Clinical manifestations and natural history of Hodgkin's lymphoma. Cancer J. 2009;15:124-128. [PMID: 19390307 DOI: 10.1097/ppo.0b013e3181a282d8]

Aggressive Mediastinal Lymphomas

The mediastinum contains essentially all major intrathoracic organs except for the lungs. A variety of both benign and malignant tumors can involve the mediastinum, of which lymphoma is the most common malignancy. Compared to secondary mediastinal involvement by systemic lymphomas, primary mediastinal lymphomas are less common with several specific entities that are mainly confined to mediastinal lymph nodes, and/or thymus. This review will summarize the clinical, histologic, immunophenotypic and molecular genetic features of the most common and most aggressive primary mediastinal lymphomas as well as provide suggested immunohistochemistry panels and differential diagnoses.

Hodgkin Lymphoma: A disease shaped by the tumor micro- and macroenvironment

The tumor microenvironment (TMicroE) and tumor macroenvironment (TMacroE) are defining features of classical Hodgkin lymphoma (cHL). They are of critical importance to clinicians since they explain the common signs and symptoms, allow us to classify these neoplasms, develop prognostic and predictive biomarkers, bioimaging and novel treatments. The TMicroE is defined by effects of cancer cells to their immediate surrounding and within the tumor. Effects of cancer cells at a distance or outside of the tumor define the TMacroE. Paraneoplastic syndromes are signs and symptoms due to effects of cancer at a distance or the TMacroE, which are not due to direct cancer cell infiltration. The most common paraneoplastic symptoms are B-symptoms, which manifest as fevers, chills, drenching night sweats, and/or weight loss. Less common paraneoplastic syndromes include those that affect the central nervous system, skin, kidney, and hematological autoimmune phenomena including hemophagocytic lymphohistiocytosis (HLH). Paraneoplastic signs such as leukocytosis, lymphopenia, anemia, and hypoalbuminemia are prognostic biomarkers. The neoplastic cells in cHL are the Hodgkin and Reed Sternberg (HRS) cells, which are preapoptotic germinal center B cells with a high mutational burden and almost universal genetic alterations at the 9p24.1 locus primarily through copy gain and amplification with strong activation of signaling via PD-L1, JAK-STAT, NFkB, and c-MYC. In the majority of cases of cHL over 95% of the tumor cells are non-neoplastic. In the TMicroE, HRS cells recruit and mold non-neoplastic cells vigorously via extracellular vesicles, chemokines, cytokines and growth factors such as CCL5, CCL17, IL6, and TGF-β to promote a feed-forward inflammatory loop, which drives cancer aggressiveness and anti-cancer immune evasion. Novel single cell profiling techniques provide critical information on the role in cHL of monocytes-macrophages, neutrophils, T helper, Tregs, cytotoxic CD8+ T cells, eosinophils, mast cells and fibroblasts. Here, we summarize the effects of EBV on the TMicroE and TMacroE. In addition, how the metabolism of the TMicroE of cHL affects bioimaging and contributes to cancer aggressiveness is reviewed. Finally, we discuss how the TMicroE is being leveraged for risk adapted treatment strategies based on bioimaging results and novel immune therapies. In sum, it is clear that we cannot effectively manage patients with cHL without understanding the TMicroE and TMacroE and its clinical importance is expected to continue to grow rapidly.

Cutaneous Localization of Classic Hodgkin Lymphoma Associated with Mycosis Fungoides: Report of a Rare Event and Review of the Literature

Mycosis fungoides and nodal classic Hodgkin lymphoma (cHL) have been reported to occur concurrently or sequentially in the same patient. A long-lasting mycosis fungoides more often precedes the onset of nodal cHL, although few cases of nodal cHL followed by mycosis fungoides have been observed. Skin involvement is a rare manifestation of cHL that may be observed in the setting of advanced disease. The decrease in skin involvement in cHL is mainly due to the improved therapeutic strategies. The concurrent presence of mycosis fungoides and cutaneous localization of classic Hodgkin lymphoma represents a very uncommon event, with only two cases reported so far. Herein, we describe the case of a 71-year-old man, with a history of recurrent nodal cHL, who developed MF and, subsequently, the cutaneous localization of cHL. The clinicopathological features of the two diseases are described focusing on the main differential diagnoses to be taken into consideration, and a review of the literature is performed.

