Management of fertility in patients treated for Hodgkin's lymphoma

Fertility status of Hodgkin lymphoma patients treated with chemotherapy and adjuvant gonadotropin-releasing hormone analogues

PURPOSE

Aim of this prospective observational study was to analyze fertility status of Hodgkin lymphoma (HL) patients treated with different types of chemotherapy while receiving GnRH analogues to preserve ovarian function.

METHODS

Fertility status was assessed among 108 females in reproductive age treated by curative chemotherapy for freshly diagnosed HL between 2005 and 2010 in university-based tertiary fertility and oncology center. All patients received GnRH analogues during chemotherapy to preserve their ovarian function. Their reproductive functions were assessed by follicle-stimulating hormone (FSH) measurement and pregnancy achievement. Ovarian function was determined separately in three groups with increasing gonadotoxicity of chemotherapy.

RESULTS

One year following the treatment, normal ovarian function was found in 89 (82.4%) of patients. Two years after chemotherapy, 98 (90.7%) of patients retained their ovarian function, and 23 (21.3%) achieved clinical pregnancy during the follow-up period. Average FSH after chemotherapy was 11.6 ± 17.9 IU/l 1 year after the treatment resp. 9.0 ± 13.8 at the 2 years interval. There were significantly more patients with chemotherapy induced diminished ovarian reserve (chDOR) among the group receiving escalated BEACOPP chemotherapy in comparison with the other types of treatment (58.1% vs. 87.9% resp. 95.5%).

CONCLUSION

The rate of chDOR is significantly higher after EB poly-chemotherapy and there is no tendency for improvement in time. The 2 + 2 chemotherapy with GnRH-a required for more advanced HL retained ovarian function significantly better after 2 years. Another important advantage of GnRH-a co-treatment is the excellent control of patient's menstrual cycle.

Feasibility of VECOPA, a dose-intensive chemotherapy regimen for children and adolescents with intermediate and advanced stage Hodgkin lymphoma: results of the GPOH-HD-2002/VECOPA pilot trial

The GPOH-HD (Gesellschaft für Pädiatrische Onkologie und Hämatologie-Hodgkin Disease) strategy for children and adolescents with intermediate and advanced stage Hodgkin lymphoma is based on two induction cycles of OEPA (vincristine, etoposide, prednisone, doxorubicin) followed by COPP (cyclophosphamide, vincristine, procarbazine, prednisone) or COPDAC (cyclophosphamide, vincristine, prednisone, dacarbazine) consolidation. The feasibility and efficacy of an intensified procarbazine-free consolidation regimen VECOPA (vinblastine, etoposide, cyclophosphamide, vincristine, prednisone, doxorubicin) were investigated. Following two OEPA and one or two VECOPA cycles, involved field radiotherapy was applied. The main endpoint was feasibility. Secondary endpoints were toxicity, proportion of delayed cycles, granulocyte-colony stimulating factor use, and event-free and overall survival. The regimen was well tolerated with mostly hematotoxicity exceeding Common Toxicity Criteria grade 2. In most patients with advanced stage the second VECOPA cycle was delayed despite hematopoietic recovery and absence of serious adverse events. Event-free survival at 36 months was 0.86 (95% confidence interval 0.70-1). The VECOPA regimen is effective and tolerable. However, its time-intensification was not fully exploited within this trial.

Fertility preservation in young females with hematological malignancies

Impaired reproductive function and possible infertility are major concerns in long-term survivors of hematological malignancies. The ongoing increase in the survival rates of these patients is therefore accompanied with a growing demand for effective, safe and specifically tailored fertility preservation options. When approaching patients facing hematological malignancy, an individual evaluation of potential infertility risks and possible preventive or preserving measures should be performed. This review aims to provide up-to-date knowledge on female reproductive risks, and ovarian, uterine and genital injuries associated with therapy regimens currently used in hemato-oncological disorders. Recent progress in fertility preservation methods including ovarian tissue cryopreservation and transplantation, egg and embryo freezing, ovarian transposition and their specific role in hematological disorders are presented. The efficacy of these methods, possible risks and future challenges are critically discussed.

