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1
Q

Significance of HL

A
  • first demonstration of the effectiveness of combination chemotherapy
  • CURABLE using different modalities depending on the extent of disease
  • distinguishing HL from NHL is useful because px and tx are different
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2
Q

Hodgkin Lymphoma

A
  • a lymphoid neoplastic disorder of B cell origin

- characterized by the presence of Reed-Sternberg cells (or variants of RS cells) in the affected tissues

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3
Q

epidemiology

A

-much less frequent than NHL
-overall M>F, (but F>M in NS subtype)
-peak incidence in 3rd decade
7800 cases dx annually (2007)

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4
Q

Associated etiological factors

A
  • EBV infection
  • smaller family size
  • higher SE status (SES)
  • white>non-white
  • possible genetic predisposition
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5
Q

Epidemiology of HL

A
  • bimodal age distribution
  • male>female
  • white>non-white
  • 2.5 risk in family members
  • peak incidence in January and December
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6
Q

What causes HL?

A
  • mutation
  • virus - EBV
  • immune dysfunction
  • We do not know for the majority
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7
Q

HL Pathology

A
  • lymphoid neoplasm defined by the presence of Reed-Sternberg (RS) cells
  • RS cells express CD30
  • The classical RS cell is binucleate, with an “owl eye” appearance
  • nodular lymphocyte predominant HL has distinctive surface markers and morphologic features such as numberous tightly packed nodules
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8
Q

WHO Classification

A
  • Classical HL 95%
  • -nodular sclerosing HL 55%
  • -mixed cellularity HL 25%
  • -Lymphocyte rich classical HL 5%
  • -Lymphocyte depletion HL 1-2%
  • -not classifiable 5%
  • Lymphocyte predominant, nodular HL 5%
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9
Q

HL Pathology

A
  • Classical HL
  • -CD30+
  • -CD15+
  • -CD20-
  • NLPHL
  • -CD30-
  • -CD15-
  • -CD20+
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10
Q

Presentation

A

General

  • lymphadenopathy: supradiaphramatic, commonly lower nece, small % subdiaphramatic
  • rubbery, painless nodes
  • cough, dyspnea, chest pressure (mediastinal mass >/ 10cm)
  • unexplained pruritus, young patients

B symptoms: unexplained fever, night sweats, unexplained weight loss

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11
Q

Dx and work-up

A

History
physical exam: lymphadenopathy, organomegaly
Labs - CBC, chem panel, liver/kidney function, ESR, HIV
Imaging - CT, FDG-PET, CXR
Biopsy - preferably excitional for lymph nodes, BM
bone scan if bone pain present and PET n/a

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12
Q

HL Tx

A

Tx is driven by stage
Goal of tx is cure with minimal long term SE
minimize risk of leukemia or other SE

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13
Q

What factors determine appropriate therapy

A

bulk
prognostic factors
duration of therapy
possible SE

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14
Q

complications of HL Tx

A
Second malignancy (chemo, XRT, splenect): 18%
Sepsis (chemo, XRT, splenect) 1-2%
Pericarditis (XRT, Adriamycin) 15%
Pneumonitis (XRT, Bleomycin) 5-10%
Sterility (MOPP, TNI) >80%
Growth retardation (XRT) kids
Hypothyroidism (XRT) >50%
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15
Q

Frontline Regimens: ABVD

A

28d cycle

  • doxorubicin 25mg/m2 IV d 1, 15
  • bleomycin 10mg/m2 IV d 1, 15
  • Vinblastine 6mg/m2 IV d 1, 15
  • Dacarbazine 375mg/m2 IV d 1, 15
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16
Q

Frontline Regimen: BEACOPP

A

21d cycle

  • Bleomycin 10mg/m2 IV d8
  • Etoposide 100mg/m2 IV d 1-3
  • Doxorubicin 25mg/m2 IV d 1
  • cyclophosphamide 650 mg/m2 IV d 1
  • vincristine 1.4 mg/m2 IV d 8
  • procarbazine 100mg/m2 PO d 1-7
  • Prednisone 40mg/m2 PO d 1-7
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17
Q

