Recurrent Hodgkin's Disease in the Neck?

Avraham Eisbruch, MD

Disclosures

August 21, 2001

Question

One year ago, a 22-year-old male was diagnosed with Hodgkin's disease, cell type nodular sclerosis, stage IIa. Initial staging showed disease limited to the right neck and mediastinum. He received 8 courses of doxorubicin, bleomycin, vinblastine, and prednisone (ABVP) followed by radiation to the mediastinum; follow-up CT scans of the chest and neck showed considerable shrinkage of the tumor. Gallium scanning posttreatment was negative, although since it was not performed pretreatment, the significance of this finding is unclear.

He has now relapsed with a single node in the right neck, night sweats, and pruritus. CT scan shows no other tumors. PET scan shows activity limited to the neck, and nothing in the mediastinum. Biopsy of the neck mass shows nodular sclerosis Hodgkin's disease. What treatment is now indicated? Is high-dose chemotherapy and stem-cell transplant appropriate?

Barry Walters, MD, FACC

Response from Avraham Eisbruch, MD

Given the local recurrence of stage IIa nodular sclerosis Hodgkin's disease (HD) 1 year after chemotherapy and mediastinal radiation, it is likely that the radiation did not encompass the right neck, or that only a low dose was delivered to the right neck. It is unusual for HD to recur at irradiated areas as an isolated recurrence following full-dose (> 30 Gy) radiation.

B symptoms, such as this patient's night sweats, usually denote more extensive disease than the clinical staging suggests, even though the PET scan, which is very sensitive in HD, does not show other sites. Bone marrow biopsy, a restaging procedure that has not yet been performed, should be done, especially in light of the B symptoms.

Assuming the biopsy is negative, treatment options include repeated standard-dose chemotherapy, radiation, or high-dose chemotherapy with stem cell transplant. A retrial of conventional-dose chemotherapy may achieve long remissions in patients with late (ie, > 1 year) relapse; this patient would be considered borderline in this regard.[1]

Radiotherapy for salvage of chemotherapy failures was described by the Stanford group for patients with limited nodal relapse. Treatment consists of total nodal irradiation (not just radiation to the relapsed site), and the salvage rate in selected patients was 26%.[2] It is likely that this patient with B symptoms would not be a good candidate for this therapy. Likewise, repeating the previous mediastinal radiation will be prohibitive in terms of spinal cord, pulmonary, and cardiac toxicity.

What remains is the third option: high-dose chemotherapy and stem cell rescue. Today, this is considered standard of care, demonstrating better results than standard-dose chemotherapy,[3] and should be well tolerated by this young patient. He should therefore be referred to a bone marrow transplantation service.

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