Long-term toxicity of the treatment of Hodgkin's disease

Testosterone Therapy for Dropped Head Syndrome: A Case Report

Dropped head syndrome (DHS) is an impairment of neck extension resulting in a chin-on-chest deformity. DHS is rarely seen but a major hindrance to daily function in affected patients. DHS has been associated with movement disorders, neuromuscular disorders, and electrolyte and endocrine abnormalities. DHS has also been seen in survivors of Hodgkin lymphoma (HL) years after irradiation. HL survivors are also at risk for endocrine hypogonadism after chemotherapy. We present the case of a 58-year-old male HL survivor with dropped head and limited strength in his atrophic neck extensor muscles. Laboratory testing and imaging, nerve conduction studies, electromyography, and muscle biopsy of the neck extensors revealed myopathic and neurogenic changes. Conservative management was unsuccessful. With a desire to avoid surgical fixation, he asked his primary care physician to check his testosterone levels, which returned as low normal. Within 4 months of starting testosterone therapy, he no longer experienced dropped head.

R-CHOP-Associated Graves' Hyperthyroidism

Radiation-induced thyroid dysfunction following oncologic treatment is not uncommon, however limited literature data has been found on patients that underwent chemotherapy only. A change in thyrometabolic autoimmune status is also a rare entity. We present a case of newly diagnosed Graves' thyrotoxicosis following a successful R-CHOP (Rituximab, Cyclophosphamide, Doxorubicine, Vincristine and Prednisone) treatment in a patient with concurrent abdominal and thyroid diffuse large B-cell lymphoma (DLBCL). Following chemotherapy, PET CT showed resolution of FDG-avid thyroid nodule as well as no evidence of the thyroid mass on repeat ultrasound. Her thyroid function also normalized. During her follow-up visit, patient reported significant unintentional weight loss and persistent fatigue over the past couple months. Repeat laboratory evaluation revealed TSH 0.005 mIU/mL, FT4 6.73 ng/dL and thyroid stimulating immunoglobulin (TSI) 535 (ref <140%). She was started on methimazole followed by radioactive iodine therapy. This unique case of Graves' disease following R-CHOP treatment in patients with known Hashimoto's and thyroid lymphoma is one of the first to be reported in the literature. The swing of pendulum from Hashimoto's to Graves' disease is very uncommon. As clinicians, we need to continue monitoring for clinical and biochemical thyroid dysfunction in this subset of population.

Need and Use of Healthcare Services in Survivors of Hodgkin Lymphoma

PURPOSE

Hodgkin lymphoma (HL) is the commonest cancer in adolescents and young adults (AYAs), aged 15-29 years. While the survival rate is high, many survivors experience adverse late effects of therapy. Yet, this age group in general makes limited use of health services. This study sought to determine whether the need for health services by HL survivors was mismatched to their health service utilization, as hypothesized a priori.

METHODS

A population-based cohort of survivors (N = 43) younger than 39 years of age was sent a mailed survey for self-assessment of need, as expressed in health-related quality of life (HRQOL), and utilization of health services by validated instruments; the Health Utilities Index and Health and Social Service Utilization Survey, respectively. Survivors who were AYAs at diagnosis were compared to children and older adults.

RESULTS

AYAs had the lowest mean HRQOL score (0.79 on a scale of 0.00-1.00) compared to children (0.86) and older adults (0.94)-clinically meaningful differences. The difference in the single attribute score for cognition reached statistical significance (0.89 vs. 0.99 vs. 1.00, p = 0.02). AYAs also had lower mean overall annual costs for health services (CAN$601) than children (CAN$753) and older adults (CAN$936) did.

CONCLUSIONS

Survivors of HL who were AYAs at diagnosis had a mismatch between high need for and low utilization of health services. Providers of healthcare to this population should be made aware of this discrepancy, and the survivors should be encouraged to seek the health services they need.

Late onset malnutrition from esophageal and phrenic dysfunction after radiotherapy for Hodgkin's lymphoma: a case report

Radiotherapy may lead to late-onset, rare, but sometimes life-threatening complications that need to be recognized for timely management. We report the case of a 39-year-old man who presented with a 20-kg weight loss with severe dysphagia and respiratory failure. His medical history was noticeable for Hodgkin's lymphoma that was treated 20 y previously. The physical examination and electroneuromyography indicated vagal and phrenic neuropathies. We concluded that the patient had late-onset esophageal motor disorder and bilateral phrenic paralysis secondary to the radiotherapy received 20 y previously for the lymphoma. The patient's management included long-term nutritional support. Although late-onset vagal and phrenic nerve injuries have been described separately after radiotherapy, we report the first case of paralysis at both sites. Another striking feature of this observation is the subsequent severe malnutrition that accompanied these paralyses.