Classical Hodgkin's lymphoma with cutaneous involvement in an adolescent male: A case study

BACKGROUND

Hodgkin's lymphoma (HL) with skin involvement is reasonably rare. It typically occurs late in the course and is associated with a poor prognosis; however, it may also be indolent in some cases.

CASE

We report a case of a 15-year-old previously healthy male with Hodgkin's lymphoma who presented with multiple lymphadenopathies of axilla and serpiginous ulcerative nodular lesions involving pectoral skin. A lymph node biopsy was performed following an initial diagnostic workup for a suspected active infectious disease, which revealed a neoplastic invasion from a mixed cellularity classical HL with skin involvement. A total of six cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) chemotherapy regimen was administered to the patient.

CONCLUSION

In comparison to other studies, this case demonstrates that a good response is possible with standard ABVD chemotherapy.

Classic Hodgkin Lymphoma: A Nonclassic Presentation

Hodgkin lymphoma classically presents as lymphadenopathy with contiguous spread with or without associated B symptoms including night sweats, weight loss, and fever. With timely diagnosis and treatment, this is a potentially curable disease. This report describes a unique case of Hodgkin lymphoma that presented with localized back pain without overt evidence of lymph node involvement. This nonclassic presentation offers a diagnostic challenge that emphasizes the importance of keeping a broad differential in an adolescent or young adult patient with lytic bone lesions.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Diffuse large B-Cell lymphoma associated with paraneoplastic Guillain-Barré syndrome: A diagnostic and therapeutic challenge

Paraneoplastic neurological syndromes are a rare manifestation of non-Hodgkin lymphoma and can make treatment of these patients more challenging. We report the case of a 67-year-old man with high grade diffuse large B-cell lymphoma who presented with severe paraneoplastic Guillain-Barré syndrome. He was treated with intravenous immunoglobulin therapy and definitive chemoimmunotherapy, and achieved a full neurological recovery. In this report, we discuss various mechanisms of neurological dysfunction seen in lymphomas. Prompt oncologic treatment and immunotherapy for Guillain-Barré syndrome if instituted concurrently and early in the course of the disease can be associated with the best outcomes.

Imaging Surveillance of Limited-stage Classic Hodgkin Lymphoma Patients After PET-CT-documented First Remission

INTRODUCTION

Early stage Hodgkin lymphoma (ESHL) is highly curable; however, 10% to 15% of patients experience relapse. We examined the utilization of follow-up imaging for patients with ESHL who achieved a metabolic complete response after upfront therapy.

MATERIALS AND METHODS

The records of adult patients treated at a single institution between 2003 and 2014 were reviewed. Positron emission tomography-computed tomography (PET-CT) and CT scan frequency was quantified during the 2 years following treatment and subsequent visits beyond 2 years.

RESULTS

The study cohort contained 179 patients. The median age was 31 years; bulky disease was present in 30%. ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) or AVD (doxorubicin, vinblastine, and dacarbazine) was given in 97%; 75% received radiation therapy. At a median follow-up of 6.9 years, the 5-year progression-free and overall survival rates were 93.7% and 98.1%, respectively. Relapse occurred in 5% (n = 9) of patients at a median of 9.1 months (range, 4.6-27.2 months) from therapy. Two patients presented with symptoms prompting imaging in follow-up. Within 2 years after therapy, 376 PET-CT scans and 3325 CT scans were performed, yielding an average of 2.1 PET-CTs and 18.6 CTs per patient. Of the initial 179 patients, 113 had follow-up conducted beyond 2 years post-therapy; an average of 2.7 PET-CTs and 33.2 CTs were performed. In the 2-year post-therapy period, 463 scans were performed per relapse detected.

CONCLUSION

In this cohort of patients with ESHL who responded completely to frontline therapy, the relapse rate was low. Routine imaging surveillance lacks clinical benefit in this patient population.

Atypical cutaneous lesions in advanced-stage Hodgkin lymphoma: A case report

BACKGROUND

Cutaneous involvement in Hodgkin lymphoma (HL) is a rare finding. Few cases have been reported in literature, most describing paraneoplastic manifestations. Only very few papers have described primary HL skin infiltration, reporting a wide range of clinical presentations that frequently include ulcers; plaques, nodules and papules have also been noticed.

