Hodgkin Lymphoma

Toxoplasma gondii infection in children with lymphoma in Eastern China: seroprevalence, risk factors and case-control studies

Epidemiological data for Toxoplasma gondii regarding malignancy have gained increasing attention; however, the information about T. gondii infection among children with malignant lymphoma (ML) in China is unclear. Therefore, 314 children with lymphoma and 314 healthy children, age- and gender-matched, were recruited to estimate the seroprevalence of T. gondii in the participants and identify the risk factors of infection. Blood samples from all participants were collected and examined for T. gondii IgG and IgM antibodies using ELISA. The results showed that the overall seroprevalence of T. gondii antibodies (including IgG and/or IgM) in ML patients and healthy controls was 19.8% and 9.9%, respectively. Contact with the cats, consumption of oysters and history of chemotherapy were estimated to be the risk factors for T. gondii infection in children with lymphoma by multivariable logistic regression analysis, whereas in healthy children, contact with cats and consumption of oysters were the risk factors. Moreover, among various histological types of lymphoma, individuals with NK/T-cell lymphoma, B-small lymphocytic lymphoma, marginal zone B-lymphoma and Hodgkin's lymphoma had a higher seroprevalence than healthy controls (P < 0.05). These findings indicated the high prevalence of T. gondii infection in children with lymphoma, and hence, efforts should be performed to evaluate the effect of the infection further in lymphoma patients.

Use of recommended posttreatment services for adolescent and young adult survivors of Hodgkin lymphoma

BACKGROUND

Hodgkin lymphoma (HL) is a leading cancer diagnosis for adolescents and young adults (AYAs), with an overall 5-year survival rate of >80%. However, to the authors' knowledge, little is known regarding posttreatment patterns of care. In the current study, the authors characterized the use of guideline-recommended services in a cohort of AYA survivors of HL in Kaiser Permanente Southern California.

METHODS

Patients with HL who were diagnosed between ages 15 and 39 years between 2000 and 2010 were identified. The authors calculated the number of patients who received recommended short-term care within 2 years after treatment cessation for those who remained enrolled and alive from 2001 through 2015. Use of recommended late-effects screening for breast cancer and cardiovascular disease was examined. Logistic regression was used to evaluate the association between receipt of recommended care and patient, cancer, and treatment characteristics.

RESULTS

A total of 354 patients were identified, with a mean age at the time of diagnosis of 26 years (standard deviation, 6.9 years). Approximately 12% of patients had stage I disease, 59% had stage II disease, 17% had stage III disease, and 13% of patients had stage IV disease. Nearly all patients received chemotherapy (95%), 51% received radiotherapy, and 5% received care from a pediatric oncologist. Overall, approximately 49% of patients received recommended short-term care. Of those patients eligible for cardiovascular screening at 10 years posttreatment (60 patients), 53% received at least 1 screening. Of those patients eligible for breast cancer screening (21 patients), approximately 50% underwent at least 1 screening. Regression results indicated that those patients treated by a pediatric oncologist were >3 times as likely to receive recommended short-term care.

CONCLUSIONS

The results of the current study highlight gaps in the delivery of posttreatment care to AYA survivors of HL. By determining areas in need of improvement, these findings can guide the development of tailored interventions with which to improve care.

[Radiation therapy planning for Hodgkin lymphoma: Focus on intensity-modulated radiotherapy, gating, protons. Which techniques to best deliver radiation?]

The optimization of radiotherapy in these young and long-lived survivors raises the question about the interest of using modern techniques to allow a better distribution of the dose. The choice of the irradiation technique must take into account the incidence of side effects related to radiation. In this context, the definition of the target volumes as well as the verification and monitoring of the delivered processing are essential. International recommendations for treatment fields are based on the "involved node radiotherapy" concept. The best irradiation technique to use remains to be defined. The use of intensity-modulated radiotherapy improves the coverage and reduces the dose to the organs at risk with a variable gain depending on the topography of the lymph nodes: upper or lower mediastinum, right or left lateralization, the techniques used. The deep inspiration breath-hold technique allows an increase of the pulmonary volume, extension of the mediastinum with an up down of the heart which make possible to move the planning target volume away from the cardiac structures. The volumetric-modulated arctherapy technique with several arches can be particularly interesting to reduce the dose to the breasts, as well as tomotherapy when bulky disease. Proton therapy with the Bragg peak specificity can play a key role in limiting doses to organs at risk, when robust planning that will take into account geometric and physical uncertainties is available. The heterogeneity of Hodgkin lymphomas in terms of volume, shape and initial location are the key elements to take into account when choosing the preferred radiotherapy technique.

