Second Malignancies After Chemotherapy and Radiotherapy for Hodgkin Disease

Long-Term Complications in Hodgkin's Lymphoma Survivors

Background

Although patients with Hodgkin's lymphoma (HL) achieve prolonged survival, long-term complications are a major cause of morbidity and mortality among long-term survivors of HL.

Methods

We retrospectively evaluated long-term complications in 336 HL survivors treated between January 1990 and January 2006 at the Department of Medical Oncology of the Hacettepe University Institute of Oncology who were >16 years old at presentation. All patients were regularly followed up every 3 months for the first 2 years after complete response, biannually for 3 years, and annually after 5 years.

Results

Median follow-up was 8.5 years. The mean age (±SD) of the patients at the time of diagnosis was 35.7 ± 13.1 years. The male to female ratio was 61%/39%. During follow-up, 29 second malignancies (8.6%) were diagnosed in 28 patients with HL; 22 were solid tumors and 7 were hematological malignancies. Forty-seven (14.0%) of all patients with HL were found to have thyroid abnormalities. During follow-up, 54 (16.1%) patients developed cardiovascular complications. Overall, 29 (8.6%) patients developed late pulmonary toxicities. The cumulative number of chronic viral infections was 13 (3.9%).

Conclusions

Long-term survivors of HL need to be properly followed up not only for disease control but also for evaluation of possible late morbidities to minimize the consequences.

Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature

Objective. A systematic review and meta-analysis was conducted to test the hypothesis that oncology health care workers are at an increased risk of cancer, reproductive complications and acute toxic events.

Design. A structured literature search of Index Medicus/MEDLINE, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews and Healthstar was performed from 1966 to December 2004 for human epidemiological studies evaluating the risk of toxic events in health care workers exposed to cytotoxic drugs. Raw data and adjusted odds ratios (OR) reported in eligible studies were combined using a random effects model to calculate point estimates and 95% confidence intervals (CI) for each potential risk outcome.

Main outcome measures. Adjusted OR for congenital malformations, stillbirths and spontaneous abortions among health care workers exposure to cytotoxic agents compared to a non-exposed control group.

Results. The systematic review identified 14 studies evaluating the outcomes of interest, seven of which were suitable for statistical pooling. Due to lack of evidence, we were unable to estimate a pooled OR for the risk of cancer and acute toxic events. However, no significant association was detected between exposure to cytotoxic drugs and; congenital malformations (OR=1.64; 95% CI: 0.91-2.94) and stillbirths (OR=1.16; 95% CI: 0.73-1.82). In contrast, an association was identified between exposure to chemotherapy and spontaneous abortions (OR=1.46; 95% CI: 1.11-1.92).

Conclusions. The results of this systematic review identified a small incremental risk for spontaneous abortions in female staff working with cytotoxic agents. Health policy decision makers should effectively communicate the magnitude of this risk to their staff and implement cost effective interventions for its reduction or elimination.

Second malignancies in Hodgkin's disease: A review of the literature and report of a case with a secondary Lennert's lymphoma

A small percentage of patients treated for Hodgkin's disease are at risk of developing a second malignancy. The appearance of secondary malignancies such as leukemia, carcinoma or non-Hodgkin's lymphomas may be attributed to the mutagenic effects of chemotherapy and/or radiotherapy. Most secondary non-Hodgkin's lymphomas are of the B-cell type, but isolated cases were reportedly of a T-cell lineage. A review of the literature pertaining to the development of secondary peripheral T-cell lymphomas is presented along with the description of an additional case. The latter developed in the tonsil and was diagnosed as a Lennert's lymphoma (lymphoepithelioid T cell lymphoma)on histological and immunological grounds. This report also reviews the development of a of peripheral T-cell lymphoma described in patients following chemotherapy and/or radiotherapy for Hodgkin's disease.