CASE SUMMARY

We report the case of a 56-year-old man who presented fever, multiple adenomegalies of neck and axilla and thick serpiginous skin lesions involving bilateral pectoral regions. After an initial diagnostic workup for a suspected active infectious disease, a lymph node biopsy was performed, which showed a neoplastic invasion from a mixed cellularity classical HL. The same histological pattern was described in a cutaneous biopsy of the chest lesions. The other staging procedures performed revealed an advanced disease, with unfavourable clinical prognostic features. The patient was prescribed 6 cycles of ABVD chemotherapy scheme (doxorubicin, bleomycin, vinblastine, dacarbazine), a regiment that requires demonstration of metabolic response achievement at the interim PET/CT scan to confirm continuation or to change therapeutic strategy.

CONCLUSION

Skin involvement in HL is a rare finding and may represent a challenging clinical presentation due to extremely various types of lesions observed.

Paraneoplastic eczematous eruption associated with Hodgkin's lymphoma

Hodgkin's disease (HD) is a common malignant lymphoma that classically presents with painless lymphadenopathy, weight loss, nocturnal sweats, fever, and generalized pruritus. Unlike other lymphoproliferative disorders, cutaneous involvement is uncommon with HD. Diffuse hyperpigmentation, prurigo nodularis, acquired ichthyosis, erythema nodosum, mycosis fungoides, herpes zoster, and vasculitis have all been described as nonspecific or paraneoplastic manifestations of HD. A small set of cases of adult new-onset recalcitrant eczema has recently been described as a nonspecific cutaneous manifestation of HD. In agreement with these reports, we present a case of a 28-year-old woman who initially presented with persistent lymphadenopathy and a pruritic eczematous dermatitis that preceded the diagnosis of HD.

Cytodiagnostic Sensitivity of Fine Needle Aspiration Biopsy for Hodgkin's Lymphoma Is Decreased in Patients with Human Immunodeficiency Virus Infection

OBJECTIVE

We aimed to evaluate the sensitivity of fine needle aspiration (FNA) for the diagnosis of Hodgkin's lymphoma (HL) in HIV-infected patients.

STUDY DESIGN

An electronic search was conducted to retrospectively identify patients diagnosed with HL who underwent FNA followed by confirmatory biopsy. FNAs were categorized as negative, atypical/suspicious/positive, or nondiagnostic. Diagnostic sensitivity in HIV+ and HIV- patients was statistically compared via Fisher's exact test, with a p value <0.05 considered significant.

RESULTS

Thirty-six patients meeting inclusion criteria were identified (24 HIV- and 12 HIV+). Average age was 36.0 ± 11.5 and 36.5 ± 7.4 years (means ± SD) in HIV- and HIV+ patients, respectively. The male-to-female ratio was 1.4:1 in HIV- patients versus 3:1 in HIV+ patients. Among these 36 patients, a total of 42 FNAs were performed. Overall sensitivity of FNA was 66.7% (95% confidence interval: 52.4-80.9%). When stratified by HIV status, a statistically significant difference in FNA sensitivity was detected, as sen-sitivity was 84.6% (70.8-98.4%) in HIV- patients versus only 37.5% (13.8-61.2%) in HIV+ patients (p =0.003).

CONCLUSION

The diagnostic sensitivity of FNA biopsy was significantly attenuated in the HIV+ cohort. In HIV-infected patients presenting with lymphadenopathy, increased clinical suspicion of HL is critical to avoid misdiagnosis.

Nivolumab for adults with Hodgkin's lymphoma (a rapid review using the software RobotReviewer)

BACKGROUND

Hodgkin's lymphoma (HL) is a cancer of the lymphatic system, and involves the lymph nodes, spleen and other organs such as the liver, lung, bone or bone marrow, depending on the tumour stage. With cure rates of up to 90%, HL is one of the most curable cancers worldwide. Approximately 10% of people with HL will be refractory to initial treatment or will relapse; this is more common in people with advanced stage or bulky disease. Standard of care for these people is high-dose chemotherapy and autologous stem cell transplantation (ASCT), but only 55% of participants treated with high-dose chemotherapy and ASCT are free from treatment failure at three years, with an overall survival (OS) of about 80% at three years.Checkpoint inhibitors that target the interaction of the programmed death (PD)-1 immune checkpoint receptor, and its ligands PD-L1 and PD-L2, have shown remarkable activity in a wide range of malignancies. Nivolumab is an anti-(PD)-1 monoclonal antibody and currently approved by the US Food and Drug Administration (FDA) for the treatment of melanoma, non-small cell lung cancer, renal cell carcinoma and, since 2016, for classical Hodgkin's lymphoma (cHL) after treatment with ASCT and brentuximab vedotin.

