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Childhood Hodgkin Lymphoma Cases and Controversies

Childhood Hodgkin Lymphoma Cases and Controversies. Eurasian Commonwealth Online Conference 5/25/05 Scott Howard, MD, MSc St. Jude Children’s Research Hospital. Relapsed HL Evaluation. Relapsed HL Evaluation. Relapsed HL Evaluation. Relapsed Hodgkin Lymphoma Treatment.

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Childhood Hodgkin Lymphoma Cases and Controversies

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  1. Childhood Hodgkin Lymphoma Cases and Controversies Eurasian CommonwealthOnline Conference5/25/05Scott Howard, MD, MScSt. Jude Children’s Research Hospital

  2. Relapsed HL Evaluation

  3. Relapsed HL Evaluation

  4. Relapsed HL Evaluation

  5. Relapsed Hodgkin LymphomaTreatment Depends on initial treatment Low-intensity (< 4 chemo cycles) High-intensity (>4 cycles + RT) Depends on the timing of relapse PD on therapy, early, late, very late Depends on the extent of relapse Localized versus extensive Depends on the site of relapse Nodal versus extranodal

  6. Treatment of HL after First Relapse • Standard salvage regimen • Intensive salvage regimen

  7. Relapsed Hodgkin LymphomaTreatment Depends on initial treatment Low-intensity (< 4 chemo cycles) High-intensity (>4 cycles + RT) Depends on the timing of relapse PD on therapy, early, late, very late Depends on the extent of relapse Localized versus extensive Depends on the site of relapse Nodal versus extranodal

  8. Treatment of HL after First Relapse • Standard salvage regimen • Similar to initial therapy for advanced stage disease • 6-8 cycles of chemotherapy • Radiation therapy 20-30 Gy • Intensive salvage regimen • Intense cytoreduction • Very intense consolidation (with stem cell rescue) • Radiation therapy 20-36 Gy

  9. Pediatric Hodgkin Lymphoma Initial Treatment Regimens MOPP and derivatives COPP, ChlVPP, CVPP, OPPA ABVD and derivatives OEPA, DBVE, VBVP, VAMP Stanford V BEACOPP

  10. Treatment of HL after First Relapse • Standard salvage regimen • Similar to initial therapy for advanced stage disease • 6-8 cycles of chemotherapy • Radiation therapy 20-30 Gy • Intensive salvage regimen • Intense cytoreduction • Very intense consolidation (with stem cell rescue) • Radiation therapy 20-36 Gy

  11. Relapsed Hodgkin LymphomaTreatment Schema • Induction (cytoreduction) • Consolidation #1 • chemotherapy vs • high dose chemotherapy with autologous stem cell rescue • Consolidation #2 • radiation therapy

  12. Treatment Schema for Relapsed HL Consolidation 1 (Intense Chemotherapy) Cytoreduction (Chemotherapy) CR or nice PR No PD Consolidation 2 (RT)

  13. Cytoreduction Regimens • ICE: Ifosfamide, Carboplatin, Etoposide • MIED: High-dose MTX, Ifosfamide, Etoposide, Dexamethasone • MIME: Methylguazone, Ifosfamide, Methotrexate, Etoposide • ESHAP/ASHAP: Etoposide/Adriamycin, Solumedrol, High-dose-AraC, Cisplatin • IV: Ifosfamide/vinorelbine • GV: Gemcitibine/vinorelbine

  14. Relapsed Hodgkin Lymphoma Case Presentation Multiple relapses in a 16 year old who received incorrect initial treatment

  15. Relapsed Hodgkin LymphomaCase Presentation #1 18421 • 16 YOHF diagnosed with stage IIA mixed cellularity HL in 8/99 • Sites: bilateral cervical, paratracheal • Treatment: • 8/99-10/99 COPP/ABVD x 2 “cycles” • 10/99 XRT 10 cGy in 2 fractions to bilateral neck • 10/99-3/00 COPP/ABVD x 4 “cycles” • 4/00 No evidence of disease

  16. Relapsed Hodgkin LymphomaCase Presentation #1 18421 • Treatment: • 4/00 No evidence of disease • 4/00-7/00 3 more “cycles” of COPP/ABVD • Recurrence #1: 8/2000 New cervical LAD • 8/00-10/00 3 “cycles” of COPP/ABVD • 11/00 XRT 36 Gy in 20 fractions to mantle, bilateral neck • 1/01-2/01 2 “cycles” of MOPP/ABVD • 4/01 No evidence of disease