A pilot investigation on impact of participation in a long-term follow-up clinic (LTFU) on breast cancer and cardiovascular screening among women who received chest radiation for Hodgkin lymphoma

BACKGROUND

Women treated with chest radiation for Hodgkin lymphoma (HL) are at significantly increased risk of breast cancer and cardiovascular disease. HL survivors are recommended to have annual dual screening with mammogram (MMG) and breast magnetic resonance imaging (MRI). They are also recommended to undergo echocardiogram (echo) 5 years after completion of radiation. We performed a pilot study to characterize the women who are and are not receiving proper dual screening for breast cancer and baseline echo, and to examine the impact of a LTFU clinic consultation on screening.

METHODS

A retrospective chart review of 114 women treated for HL at University of Minnesota (UMN) between 1993 and 2009 was performed. Demographics, disease and treatment history (age at diagnosis, stage, radiation dose and field, chemotherapy, recurrence) were assessed, as well as screening practices (MMG, MRI, both and echo), participation in LTFU clinic, and recommendations from providers. Data was summated in yes/no (y/n) format; statistical analysis was performed using chi-squared and Fisher's exact tests. Breast cancer and cardiovascular screening outcomes were compared by participation in the LTFU clinic (y/n) using Fisher's exact tests. P values < 0.05 were considered statistically significant.

RESULTS

Forty-one of 114 women met inclusion criteria and had follow-up data for analysis. Median age at diagnosis was 29 years; 67.6% were diagnosed at stage IIa. Median dose of radiation was 3570 cGy. 56.1% participated in the LTFU clinic at the UMN. 36.6% had dual screening with both MMG and MRI, 41.5% had screening with only MMG, and 19.5% had no screening performed. Women were more likely to have dual screening if they were seen in LTFU clinic vs not seen in LTFU clinic (52.2 vs 16.7%, p = 0.02). 67.5% of women were screened with echo; women were also more likely to have screening with echo if seen in LTFU clinic vs not seen (86.4 vs 44.4%, p = 0.007).

CONCLUSION

Many women are not getting the proper dual screening for breast cancer despite their increased risk, with only 36.6% of our study sample getting dual screening. Having a consultation in a LTFU clinic increases dual screening for breast cancer and echo screening for cardiovascular disease. Proper screening allows for detection of secondary breast cancer at earlier stages where treatment can be local therapy. Diagnosing CV disease early could allow for proper preventative treatment or intervention.

The evolving role of targeted drugs in the treatment of Hodgkin lymphoma

INTRODUCTION

Hodgkin lymphoma (HL) is a B-cell-derived malignancy mostly affecting young adults. More than 80% of patients are cured after stage-adapted first-line treatment with chemotherapy and/or radiotherapy. About 50% of patients with disease recurrence achieve long-term remission with second-line treatment consisting of high-dose chemotherapy and autologous stem cell transplantation. However, HL treatment is often associated with acute toxicity and in part life-threatening late effects. Implementing targeted drugs may reduce toxicity and potentially further optimize efficacy. In recent years, the CD30-directed antibody-drug conjugate brentuximab vedotin (BV) and anti-PD-1 antibodies, nivolumab and pembrolizumab, underwent extensive evaluation in HL. They have exhibited encouraging single agent activity and a favorable toxicity profile in patients with multiple relapses. Therefore, they are currently under investigation in different additional indications. Areas covered: This article gives an overview over clinical trials evaluating targeted drugs either as single agent or as part of combination therapies in HL patients. Expert commentary: A multitude of targeted drugs are investigated in HL. Promising data have particularly emerged from studies with BV and anti-PD-1 antibodies. However, mature data needed for final conclusions are still pending.

