Initial dose intensity has limited impact on the outcome of ABVD chemotherapy for advanced Hodgkin lymphoma (HL): data from UKLG LY09 (ISRCTN97144519)

Treatment outcomes and relative dose intensity of chemotherapy in patients with advanced Hodgkin lymphoma

The present retrospective study was undertaken to investigate the association of relative dose intensity (RDI) with the outcome of patients with advanced stage Hodgkin lymphoma (HL) receiving ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and escalated BEACOPP regimens (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone). A total of 114 patients with HL treated between 2004 and 2013 were enrolled for evaluation. The association of variables with overall survival (OS) and progression-free survival (PFS) was analysed using univariate and multivariate Cox proportional hazards models. The median age of patients was 39 years, and the majority were male and had stage IV disease. A total of 54 patients received ABVD and 60 received BEACOPP chemotherapy with 24 and four deaths, respectively. Patients in the BEACOPP group were significantly younger with lower Charlson comorbidity index (CCI) and better performance status in comparison with the ABVD group, making the comparison of groups not possible. In the ABVD group, RDI was not significantly associated with OS (P=0.590) or PFS (P=0.354) in a multivariate model where age was controlled. The low number of events prevented this analysis in the BEACOPP group. The age of patients was strongly associated with both OS and PFS; all statistically significant predictors for OS and PFS from univariate analyses (chemotherapy regimen, CCI, RDI, performance status) lost their effect in multivariate analyses where age was controlled. Based on these observations, it was concluded that RDI was not associated with OS or PFS after age is controlled, neither in all patients combined nor in the ABVD group.

Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation

PURPOSE

Hodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented.

METHODS

We conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes.

RESULTS

Eighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival.

CONCLUSION

Treating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.

Quantitative analysis of basal and interim PET/CT images for predicting tumor recurrence in patients with Hodgkin's lymphoma

OBJECTIVES

The qualitative analysis of interim PET has been reported to be useful for predicting the outcome of Hodgkin's lymphoma (HL) after chemotherapy. As the next step, our study aims to present a quantitative analysis on the basis of both a basal (PET/CT0) and an interim (PET/CT2) scan to improve the prognostic value of imaging in HL patients.

PATIENTS AND METHODS

A cohort of 68 patients undergoing a basal and an interim scan with F-fluorodeoxyglucose after two cycles of chemotherapy consisting of adriamycin, bleomycin, vinblastine, and dacarbazine were examined. Two subsets of patients with a positive and a negative interim scan were selected.

RESULTS

In patients with a negative scan, a total of 108 lymph node lesions showing a good response to chemotherapy were contoured, whereas in the remaining patients with positive scans, six responder and 12 relapsing lymph node lesions were contoured. Standardized uptake value (SUV) and Hounsfield unit (HU) values were included in the volumes contoured on coregistered basal and interim scans and included in a database. A linear regression model was used to identify the predictor of relapse at the lesion level. The support vector machine analysis and bootstrap approach were used to determine the model capability. The predictive models were presented as nomograms on the basis of basal or both basal and interim studies. SUV at the basal/interim study and basal HU values were predictors of a poor prognosis. In particular, the higher points were associated with lower values of SUV and HU at baseline and the higher values of SUV at the interim study. Using the bootstrap and support vector machine approach, the cut-off of the model increased up to 89%.

CONCLUSION

The novel tool enables estimation of the risk of tumor relapse after chemotherapy in HL patients on the basis of basal and interim PET/CT scans including SUV and densitometric information.