OBJECTIVES

To assess the benefits and harms of nivolumab in adults with HL (irrespective of stage of disease).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, International Pharmaceutical Abstracts, conference proceedings and six study registries from January 2000 to May 2018 for prospectively planned trials evaluating nivolumab.

SELECTION CRITERIA

We included prospectively planned trials evaluating nivolumab in adults with HL. We excluded trials in which less than 80% of participants had HL, unless the trial authors provided the subgroup data for these participants in the publication or after we contacted the trial authors.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed potential risk of bias. We used the software RobotReviewer to extract data and compared results with our findings. As we did not identify any randomised controlled trials (RCTs) or non-RCTs, we did not meta-analyse data.

MAIN RESULTS

Our search found 782 potentially relevant references. From these, we included three trials without a control group, with 283 participants. In addition, we identified 14 ongoing trials evaluating nivolumab, of which two are randomised. Risk of bias of the three included studies was moderate to high. All of the participants were in relapsed stage, most of them were heavily pretreated and had received at least two previous treatments, most of them had also undergone ASCT. As we did not identify any RCTs, we could not use the software RobotReviewer to assess risk of bias. The software identified correctly that one study was not an RCT and did not extract any trial data, but extracted characteristics of the other two studies (although also not RCTs) in a sufficient way.Two studies with 260 participants evaluated OS. After six months, OS was 100% in one study and median OS (the timepoint when only 50% of participants were alive) was not reached in the other trial after a median follow-up of 18 months (interquartile range (IQR) 15 to 22 months) (very low certainty evidence, due to observational trial design, heterogenous patient population in terms of pretreatments and various follow-up times (downgrading by 1 point)). In one study, one out of three cohorts reported quality of life. It was unclear whether there was an effect on quality of life as only a subset of participants filled out the follow-up questionnaire (very low certainty evidence). Three trials (283 participants) evaluated progression-free survival (PFS) (very low certainty evidence). Six-month PFS ranged between 60% and 86%, and median PFS ranged between 12 and 18 months. All three trials (283 participants) reported complete response rates, ranging from 12% to 29%, depending on inclusion criteria and participants' previous treatments (very low certainty evidence).One trial (243 participants) reported drug-related grade 3 or 4 adverse events (AEs) only after a median follow-up of 18 months (IQR 15 to 22 months); these were fatigue (23%), diarrhoea (15%), infusion reactions (14%) and rash (12%). The other two trials (40 participants) reported 23% to 52% grade 3 or 4 AEs after six months' follow-up (very low certainty evidence). Only one trial (243 participants) reported drug-related serious AEs; 2% of participants developed infusion reactions and 1% pneumonitis (very low certainty evidence).None of the studies reported treatment-related mortality.

AUTHORS' CONCLUSIONS

To date, data on OS, quality of life, PFS, response rate, or short- and long-term AEs are available from small uncontrolled trials only. The three trials included heavily pretreated participants, which had previously undergone regimens of BV or ASCT. For these participants, median OS was not reached after follow-up times of at least 16 months (more than 50% of participants with a limited life expectancy were alive at this timepoint). Only one cohort out of three only reported quality of life, with limited follow-up data so that meaningful conclusions were not possible. Serious adverse events occurred rarely. Currently, data are too sparse to make a clear statement on nivolumab for people with relapsed or refractory HL except for heavily pretreated people, which had previously undergone regimens of BV or ASCT. When interpreting these results, it is important to consider that proper RCTs should confirm these findings.As there are 14 ongoing trials evaluating nivolumab, of which two are RCTs, it is possible that an update of this review will be published in the near future and that this update will show different results to those reported here.

Roles of Loss of Chromosome 14q Allele in the Prognosis of Renal Cell Carcinoma with C-reactive Protein Abnormity

Background:

Renal cell carcinoma (RCC) is frequently associated with paraneoplastic inflammatory syndrome (PIS). This study aimed at exploring the connections between the survival rate and specific gene alterations and the potential mechanism.