Gingival enlargement as an early diagnostic indicator in therapy-related acute myeloid leukemia: A rare case report and review of literature

Treatment for Hodgkin's lymphoma (HL) has resulted in excellent survival rates but is associated with increased risks of secondary therapy-related acute myeloid leukemia (t-AML). Gingival enlargement associated with bleeding and ulceration is the most common rapidly appearing oral manifestations of leukemic involvement. An 8 months pregnant patient reported with generalized gingival enlargement, with localized cyanotic and necrotic papillary areas. Co-relating the hematological report with the oral lesions and her past medical history of HL, a diagnosis of t-AML secondary to treatment for HL was made by the oncologist. As oral lesions are one of the initial manifestations of acute leukemia, they may serve as a significant diagnostic indicator for the dental surgeons and their important role in diagnosing and treating such cases. Furthermore, this case report highlights the serious complication of t-AML subsequent to HL treatment and the important role that a general and oral health care professional may play in diagnosing and treating such cases.

Safe handling of parenteral cytotoxics: recommendations for ontario

In caring for patients with cancer, health care workers may be exposed to cytotoxic agents. Recommendations are needed to mitigate potential risks for cancer and adverse reproductive outcomes associated with exposure.

Targeting the microenvironment

The microenvironment in which cancer arises plays a critical role in tumorigenesis. Although previously regarded as an innocent bystander, evidence has accumulated over the past 10 years that the microenvironment contributes to tumor growth and progression by providing nutrients and survival signals, and protecting the tumor from normal immune responses and anticancer drugs. Exactly how normal stromal cells, whose function should be to suppress malignant growth, become co-opted into facilitating tumor development is only just beginning to be understood, but a complex story is emerging wherein tumor and stromal cells appear to co-evolve. A better understanding of tumor-stromal interactions and the molecular alterations that result in stromal dysfunction may help to identify patients who will benefit from either more aggressive or risk-adapted therapy regimens, and/or novel compounds that disrupt the tumor microenvironment and re-establishing normal control mechanisms.

Bilateral breast cancer in a survivor of acute lymphoblastic leukemia: a case report

Although breast cancer is the most common disease for women, bilateral breast cancer is a rare situation. Development of a second malignancy which is the most frightening side effect, may be related with genetic predisposition or cancer treatment. Because our case is a survivor of acute lymphoblastic leukemia, development of bilateral breast cancer which occurs rarely in early ages, is discussed with the help of literature.

Malignant epithelial tumors and hematologic malignancy

The aim of this study was to analyze the value of cytology in differentiation between malignant epithelial tumor metastases and hematologic malignancy. The follow-up of ten (10) patients who underwent diagnosis and treatment of two malignant diseases, i.e. carcinoma and hematologic malignancy, was performed in the 2000-2005 period. The median of age of our patients was 72 years (range: 49-79). Cytological examination included epithelial tumors, lymph nodes and bone marrow standard Pappenheim and immunocytochemically stained smears. Carcinoma was initially diagnosed in 40% (4/10) patients and hematologic malignancy in 50% (5/10) patients, while both diseases co-occurred in one patient (1/10). Most of hematologic malignancy cases (4/10) were diagnosed as lymphoma. Multiple myeloma was diagnosed in 3 out of 10 patients (30%). Individual cases of acute myeloblastic leukemia, chronic lymphocytic leukemia, and chronic myeloid leukemia were diagnosed in the remaining three patients. Most carcinomas were breast cancer (8/10), while prostate and thyroid gland cancer were diagnosed each in one patient, respectively.

Concurrent epithelioid malignant peripheral nerve sheath tumor and papillary thyroid carcinoma in the treated field of Hodgkin's disease

BACKGROUND

Simultaneous malignancies in the field of radiation for Hodgkin's disease is an extremely rare event. A unique case of concurrent thyroid and neck mass in the postirradiation field of a young patient with Hodgkin's disease is presented.

METHODS AND RESULTS

Thyroidectomy and excision biopsy of the neck mass were performed. A 1.5-cm papillary thyroid carcinoma was identified in thyroidectomy and an initial diagnosis of undifferentiated malignant neoplasm was rendered on the neck mass biopsy. Subsequent surgical excision of the neck mass and immunohistochemical analysis revealed malignant peripheral nerve sheath tumor.

CONCLUSION

Concurrent malignancies in the field of treatment of Hodgkin's disease may occur. Rare malignancies including malignant peripheral nerve sheath tumor may be encountered along with the more common papillary thyroid carcinoma.

