Investigating PET Responses to Treatment in Nodular Lymphocyte-Predominant Hodgkin Lymphoma

PURPOSE/OBJECTIVE(S)

There is no standard treatment for nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL). Although response by positron emission tomography (PET) for classic Hodgkin lymphoma (cHL) has allowed for response-adapted treatment, similar approaches for NLPHL have not been developed. This is in part due to the lack of data for PET response to treatment. Therefore, we sought to investigate PET responses to management for NLPHL.

MATERIALS/METHODS

We retrospectively identified 47 patients who were diagnosed with or treated for NLPHL between 2001-2018 at a single institution and underwent a staging PET. We recorded clinical data and PET metrics for patients who received various forms of management, including chemotherapy (CT), radiation therapy (RT), combined modality therapy (CMT = CT+RT, with rituximab in a subset), rituximab monotherapy, and observation after excision. Metabolic response was scored according to the Deauville 5-point scale criteria, with complete metabolic response defined as a score 1-3.

RESULTS

We identified 47 patients with median age of 26 (IQR = 17-50). They predominantly were male (74.5%) and had early stage (23.4% I, 36.2% II) versus advanced stage (29.8% III, 10.5% IV) NLPHL. The majority of patients had their immunoarchitectural pattern scored (n = 36, 76.6%), with typical pattern (A/B) being the most frequent type (58.3%). The median follow-up was 5.7 years (IQR = 2.3-9.3). Overall survival was 100% at 5 years and 92.3% at 10 years. Primary management included CMT (n = 10, 21.3%; with rituximab in a subset n = 1, 10.0%), CT alone (n = 22, 46.8%; with rituximab in a subset n = 5, 22.7%), RT alone (n = 8, 17.0%), rituximab alone (n = 3, 6.4%), and observation after excision (n = 4, 8.5%). On baseline PET, median SUVmax was 10.7 (range = 1.7-35.4). Of the 10 patients who received CMT, the complete metabolic response rates were 42.9% at interim-chemotherapy PET and 75% at post-chemotherapy PET, which improved to 100% after consolidative radiotherapy. There was no difference in complete metabolic response rate to chemotherapy for typical versus variant pattern (P = 0.60). Of the 22 patients who received CT alone, 66.7% had a complete metabolic response at the interim PET and 72.7% at the end of chemotherapy. For RT, rituximab alone, and observation, the complete metabolic response rates at median 3 months (range 1-5 months) after treatment were 87.5%, 66.7%, 75.0%, respectively.

CONCLUSION

Based on our cohort, we found that patients with NLPHL had a lower complete metabolic response to CT (∼75%) compared to cHL (∼85-90%) and PET-response was improved following RT for those receiving CMT. There was no significant difference in PET-response for those with variant versus typical immunoarchitectural patterns. Our findings will allow for the development of PET response-adapted therapy for NLPHL.

Histologic subtypes of breast cancer following radiotherapy for Hodgkin lymphoma

BACKGROUND

The purpose of the study was to determine whether breast cancers (BCs) that develop in women previously irradiated for Hodgkin lymphoma (HL) are biologically similar to sporadic BC.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients who developed BC after radiotherapy (RT) for HL. Tumors were classified as ductal carcinoma in situ (DCIS) or invasive carcinoma. Invasive carcinomas were further characterized according to the subtype: hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, HR+/HER2+, HR-/HER2+, and HR-/HER2-. BCs after HL were compared with four age-matched sporadic, non-breast cancer (BRCA) I or II mutated BCs.

RESULTS

One hundred forty-seven HL patients who were treated with RT between 1966 and 1999 and subsequently developed BCs were identified. Of these, 65 patients with 71 BCs had complete pathologic information. The median age at HL diagnosis was 23 (range, 10-48). The median age at BC diagnosis was 44 (range, 28-66). The median time to developing BC was 20 years. Twenty cancers (28%) were DCIS and 51 (72%) were invasive. Of the 51 invasive cancers, 24 (47%) were HR+/HER2-, 2 (4%) were HR+/HER2+, 5 (10%) were HR-/HER2+, and 20 (39%) were HR-/HER2-. There were no differences in BC histologic subtype according to the age at which patients were exposed to RT, the use of chemotherapy for HL treatment, or the time from RT exposure to the development of BC. In a 4 : 1 age-matched comparison to sporadic BCs, BCs after HL were more likely to be HR-/HER2- (39% versus 14%) and less likely to be HR+/HER2- (47% versus 61%) or HR+/HER2+ (4% versus 14%) (P = 0.0003).