Initial staging of Hodgkin's disease: role of contrast-enhanced 18F FDG PET/CT

The objective of this study was to compare the diagnostic accuracy of positron emission tomography/low-dose computed tomography (PET/ldCT) versus the same technique implemented by contrast-enhanced computed tomography (ceCT) in staging Hodgkin's disease (HD).Forty patients (18 men and 22 women, mean age 30 ± 9.6) with biopsy-proven HD underwent a PET/ldCT study for initial staging including an unenhanced low-dose computed tomography for attenuation correction with positron emission tomography acquisition and a ceCT, performed at the end of the PET/ldCT scan, in the same exam session. A detailed datasheet was generated for illness locations for separate imaging modality comparison and then merged in order to compare the separate imaging method results (PET/ldCT and ceCT) versus merged results positron emission tomography/contrast-enhanced computed tomography (PET/ceCT). The nodal and extranodal lesions detected by each technique were then compared with follow-up data that served as the reference standard.No significant differences were found at staging between PET/ldCT and PET/ceCT in our series. One hundred and eighty four stations of nodal involvement have been found with no differences in both modalities. Extranodal involvement was identified in 26 sites by PET/ldCT and in 28 by PET/ceCT. We did not find significant differences concerning the stage (Ann Arbor).Our study shows a good concordance and conjunction between PET/ldCT and ceCT in both nodal and extranodal sites in the initial staging of HD, suggesting that PET/ldCT could suffice in most of these patients.

Factors affecting intrapatient liver and mediastinal blood pool ¹⁸F-FDG standardized uptake value changes during ABVD chemotherapy in Hodgkin's lymphoma

PURPOSE

The aim of our study was to assess the intrapatient variability of 2-deoxy-2-((18)F)-fluoro-D-glucose ((18)F-FDG) uptake in the liver and in the mediastinum among patients with Hodgkin's lymphoma (HL) treated with doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy (CHT).

METHODS

The study included 68 patients (30 men, 38 women; mean age 32 ± 11 years) with biopsy-proven HL. According to Ann Arbor criteria, 6 were stage I, 34 were stage II, 12 were stage 3 and 16 were stage 4. All of them underwent a baseline (PET0) and an interim (PET2) (18)F-FDG whole-body positron emission tomography (PET)/CT. All patients were treated after PET0 with two ABVD cycles for 2 months that ended 15 ± 5 days prior to the PET2 examination. All patients were further evaluated 15 ± 6 days after four additional ABVD cycles (PET6). None of the patients presented a serum glucose level higher than 107 mg/dl. The mean and maximum standardized uptake values (SUV) of the liver and mediastinum were calculated using the same standard protocol for PET0, PET2 and PET6, respectively. Data were examined by means of the Wilcoxon matched pairs test and linear regression analysis.

RESULTS

The main results of our study were an increased liver SUVmean in PET2 (1.76 ± 0.35) as compared with that of PET0 (1.57 ± 0.31; p < 0.0001) and PET6 (1.69 ± 0.28; p = 0.0407). The same results were obtained when considering liver SUVmax in PET2 (3.13 ± 0.67) as compared with that of PET0 (2.82 ± 0.64; p < 0.0001) and PET6 (2.96 ± 0.52; p = 0.0105). No significant differences were obtained when comparing mediastinum SUVmean and SUVmax in PET0, PET2 and PET6 (p > 0.05). Another finding is a relationship in PET0 between liver SUVmean and SUVmax with the stage, which was lower in those patients with advanced disease (r (2) = 0.1456 and p = 0.0013 for SUVmean and r (2) = 0.1277 and p = 0.0028 for SUVmax).

CONCLUSION

The results of our study suggest that liver (18)F-FDG uptake is variable in patients with HL during the CHT treatment and the disease course and should be considered carefully when used to define the response to therapy in the interim PET in HL.

Is cerebral glucose metabolism affected by chemotherapy in patients with Hodgkin's lymphoma?

OBJECTIVE

The aim of the study was to investigate the effect of chemotherapy treatment with ABVD on brain glucose metabolism in patients with Hodgkin's disease (HD).

METHODS

A total of 49 patients (23 men, 26 women; mean age 32±9 years) diagnosed with HD were included in the study. All of them underwent a baseline (PET0) and an interim (PET2) 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F-FDG) PET/computed tomography (CT) brain scan. All patients were treated after PET0 with two cycles of ABVD consisting of doxorubicin (adriamycin), bleomycin, vinblastine, and dacarbazine for 2 months. Thirty-five patients were evaluated further 15±6 days after four additional cycles (PET6). Differences in brain (18)F-FDG uptake were analyzed by statistical parametric mapping (SPM2).

RESULTS

Compared with PET0, PET2 showed a significantly higher metabolic activity in the right angular gyrus (Brodmann area 39) and a significant metabolic reduction in Brodmann areas 10, 11, and 32 bilaterally. All these changes disappeared at PET6.