Frontline Regimen: Escalated BEACOPP

A

21d cycle

  • Bleomycin 10mg/m2 IV d8
  • Etoposide 200mg/m2 IV d 1-3
  • Doxorubicin 35mg/m2 IV d 1
  • cyclophosphamide 1250 mg/m2 IV d 1
  • vincristine 1.4 mg/m2 IV d 8
  • procarbazine 100mg/m2 PO d 1-7
  • Prednisone 40mg/m2 PO d 1-7
18
Q

Frontline Regimen: BEACOPP 14

A

same doses given on sane day as baseline during a 14d cycle

GCSF SQ d9-13

19
Q

Frontline Regimen: Stanford V

A
  • mustard 6mg/m2 IV weeks 1-5-9
  • bleomycin 5mg/m2 IV weeks 2-4-6-8-10
  • doxorubicin 25mg/m2 IV weeks 1-3-5-7-9-11
  • etoposide 60mg/m2 IV weeks 3-7-11
  • vinblastine 6mg/m2 IV weeks 1-3-5-7-9-11
  • vincristine 1.4mg/m2 IV weeks 2-4-6-8-10
  • prednisone 40mg/m2 PO q other day, taper weeks 10-12
20
Q

International Prognostic Score (IPS)

A
IPS for stage advanced III/IV HL
1-point per factor
Serum albumin <4 g/dl
Hgb <10.5 g/dl
Male gender
Ann Arbor Stage IV disease
Age >/ 45
WBC>/ 15000/mm3
lymphocyte count <600/mm3 or <8% of WBC
21
Q

Frontline Tx and Px Summary

A

ABVD remains the preferred tx regimen

5-year OS >90% in early stage HL; ~80% in advanced disease

22
Q

Tx of refractory or relapsed HL

A

Disease requiring secondary tx
Refractory: progression during or within <3 months of primary tx
Relapsed: progression >3 months after primary tx

23
Q

Current HL TX: First Line

A

Multi-agent chemo +/- RT
ABVD
Stanford V
BEACOPP

24
Q

Current HL TX: Second Line

A

multi-agent chemo
ICE, C-MOPP, ChIVPP, DHAP, ESHAP, GVD, IGEV, Mini-BEAM, MINE, VIM-D

HDCT/ASCT

25
Current HL TX: Third-Line
Chemo/RT New Agents Allograft Palliation
26
Tx of R/R HL Goals of TX
treated so they are candidates for transplant pts need cytoreduction prior to chemo what is appropriate choice for cytoreduction? what is appropriate txp? auto vs allo
27
Second-Line TX | ICE
ifosfamide carboplatin etoposide
28
Second Line TX | C-MOPP
cyclophosphamide vincristine procarbazine prednisone
29
second line tx | ChlVPP
chlorambucil vinblastine procarbazine prednisone
30
second line tx | DHAP
dexamethasone cisplatin high dose cytarabine
31
second line tx | ESHAP
etoposide methylprednisolone high dose cytarabine cisplatin
32
second line tx | GVD
gemcitabine vinorelbine pegylated liposomal doxorubicin
33
second line tx | IGEV
ifosfamide gemcitabine vinorelbine
34
second line tx | Mini BEAM
carmustine cytarabine etoposide melphalan
35
second line tx | MINE
etoposide ifosfamide mesna mitoxantrone
36
second line tx | VIM-D
etoposide ifosfamide mitoxantrone dexamethasone
37
second line tx | GCD
gemcitabine carboplatin dexamethasone
38
R/R disease presents a challenge
up to 30% of pts with HL will eventually relapse only 1 in 4 pts achieves a CR with salvage chemo Auto HSCT is effective in only 50% of pts w/ R/R HL -pts who are PET negative have best px -risk factors reduce survival (extranodal sites, CR <1 year, primary refractory disease, B symptoms, detectable disease at txp, bulky disease at dx)
39
Unmet medical need in R/R post ASCT
Chemo options post ASCT - largely palliative - induce substantial morbidity - no approved tx - NCCN guidelines list no standard tx for R/R HL - pronounced unmet need
40
Other tx options in RR HL
Everolimus (mTORi) Lenalidomide Bendamustine