Hodgkin's Disease

Question 1

What is the flow phenotype of Classic Hodgkins with Reed sternberg Cells?

Answer 1

CD 15 and CD 30 positive, CD 20 neg

Question 2

What is the flow for the rare type of Hodgkins Nodular Lymphocyte Predominant B cell type?

Answer 2

CD 20 positive, CD 15/30 are neg

Question 3

What is defined as bulky disease?

Answer 3

Anything greater than 10cm or greater than 1/3 of the intrathoracic diameter.

Question 4

What determines unfavorable disease vs favorable?

Answer 4

Bulky mediastinal disease (greater than 1/3 width) or adenopathy greater than 10cm, ESR (50 if asymptomatic, 30 if B symptoms), more than 3 involved lymph node areas, age 50 or older (EORTC).

Question 5

In general what is the treatment approach in a patient with early stage favorable disease?

Answer 5

They will start with 2 cycles of ABVD followed by a PET/CT scan. Those with Deauville score 1-2 will either get 2 additional cycles or do a combo of 1 cycle of chemo w/RT or can do RT alone

Question 6

If after initial treatment with ABVD for favorable early stage disease have a deauville score of 4 what do you do? What about a score of 5?

Answer 6

Score of 4-give AVD for 1 cycle and reassess with PET/CT, if good response give RT
Score of 5-do biopsy to rule out transformation.

Question 7

What is the benefit to adding RT to chemo in early stage Hodgkins?

Answer 7

It is assoc with a PFS benefit, but not an OS benefit when compared to not giving RT.

Question 8

For those with unfavorable or bulky early stage disease what is the approach?

Answer 8

2 cycles of ABVD, if PET neg (deauville 1-3) you can give 4 additional cycles of AVD or 2 more cycles of ABVD with RT. If PET positive you give escalated BEACOPP

Question 9

For advanced stage disease what is the treatment approach when using ABVD?

Answer 9

Start with ABVDx2 cycles. If PET neg give 4 additional cycles of AVD. If PET positive give escalated BEACOPP

Question 10

Besides ABVD chemo what else can you do for advanced stage Hodgkins? What benefit in survival do you see?

Answer 10

Give Brentuximab Vedotin with AVDx 6 cycles. There is an OS and PFS benefit!

Question 11

What CD marker is targeted with Brentuximab? How does it work?

Answer 11

CD 30. It’s an antibody drug conjugate, delivers MMAE to disrupt microtubules.

Question 12

When using Brentuximab who should this be used with caution in or avoided?

Answer 12

In those over the age of 60 be careful with using this. Def avoid in those who have neuropathy.

Question 13

What is one particular side effect of Brentuximab that can put patients in the hospital? What are other side effects?

Answer 13

Febrile Neutropenia
Other-skin rash and neuropathy

Question 14

What is the general treatment approach for refractory disease?

Answer 14

You give second line therapies followed by auto transplant +/- RT

Question 15

What are some second line therapies that are used for refractory disease?

Answer 15

Brentuximab w/Bendamustine or Nivolumab, DHAP, GVD (w/Pembro), ICE (w/Brentuximab or Nivolumab)

Question 16

What is the recommendation and benefit to giving Brentuximab as maintenance therapy after auto SCT in relapsed disease?

Answer 16

Patients who are high risk should receive Brentuximab maintenance. High risk is defined as having 2 or more of the following: remission duration less than 1 year, extranodal involvement, FDG-PET positive response at time of transplant, B symptoms, or getting more than 1 second line tx

Question 17

What was the benefit of Brentuximab maintenance in relapsed dx after transplant?

Answer 17

Only PFS benefit, no OS benefit.

Question 18

What are determinants of the IPI score in Hodgkins disease?

Answer 18

Serum albumin <4 g/dL
Hemoglobin <10.5 g/dL
Male gender
Age >45 years
Stage IV disease
White blood cell count ≥15,000/microL
ALC <600/microL and/or <8 percent of the total WBC