Methods:

We retrospectively studied 69 surgical RCC cases from August 2014 to February 2016, including 18 cases of clear cell RCC (ccRCC) demonstrating elevated pretreatment serum C-reactive protein (CRP, Group A). Twelve of the 18 cases were symptomized with febrile episode. We also selected 49 cases of ccRCC with normal pretreatment CRP (Group B). Using 22 microsatellite markers, we compared the incidence of loss of heterozygosity (LOH) between Group A and Group B. All statistical tests are two-sided.

Results:

The 3p LOH was common in both Group A (89%) and Group B (92%). The frequency of 14q LOH in Group A (16 of 18) was higher than Group B (4 of 49, χ² = 40.97 P < 0.0001). The 3p and 14q LOH were the characteristics of ccRCC with elevated acute phase reactants, including PIS, regardless of the presence of metastasis. On the contrary, 14q LOH was a rare genomic alternation in advanced-staged ccRCC without PIS. The overall survival of patients with elevated CRP (33.3%) was lower than its counterparts (6.1%, hazard ratio=1.852, P < 0.0001) in Kaplan-Meier curve.

Conclusions:

The results imply that the disruption of a 14q gene(s) might result in not only the inflammatory manifestations in the tumor host but also the poor survival rate as well. The isolation of the gene(s) on 14q might be a vital goal in the treatment of PIS-associated RCC.

Secondary Sclerosing Cholangitis and Hodgkin's Lymphoma

CONTEXT

Liver damage is relatively common in patients affected by HL, but paraneoplastic cholestasis is an uncommon presenting symptom in HL.

CASE REPORT

We report the case of a 38-year-old man who came to our hospital with jaundice, pruritis, nausea, vomiting, weight loss, and recurrent episodes of fever without any hepatosplenomegaly or lymphadenopathy. Laboratory findings showed abnormal liver functioning with mixed hepatocellular and cholestatic patterns. Sonographic evaluation of the biliary tract was normal. We ruled out viral infections, autoimmune process, and hemochromatosis. The patient was put on ursobile and NAC (N-acetyl-systeine) and prednisolone treatment. In magnetic resonance cholangiopancreatography examination, there were multiple strictures in the intrahepatic and extrahepatic bile ducts with mild dilatation. Histologic finding of liver biopsy was compatible with sclerosing cholangitis or drug-induced cholestasis. General condition and laboratory examination results of the patient became better, but we found lymph-adenopathy on monthly follow-up examination. Histological finding of the lymph node was compatible with HL.

CONCLUSION

This report emphasizes that HL can be presented with different paraneoplastic symptoms and that one of them is secondary sclerosing cholangitis. It has better prognosis than vanishing bile duct syndrome, and perhaps steroid treatment can be suggested.

Very low utility of surveillance imaging in early-stage classic Hodgkin lymphoma treated with a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine and radiation therapy

BACKGROUND

This study evaluated the need for surveillance imaging in early-stage classic Hodgkin lymphoma (cHL) after planned combined-modality therapy (CMT).

METHODS

Primary early-stage cHL patients who underwent CMT were included. Positron emission tomography (PET)/computed tomography (CT), CT, or both were performed at the initial staging, during or after chemotherapy, and for at least 2 years during follow-up. Imaging studies and medical records were reviewed to determine if and when relapse had occurred. Radiation doses and costs were also calculated from follow-up imaging.

RESULTS

The study included 78 patients with a median follow-up of 46 months; 85% of the patients had stage II disease (32% with bulky disease). Four of 77 interim PET scans were positive; none of these patients relapsed during follow-up, which ranged from 24 to 80 months. After a total of 466 follow-up imaging studies (91% with CT and 9% with PET/CT), no cHL relapse was detected. Eleven abnormal findings were noted on surveillance imaging: 9 were false-positives, and 2 were second primary malignancies. The average cumulative dose per patient from follow-up imaging was 107 mSv, which translated into an estimated lifetime excess cancer risk of 0.5%; the estimated total costs were $296,817 according to Medicare reimbursements.

