Mark A. Socinski, MD

Disclosures

June 30, 2000

Question

A 48-year-old male developed a large left axillary mass, weight loss, and night sweats. A biopsy revealed NS Hodgkin's disease. Staging studies identified a 12-cm mediastinal mass, a 7-cm left axillary mass, and an involved spleen. He was clinically staged as IIIBX. The plan was to administer a minimum of 6 cycles of Adriamycin (doxorubicin), bleomycin, vinblastine, and dacarbazine (ABVD), followed by mediastinal and possibly left axillary radiation. He underwent 6 cycles of ABVD with resolution of B symptoms and a near complete radiographic response, followed by 2 additional cycles of ABVD. Follow-up staging demonstrated no further change in a 2-cm residual mediastinal mass. A gallium scan performed for the first time demonstrated positivity in the mediastinum. He has an excellent performance status.

Should this patient now receive radiotherapy to the mediastinum to complete the original plan, or should this be considered primary refractory disease, suggesting the use of high-dose chemotherapy and stem-cell rescue followed by consolidative x-ray therapy?

Response from Mark A. Socinski, MD

The patient with stage IIIB Hodgkin's disease, who received 8 cycles of ABVD, has a near complete remission (B symptoms have resolved and he is left with a 2-cm residual mediastinal mass). A gallium scan shows activity in this mass. I wonder whether the gallium scan was done with single photon emission computed tomography (SPECT) imaging to be sure the mass was avid and the gallium did not represent residual activity perhaps in hilar nodes, which could not be distinguished from the mass. This may happen following chemotherapy, and I would query the nuclear medicine physician about this issue.

We will, however, assume that SPECT images were obtained and this represented persistent disease. I would continue with radiation therapy to the chest to a dose of approximately 4000 cGy and reassess by CT and gallium scanning following radiation. With a clinical follow-up and a compliant patient, I believe there would be little to lose. I would not necessarily consider the patient truly refractory and move to high-dose therapy at this time. I am concerned about the continued gallium activity, but if it is truly focal and real, radiotherapy would be my choice. Another option would be to treat the patient with a "salvage" regimen for 2 cycles and reassess by CT and gallium at that time; however, my first choice would be to radiate and reassess.

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