CONCLUSION(S)

BCs arising in previously irradiated breast tissue were more likely to be triple negative compared with age-matched sporadic invasive cancers and less likely to be HR positive. Further studies will be important to determine the molecular pathways of carcinogenesis in breast tissue that is exposed to RT.

Efficacy of abbreviated Stanford V chemotherapy and involved-field radiotherapy in early-stage Hodgkin lymphoma: mature results of the G4 trial

INTRODUCTION

To assess the efficacy of an abbreviated Stanford V regimen in patients with early-stage Hodgkin lymphoma (HL). PATIENTS AND METHODS PATIENTS: with untreated nonbulky stage I-IIA supradiaphragmatic HL were eligible for the G4 study. Stanford V chemotherapy was administered for 8 weeks followed by radiation therapy (RT) 30 Gy to involved fields (IF). Freedom from progression (FFP), disease-specific survival (DSS) and overall survival (OS) were estimated.

RESULTS

All 87 enrolled patients completed the abbreviated regimen. At a median follow-up of 10 years, FFP, DSS and OS are 94%, 99% and 94%, respectively. Therapy was well tolerated with no treatment-related deaths.

CONCLUSIONS

Mature results of the abbreviated Stanford V regimen in nonbulky early-stage HL are excellent and comparable to the results from other contemporary therapies.

Confirmation of the prognostic value of the EORTC/WHO classification of primary cutaneous B-cell lymphoma in the United States: The Stanford University experience

8028

Background: Primary cutaneous B cell lymphoma (CBCL) represent distinct clinicopathologic entities with superior prognosis compared to their nodal counterparts. In the new WHO/EORTC Classification of Cutaneous Lymphomas (WHOc), CBCL are classified as either Marginal Zone (MZ), Follicle center lymphoma (FC) or diffuse large cell-leg type (DLBCL leg-type). WHOc combined previous FL and DLBCL into the category of FC. Only DLBCL leg-type was considered to be aggressive and thus separately categorized. In order to confirm the utility of the WHOc categories, we reclassified our cases. Methods: Records of 154 CBCL patients (pts) managed at Stanford University were reviewed. A diagnosis of CBCL was made based on H&E evaluation, immunohistochemistry including CD20 staining, along with a negative systemic staging evaluation. All pts were reclassified according to the WHO/EORTC classification of CBCL. Overall Survival (OS), disease specific survival (DSS) and freedom from progression (FFP) were analyzed according to the method of Kaplan and Meier. Prognostic factors were evaluated by multivariate regression model and included initial therapy, histology, LDH, stage, IPI, extent of disease and anatomic location. Results: 154 cases were reclassified as follows: 87 FC, 58 MZ, and 9 DLBCL leg-type. The median follow-up was 46 months. The 5 year OS and DSS were 86 and 95% respectively. For the MZ and FC subtypes the % 10 year OS/DSS was: 93/100, and 86/97 respectively. For DLBCL leg-type the % 5 year OS/DSS was 17/33 respectively. There were 22 deaths, seven of which were disease specific (4 DLBCL-leg type and 3 were FC). FFP was unaffected by the type of therapy given (chemotherapy or skin-directed). Conclusions: Our series is the largest single center experience in CBCL. We confirm the utility of the WHOc in distinguishing categories with differing prognosis. The indolent histologies have an excellent outcome and can be managed with local skin-directed therapy. The outcome of pt with DLBCL leg-type is significantly worse than the FC or MZ types and warrants a more aggressive approach in management.

No significant financial relationships to disclose.

A prospective trial of involved field radiation (IFRT) + chemotherapy compared to extended field (EFRT) radiation for favorable Hodgkin disease: Survival differences and implications of mature follow-up for current combined modality therapy