Bleomycin pulmonary toxicity does not adversely affect the outcome of patients with Hodgkin lymphoma

Bleomycin pulmonary toxicity (BPT) is a well-described complication of bleomycin-containing regimens. Previous data on risk factors and the impact of BPT on survival in Hodgkin lymphoma (HL) were conflicting. We reviewed 253 HL patients treated with adriamycin, bleomycin, vinblastine, dacarbazine (ABVD) at the Princess Margaret Hospital from 1999 to 2009 to examine the incidence and risk factors for BPT, and the effect of BPT on survival. BPT was defined by pulmonary symptoms, bilateral interstitial infiltrates on computed tomography, and the absence of infection. Kaplan-Meier estimates were used to compare overall survival (OS) and progression-free survival (PFS) between groups. The incidence of BPT was low (11%). Age ≥45 (OR = 2.5) and granulocyte colony-stimulating factor use (OR = 3.6) were identified as predictors of BPT on multivariable logistic models. At a follow-up of 5 years, OS and PFS were 88% and 82%, respectively. Neither BPT nor bleomycin discontinuation had significant impact on survival outcomes.

Breast implants and possible association with ALCL: A retrospective study including a histological analysis of 296 explanted breast tissues and current literature

AIM

To identify a possible connection between anaplastic large cell lymphoma and different types of breast implants.

METHODS

We conducted a retrospective evaluation of 296 breast tissues of 227 women with different breast implant types undergoing surgical revision or explantation between January 2000 and June 2015. Histological and selected immunohistochemical analyses of CD30-&ALK-1-markers of the breast capsules were performed.

RESULTS

The womens' average age was 42.91±12.66 years (median: 43.83 years) during implantation and 51.40±11.40 years (median: 52.37 years) during revision or explantation of the implants. Average implant residing time was 8.49±8.90 years (median: 5.83 years). In 51% implantation was for reconstructive, in 48% for aesthetic reasons, in 1% for other reasons. At 59% the main reason for explantation or removal was capsular fibrosis (n = 173). In 296 breast capsules we could not find pathological lymphoma cells according to ALCL, retrospectively.

CONCLUSION

In our study we detected high incidences of various cells in relationship to the implant's type and residing time, which will be published in further articles. We could not find ALCL-cells in breast capsules of explanted or revised breast implants during 2000-2015, retrospectively.There should be a heightened awareness of a possible relationship between the development of cancer and breast implants. To date there are case reports about a possible association between the development of ALCL and breast implants. The number of cases are few and our knowledge of the pathogenesis is little. Further investigation is needed to understand the possible link between breast implants and ALCL found in the breast.

Assessment of bone marrow involvement in patients with lymphoma: report on a consensus meeting of the Korean Society of Hematology Lymphoma Working Party

In September 2011, the Korean Society of Hematology Lymphoma Working Party held a nationwide conference to establish a consensus for assessing bone marrow (BM) involvement in patients with lymphoma. At this conference, many clinicians, hematopathologists, and diagnostic hematologists discussed various topics for a uniform consensus in the evaluation process to determine whether the BM is involved. Now that the discussion has matured sufficiently to be published, we herein describe the consensus reached and limitations in current methods for assessing BM involvement in patients with lymphoma.

Comparative Risk Predictions of Second Cancers After Carbon-Ion Therapy Versus Proton Therapy

PURPOSE

This work proposes a theoretical framework that enables comparative risk predictions for second cancer incidence after particle beam therapy for different ion species for individual patients, accounting for differences in relative biological effectiveness (RBE) for the competing processes of tumor initiation and cell inactivation. Our working hypothesis was that use of carbon-ion therapy instead of proton therapy would show a difference in the predicted risk of second cancer incidence in the breast for a sample of Hodgkin lymphoma (HL) patients.

METHODS AND MATERIALS

We generated biologic treatment plans and calculated relative predicted risks of second cancer in the breast by using two proposed methods: a full model derived from the linear quadratic model and a simpler linear-no-threshold model.