Ovarian tissue cryopreservation: a committee opinion

Ovarian tissue cryopreservation is an option to preserve reproductive potential in patients who must urgently undergo aggressive chemotherapy and/or radiotherapy or who have other medical conditions requiring treatment that may threaten ovarian function and subsequent fertility. Ovarian tissue cryopreservation may be the only option available to prepubertal girls undergoing such treatments. However, these techniques are still considered to be experimental. This document outlines the current technology, clinical outcomes, and risks of ovarian tissue cryopreservation and recommendations for clinical applications. This document and the document "Mature Oocyte Cryopreservation: A Guideline" published in 2013 (Fertil Steril 2013;99:37-43) replace the document "Ovarian Tissue and Oocyte Cryopreservation" last published in 2008 (Fertil Steril 2008;90:S241-6).

Which tools may help physicians in female fertility prediction after autologous bone marrow transplantation for lymphoma? A pilot study

OBJECTIVE(S)

The report of our experience on fertility preservation and the validation of some tools useful to predict fertility in young females who underwent haematopoietic cell transplantation for their lymphoma.

STUDY DESIGN

A retrospective study involving 17 consecutive women of child-bearing age affected by lymphoma and submitted to haematopoietic cell transplantation in our centre.

RESULTS

We described a high rate of parenthood in our patient series: 5 out of 17 (29%) patients became pregnant and 1 out of 5 had two pregnancies. It is suggestive that only patients who received gonadotropin-releasing hormone (GnRH) analogues co-treatment conceaved. Antral follicles number or ovarian volume, ascertained through transvaginal ultrasound before starting treatment, more than anti-Mullerian hormone (AMH) value, are tools that may help physicians to better predict fertility in young females of child-bearing age affected by lymphoma who desire to get pregnant after cancer cares.

CONCLUSION(S)

The high rate of maternity we recorded may lead to comfort the young women who hope to become pregnant after cancer cares because pregnancy is possible in a certain percentage of cases even after highly toxic treatments to the ovaries. A higher ovarian volume or a higher number of antral follicles, before treatment start, ensures a greater chance of successful pregnancies. AMH value in lymphoma survivors is not sufficient to guide physicians in fertility predictions.

Brentuximab vedotin combined with ABVD or AVD for patients with newly diagnosed Hodgkin's lymphoma: a phase 1, open-label, dose-escalation study

BACKGROUND

Roughly 70-80% of patients with advanced stage Hodgkin's lymphoma are cured with various first-line and second-line treatments, including ABVD, BEACOPP, and stem-cell transplantation. Brentuximab vedotin has shown significant clinical activity, with a manageable safety profile, in patients with relapsed or refractory Hodgkin's lymphoma. We aimed to assess the safety and early clinical efficacy of this drug as first-line treatment in combination with standard or modified-standard treatment in patients with previously untreated Hodgkin's lymphoma.

METHODS

We did a phase 1, open-label, dose-escalation safety study comparing brentuximab vedotin in combination with standard (ABVD) or a modified-standard (AVD) treatment. Patients were enrolled into the groups sequentially. Main entry criteria were newly diagnosed, treatment-naive, CD30-positive patients with Hodgkin's lymphoma who had histologically confirmed stage IIA bulky disease or stage IIB-IV disease and an Eastern Cooperative Oncology Group performance status of two or less. Patients received doses of 0·6, 0·9, or 1·2 mg/kg brentuximab vedotin by intravenous infusion every 2 weeks with either ABVD (25 mg/m(2) doxorubicin, 10 units/m(2) bleomycin, 6 mg/m(2) vinblastine, and 375 mg/m(2) dacarbazine) or AVD (ABVD modified regimen without the inclusion of bleomycin) for up to six cycles. Our primary objectives were to assess the safety profile and establish the maximum tolerated dose (MTD) of brentuximab vedotin in combination with ABVD and AVD. The safety profile and MTD was assessed for the safety population. The study has completed and the final analysis is presented. This study was registered with ClinicalTrials.gov, number NCT01060904.