  17. Relapsed Hodgkin LymphomaCase Presentation #1 18421 • Recurrence #2: 7/01 New left supraclavicular and axillary LAD • 8/01 MIED #1 (CR after cycle #1!) • 9/01 MIED #2 • 10/01 CYTOP • 11/01 XRT 36 Gy to left supraclavicular and axillary area • Off-therapy evaluation 12/01

  18. Patient 18421After 2 Relapses (date 9/11/01)

  19. Patient 18421Off Therapy Evaluation (date 12/14/01)

  20. Patient 18421Four months later (3/25/02)

  21. Patient 18421 3/25/02

  22. Histoplasmosis vs. Relapse

  23. Relapsed Hodgkin Lymphoma Case Presentation First relapse in a 13 year old who received VAMP/COP (2 cycles each) + RT 25.5 Gy as initial treatment

  24. Relapsed Hodgkin LymphomaCase Presentation #18012 • 13 year old white male • Left cervical lymphadenopathy • strep negative • monospot negative • s/p multiple courses of antibiotics • no soaking night sweats • ADHD, weight loss temporal correlation with Ritalin.

  25. Relapsed Hodgkin LymphomaCase Presentation #18012 • PE: matted left posterior cervical lymph nodes; 9 cm X 10 cm. • ESR 20 • LDH 502 • mediastinal fullness • gallium uptake in left cervical region only • bone marrow negative

  26. Relapsed Hodgkin LymphomaCase Presentation #18012 • Stage IIA • enrolled on HOD 99 • 2 cycles VAMP • 2 cycles COP • 2550 mantle irradiation

  27. Relapsed Hodgkin LymphomaCase Presentation #18012 • 6 month off-therapy evaluation • left cervical lymphadenopathy • 1.2 x 1.5 cm on exam • needle biopsy : Hodgkin disease • restaging: localized recurrence, • gallium negative

  28. 18012 3-25-02

  29. 2/7/2002

  30. 18012 3-25-02

  31. Relapsed Hodgkin Lymphoma Case Presentation First relapse in a 21 year old who received VAMP/COE (2 cycles each) + RT 25.5 Gy as initial treatment

  32. Relapsed Hodgkin LymphomaCase Presentation #19090 • 21 YOWF with Stage IIA nodular sclerosing HL (intermediate risk) diagnosed 5/17/02 • Enrolled on Hod 99  4 cycles of VAMP/COE + modified mantle RT (25.5 Gy) • Completed treatment 11/13/02 • Relapse 1/8/04 in porta hepatis and para-aortic lymph nodes

  33. Relapsed Hodgkin LymphomaCase Presentation #19090 • MIED x 2 cycles (1/19/04-1/24/04 and 2/4/04-2/9/04)  30% tumor shrinkage, PET negative • Stem cell pheresis on 2/16/04 • ICE x 2 cycles (2/25/04-3/2/04 and 3/19/04-3/24/04)  PR (tumor shrank to 50% of initial relapse volume)

  34. 19090 At relapse 11/6/03

  35. Relapsed Hodgkin LymphomaCase Presentation #19090 • ICE #2 complicated by hospitalization for febrile neutropenia • Incidental PET finding: persistent avidity at the spinous process of C7 • Biopsied and found to be necrotic Hodgkin lymphoma (possibly present at diagnosis 18 months prior, when PET scans were not routinely done)

  36. Relapsed Hodgkin Lymphoma Case Presentation Progressive disease during therapy in a 16 year old who received VAMP/COE (2 cycles each) as initial treatment

  37. Relapsed HL Case#20374 • 16 YOWF with nodular sclerosing Hodgkin lymphoma diagnosed 11/11/03 • Lab: normal CBC, normal chemistry and coagulation profiles, ESR 56, CRP 0.8. • Sites of disease: bilateral supraclavicular, bilateral anterior cervical, internal mammary, and bilateral paratracheal nodes, and upper mediastinum

  38. BP #20374 • Gallium and PET avid in the bilateral supraclavicular nodes, mediastinum, and bilateral paratracheal nodes • Stage IIA, intermediate risk (because of > 3 sites of disease) Hodgkin lymphoma • Started therapy 11/26/03

  39. BP #20374 • VAMP x 2 cycles, COE x 2 cycles • Came for radiation planning – exam ok, CT ok • Returned 2 weeks later to start RT • Had palpable lymphadenopathy in the left supraclavicular area • Biopsy confirmed progressive Hodgkin lymphoma

  40. BP #20374 • Restaging evaluation: PET-positive enlarged lymph nodes in the left supraclavicular area and mediastinum • Treated with MIED x 1  febrile neutropenia, partial response of the neck node by exam • MIED #2 in process

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