo
- Adam J. Olszewski and Rajesh Shrestha, Alpert Medical School of Brown University, Providence; Adam J. Olszewski and Rajesh Shrestha, Memorial Hospital of Rhode Island, Pawtucket, RI; and Jorge J. Castillo, Dana-Farber Cancer Institute-Harvard Medical School, Boston, MA
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