Do we need an early unfavorable (intermediate) stage of Hodgkin's lymphoma?

The outcome of patients who have early unfavorable or intermediate-stage Hodgkin's lymphoma has greatly improved. The increasing efficacy of chemotherapy and late toxic effects of wide-field radiotherapy justify the careful testing of the new involved-node radiotherapy principle in the combined-modality approach. For the purpose of tailoring treatment to the individual patient we need more accurate measures, preferably predictive factors that may tell us how the individual patient should be treated. The result of an early positron emission tomography scan with fluorodeoxyglucose may well become the major new treatment-related guidance for an individually tailored treatment approach.

Inhibition of p53-murine double minute 2 interaction by nutlin-3A stabilizes p53 and induces cell cycle arrest and apoptosis in Hodgkin lymphoma

PURPOSE

p53 is frequently expressed but rarely mutated in Hodgkin and Reed-Sternberg (HRS) cells of Hodgkin's lymphoma (HL). p53 protein levels are regulated by murine double minute 2 (MDM2) through a well-established autoregulatory feedback loop. In this study, we investigated the effects of nutlin-3A, a recently developed small molecule that antagonizes MDM2 and disrupts the p53-MDM2 interaction, on p53-dependent cell cycle arrest and apoptosis in cultured HRS cells.

EXPERIMENTAL DESIGN

HL cell lines carrying wild-type (wt) or mutated p53 gene were treated with the potent MDM2 inhibitor nutlin-3A or a 150-fold less active enantiomer, nutlin-3B.

RESULTS

We show that nutlin-3A, but not nutlin-3B, stabilizes p53 in cultured HRS cells carrying wt p53 gene resulting in p53-dependent cell cycle arrest and apoptosis. Cell cycle arrest was associated with up-regulation of the cyclin-dependent kinase inhibitor p21. Nutlin-3A-induced apoptotic cell death was accompanied by Bax and Puma up-regulation and caspase-3 cleavage and was abrogated, in part, by inhibition of caspase-9 and caspase-3 activity. By contrast, no effects on cell cycle or apoptosis were found in HL cell lines harboring mutated p53 gene. Furthermore, combined treatment with nutlin-3A and doxorubicin revealed enhanced cytotoxicity in HRS cells with wt p53 gene. Blocking of nuclear export by leptomycin B, or inhibition of proteasome by MG132, stabilized p53 at a level comparable with that of nutlin-3A treatment in HRS cells with wt p53.

CONCLUSIONS

These data suggest that nutlin-3A stabilized p53 by preventing MDM2-mediated p53 degradation in HRS cells. wt p53 stabilization and activation by nutlin-3A may be a novel therapeutic approach for patients with HL.

Long-term results and competing risk analysis of the H89 trial in patients with advanced-stage Hodgkin lymphoma: a study by the Groupe d'Etude des Lymphomes de l'Adulte (GELA)

From 1989 to 1996, 533 eligible patients with stage IIIB/IV Hodgkin lymphoma (HL) were randomly assigned to receive 6 cycles of hybrid MOPP/ABV (mechlorethamine, vincristine, procarbazine, prednisone/Adriamycin [doxorubicin], bleomycin, vinblastine; n = 266) or ABVPP (doxorubicin, bleomycin, vinblastine, procarbazine, prednisone; n = 267). Patients in complete remission (CR) or partial response of at least 75% after 6 cycles received 2 cycles of consolidation chemotherapy (CT) (n = 208) or subtotal nodal irradiation (RT) (n = 210). A better survival probability was observed after ABVPP alone: the 10-year overall survival (OS) estimates were 90% for ABVPP×8, 78% for MOPP/ABV×8, 82% for MOPP/ABV with RT, and 77% for ABVPP×6 with RT (P = .03); and the 10-year disease-free survival (DFS) estimates were 70%, 76%, 79%, and 76%, respectively (P = .09). The 10-year DFS estimates for patients treated with consolidation CT or RT were 73% and 78% (P = .07), and OS estimates were 84% and 79%, respectively (P = .29). These results showed that RT was not superior to consolidation CT after a doxorubicin-induced CR in patients with advanced HL. An analysis of competing risks identified age more than 45 years as a significant risk factor for death, relapse, and second cancers. Prospective evaluation of late adverse events may improve the management of patients with HL.

