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Pediatric Hodgkin Lymphoma Dr Matthias SCHELL, IHOP, Lyon

Pediatric Hodgkin Lymphoma Dr Matthias SCHELL, IHOP, Lyon. Plan. Part one: Should patients ≤ 18 years with HL be treated with specific pediatric protocols? Part two: PET CT in HL. 56%. Risk to develop breast cancer. Bhatia S 1996. Vanleeuwen 1994. 10. 20. Age au dg.

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Pediatric Hodgkin Lymphoma Dr Matthias SCHELL, IHOP, Lyon

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  1. Pediatric Hodgkin Lymphoma Dr Matthias SCHELL, IHOP, Lyon

  2. Plan • Part one: • Should patients ≤ 18 years with HL be treated with specific pediatric protocols? • Part two: • PET CT in HL

  3. 56%

  4. Risk to develop breast cancer Bhatia S 1996 Vanleeuwen 1994 10 20 Age au dg Si 20 Gy : RR = 5.9 Si 40 Gy : RR = 23.7

  5. Other major late effects • Cardiac dysfunction • Increased risk in adult protocols: • ABVD + IF RT : myocarial dysfunction in the majority of HL survivors (Pediatr Blood Cancer 2005;45:700–705) • Lower risk in pediatric protocols • EBVP : no antracyclines • OEPA : no RT if CR in low stage HL • Gonadal toxicity : • Male sterility by alkylating agents • OEPA, VAMP, ABVE, EBVP, COPDAC • Hypothyroidism : cervical RT Late effects and late toxic death in HL are of major concern Aims in pediatric HL protocols : decrease the risk of late effects and toxic deaths without compromising good survival rates

  6. How to treat HL in children and adolescents ? • GPOH-HD-2002 study(J Clin Oncol. 2010 Aug 10;28(23):3680-6) • OEPA + COPP or COPDAC • OS and EFS rates at 5 years in TG-1 (≤ IIA) were • 97.4% +/- 0.7% and 89.0% +/- 1.4%, respectively. • EFS of pts without irradiation (93.2% +/- 3.3%) • similar to that of irradiated patients (91.7% +/-2.5%), • TG-2+3(≥IIB), EFS between boys and girls not different (90.2% +/- 2.3 v 84.7% +/- 2.7, respectively; P = .12). • Current protocol: • European protocol: • Omission of RT in good responders ( risk of 2ne cancer…) • Randomisation: COPP vs COPDAC ( risk of gonadal toxicity…)

  7. First conclusion: • As survival in pediatric as well as in adult protocols are excellent and identical • And late effects are treatment related • Pediatric protocols should be used to treat children and adolescents • To decrease late effects, and late treatment related deaths • Use of less adriamycin (160 mg/m2 in OEPAx2) • and less or no alkylating agents (COPDAC)

  8. Part 2: PET CT in pediatric HL • Initial PET CT in HL: • PET CT has a sensitivity between 88-100% and a specificity ≈78-100% (Lang 2001, De WIT 2001) • Should always be related to CT or MRI images • To exclude non HL related uptake (i.e.brown fat) • To confirm pathological uptake (i.e. bone) • Image the entire body detecting peripheral metastatic lesions • May lead to up- or down staging when compared to CT alone • Define what is PET+

  9. Different PET staging systems • Pediatric Euronet PET maual:

  10. b) Adult Dauville modified criteria It includes visual and quantitative analysis 1. No uptake. 2 Uptake < mediastinum. 3. Uptake > mediastinum but < liver. 4. Uptake moderately more than liver uptake, at any site. A moderately uptake more than liver uptake is define as an uptake more or equal than 140% of SUV max liver (assessed on 3 slides on the liver middle region) 5. Markedly increased uptake at any site or new sites of disease. A markedly uptake more than liver uptake is define as an uptake more or equal than 200% of SUV max liver (assessed on 3 slides on the liver middle region) o PET positive is defined by scale level 4 and 5 (as described above) o PET negative is defined by scale level 1, 2 and 3.

  11. PET Staging • No consensus what is an abnormal uptake • Make sure that your colleagues use the accurate manual • Interdisciplinary discussions between • Medical doctors • Nuclear medicine • Radiologist • and radiotherapists • are indispensible • To avoid wrong initial staging • Further on : • Initial PET staging influences radiotherapy

  12. Influence of initial PET CT on RT fields

  13. Influence of PET staging system on early response assessment

  14. In conclusion • Please use pediatric protocols for patients with HL < 18 years • Less toxic late effects while similar OS and EFS • Initial PET CT is important • To define initial involved fields • To decide the volumes and the fields for radiotherapy • Make sure that you nuclear physician uses the right manual • Organize a pluriprofessional staff to discuss • Initial involved fields • As it remains unclear what is PET+ after treatment and • As it remains unknown for what pts RT may be omitted • Don’t use PET CT response assessment to omit RT outside a protocol

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