RESULTS

For our reference calculation, we found the predicted risk of breast cancer incidence for carbon-ion plans-to-proton plan ratio, <Rc/Rp>, to be 0.75 ± 0.07 but not significantly smaller than 1 (P=.180).

CONCLUSIONS

Our findings suggest that second cancer risks are, on average, comparable between proton therapy and carbon-ion therapy.

A Pound of Cure Requires An Ounce (or More) of Prevention: Survivorship and Complications of Therapy for Hematologic Malignancies

Patients treated for a hematologic malignancy are at risk for treatment-related complications. As the goal of therapy is frequently curative, treatments are especially intensive and long-term toxicity is common. Chemotherapy and radiation are associated with increased risk for cardiac and pulmonary disease, endocrine disorders, infertility, sexual dysfunction, second cancers, and psychosocial distress. The risk for each complication is dictated by patient characteristics including age, co-morbidities, and genetic predispositions, as well as the specifics of therapy. Survivors of pediatric cancers and allogeneic hematopoietic stem cell transplantation have unique risks due to vulnerable age at time of toxic exposure and ongoing immune dysfunction, respectively.

Brentuximab vedotin in relapsed/refractory Hodgkin lymphoma post-autologous transplant: meta-analysis versus historical data

OBJECTIVE

This meta-analysis evaluated the antitumor activity of brentuximab vedotin versus historical values in patients with relapsed/refractory Hodgkin lymphoma post-autologous stem cell transplantation (ASCT).

METHODS

A systematic literature review identified studies (1993-February 2013) reporting complete remission (CR) rates in patients with relapsed/refractory Hodgkin lymphoma post-ASCT. Publications reporting CR rates, identified through interrogation of multiple electronic databases and manual searches (with search terms used to capture 'relapsed', 'refractory', 'HL', and 'ASCT'), were included if they reported: ≥20 relapsed/refractory Hodgkin lymphoma patients, where ≥80% were aged ≥12 years and ≥50% had failed prior ASCT. Overall CR rate was determined using a random-effect model, and compared with that reported for brentuximab vedotin in a pivotal phase 2 trial (SG035-0003).

MAIN OUTCOME MEASURES

Across 17 evaluable studies of historical or experimental agents (n = 812), the estimated overall CR rate was 11.1% (95% confidence interval [CI] 7.0, 17.6; range, 0-38.5%) versus 33.3% (95% CI 25.3, 43.9) for brentuximab vedotin (p < 0.0001). In sensitivity analyses, the estimated overall CR rates for historical/experimental agents were 13.6% (95% CI 8.7, 21.4) when only HL trials that reported a CR rate of >0% were included (13 studies; n = 696; p = 0.0009 vs. brentuximab vedotin), and 9.0% (95% CI 4.9, 16.6) when only HL trials were included where CR definition was reported and was measured using the same criteria as in the SG035-0003 study (12 studies; n = 562; p = 0.0001 vs. brentuximab vedotin).

CONCLUSIONS

Indirect comparisons against a heterogeneous historical sample population naturally limit our ability to draw comparisons, yet the results from this quantitative meta-analysis suggest that the antitumor activity of brentuximab vedotin may exceed that of other therapies used to treat patients with relapsed/refractory Hodgkin lymphoma post-ASCT.

Changes in the use of radiation therapy for early classical Hodgkin lymphoma in adolescents and young adults: implications for survival and second malignancies

Omission of radiation therapy (RT) in adolescents and young adults (AYA) with early classical Hodgkin lymphoma (cHL) may affect survival and risk of second malignancies (SMN). Using the Surveillance, Epidemiology and End Results database we found reduction in RT use from 60.8% among 2614 cases from 1995 to 2002 to 52.9% among 2542 cases from 2003 to 2010, p<0.001. Survival at 5 years with and without RT was 95.1% vs. 93.3%, p=0.013 for 1995-2002 and 97.7% vs. 96.4%, p=0.021 for 2003-2010. Omission of RT was affected by 2003-2010 era, race-ethnicity, income and education and independently increased the risk of death (hazard ratio 1.34, p=0.011). The cumulative risk of SMN at 150 months was 3.3% vs. 3.0% (p=0.87) while the risk of death without SMN (competing risk) was 5.7% vs. 8.8% for RT and no-RT patients, respectively (p=0.0009). Omission of RT for early cHL in AYA may increase mortality without reduction in SMN.

