Hodgkin Lymphoma (HL)
Haematological Pathway
for
South Wales Cancer Network
Document Control Sheet
Organisation / South Wales Cancer NetworkSpecialty/Project / Haematological Site Specific Group
Document Title / Hodgkin Lymphoma (HL)
Document Number / 05/016
Version / Author/s / Ratified by
1.0 / Dr Eve Gallop-Evans / Dr W Ingram
Approved by / Approval date / Date of next review
South Wales Haematology Cancer Network Group / 17/09/14 / 16/09/15
NSAG Hodgkin Lymphoma Patient Care Pathway
Diagnosis
An excision biopsy is recommended in preference to a core biopsy to ensure adequate tissue for diagnosis.
AWLP confirmation required for diagnosis of:
· Classical HL
· Nodular lymphocyte predominant HL
All cases should be discussed at a Lymphoma MDT meeting:
· At diagnosis and on completion of staging, to confirm management plan and discuss any relevant clinical trials.
· At time of response assessment, during and at the end of treatment, to decide on appropriate management.
All patients aged from 15-24 should be referred to the appropriate TYA team and discussed at the TYA MDT.
· Patients under the age of 18 must receive care in the principal treatment centre offering age-appropriate facilities and access to the TYA MDT. Patients aged 19 to 24 yrs should be referred to the TYA MDT for support, and should also be offered the choice of being treated at the PTC or locally.
Staging, clinical & prognostic markers and pre-treatment investigations
· Documentation of stage, systemic symptoms, International Prognostic Score, co-morbidities.
· FBC, ESR, renal, liver & bone profile, LDH, viral screen (HIV, hepatitis B and C).
· Contrast-enhanced CT scan of neck, thorax, abdomen, pelvis,
· Staging PET-CT scan (if contrast given for this, can omit separate CT).
· Bone marrow examination is not mandated except if required as part of clinical trial, or in advanced disease where staging PET-CT has not been performed [1].
· Consider baseline lung function for patients receiving bleomycin. The risk of bleomycin toxicity is significantly increased in smokers and patients over the age of 60 years.
· Consider baseline cardiac assessment (ECG, echo or MUGA) for all patients receiving anthracyclines and/or mediastinal radiotherapy, and this is mandated in patients with cardiac risk factors or over the age of 70 yrs.
· The requirement for irradiated blood products should be registered with the Blood Transfusion Service.
· Referral for discussion of fertility preservation options where relevant (see intranet for details including referral form and required pre-referral investigations)
Information Required at MDT
· AWLP report (if final report not available at the time of commencing treatment the case should be re-listed when the final report is issued in order to complete registration and ensure no changes to treatment plan are required)
· Ann Arbor staging information including PET-CT result
· Risk grouping – early (stage I-IIA, presence or absence of risk factors) or advanced (stage 2B+)
· Performance status/relevant co-morbidities
· Clinical trial eligibility
· Fertility preservation options offered/completed
· Referral to TYA MDT where appropriate
Treatment of Classical HL
Early stage – stage I-IIA
The UK convention has been to designate all patients with stage I-IIA disease as early stage, where the German Hodgkin Study Group stratifies patients according to the presence or absence of the following risk factors:
· Mediastinal bulk (≥ one third transverse thoracic diameter)
· ≥3 nodal areas
· ESR ≥50 without B symptoms, or ESR ≥30 with B symptoms
· Extra-nodal site of disease
Combined modality treatment remains the standard approach, with progression free survival ranging from 90-95%.
o Early stage I-IIA, no risk factors
§ 2 cycles ABVD and 20 Gy IFRT [2]
o Early stage with risk factors
§ 4 cycles ABVD and 30 Gy IFRT [3]
For these patients, once the treatment plan is decided, no interim assessment of response is required unless there is clinical concern. Discussion with and referral to a clinical oncologist is recommended prior to starting treatment.
A chemotherapy-only approach is an alternative strategy which may allow omission of RT following discussion of risk/benefit [4]. This may be because the risk of late effects from radiotherapy are considered to outweigh the increased risk of relapse, and should be decided upfront. Patients must be counselled with respect to the small increase in relapse risk. Interim PET request must state that this is for consideration of de-escalation for responders.
o NCRI RAPID study for early stage HL I-IIA, non bulky, reported on results after 3 cycles of ABVD [5]
o Interim PET is performed from day 9-13 after cycle 3B
o If PET negative (Deauville score 1-2) after 3 cycles of ABVD, patients receiving no further treatment had a 3 yr progression free survival of 91% compared to 97% for pts receiving 30 Gy IFRT.
o If PET positive (score 3 or more) for 1 further cycle of ABVD and 30 Gy IFRT. Expected early PFS for this group is 86.2%.
o Patients with early relapse in the initially involved site have received successful salvage treatments which include involved field radiotherapy, BEACOPP-based regimes, with a small proportion having high dose chemotherapy.
o Await publication and longer term follow up data.