CONCLUSIONS

Surveillance imaging with either CT or PET/CT can be omitted safely for early-stage cHL treated with a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine and radiation therapy because the risk of relapse is extremely low. This observation also applies to patients with bulky disease. The elimination of surveillance imaging will also reduce healthcare expenses and cumulative radiation doses in these predominantly young patients.

The role of radiotherapy in Hodgkin's lymphoma: what has been achieved during the last 50 years?

Currently, Hodgkin's lymphoma (HL) has an excellent clinical outcome, with overall survival of approximately 90% in early stages of the disease. Based on young age of the majority of patients at the time of diagnosis and their long survival time, increased attention has been focused on long-term toxicity of therapy. While novel, directly targeting antitumor agents, with an excellent safety profile, have been developed for HL treatment, the role of radiotherapy is still debated. Radiotherapy may induce cardiovascular disease and impairment of thyroid or pulmonary function and, most importantly, may lead to development of secondary cancers. As a consequence, the current radiation therapy planning paradigm is mainly focused on a reduction of field size. As it was investigated in clinical trials regional therapy is as effective as extended field radiotherapy, but less toxic. Although chemotherapy is the mainstay of HL treatment, consolidative involved field radiation therapy is still considered to be the standard of care in both early and advanced stages. Recently, further field reduction has been investigated to further decrease the late radiation-induced toxicity. In this paper we describe the role and safety profile of radiotherapy in the past and present and hope for the novel techniques in the future.

Positron emission tomography-adapted therapy for first-line treatment in individuals with Hodgkin lymphoma

BACKGROUND

Hodgkin lymphoma (HL) is a B-cell lymphoma accounting for 10% to 15% of all lymphoma in industrialised countries. It has a bimodal age distribution with one peak around the age of 30 years and another after the age of 60 years. Although HL accounts for fewer than 1% of all neoplasms worldwide, it is considered to be one of the most common malignancies in young adults and, with cure rates of 90%, one of the most curable cancers worldwide. Current treatment options for HL comprise more- or less-intensified regimens of chemotherapy plus radiotherapy, depending on disease stage. [18F]-fluorodeoxy-D-glucose (FDG)-positron emission tomography (PET, also called PET scanning) is an imaging tool that can be used to illustrate a tumour's metabolic activity, stage and progression. Therefore, it could be used as a standard interim procedure during HL treatment, to help distinguish between individuals who are good or poor early responders to therapy. Subsequent therapy could then be de-escalated in PET-negative individuals (good responders) or escalated in those who are PET-positive (poor responders). It is currently unknown whether such response-adapted therapeutic strategies are of benefit to individuals in terms of overall and progression-free survival, and the incidence of long-term adverse events (AEs).

OBJECTIVES

To assess the effects of interim [18F]-FDG-PET imaging treatment modification in individuals with HL.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; latest issue) and MEDLINE (from 1990 to September 2014) as well as conference proceedings (American Society of Hematology; American Society of Clinical Oncology; European Hematology Association; and International Symposium on Hodgkin Lymphoma) for studies. Two review authors independently screened search results.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing FDG-PET-adapted therapy with non-adapted treatment in individuals with previously untreated HL of all stages and ages.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the quality of trials. As none of the included studies provided HRs for OS, we described risk ratios (RRs) for this outcome and did not pool the data. As an effect measure we used hazard ratios (HRs) for progression-free survival (PFS). We described RRs for the dichotomous data on AEs. We also calculated 95% confidence intervals (CIs).

