TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we pick a challenging clinical question submitted through the Consult a Colleague program and
post the expert’s response, but we also want to know what you would do. Send in your response to next month’s clinical dilemma and
see how your answer matches up to the expert’s in the next print issue.
This month, David Straus, MD, discusses treatment options for a young woman with stage 2a Hodgkin lymphoma and fertility concerns.
Clinical Dilemma:
I have a 22-year-old female patient with stage 2a lymphocyte-predominant Hodgkin lymphoma involving lymph nodes
in the pelvis. She presented while pregnant. (She has since delivered a healthy child.) Her disease is progressing slowly,
but a recent CT scan showed slightly increasing nodes, so she needs to begin therapy. The radiation oncologist does not
want to treat her because it may affect future fertility. I sent her to a fertility clinic that recommended harvesting eggs,
but the patient refused and “will let God decide” whether she has children. I have presented her case at our lymphoma
rounds and the recommendation was for six cycles of R-CHOP rather than an ABVD regimen. What would you do? If
R-CHOP is the right approach, would you add an LHRH agonist?
Expert Opinion
Consult a Colleague is a service for ASH
members that helps facilitate the exchange
of information between hematologists
and their peers. ASH members can
seek consultation on clinical cases from
qualified experts in 11 categories:
David Straus, MD
Attending Physician, Lymphoma Service
Memorial Sloan Kettering Cancer Center
New York, NY
I don’t know the clinical details on
this patient, but a slight increase in
adenopathy would often not be a
reason to treat unless transformation
is documented by biopsy. I am very
conservative with patients with this
diagnosis because they usually have
an excellent outcome regardless of
whether they are treated. I would try
to defer treatment if possible.
Sven Borchmann, MD, pre-
sented our experience at Memorial
Sloan Kettering Cancer Center with
management of nodular lymphocyte
predominant Hodgkin lymphoma
at the 2017 ASH annual meeting,
and a manuscript is undergoing
revisions for publication. 1 The
analysis included 163 patients seen
between 1974 and 2016. The median
follow-up time was 5.7 years (range
= 0.3 -42.7) and 24.5 percent of
patients were followed for at least 10
years. Initial management was active
surveillance in 37 patients (22.7%)
and active treatment – including
radiation therapy only, rituximab
monotherapy, chemotherapy with
or without rituximab, and combined
chemotherapy and radiation therapy
with or without rituximab – in 126
patients (77.3%). There was no
difference in 10-year overall survival
(96.6%) or second progression after
active treatment (92.5%) in either active surveillance
or active treatment groups. Transformation to more
aggressive non-Hodgkin lymphoma was approximately
1 percent/year in both groups. Treatment-related deaths
exceeded deaths due to lymphoma. Bulky disease and
extranodal disease were identified as possible risk factors
for progression.
REFERENCE
Borchmann S, Joffe E, Moskowitz CH, et al. Active surveillance for newly diagnosed nodular
lymphocyte-predominant Hodgkin lymphoma. Blood. 2017;130(suppl 1):654.
ASHClinicalNews.org
Consult a Colleague
Through ASH
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative neoplasms
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult a Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
Next Month’s Clinical Dilemma:
I have a 66-year-old female patient recently diagnosed
with Philadelphia chromosome–positive B-cell acute
lymphocytic leukemia (ALL). Conventional cytogenetics
showed hyperdiploid karyotype plus FISH/PCR positive
for BCR-ABL. After four cycles of hyper-CVAD (cyclo-
phosphamide, vincristine, doxorubicin, dexamethasone)
plus dasatinib, PCR is negative. Bone marrow aspirate
is also negative for ALL. Should she be considered for
allogeneic hematopoietic cell transplantation?
How would you respond? Email us at
[email protected]. ●
* If you have a request related to a
hematologic disorder not listed here,
please email your recommendation to
[email protected] so it can be
considered for addition in the future.
DISCLAIMER: ASH does not recommend
or endorse any specific tests, physicians,
products, procedures, or opinions, and
disclaims any representation, warranty, or
guaranty as to the same. Reliance on any
information provided in this article is solely
at your own risk.
ASH Clinical News
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