[Intracranial menigioma manifested after delivery in a patient with Hodgkin's disease]

BACKGROUND

Intracranial meningioma is rerely reported in the patients treated for Hodgkin's disease (HD), known to mainly occur in the area of radiation therapy.

CASE REPORT

A 26-year-old woman with HD, and intracranial meningioma following the delivery, was presented. As we knew, a similar case had not been reported in the literature before. Three years prior the surgery for intracranial tumor, the patient had been started to be treated for HD of neoplasm stage I (NS I) type, by the use of the standard (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) BEA-COPP protocol. The remission of HD, achieved after 7 cycles, persisted over a 27-month-period up to the delivery. Within this period, the patient was without neurologic disorder, but with the obvious psychotic behavior, for which the patient was treated with haloperidol. Two days following the normal delivery, during the acute disorder of the consciousness, intracranial tumor was found. A complete bilateral meningioma (11.7 x 8.3 x 8.1 cm) of the frontal parietal zone was removed.

CONCLUSION

there were no reliable signs of the use of an intensive hemotherapy in the reported case (alkylating cytostatics and topoisomerases inhibitors) which might have caused the proliferation of a benign solid tumor. The pregnancy was supposed to be the possible second risk factor for causing the growth of a meningioma. On the basis of the significant psychic disorders before the pregnancy, as well as upon the size of the operated on tumor, we concluded that the occurrence of intracranial meningioma could be regarded the parallel neoplastic disease or the second primary tumor.

Tertiary prevention: implications for improving the quality of life of long-term survivors of cancer

OBJECTIVE

To provide an overview of the incidence, epidemiology, and appropriate screening for second primary malignancies, as well as the nursing implications of tertiary cancer prevention.

DATA SOURCES

Published review articles, book chapters, research reports, and the clinical experience of the author.

CONCLUSION

Many persons successfully treated for malignancy are at risk for a second malignancy. This risk is related to shared risk factors, genetic predisposition, and the toxic effects of therapy. Persons particularly at risk are those who have been successfully treated for breast, gynecologic, colorectal, skin, and lymphoma malignancies.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be knowledgeable regarding the principles of tertiary prevention, be able to identify persons at risk, and provide appropriate patient education and psychosocial support on how to manage the risk and detect second malignancies early.

Lung cancer after treatment for Hodgkin's lymphoma: a systematic review

Developments in modern chemotherapy and radiotherapy mean that most patients with Hodgkin's lymphoma can now be cured. However, the long-term effects of anticancer treatment include an increased risk of a second malignant disease. We have done a systematic review of studies reporting long-term complications of the treatment of Hodgkin's lymphoma published in English since 1985. These studies show that risk of lung cancer is significantly increased in patients treated for Hodgkin's lymphoma, with a reported mean relative risk of 2.6-7.0 and a significantly increased absolute excess risk. The absolute excess risk increases with time from treatment, for as long as 20-25 years, and is highest in patients treated at age 45 years or older. Both chemotherapy and radiotherapy contribute to the risk, and evidence suggests that the effects are additive. Cigarette smoking seems to multiply the risk associated with both chemotherapy and radiotherapy. In the high-risk group of patients, 50-150 patients per 1000 are expected to develop lung cancer by 10-20 years after treatment. The role of screening in this group of patients has not yet been assessed, but an international study combining CT with genomic and proteomic assessment is planned.