Advanced stage
· The standard treatment is considered 6-8 cycles of ABVD, with recent clinical trials using 6 cycles in the standard arm.
· There is published evidence that a positive interim PET scan after 2 cycles of ABVD predicts a poor outcome with ABVD alone [6], though there is as yet no evidence that changing therapy on this basis is beneficial.
· An inadequate response to 2 cycles ABVD may be considered a basis to escalate treatment in fit patients.
· If a patient is fit for escalation, an interim PET scan may be requested after 2 cycles of ABVD, and the indication made clear on the request form.
· If PET positive (Deauville score 4-5), particularly with an inadequate CT response, consider intensification to escalated BEACOPP. Imaging should be reviewed at the Lymphoma MDT, and management plan discussed.
· If PET negative (Deauville score 3 or less), continue with a further 4 cycles of ABVD.
· If there is clinical or radiological evidence of bleomycin toxicity, consider omission of bleomycin and continue with AVD, or change chemotherapy regime if necessary.
· Interim PET scans in patients who did not have a staging PET scan should be interpreted with caution, and the default position would be to give 6 cycles ABVD (if responding) and reassess at the end of treatment.
· Interim PET scans should not be undertaken in patients unsuitable for intensification.
· For patients presenting with bulky mediastinal masses, consolidation RT (30 Gy) to the residual mass should be considered at the end of planned chemotherapy, prior to PET re-evaluation.
ABVD chemotherapy (cycle repeats every 28 days)
Doxorubicin 25 mg/m2 iv days 1, 15
Bleomycin 10,000 units/m2 iv days 1, 15
Vinblastine 6 mg/m2 iv days 1, 15
Dacarbazine 375 mg/m2 iv days 1, 15
This will be given at full dose and on schedule, regardless of blood count. Growth factors may be used at the discretion of clinicians but are not routinely advised [7, 8]
Escalated BEACOPP (Cycle repeats every 21 days)
Doxorubicin 35 mg/m2 iv day 1
Cyclophosphamide 1250 mg/m2 iv day 1
Etoposide 200 mg/m2 iv days 1-3
Procarbazine 100 mg/m2 po days 1-7
Prednisolone 40 mg/m2 po days 1-14
Bleomycin 10,000 units/m2 iv day 8
Vincristine 1.4 mg/m2 iv day 8, maximum 2 mg
G-CSF 263/300mcg s/c day 9 -13 or PEG-filgrastim 6 mg single dose .
Radiotherapy
Published guidelines now recommend the use of involved node radiotherapy (INRT) or involved site radiotherapy (ISRT) instead of involved field radiotherapy (IFRT)[9] [10]. This allows for treatment of smaller volumes around originally involved lymph nodes and may reduce the risk of late effects. However, if pre-treatment imaging is not available or did not include a PET-CT scan, or there is uncertainty about the extent of involvement, then the default remains IFRT. Ideally patients should have diagnostic scans in the same position as the radiotherapy planning scan, and the latter should be performed with iv contrast.
Please refer to RT protocol for more details.
Older/comorbid patients
If not fit for ABVD, consider AVD, ChlVPP chemotherapy [11, 12] or VEPEMB [13].
Patients with stage IA non bulky disease may be treated with IFRT alone.
ChlVPP 28 day cycle
Chlorambucil 6 mg/m2 po od days 1-14
Vinblastine 6 mg/m2 capped at 10 mg iv days 1 and 8
Procarbazine 100 mg/m2 od capped at 200 mg po days 1-14
Prednisolone 40 mg/m2 po days 1-14
End of treatment assessment
For patients who have had a negative interim PET scan, this does not need to be repeated, but an end of treatment contrast-enhanced CT scan (4-6 weeks post chemotherapy) should be done as a baseline for follow-up, and to exclude progressive disease.
If a PET scan is required for response assessment on completion of all therapy, this should be done at 6-8 wks post chemotherapy, or 8-12 wks post radiotherapy [14, 15].
Patients with refractory/progressive/relapsed disease [16]
Strong consideration should be given for biopsy to confirm refractory/progressive/relapsed disease.
Prognostic factors
Does the patient have primary progressive/refractory disease, early relapse (within 12 months of complete remission) or late relapse (more than 12 months since complete remission)? Has the patient already had escalation of therapy as part of first line treatment?
Primary consideration:
Is patient fit for high dose chemotherapy and autograft?
· Discuss at MDT meeting with transplant team.
· The aim of salvage chemotherapy is to debulk and confirm chemo-sensitive disease suitable for high dose therapy.