MAIN RESULTS

Our search strategies led to 308 potentially relevant references. From these, we included three studies involving 1999 participants. We judged the overall potential risk of bias as moderate. The studies were reported as RCTs; blinding was not reported, but given the study design it is likely that there was no blinding. One study was published in abstract form only; hence, detailed assessment of the risk of bias was not possible.Two trials compared standard treatment (chemotherapy plus radiotherapy) with PET-adapted therapy (chemotherapy only) in individuals with early-stage HL and negative PET scans. The study design of the third trial was more complex. Participants with early-stage HL were divided into those with a favourable or unfavourable prognosis. They were then randomised to receive PET-adapted or standard treatment. Following a PET scan, participants were further divided into PET-positive and PET-negative groups. To date, data have been published for the PET-negative arms only, making it possible to perform a meta-analysis including all three trials.Of the 1999 participants included in the three trials only 1480 were analysed. The 519 excluded participants were either PET-positive, or were excluded because they did not match the inclusion criteria.One study reported no deaths. The other two studies reported two deaths in participants receiving PET-adapted therapy and two in participants receiving standard therapy (very-low-quality evidence). Progression-free survival was shorter in participants with PET-adapted therapy (without radiotherapy) than in those receiving standard treatment with radiotherapy (HR 2.38; 95% CI 1.62 to 3.50; P value < 0.0001). This difference was also apparent in comparisons of participants receiving no additional radiotherapy (PET-adapted therapy) versus radiotherapy (standard therapy) (HR 1.86; 95% CI 1.07 to 3.23; P value = 0.03) and in those receiving chemotherapy but no radiotherapy (PET-adapted therapy) versus standard radiotherapy (HR 3.00; 95% CI 1.75 to 5.14; P value < 0.0001) (moderate-quality evidence). Short-term AEs only were assessed in one trial, which showed no evidence of a difference between the treatment arms (RR 0.91; 95% CI 0.54 to 1.53; P value = 0.72) (very-low-quality evidence). No data on long-term AEs were reported in any of the trials.

AUTHORS' CONCLUSIONS

To date, no robust data on OS, response rate, TRM, QoL, or short- and long-term AEs are available. However, this systematic review found moderate-quality evidence that PFS was shorter in individuals with early-stage HL and a negative PET scan receiving chemotherapy only (PET-adapted therapy) than in those receiving additional radiotherapy (standard therapy). More RCTs with longer follow ups may lead to more precise results for AEs, TRM and QoL, and could evaluate whether this PFS advantage will translate into an overall survival benefit.It is still uncertain whether PET-positive individuals benefit from PET-based treatment adaptation and the effect of such an approach in those with advanced HL.

Treatment decisions in a man with Hodgkin lymphoma and Guillian-Barré syndrome: a case report

Introduction

Guillain-Barre syndrome, or acute inflammatory demyelinating polyneuropathy, has been described in the presence of malignancies such as lymphoma. Guillain-Barre syndrome/acute inflammatory demyelinating polyneuropathy causes paresthesias and weakness, which can make the treatment of lymphoma with chemotherapy challenging. Given the rarity of this co-presentation it is not known if the effects of Guillain-Barre syndrome should be considered when selecting a treatment regimen for Hodgkin lymphoma. To the best of our knowledge, the impact of these treatment modifications has not been previously reported.

Case presentation

We report the case of a 37-year-old Caucasian man with a diagnosis of stage IIB classical Hodgkin lymphoma with concomitant Guillain-Barre syndrome. Our patient originally presented with an enlarged cervical lymph node and quickly developed distal paresthesia and progressive weakness of all four extremities. He was diagnosed with Hodgkin’s lymphoma and initiated on treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine. Doses of bleomycin and vinblastine were held or dose-reduced throughout his initial treatment course due to underlying neuropathy and dyspnea. He continued to have persistent disease after five cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine and went on to receive salvage treatments including more chemotherapy, radiation, autologous stem cell transplant and is currently preparing for an allogeneic stem cell transplant.

Conclusions

Paraneoplastic syndromes such as Guillain-Barre syndrome/acute inflammatory demyelinating polyneuropathy can make the treatment of patients with Hodgkin lymphoma more challenging and can interfere with delivering full-dose chemotherapy. Further case series are needed to evaluate the effect that paraneoplastic syndromes, or adjustments made in therapy due to these syndromes, negatively affect the prognosis of patients with Hodgkin lymphoma.

Hodgkin lymphoma in pregnancy

The peak incidence of Hodgkin lymphoma (HL) coincides with reproductive years, and as many as 3 % of all HL patients present with concurrent pregnancy. The management of a pregnant patient with HL requires a multidisciplinary approach combining expertise in medical oncology, high-risk obstetrics, and neonatology, as well as effective communication with the patient and her family. The goal is to optimize the mother's chance of a cure while allowing for delivery of a healthy child. A pregnant patient with HL should be staged by clinical examination and judicious use of non-radiation imaging such as ultrasound, balancing the need for accurate disease assessment with the need to minimize invasive procedures. The treatment strategy is individualized to the symptoms, lymphoma stage, gestational age and the patients' wishes. Therapeutic options include treatment deferral or single-agent vinblastine with reservation of multi-agent chemotherapy until the second or third trimester for the small minority of patients with aggressive clinical presentation.

