You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts’ in the next print issue.
This month, John Sweetenham, MD, advises on treatment options for an
elderly patient with Hodgkin lymphoma.
Clinical Dilemma:
I have a 90-year-old female patient with relatively poor performance status and newly diagnosed bulky, symptomatic
Hodgkin lymphoma. What treatment options does she have – chemotherapy with ABVD (doxorubicin [Adriamycin],
bleomycin, vinblastine, and dacarbazine), gemcitabine as a single agent, brentuximab vedotin, others? I worry that she
won’t be able to tolerate ABVD.
Experts Make the Call
Next Month’s Clinical Dilemma:
I have a 23-year-old male patient
with nodular sclerosis classical Hodgkin lymphoma – stage IIIb with bulky
mediastinal disease and an International Prognostic Index score of 3. He has
received two cycles of ABVD, resulting in a 21 percent decrease in carbon
monoxide diffusing capasity (DLCO) and
symptomatic bleomycin lung toxicity. A
18-fluorodeoxyglucose (FDG) positron
emission tomography (PET) scan after
two cycles revealed two persistent areas
of FDG avidity: persistent disease versus
disease secondary to inflammation from
bleomycin lung damage. His symptoms
did improve with steroid treatment.
Subsequently, he received four cycles of
ABVD. A PET scan performed after four
cycles of chemtherapy was negative, and
we are currently awaiting a post-treatment PET scan.
In someone with bleomycin lung injury,
Would you recommend radiation therapy
post-chemotherapy, due to initial bulky
disease and persistent FDG avidity in
interim PET scan?
John Sweetenham, MD
Senior Director of Clinical Affairs
Executive Medical Director
Huntsman Cancer Institute
Salt Lake City, UT
As you know, treatment of Hodgkin lymphoma in elderly
patients is challenging – mainly due to the risks of excessive treatment-related toxicity, and the fact that older
patients with the disease have a significantly worse prognosis than younger patients. Since your patient is not a
candidate for ABVD, I am assuming that her performance status is also poor, which will limit therapeutic options.
I think brentuximab vedotin is worth considering in this scenario. The risk of peripheral neuropathy associated
with this treatment, however, can be dose-limiting. Even so, I think this is one of the most active single agents for
Hodgkin lymphoma and a reasonable option – especially because the peripheral neuropathy can be managed by
dose reduction if it interferes with her activities of daily living.
Since this is a palliative rather than curative situation, oral chlorambucil is another option to consider if the
patient does not tolerate brentuximab vedotin. I know it sounds unlikely, but chlorambucil does have single-agent
activity in Hodgkin lymphoma and was a component of front-line regimens for Hodgkin lymphoma in younger
patients in Europe for many years. It is certainly well tolerated.
Finally, rituximab as a single agent may also be worth considering. It has a 20 to 30 percent response rate in classical Hodgkin lymphoma, and I have had some impressive anecdotal experiences with this approach.
How would you respond? Email us at
[email protected].
Consult a Colleague Through ASH 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:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macgroglobulinemia
• Myeloproliferative Disorders
• Myelodysplastic Syndromes
• Thrombocytopenias
Assigned volunteer (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
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.
38
ASH Clinical News
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.
*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.
March 2015