Utility of prechemotherapy evaluation of left ventricular function for patients with lymphoma

BACKGROUND

Published guidelines recommend baseline cardiac function testing before initiating anthracycline-based chemotherapy. These recommendations are based largely on consensus, and there is little information regarding how often testing leads to alterations in therapy or whether testing is able to predict subsequent cardiac toxicity.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with Hodgkin lymphoma and non-Hodgkin lymphoma to determine whether there was a prechemotherapy evaluation of left ventricular function and whether findings from the evaluation led to alterations in therapy. Records also were reviewed to evaluate subsequent test results of cardiac function.

RESULTS

We identified 309 patients with lymphoma between 2004 and 2012 with a planned anthracycline- or anthracenedione-based regimen. Of this total, 232 patients (75%) had a pretreatment cardiac evaluation. There were 201 patients (87%) in this group with no history of cardiac disease. Although 22 of these patients (11%) had abnormal echocardiograms, none had a change in therapy and no subsequent cases of cardiomyopathy were identified. Five of the remaining 179 patients with a normal cardiac evaluation developed a cardiomyopathy. Thirty-one patients had a history of cardiac disease, and only 4 patients had a change in therapy. There were 77 patients (25%) who did not have a prechemotherapy cardiac evaluation. No subsequent cases of cardiomyopathy were identified in this group.

CONCLUSIONS

Pretreatment evaluation rarely leads to a change in management and is not helpful in predicting subsequent cardiomyopathy. Guidelines that recommend evaluation of left ventricular function in all patients before anthracycline-based chemotherapy should be reexamined.

Impact of risk factors on outcomes in early-stage Hodgkin's lymphoma: an analysis of international staging definitions

BACKGROUND

In early-stage Hodgkin's lymphoma (HL), treatment according to the early favorable or unfavorable subgroup is guided by staging definitions, which differ between various study groups worldwide. We analyzed risk factors used in different international staging systems and their impact on the outcome of early-stage HL patients.

PATIENTS AND METHODS

In 1173 early-stage HL patients treated homogenously within the German Hodgkin Study Group (GHSG) trials HD10 and HD11, the impact of three staging systems developed and used by the GHSG, the European Organization for Research and Treatment of Cancer (EORTC), and the National Comprehensive Cancer Network (NCCN) in discriminating risk groups for progression-free survival (PFS) and overall survival (OS) was assessed and the relevance of their single risk factors was investigated.

RESULTS

All the three staging systems defined an unfavorable risk group out of early-stage patients of comparable size (56%, 55%, and 57%), having a significantly poorer PFS and OS as compared with the corresponding favorable group; 5-year differences between early favorable and early unfavorable in terms of PFS were 9.4% (HR 2.61, 95% CI 1.74-3.91), 6.7% (HR 2.10, 95% CI 1.41-3.13), and 8.6% (HR 2.14, 95% CI 1.45-3.16) with the GHSG, EORTC, and NCCN definition, respectively. Sensitivity was high for all systems (84%, 79%, and 83%); however, there was a low specificity with high rates of false-positive results (1-specificity 54%, 53%, and 55%, respectively). Models of high sensitivity included risk factors associated with large tumor burden and high tumor activity. Most risk factors for tumor-specific end points were also predictive of OS.

CONCLUSIONS

Differentiating between a favorable and an unfavorable risk group has significant impact on PFS and OS in early-stage HL patients in the modern treatment era. Risk-adapted treatment strategies using new risk factors with higher specificity are needed.

An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma

BACKGROUND

Treatment options for patients with nonbulky stage IA-IIA Hodgkin lymphoma include combined modality therapy (CMT) using doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) plus involved-field radiation therapy (IFRT), and chemotherapy with ABVD alone. There are no mature randomized data comparing ABVD with CMT using modern radiation techniques.