· Baseline and response assessment PET scans are required.
· Metabolic remission on PET prior to autograft is associated with an improved outcome and should be the aim of salvage treatment [17].
· Arrangements should be made for stem cell collection.
Salvage therapy
The choice of salvage therapy including a clinical trial option may depend on any existing comorbidities eg renal impairment.
Recommended regimes include:
· IGEV
· ESHAP
· ICE
· miniBEAM
· GemP
Suggested treatment protocol:
· Cycle 1
· Cycle 2
• Stem cell collection
• CT evaluation – if good PR:
· Cycle 3
• PET-CT – if metabolic CR, then transplant work up and admission for HDC/ASCT
Avoid doing PET at time of G-CSF use for stem cell mobilisation, or make sure that this information is detailed on request form.
Poor responders:
If PET positive – depending on degree of response (PR, SD or PD) and fitness of patient:
• discuss with transplant team
• consider potential for allograft (sibling/MUD).
Patients who have previously received intensification as part of first line therapy may be considered to have failed 2 lines of treatment by this stage, and brentuximab should be considered.
Brentuximab
1.8 mg/kg, capped at a weight of 100 kg, iv day 1 on a 21 day cycle
2nd line salvage
As listed above
For progressive disease following 2nd line salvage, consider best supportive care, palliative radiotherapy or chemotherapy or brentuximab to achieve stable disease if allograft is still a potential option.
Consideration of allograft over autograft if:
· Chemo-refractory HL and stable or slowly progressive disease after at least 1 line of salvage therapy
· Adequate performance status/no significant co-morbidities
· Suitable donor options
Relapse post-autograft
Prognostic factors include duration of remission, age and extent of relapse.
Consider allograft if donor options available,.
Treatment options include brentuximab as a bridge to transplant.
Relapse post-allograft
PET-directed DLI +/- brentuximab may be considered.
Palliative treatment
For patients not suitable for curative options due to progressive disease or poor performance status.
Best supportive care (BSC) with early involvement of community cancer teams and palliative care services is recommended.
Patients may have active surveillance and BSC, and treatment offered at time of symptomatic progression.
Treatment options:
ChlVPP
CCEP
Bendamustine 120 mg/m2 days1,2 on a 28 day cycle [18]
Radiotherapy
Clinical trial
Response assessment should be performed according to published criteria:
International Working Group response criteria - Cheson [14]
Deauville scoring for PET reporting [15]
Radiotherapy to the mediastinum
In 2003, the Department of Health launched a notification and management programme for women treated for HL with supradiaphragmatic radiotherapy under the age of 36 years [19]. Women were informed that if treated in childhood or young adulthood, they had a 1 in 3 to 1 in 7 risk of developing breast cancer by age 40-50, against a general population risk of 1 in 50 by age 50.
Annual breast screening is offered 8 years post-radiotherapy, or starting at age 25; by MRI if aged under 30 years and by mammography if aged 30-50. Standard 3-yearly mammography is performed after age 50.
All patients eligible for screening should be referred to the lead clinical oncologist in the Network for registration on the Breast Test Wales database. Patients treated for NHL with curative intent who are also considered at risk will be included.
At the time of initiation of screening, patients are offered a consultation and will be required to sign a consent form.
South East – Eve Gallop-Evans
South West – Roger Taylor
North Wales –Angel Garcia
Radiotherapy to superior mediastinum/neck
This confers a late risk of hypothyroidism, and lifelong annual monitoring of TFTs is recommended.
Follow up on completion of treatment
Early stage
1st year – 3 monthly
2nd year – 6 monthly
3rd year – annually until 5 yrs then discharge
Advanced stage
1st year – 3 monthly
2nd year – 4 monthly
3rd year – 6 monthly
4th year – annually for 5 yrs then discharge
There is no evidence for routine surveillance imaging during clinical remission. [20]
Nodular lymphocyte predominant Hodgkin lymphoma
NLPHL may present as slowly progressive lymphadenopathy at a peripheral site such as the neck, axilla or groin, and rarely involves mediastinal nodes. It is more common in men in the 3rd or 4th decade. Expert haematopathology review is essential, as it can transform to T-cell rich B cell lymphoma. A retrospective analysis of 131 patients with early stage low-risk disease treated within clinical studies of the GHSG showed no difference in outcome between extended- or involved-field RT, or combined-modality treatment (Nogová et al., 2005). Local RT gives durable control, and given the predominantly peripheral sites involved, late effects are rare [21]. Although the clinical behavior of NLPHL resembles that of a low grade B cell lymphoma, higher stages have traditionally been treated as for classical HL. The role of rituximab remains unclear but an alternative approach would be R-ABVD.