Neurologic aspects of lymphoma and leukemias

The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This review's focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.

Limited positron emission tomography-computed tomography for restaging of lymphoma: a strategy for reducing radiation exposure among patients with early-stage curable lymphoma

Repeated imaging with positron emission tomography-computed tomography (PET-CT) is associated with cumulative exposure to substantial doses of radiation. Furthermore, PET-CT is an expensive and limited resource in many institutions. We conducted a retrospective analysis to evaluate whether limited PET-CT focused on the initially involved field of view (FOV) at diagnosis, corresponding to an above- or below-the-diaphragm scan, is sufficient for follow-up of patients with Hodgkin (HL) and aggressive non-Hodgkin lymphoma (NHL). One hundred thirty-one examinations of 44 patients with early-stage (I-II) HL (n = 27) and aggressive NHL (n = 17) who had PET-CT performed as part of their initial staging and at follow-up were analyzed. Regardless of the extent of response to treatment, there was no single case in which the disease progressed outside of the initially involved FOV (0/44, 95% CI 0-0.08). This was true even in cases of disease progression, including in the setting of relapse. Our findings suggest that limited PET-CT analysis of the initially involved FOV in patients with early-stage curable lymphoma may be satisfactory for response assessment.

18F-FDG-PET/CT in the surveillance of patients with lymphoma: detection of asymptomatic recurrences

AIM

To assess the diagnostic accuracy of (18)F-FDG-PET/CT in detecting asymptomatic recurrences in patients with lymphoma. To define uptake patterns of recurrence indicative of recurrence.

MATERIAL AND METHODS

Those patients with lymphoma who fulfilled the following inclusion criteria of clinical complete remission and negative PET/CT study were included retrospectively and longitudinally. Conventional surveillance of these patients was performed only by (18)F-FDG PET/CT following a standardized procedure. Pathologic locations (supra- and infradiaphragmatic) and their character (single or multiple) were analyzed in order to determine reliable metabolic patterns of recurrence. The final diagnosis was established by histopathological analysis or clinical follow-up greater than 8 months.

RESULTS

A total of 199 explorations belonging to 106 patients with lymphoma were included. Of these patients, 59 had Hodgkin's lymphoma and 47 non-Hodgkin's lymphoma. There was suspicion of relapse from the metabolic point of view in 27 of the PET/CT scans. Of these, 14 (10 patients) were false positive (FP), and 13 (8 patients) true positive. The remaining studies were true negative, no false negatives being detected. The pattern most frequently related to recurrence was infradiaphragmatic lymph node involvement while most of the FP had isolated supradiaphragmatic involvement. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET/CT parameters for the study were 100%, 92%, 48%, 100% and 93%, respectively.

CONCLUSION

(18)F-FDG-PET/CT is a sensitive technique in the detection of asymptomatic recurrences in patients with lymphoma during their follow-up. Multiple character and infradiaphragmatic locations were the patterns that best correlated to the diagnosis of recurrence.

3D imaging of telomeres and nuclear architecture: An emerging tool of 3D nano-morphology-based diagnosis

Patient samples are evaluated by experienced pathologists whose diagnosis guides treating physicians. Pathological diagnoses are complex and often assisted by the application of specific tissue markers. However, cases still exist where pathologists cannot distinguish between closely related entities or determine the aggressiveness of the disease they identify under the microscope. This is due to the absence of reliable markers that define diagnostic subgroups in several cancers. Three-dimensional (3D) imaging of nuclear telomere signatures is emerging as a new tool that may change this situation offering new opportunities to the patients. This article will review current and future avenues in the assessment of diagnostic patient samples.

Recent Advances in the Pathobiology of Hodgkin's Lymphoma: Potential Impact on Diagnostic, Predictive, and Therapeutic Strategies

From its first description by Thomas Hodgkin in 1832, Hodgkin's disease, now called Hodgkin's lymphoma, has continued to be a fascinating neoplasm even to this day. In this review, historical aspects, epidemiology, diagnosis, tumor biology, new observations related to host-microenvironment interactions, gene copy number variation, and gene expression profiling in this complex neoplasm are described, with an exploration of chemoresistance mechanisms and potential novel therapies for refractory disease.