PATIENTS AND METHODS

Using German Hodgkin Study Group HD10/HD11 and NCIC Clinical Trials Group HD.6 databases, we identified 588 patients who met mutually inclusive eligibility criteria from the preferred arms of HD10 or 11 (n = 406) and HD.6 (n = 182). We evaluated time to progression (TTP), progression-free (PFS) and overall survival, including in three predefined exploratory subset analyses.

RESULTS

With median follow-up of 91 (HD10/11) and 134 (HD.6) months, respective 8-year outcomes were for TTP, 93% versus 87% [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24-0.78]; for PFS, 89% versus 86% (HR 0.71, 95% CI 0.42-1.18) and for overall survival, 95% versus 95% (HR 1.09, 95% CI 0.49-2.40). In the exploratory subset analysis including HD10 eligible patients who achieved complete response (CR) or unconfirmed complete response (CRu) after two cycles of ABVD, 8-year PFS was 87% (HD10) versus 95% (HD.6) (HR 2.8; 95% CI 0.64-12.5) and overall survival 96% versus 100%. In contrast, among those without CR/CRu after two cycles of ABVD, 8-year PFS was 88% versus 74% (HR 0.35; 95% CI 0.16-0.79) and overall survival 95% versus 91%, respectively (HR 0.42; 95% CI 0.12-1.44).

CONCLUSIONS

In patients with nonbulky stage IA-IIA Hodgkin lymphoma, CMT provides better disease control than ABVD alone, especially among those not achieving complete response after two cycles of ABVD. Within the follow-up duration evaluated, overall survivals were similar. Longer follow-up is required to understand the implications of radiation and chemotherapy-related late effects.

CLINICAL TRIALS

The trials included in this analysis were registered at ClinicalTrials.gov: HD10 - NCT00265018, HD11 - NCT00264953, HD.6 - NCT00002561.

Interim 18F-FDG PET in Hodgkin lymphoma: would PET-adapted clinical trials lead to a paradigm shift?

Hodgkin lymphoma (HL) is a curable disease with currently available chemotherapy regimens. Major late morbidities can potentially be avoided in most limited-stage HL patients if the treatment can be adapted to the patient's early response profile. The therapy efficacy can also be increased early during therapy in nonresponding HL patients with the addition of involved-field radiation therapy or a switch to an escalated therapy protocol, particularly in advanced-stage or unfavorable-risk patients. (18)F-FDG PET is a well-established surrogate for tumor chemosensitivity early during therapy. The ongoing PET-adaptive clinical trials are testing the hypothesis that a decision can reliably be made on escalating or deescalating therapy based on interim PET results. Discussed in this review is the integral role of interim (18)F-FDG PET in HL, challenges, critical issues to improve its accuracy, and the observations from completed interim PET studies and ongoing PET-adaptive clinical trials.

Therapeutic approaches to haematological malignancies in adolescents and young adults

Tremendous strides have been made in improving the outcomes of haematological malignancies (HM) over the last three decades, but adolescents and young adult (AYA) patients have not benefitted equally compared to younger and older patients. Excellent outcomes in Hodgkin lymphoma have allowed tailoring of highly effective regimens that limit the incidence of late effects. Early successes in paediatric acute lymphoblastic leukaemia set the stage for a series of studies in young adults utilizing a paediatric-type treatment strategy. These studies have determined that AYAs benefit from paediatric-type chemotherapy regimens. Despite the increased incidence of acute myeloid leukaemia and non-Hodgkin lymphoma in the AYA age group, optimal strategies for these patients have not been systematically pursued. There is renewed interest in improving HM outcomes in AYA patients and this will rely on the development of clinical trials that specifically target these patients. Understanding and addressing the unique psychosocial challenges of this population will be critical in supporting this endeavor.

Hematopoietic progenitor cells transplantation for recurrent or refractory Hodgkin's lymphoma

INTRODUCTION

Advanced-stage Hodgkin's lymphoma (HL) has become a curable disease in the majority of patients. Despite this, about 20% of these patients relapsed or are primary refractory to the first-line treatment and high-dose chemotherapy (HDC) and autologous (Auto) hematopoietic progenitor cells transplantation (HPCT) are considered a therapeutic option.