FINDINGS

Between Jan 29, 2010, and Sept 17, 2012, 51 patients were enrolled and received at least one dose of brentuximab vedotin. The maximum tolerated dose of brentuximab vedotin when combined with ABVD or AVD was not exceeded at 1·2 mg/kg. 21 (95%) of 22 patients given brentuximab vedotin and ABVD achieved complete remission, as did 24 (96%) of 25 patients given brentuximab vedotin and AVD. Adverse events were generally grade 1 or 2; however, an unacceptable number of patients in the brentuximab vedotin and ABVD groups had pulmonary toxic effects (11 [44%] of 25), which exceeded the historical incidence for ABVD alone. No patients experienced pulmonary toxic effects when treated with brentuximab vedotin plus AVD. The most common grade 3 or worse events were neutropenia (20 [80%] of 25 patients in the brentuximab vedotin and ABVD group vs 20 [77%] of 26 patients in the brentuximab vedotin and AVD group), anaemia (five [20%] vs three [12%]), febrile neutropenia (five [20%] vs two [8%]), pulmonary toxic effects (six [24%] vs 0), syncope (three [12%] vs two [8%]), dyspnoea (three [12%] vs one [4%]), pulmonary embolism (three [12%] vs 0), fatigue (one [4%] each), and leucopenia (one [4%] each). Serious events occured in 41% of all patients (14 [56%] in the brentuximab vedotin and ABVD group and seven [27%] in the brentuximab vedotin and AVD group). Serious events occurring in 10% of patients or more overall were febrile neutropenia (four [16%] in the brentuximab vedotin and ABVD group vs two [8%] in the brentuximab vedotin and AVD group), and, in the brentuximab vedotin and ABVD group only, pulmonary toxic effects (six [24%]).

INTERPRETATION

Brentuximab vedotin should not be given with bleomycin in general or specifically as first-line therapy for patients with treatment naive, advanced stage Hodgkin's lymphoma. 1·2 mg/kg brentuximab vedotin combined with AVD given every 2 weeks was generally well tolerated by patients. At present, a phase 3 trial comparing brentuximab vedotin plus AVD to ABVD alone is ongoing (ClinicalTrials.gov, number NCT01712490) and will formally assess whether brentuximab vedotin plus AVD might redefine therapy in treatment-naive patients with Hodgkin's lymphoma.

FUNDING

Seattle Genetics Inc and Takeda Pharmaceuticals International Co.

Study of the prevalence of azoospermia in patients with Hodgkin's lymphoma prior to treatment

Background:

Infertility is one of the main problems of patients with Hodgkin's lymphoma, as this causes specific effects in the social, family, and emotional life of patients. Hodgkin's lymphoma is a neoplastic disorder that comprises of 0.6% of all cancers and often occurs in middle-aged people, with a mean age of 26 years. It originates from neoplastic changes in the lymphoid cells, which lead to different complications in the body organs. One important complication of Hodgkin's lymphoma is humoral and cellular immune system dysfunction that can cause numerous and dangerous problems for patients. Another complication of Hodgkin's lymphoma is sterility, more specifically hypogonadism and azoospermia. Sterility may appear after treatment. Considering that most patients with Hodgkin's lymphoma have a good survival, diagnosing and treating this complication and preventing its incidence contributes to improving the quality of social life and emotional status of these patients.

Materials and Methods:

In this study, 238 patients whose Hodgkin's lymphoma was approved by Pathology were included in the study, before receiving any medical intervention, and they were examined for sterility (sperm status). Sterility of the male patients was confirmed using a spermogram test. The serum levels of the luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone (T) were checked.

Results:

Among the studied patients, 24 patients (10.08%) suffered from azoospermia, which was evident in its progressive stages.

Conclusion:

In such cases, treatment of Hodgkin's lymphoma and improvement of the immune system could overcome azoospermia and sterility.

Anti-Müllerian hormone and antral follicle count reveal a late impairment of ovarian reserve in patients undergoing low-gonadotoxic regimens for hematological malignancies

The impact of cancer therapy on the reproductive potential of patients is increasingly recognized because survival rates of patients have clearly improved in recent years. Different fertility preservation methods, either generally accepted or still experimental, are currently available, and counseling of patients requires a delicate balance between the efficacy and side effects of the proposed method and the characteristics of both the tumor and the therapy. Deeper knowledge of the effects of cancer therapy on the reproductive potential of patients over time is required to identify the most appropriate fertility preservation method. In this paper, we report a case-control study in which female patients who were diagnosed with hematological malignancies and treated with chemotherapy and/or radiotherapy were compared with age-matched controls in terms of ovarian reserve, as measured by ultrasound examination and hormonal status. By stratifying patients for gonadotoxicity of the therapy received and time elapsed from the end of the therapy, we report that patients treated with low gonadotoxic therapies, while being similar to age-matched controls in their ovarian reserve when evaluated within a few years from the end of the therapy, show a clear impairment over longer times. We also report that anti-Müllerian hormone is the most sensitive hormonal parameter in detecting changes in ovarian reserve when compared with follicle-stimulating hormone or inhibin-B. This study stresses the importance of accurate counseling at the time of diagnosis of cancer and emphasizes the risks of infertility with low gonadotoxic therapies that may reduce the reproductive window of survivors.