A 10-year median follow-up study after allogeneic stem cell transplantation for chronic myeloid leukemia in chronic phase from HLA-identical sibling donors

We report long-term outcome in 102 patients with cCML transplanted from an HLA-identical sibling donor from 1982 to 1998. The conditioning regimen was based on cyclophosphamide associated with either total body irradiation (TBI) (37 patients) or with busulfan (63 patients). Graft-versus-host disease (GvHD) prophylaxis consisted of cyclosporin and methotrexate in the majority of the patients. Fifteen year overall survival was estimated at 53% (95% confidence interval (CI), 44-65) with a plateau after 2.5 years. Long-term survival was adversely affected by: longer time from chronic myeloid leukemia (CML) diagnosis to transplantation, older age at time of transplantation and GvHD (acute grade III-IV or chronic extensive). The main cause of death was infection, related to GvHD in 69% of patients. Splenectomy also significantly increased the risk of bacterial infection. 15-year relapse was estimated at 8% (95% CI, 0.1-14). Late malignancies occurred in seven patients, four of whom had an invasive cancer. Other frequent late complications included cataracts, psychological depression, osteonecrosis and hypothyroidism. These complications were more frequent following splenectomy, TBI and in patients with chronic extensive GvHD. We conclude that allogeneic transplantation with a related donor can cure more than half of CML patients in chronic phase, although physicians should be alert to long-term complications.

Secondary transitional cell carcinoma and nitrogen mustard treatment

Transitional cell carcinoma (TCC) of the bladder in children is a rare occurrence. Cyclophosphamide is a known risk factor for the development of TCC. Other alkylating agents, such as nitrogen mustard, have not been implicated in the development of secondary adult or pediatric TCC. The role of radiotherapy in the development of secondary malignancies of the bladder remains controversial. We report a case of childhood TCC in a patient in remission from Hodgkin's lymphoma previously treated with non-cyclophosphamide chemotherapy and low-dose nodal radiotherapy.

18F-FDG PET in malignant lymphoma: significance of positive findings

PURPOSE

The aim of this study was to evaluate the significance of increased uptake of 18F-fluorodeoxyglucose (FDG) in patients with malignant lymphoma (ML) studied by positron emission tomography (PET).

METHODS

A total of 1,120 consecutive scans carried out in 848 patients were reviewed; all patients had a diagnosis of ML [574 non-Hodgkin's lymphoma (NHL) and 274 Hodgkin's disease (HD)] and were studied at completion of therapy, for suspected recurrence or during follow-up. PET was carried out after intravenous injection of 370 MBq of 18F-FDG; images were recorded after 60-90 min. Patients were selected whose reports indicated areas of increased FDG uptake. PET findings were considered positive for lymphomatous localisation when uptake occurred at sites of previous disease, in asymmetrical lymph nodes or in nodes unlikely to be affected by inflammation (mediastinal, except for hilar, and abdominal). PET findings were adjudged negative for neoplastic localisations in the following instances: physiological uptake (urinary, muscular, thymic or gastrointestinal in patients without MALT), symmetrical nodal uptake, uptake in lesions unrelated to lymphoma that had already been identified by other imaging methods at the time of PET scan, uptake at sites atypical for lymphoma, very low uptake and non-focal uptake. PET findings were compared with the results of other diagnostic procedures (including CT and ultrasound), biopsy findings and follow-up data.

RESULTS

Overall, 354 scans (in 256 patients) showed increased FDG uptake (244 scans in NHL and 110 in HD): in 286 cases, FDG uptake was considered pathological and indicative of ML, in 41 cases the findings were described as uncertain or equivocal and in 37 cases, FDG uptake was considered unrelated to ML (in ten scans, concurrent findings of abnormal FDG uptake attributed to ML and uptake assigned to other causes were obtained) . Of the 286 patients with positive PET findings, 274 (95.8%) were found to have residual or recurrent ML (i.e. true positives). Four of the 41 patients with inconclusive findings turned out to have ML, while in 13 patients, pathological processes other than ML could be identified as the cause of FDG uptake. ML was excluded in all patients with findings reported as non-pathological (100% true-negative rate). Therefore, the false-positive rate in our series was about 5%. The main cause of increased FDG uptake mimicking ML was inflammation.

CONCLUSION

Our data confirm that 18F-FDG-PET has very high but not absolute specificity for ML. As already suggested, increased FDG uptake may also be observed in patients without active disease; in most cases, however, non-pathological FDG accumulation is properly identified. Less frequently, inconclusive scans are encountered; these cases are usually caused by inflammation, which subsequently resolves.