AREAS COVERED

The authors reviewed HDC and HPCT treatment strategies in recurrent or refractory HL patients, with the goal of providing an overview of this approach.

EXPERT OPINION

Patients younger than 60-65 years with relapsed disease or refractory to first-line therapy should receive a second-line chemotherapy, followed by HDC and Auto-HPCT. Progression-free and overall survival results are significantly better when a second remission or a minimal disease status is achieved before Auto-HPCT, and demonstrate that this strategy is able to cure more than half of the advanced HL patients. Myeloablative allogeneic HPCT (Allo-HPCT) has been employed in advanced phases of the disease, but there have been significant concerns due to treatment-related mortality (TRM). The safety of allogeneic transplantation has improved with the use of reduced-intensity allogeneic (RIC-Allo) HPCT strategies. Despite early favorable results, mature results of RIC-Allo available in the literature are consistent in demonstrating a lack of long-term disease control.

PET scan integration in lymphoma management

SUMMARY Despite a marked improvement in lymphoma treatment outcome, current prognostic models, relying on a pretreatment set of static clinical variables, appear unable to support a risk-adapted therapeutic strategy. On the other hand, functional imaging with 18F-fluoro-2-deoxy-D-glucose (FDG)-PET proved to be a reliable tool to dynamically assess tumor FDG uptake changes during and after treatment. In this article we aim to review the prognostic value of FDG-PET in all the stages of Hodgkin’s and non-Hodgkin’s lymphoma management, without the intent to address the diagnostic value of PET or to replace available consensus guidelines. In particular we focused on two critical issues: the cost–effectiveness of PET in the overall strategy of lymphoma diagnosis and treatment; and ongoing clinical trials adopting an interim PET-based strategy to modulate treatment intensity based on PET results. Finally, new trends in multimodality imaging, as well as in new radiopharmaceutical tracers, are briefly reviewed.

Enhancement characteristics of retroperitoneal lymphomatous lymph nodes

BACKGROUND

Previous studies of CT enhancement of lymphomatous lymph nodes (LLN) of the neck and the mediastinum showed that the LLN had lower enhancement values than normal lymph nodes.

PURPOSE

To elucidate the contrast medium enhancement curves of LLN in the retroperitoneum by comparing the curves of LLN with those of normal lymph nodes, to test whether differences between these curves could be of diagnostic value, and to compare the present enhancement curves of LLN of the retroperitoneum with the curves of LLN of the neck and the mediastinum from previous similar investigations.

MATERIAL AND METHODS

Twenty-eight consecutive patients with LLN of the retroperitoneum (three with Hodgkin's lymphoma [HL]) and 21 control patients with sarcomas and thus presumably normal retroperitoneal nodes underwent dynamic CT examinations. The previous, similar investigation of lymph nodes of the neck comprised 28 patients with LLN and the investigation of mediastinal lymph nodes comprised 24 patients with LLN.

RESULTS

The enhancement curves of the retroperitoneal LLN had significantly lower attenuation than those of the retroperitoneal control nodes. A combination of peak contrast value and time to peak adjusted to total body weight yielded a diagnostic accuracy which at the best showed a sensitivity of 90.5% with a specificity of 82.6%. The LLN of the retroperitoneum had higher attenuation values than corresponding nodes of the mediastinum but no significant difference was found between LLN of the retroperitoneum and LLN of the neck in previous similar investigations.

CONCLUSION

The comparison of enhancement curves of retroperitoneal LLN with retroperitoneal control nodes showed a marked similarity with and substantiates our previous findings in lymph nodes of the neck and of the mediastinum. The best diagnostic accuracy was achieved by combining the parameters peak contrast value and time to peak and adjusting these values to the body weight. Peak enhancement of the retroperitoneal LLN was higher and arrived earlier than that of the mediastinal nodes from the previous investigation.