8014

Background: We conducted a prospective randomized trial from 1980–88 comparing IFRT plus VBM (vinblastine, bleomycin, methotrexate) chemotherapy to extended field radiation (EFRT) in patients with favorable stage I-IIIA disease to limit radiation exposure and define an effective treatment regimen that preserved fertility and did not increase the risk of leukemia. Methods: Patients (pt) with favorable, laparotomy-staged disease were defined as those with no bulky mediastinal disease, no or minimal abdominal disease (<5 cm), no or minimal splenic disease, and <1 extranodal site. VBM was given for 6 cycles after 44 Gy IFRT. EFRT was subtotal lymphoid for stage I-IIA and total lymphoid irradiation for I-IIB, IIIA pt. We previously reported (J Clin Oncol 6:1822, 1988) no survival differences in this study. Follow-up was similar for both arms and was further supplemented by an approved SSA Epidemiologic Vital Status Data Record application. Results: 72 pt were randomized, 34 to IFRT + VBM and 38 to EFRT. Median follow-up is 20.8 yr (10.3–25.1) and just 8 pt were censored at <15 yr. Twenty-one yr freedom from progression is 96% for IFRT + VBM vs 74% for EFRT (p= 0.035). A single death at 18 yr was recorded in IFRT + VBM pt (3%) whereas 11 deaths occurred among EFRT pt (29%). Overall survival (OS) at 21 yr is 95% for IFRT + VBM vs 68% for EFRT (p=0.003). As previously reported, fertility was informally assessed, but premature menopause was not observed and both men and women conceived after IFRT + VBM. Conclusion: The reduction of radiation to IFRT, combined with a less toxic chemotherapy in our study, resulted in excellent long-term OS that was significantly superior to EFRT. The survival data with IFRT + VBM also compare favorably with our historical EFRT experience. Moreover, these results have implications for current combined modality therapy where much lower doses of RT, more limited fields and brief chemotherapy should lead to even less late morbidity and mortality.

No significant financial relationships to disclose.

Incidence of secondary leukemia/myelodysplasia (AML/MDS) in Hodgkin’s disease (HD) with three generations of therapy at Stanford University

7516

Background: Long term HD survivors have an increased risk of therapy-related AML/MDS that peaks about 5 years (yr) after alkylating agent (AA)-based chemotherapy (CT). Successive generations of Stanford studies limited AA exposure to address this risk. Methods: Patients (pt) treated with CT from 1974–2003 (RT only excluded) were retrospectively analyzed. S study pt received AA-based CT (MOPP or PAVE) alone (6%), with involved (IF) (21%) or extended field (EF) radiotherapy (RT) (73%); C pt received AA-based CT alone (26%) or with RT (37%) or non-AA-based CT (VBM or ABVD) + IFRT (37%); G pt received VBM + IFRT (12%) or the Stanford V + RT regimen (88%). Results: 21 (3.3%) of 639 pt developed AML/MDS: 13 after primary and 8 after secondary CT. AML/MDS incidence was significantly less in G pt (0.3%) compared to S (6.7%) and C pt (4.5%), p < 0.0001 and remained significant when pt followed <5 yr (18%) were excluded, p = 0.001. Secondary therapy was required more often for S (29%) and C (28%) pt than G (11%) pt. Number and Percent of AML/MDS in Three Eras Conclusion: AML/MDS was rare in the current Stanford V regimen era, indicating that limiting the cumulative dose of AA CT in combination with lesser RT volumes have significantly reduced the incidence of leukemia and the need for secondary CT. Longer follow-up is required to assess the impact of the Stanford V regimen on solid tumor and cardio-vascular risks.

[Table: see text]

No significant financial relationships to disclose.

Plasmablastic lymphoma presenting in a human immunodeficiency virus-negative patient: a case report

Plasmablastic lymphoma (PBL), an aggressive non-Hodgkin's lymphoma that carries a poor prognosis, previously has been identified almost exclusively in patients infected with the human immunodeficiency virus (HIV). We present a case of a 42-year-old HIV-negative patient presenting with an isolated nasal cavity mass, the typical presentation for PBL. The patient was given systemic chemotherapy, central nervous system prophylaxis, and consolidative locoregional radiotherapy and achieved a complete clinical response. This case suggests PBL should be considered in HIV-negative patients with characteristic findings.

Treatment of early-stage Hodgkin's disease

The management of early-stage Hodgkin's disease has been evolving over the past 25 years, largely due to recognition of early and late complications associated with radiation therapy and the demonstration of minimally toxic but effective chemotherapy. Thus, extended-field radiation is no longer the "gold standard" of treatment. Rather, combined modality approaches with abbreviated chemotherapy and limited radiation, which obviates the need for precise staging offered by laparotomy, provide excellent results with the potential for fewer adverse late effects. Several controlled clinical trials are ongoing to determine the minimal duration of chemotherapy and extent and dose of radiotherapy that will not compromise the excellent cure rate of early-stage disease.