How would you treat a patient with Hodgkin lymphoma and bleomycin lung injury?

William Rosenberg Professor of Medicine, Harvard Medical School, Dana-Farber Cancer Institute, Boston, Massachusetts

This month, George P. Canellos, MD, advises on treatment options for a young patient with Hodgkin lymphoma and bleomycin lung injury.

CLINICAL DILEMMA

A 23-year-old male patient with nodular sclerosis classical Hodgkin lymphoma – stage IIIb with bulky mediastinal disease, International Prognostic Index score of 3 points. He has received two cycles of ABVD, resulting in a 21 percent decrease in carbon monoxide diffusing capasity (DLCO) and symptomatic bleomycin lung toxicity. A 18-fluorodeoxyglucose (FDG) positron emission tomography (PET) scan after two cycles revealed two persistent areas of FDG avidity: persistent disease versus disease secondary to inflammation from bleomycin lung damage. His symptoms did improve with steroid treatment. Subsequently, he received four cycles of ABVD. A PET scan performed after four cycles of chemotherapy was negative, and we are currently awaiting a post-treatment PET scan. In someone with bleomycin lung injury, would you recommend radiation therapy post-chemotherapy, due to initial bulky disease and persistent FDG avidity in interim PET scan?

EXPERTS MAKE THE CALL

I would say you did the right thing by giving ABVD to complete the chemotherapy regimen. Because the patient is only 23 years old, I would be cautious about radiation therapy – given the high risk of long-term cardiac toxicity. If he is indeed PET-negative, there is a chance that he is already cured.

However, there is a 10 to 20 percent chance of disease recurrence. But, being that he has stage IIIb disease, the patient’s disease could recur anywhere.

I would follow the patient closely with CT or PET/CT scans repeated at six months. If the disease recurs only in the mediastinum, then a cycle of ABVD followed by radiation therapy to the mediastinum – if this is the only site of relapse – would be advisable. In a PET-negative circumstance, I would say six months is a liberal interval of time, but I assume the patient will be seen sooner on a clinical basis. In fact, one could say that the longer the PET remains negative, the less likely a relapse will occur.

It would worry me if an early mediastinal relapse occurred because it was not confined to that site and the disease may recur in other sites over time.

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