Point/counterpoint: early-stage Hodgkin lymphoma and the role of radiation therapy

The results of recent clinical trials for the management of limited-stage Hodgkin lymphoma have led to considerable debate, especially regarding the role of radiation therapy. This review highlights those recent trials and provides perspectives regarding their interpretation from a radiation oncologist and a hematologist. The trial protocol is available at http://www.nejm.org/doi/suppl/10.1056/NEJMoa1111961/suppl_file/nejmoa1111961_protocol.pdf.

How does PET/CT help in selecting therapy for patients with Hodgkin lymphoma?

Positron emission tomography/computed tomography (PET/CT) has emerged as the most accurate tool for staging, treatment monitoring, and response evaluation in Hodgkin lymphoma (HL). Accurate staging and restaging are very important for the optimal management of HL, but we are only beginning to understand how to use PET/CT to improve treatment outcome. More precise determination of disease extent may result in more precise pretreatment risk stratification, and is also essential for the minimal and highly individualized radiotherapy volumes of the present era. Several trials are currently investigating the use of PET/CT for early response-adapted therapy, with therapeutic stratification based on interim PET/CT results. Posttreatment PET/CT is a cornerstone of the revised response criteria and enables the selection of advanced-stage patients without the need for consolidation radiotherapy. Once remission is achieved after first-line therapy, PET/CT seems to have little or no role in the routine surveillance of HL patients. PET/CT looks promising for the selection of therapy in relapsed and refractory disease, but its role in this setting is still unclear.

Point/counterpoint: early-stage Hodgkin lymphoma and the role of radiation therapy

The results of recent clinical trials for the management of limited-stage Hodgkin lymphoma have led to considerable debate, especially regarding the role of radiation therapy. This review highlights those recent trials and provides perspectives regarding their interpretation from a radiation oncologist and a hematologist. The trial protocol is available at http://www.nejm.org/doi/suppl/10.1056/NEJMoa1111961/suppl_file/nejmoa1111961_protocol.pdf.

ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma

BACKGROUND

Chemotherapy plus radiation treatment is effective in controlling stage IA or IIA nonbulky Hodgkin's lymphoma in 90% of patients but is associated with late treatment-related deaths. Chemotherapy alone may improve survival because it is associated with fewer late deaths.

METHODS

We randomly assigned 405 patients with previously untreated stage IA or IIA nonbulky Hodgkin's lymphoma to treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone or to treatment with subtotal nodal radiation therapy, with or without ABVD therapy. Patients in the ABVD-only group, both those with a favorable risk profile and those with an unfavorable risk profile, received four to six cycles of ABVD. Among those assigned to subtotal nodal radiation therapy, patients who had a favorable risk profile received subtotal nodal radiation therapy alone and patients with an unfavorable risk profile received two cycles of ABVD plus subtotal nodal radiation therapy. The primary end point was 12-year overall survival.

RESULTS

The median length of follow-up was 11.3 years. At 12 years, the rate of overall survival was 94% among those receiving ABVD alone, as compared with 87% among those receiving subtotal nodal radiation therapy (hazard ratio for death with ABVD alone, 0.50; 95% confidence interval [CI], 0.25 to 0.99; P=0.04); the rates of freedom from disease progression were 87% and 92% in the two groups, respectively (hazard ratio for disease progression, 1.91; 95% CI, 0.99 to 3.69; P=0.05); and the rates of event-free survival were 85% and 80%, respectively (hazard ratio for event, 0.88; 95% CI, 0.54 to 1.43; P=0.60). Among the patients randomly assigned to ABVD alone, 6 patients died from Hodgkin's lymphoma or an early treatment complication and 6 died from another cause; among those receiving radiation therapy, 4 deaths were related to Hodgkin's lymphoma or early toxic effects from the treatment and 20 were related to another cause.

CONCLUSIONS

Among patients with Hodgkin's lymphoma, ABVD therapy alone, as compared with treatment that included subtotal nodal radiation therapy, was associated with a higher rate of overall survival owing to a lower rate of death from other causes. (Funded by the Canadian Cancer Society and the National Cancer Institute; HD.6 ClinicalTrials.gov number, NCT00002561.).