Late non-neoplastic events in patients with aggressive non-Hodgkin's lymphoma in four randomized European Organisation for Research and Treatment of Cancer trials

BACKGROUND

A significant proportion of patients with aggressive non-Hodgkin's lymphoma (NHL) become long-term survivors. A European Organisation for Research and Treatment of Cancer database of patients with aggressive NHL, consistently treated with doxorubicin-based chemotherapy since 1980, afforded the possibility to explore late complications in this patient group.

PATIENTS AND METHODS

Of 951 randomized patients, complete data on late complications could be collected in 757 patients who were alive > or = 2 years after the start of therapy and were seen at yearly follow-ups (median follow-up, 9.4 years; range, 2.1-20.4 years). We computed cumulative incidences of late events in a competing risk model by Gray (death being the competing event) to avoid bias caused by the high percentage of NHL-related deaths. Risk factors were estimated in a Cox proportional-hazards model and also evaluated with the Gray test.

RESULTS

Late non-neoplastic events were found in 46% of the 757 patients. At 15 years, the cumulative incidences of cardiac disease and infertility were 20% and 29%, respectively. Renal insufficiency (11%), acquired hypertension (8%), and disabling neuropathy (13%) were also frequent. Salvage treatment was a risk factor in most cases. Smoking, age > 50 years during treatment, and preexistent hypertension were the main risk factors for cardiovascular disease. In-field radiation therapy (RT) was related to hypothyroidism, lung fibrosis, hypertension, gastrointestinal toxicity, and renal insufficiency but not to cardiovascular events. Autologous stem cell transplantation and cisplatin- and MOPP (mechlorethamine/vincristine/procarbazine/prednisone)-containing therapies were associated with infertility and renal insufficiency.

CONCLUSION

Altogether, almost half the patients with aggressive NHL experienced events addressed as late non-neoplastic complications. Salvage therapy, smoking, age > 50 years, and in-field RT are important risk factors.

Initial Staging of Lymphoma With Positron Emission Tomography and Computed Tomography

Lymphomas represent a diverse range of diseases with manifold presentations, outlook, and therapeutic approaches. Key to the modern management of lymphoma is accurate delineation of the extent of disease. The inability of computed tomography (CT) to identify the involvement of nonenlarged nodes and its relatively poor sensitivity in the detection of extra-nodal sites of involvement limit the performance of noninvasive staging techniques. Functional imaging techniques such as Ga-67 scintigraphy have been used for many years to improve the evaluation of patients with lymphoma. While providing complementary information to CT in many clinical settings, functional imaging has never had sufficient accuracy or localizing ability to seriously challenge conventional primary staging paradigms. (18)F-Fluorodeoxyglucose positron emission tomography (FDG PET), however, has been demonstrated to have both higher sensitivity and specificity than CT in many comparative series. Now that this technology also can be performed at the same time as structural imaging in the form of hybrid PET/CT devices, clinicians are rethinking the methods used to select, plan, and monitor therapy of lymphoma patients. In our institution, FDG PET/CT has become the preferred initial staging tool for patients with lymphoma.

Health profiles in 5836 long-term cancer survivors

Increasingly, prolonged survival follows the diagnosis of cancer. Cancer therapies result in complex and lasting health effects that create unique health-care needs for the survivors but are poorly understood (especially in survivors of adult cancers). Cancer survivors were asked to respond to a mailed health survey and provide medical and social information pertaining to their cancer experience. Information about demographics and perceived disease-related medical problems was analyzed. We analyzed the response of 5,836 survivors of adult cancers. Two-thirds of the responses came from women, and the response rate was 51% in both sexes. The mean interval since cancer diagnosis was 18.0 +/- 8.5 years. Younger survivors and men were more likely to report that cancer had affected their health. The health effect most commonly reported by survivors was arthritis/osteoporosis (26% of respondents). Survivors of Hodgkin's disease prominently reported thyroid and lung problems (33.8% of responders with the diagnosis). Prior diagnosis of lymphoma was associated with frequent mention of memory loss (14.7%). The passage of time decreased some perceived effects (memory loss) but increased others (arthritis/osteoporosis, cataracts). Compared with the general population, the incidence of several age- and gender-adjusted health conditions in cancer survivors is different. This group of cancer survivors reported generally good health but outlined multiple lasting medical problems. The health survey described represents 1 approach to the development of comprehensive information about the health needs of cancer survivors.