HL Eurasian Commonwealth Part 3 - cases and controversies 5-25-05 Handout.ppt

Childhood Lymphomas

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

2. Relapsed HL Evaluation
Above the
diaphragm
Chest radiograph,
Computed tomography
Below the
diaphragm
Computed tomography
or ultrasonography
Tumor activity
(Functional
imaging)
Gallium scan
18
FDG Positron
emission tomography
(PET)

3. Relapsed HL Evaluation
Bone marrow
biopsies
All patients
Bone scan If there is bone pain, elevated
alkaline phosphatase, or
other sites of extranodal
disease

4. Relapsed HL Evaluation
Lymph node
biopsy or fine
needle
aspirate
Relapse therapy should
NEVER be started without
histologic confirmation of
relapse.
Evaluation of suspected
relapse is the ONLY time a
fine needle aspirate should
be used for diagnosis of
lymphoma in children.

5. Relapsed Hodgkin Lymphoma
Treatment
•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 Lymphoma
Treatment
•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
–Localizedversus extensive
•Depends on the site of relapse
–Nodalversus 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 Lymphoma
Treatment 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
Cytoreduction
(Chemotherapy)
Consolidation 1
(Intense
Chemotherapy)
Consolidation 2
(RT)
CR or nice PR
No PD

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 Lymphoma
Case 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 Lymphoma
Case 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 Lymphoma
Case 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 18421
After 2 Relapses (date 9/11/01)

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

20. Patient 18421
Four 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 Lymphoma
Case 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 Lymphoma
Case 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 Lymphoma
Case Presentation #18012
•Stage IIA
•enrolled on HOD 99
•2 cycles VAMP
•2 cycles COP
•2550 mantle irradiation

27. Relapsed Hodgkin Lymphoma
Case 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 Lymphoma
Case 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 Lymphoma
Case 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 Lymphoma
Case 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