Therapy-Related Late Adverse Events in Hodgkin’s Lymphoma

Hodgkin's lymphoma (HL) is one of the most curable hematologic diseases with an overall response rate over 80%. However, despite this therapeutic efficacy, HL survivors show a higher morbidity and mortality than other people of the same age because of long-term therapy-related events. In the last decades, many efforts have been made to reduce these effects through the reduction of chemotherapy dose, the use of less toxic chemotherapeutic agents, and the introduction of new radiation techniques. In this paper, we will describe the main long-term effects related to chemotherapy and radiotherapy for HL, the efforts to reduce toxicity made in the last years, and the clinical aspects which have to be taken into consideration in the followup of these patients.

[Fertility preservation among patients with cancer: report of a French regional practical experience]

OBJECTIVE

Improvement in cancer treatments has led to reconsider the importance of quality of life after cancer, especially concerning maintening the potential of fertility since it is often altered after healing. Our objective was to estimate the knowledge and practices of the physicians in the field of Oncology in a French Region (Provence Alpes- Côte d'Azur).

PATIENTS AND METHOD

Prospective survey, conducted between January and April 2012, amongst oncologists working in Provence Alpes Côte d'Azur region, through questionnaires distributed during multidisciplinary meetings in oncology.

RESULTS

Among 225 replies, 54% of the physicians had sent no patient to any oncofertility consultation during the previous six months (n=120). Besides, 33% of the oncologists (n=68) declared they had difficulties in addressing their patients to oncofertility consultation, and 58% of them (n=39) considered they lacked information on techniques and indications of fertility preservation.

CONCLUSION

This study provides an estimation of the current practices in PACA region concerning oncofertility and underlines the physicians' need of information. In this context, the regional oncology network has set up a regional network « cancer and fertility » in order to facilitate the access to fertility preservation prior to any potentially sterilizing treatment for all patients.

Fertility in female survivors of Hodgkin's lymphoma

Currently, Hodgkin's lymphoma is one of the most curable types of cancer. Patients are often young and so the long-term morbidities of treatment have become of increasing concern. Among these, infertility is one of the most challenging consequences for patients in reproductive age. Premature ovarian failure in premenopausal women is a serious long-term sequel of the toxicity of chemotherapy. The main consequence of this syndrome is infertility, but women also present other symptoms related to estrogen deprivation. Different rates of impaired gonadal function are reported, depending on the patient's age, stage of disease, dose and intensity of chemotherapy and the use of radiation therapy. The most established strategy in female infertility is cryopreservation of embryos after in vitro fertilization. Additionally, the use of oral contraceptives or gonadotropinreleasing hormone analogs (GnRH-a) during treatment is under study. This review will provide a general overview of the main studies conducted to evaluate the infertility rate among female Hodgkin's lymphoma survivors and risk factors associated to treatment, different end-point definitions for evaluating fertility and also a brief description of the available strategies for fertility preservation.

Fertility-preserving treatment options in patients with malignant hematological diseases

The number of patients of reproductive age diagnosed with various malignant hematological diseases increases every year. These patients undergo chemotherapy, radiotherapy, and various other treatments that may have gonadotoxic effects. The life expectancy of these patients is increasing rapidly due to the variety of treatment options. As such, an increasing number of patients-as well as their parents and spouses-express their concerns about the patient's fertility post treatment. In the present review it was aimed to provide an overview of current fertility-preserving treatment options and the future of fertility preservation.

Hodgkin's lymphoma in adults

Management of Hodgkin's lymphoma continues to develop. Outcomes for patients with favourable-risk, early-stage disease are excellent, and serial reductions in intensity of treatment have been made to retain the excellent prognosis while reducing the late effects of treatment. Prognosis is also very good in advanced-stage disease but the rate of relapse is higher than in early-stage disease, and the optimum first-line treatment is unclear. Workers are investigating the role of functional imaging to assess whether treatment can be tailored according to response, with the most intensive therapies reserved for patients predicted to have poor outcomes. In this Seminar we critically appraise the management of Hodgkin's lymphoma in early-stage disease, advanced-stage disease, and at relapse, with a focus on late effects of treatment.