CONCLUSION

Our results support the conclusion of a very limited impact of ABVD chemotherapy on brain metabolism in patients with HD.

Granulocyte colony-stimulating factor as secondary prophylaxis of febrile neutropenia in the management of advanced-stage Hodgkin lymphoma treated with adriamycin, bleomycin, vinblastine and dacarbazine chemotherapy: a decision analysis

Current practice guidelines are unclear regarding the role of secondary prophylaxis of febrile neutropenia in advanced-stage Hodgkin lymphoma despite several small retrospective studies that demonstrate the omission of growth factors to be a safe and economic practice. We used a decision-analytic model to compare secondary prophylaxis with granulocyte colony-stimulating factor (G-CSF) to no G-CSF with the onset of severe neutropenia for a hypothetical cohort of patients with advanced-stage Hodgkin lymphoma treated with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). There was a net benefit of 0.017 years and 0.037 quality-adjusted life years for no G-CSF use in severe neutropenia. On microsimulation (10 000 trials), 96% of the simulations showed that the no G-CSF strategy is preferred to the use of G-CSF. This finding was robust across a wide range of sensitivity analyses. Our analysis suggests that G-CSF not be used as secondary prophylaxis of febrile neutropenia in advanced-stage Hodgkin lymphoma.

Reduced relative dose intensity of primary chemotherapy does not influence prognosis of patients with Hodgkin lymphoma

AIMS

A retrospective analysis of patients with Hodgkin lymphoma (HL) was performed to assess their outcome regarding relative dose intensity (RDI) of chemotherapy administered in primary treatment.

METHODS

A total of 194 patients were divided into three groups with different RDI of primary chemotherapy (100%, 90-99% and <90%). Reduced RDI in two groups (90-99% and <90%) was caused by the delay of the interval between the administration of some chemotherapeutic courses. The probability of complete remission (CR), disease relapse, event-free survival (EFS) and overall survival (OS) as the basic parameters of patient outcome were statistically compared.

RESULTS

Multivariate analysis showed here were no significant differences in probability of CR (HR 0.9, 95% CI [0.75-1.08], P=0.5), risk of relapse (HR 1.34, 95% CI [0.92-1.94], P=0.11) or death (HR 1.52, 95% CI [0.94-2.5], P=0.13). There were also no significant differences in probability of EFS (mean 13 vs. 10 vs. 12 years, P=0.17; HR 1.54, 95% CI [0.91-2.6], P=0.22) or OS (mean 15 vs. 13 vs. 14 years, P=0.13; HR 1.52, 95% CI [0.93-2.5], P=0.13).

CONCLUSION

We found no significant impact of primary chemotherapy delay resulting in reduced RDI on outcome in HL patients.

Long-term survival after treatment for Hodgkin's disease (1973-2002): improved survival with successive 10-year cohorts

Background:

The Nottinghamshire Lymphoma Registry contains the details of all the patients diagnosed with lymphoma (since 1 January 1973) within a defined geographical area with a population of 1.1 million. It was therefore possible to study the outcome of treatment for Hodgkin’s disease for three 10-year cohorts (1973–1982, 1983–1992 and 1993–2002).

The aims of the study were to compare survival time among the three patient cohorts, to identify prognostic factors and to estimate relative survival.

Methods:

A total of 745 patients diagnosed between 1973 and 2002 were analysed for survival. Survivorship was estimated by the Kaplan-Meier method and parametric survival models. An accelerated failure-time regression was used for multivariate analysis.

Results:

Overall, patients were observed for 9.8 (0.3–34.82) years (median(range)), on average. One, five and fifteen-year disease-specific survival was found to be 87% (85–90%), 77% (74–80%) and 70% (67–74%), respectively. For those for diagnosed between 1973 and 1982, the 15-year survival was found to be 57% for 1983–1992, it was 74% and for 1993–2002, it was 83% (P<0.001). The difference remained significant after adjusting for prognostic factors. The actuarial risk of developing a second malignancy at 20 years was for the 1973–1982 cohort, 12.4%, and for the 1983–1992 cohort, 18.8%.

Conclusion:

Treatment advances and effective management of toxicities of treatment over time, have resulted in a significantly longer survival for patients with Hodgkin’s disease diagnosed within a defined population.