Preservation of ovarian function and fertility despite gonadotoxic chemotherapy

The author aims to review the various strategies and avenues for fertility preservation despite gonadotoxic chemotherapy in young women. The recent increase in the survival of young patients has increased the worldwide attempts toward fertility preservation. The currently utilized methods are sperm cryopreservation and banking in male patients, and cryopreservation of embryos, unfertilized oocytes and ovarian tissue, as well as administration of gonadotropin-releasing hormone agonists (GnRH-a) before and during the gonadotoxic chemotherapy in young female patients. For those patients in whom pelvic irradiation is planned, ovariopexy is suggested. Since none of the suggested methods are ideal and none guarantees future fertility, a combination of several methods may optimize patients' chance of fertility preservation. GnRH-a co-treatment may reduce ovarian damage significantly in female patients treated with gonadotoxic chemotherapy. GnRH-a should be considered for women of reproductive age receiving gonadotoxic chemotherapy in addition to assisted reproduction and cryopreservation of embryos, oocytes and ovarian tissue.

Ovarian tissue and follicle transplantation as an option for fertility preservation

OBJECTIVE

To review and summarize data from the scientific literature on ovarian tissue and follicle transplantation as an option for fertility preservation.

DESIGN

Review of pertinent literature.

SETTING

University hospital.

PATIENT(S)

Women having undergone ovarian tissue transplantation.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Review of the literature.

RESULT(S)

Over the last decade, the field of ovarian transplantation and cryopreservation has significantly progressed, becoming applicable in humans. Indeed, fresh and frozen cortical ovarian tissue transplantations have been successfully reported worldwide, resulting in around 28 healthy babies. Although ovarian-tissue harvesting seems to be safe, the risk of reimplantation of cancer from ovarian cortical transplants cannot be estimated at this time. As a consequence, auto-transplantation of ovarian tissue in women having suffered from systemic hematological malignancies is not recommended. In these situations, reimplantation of isolated ovarian follicles might represent an interesting option in the future.

CONCLUSION(S)

Although the clinical experience is limited, the robust results obtained open new perspectives for the management of premature ovarian failure resulting or not from gonadotoxic treatments.

Recent advances in oocyte and ovarian tissue cryopreservation and transplantation

Options for preserving fertility in women include well-established methods such as fertility-sparing surgery, shielding to reduce radiation damage to reproductive organs, and emergency in-vitro fertilisation after controlled ovarian stimulation, with the aim of freezing embryos. The practice of transfering frozen or thawed embryos has been in place for over 25 years, and today is a routine clinical treatment in fertility clinics. Oocytes may also be frozen unfertilised for later thawing and fertilisation by intracytoplasmic sperm injection in vitro. In recent years, oocyte cryopreservation methods have further developed, reaching promising standards. More than 1000 children are born worldwide after fertilisation of frozen and thawed oocytes. Nevertheless, this technique is still considered experimental. In this chapter, we focus on options for fertility preservation still in development that can be offered to women. These include freezing of oocytes and ovarian cortex and the transplantation of ovarian tissue.

Chemotherapy and fertility

The overall increase in cancer prevalence and the significant increase in long-term survival have generated worldwide interest in preserving fertility in young women exposed to gonadotoxic chemo- and radiotherapy. Infertility represents one of the main long-term consequences of combination chemotherapy given for lymphoma, leukaemia and other malignancies in young women. The gonadotoxic effect of various chemotherapeutic agents is diverse, may involve a variety of pathophysiologic mechanisms, and is not unequivocally understood. Proliferating cells, such as in tissues with high turnover (i.e. bone marrow, gastrointestinal tract and growing ovarian follicles) are more vulnerable to the toxic effect of alkylating agents. These agents may also be cytotoxic to cells at rest, as they are not cell-cycle specific. Alkylating agents, the most gonadotoxic chemotherapeutic medications, cause dose-dependent, direct destruction of oocytes and follicular depletion, and may bring about cortical fibrosis and ovarian blood-vessel damage. The reported rate of premature ovarian failure after various diseases and chemotherapeutic protocols differ enormously, and depend mainly on the chemotherapeutic protocol used and age range of the woman. Several options have been proposed for preserving female fertility, despite gonadotoxic chemotherapy: ovarian transposition, cryopreservation of embryos, unfertilised metaphase-II oocytes and ovarian tissue, and administration of gonadotropin-releasing hormone agonistic analogs in an attempt to decrease the gonadotoxic effects of chemotherapy by simulating a prepubertal hormonal milieu. None of these methods is ideal and none guarantees future fertility in all survivors; therefore, a combination of methods is recommended for maximising women's chances of future fertility.