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, George P. Canellos, MD, advises on treatment options for a young
patient with Hodgkin lymphoma and bleomycin lung injury.
Clinical Dilemma:
A 23-year-old male patient with nodular sclerosis classical Hodgkin lymphoma – stage IIIb with bulky mediastinal
disease, International Prognostic Index score of 3 points. He has received two cycles of ABVD, resulting in a 21 percent
decrease in carbon monoxide diffusing capacity (DLCO) and symptomatic bleomycin lung toxicity. An 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 chemotherapy was negative, and we are currently awaiting a post-treatment PET scan.
Experts Make the Call
George P. Canellos, MD
William Rosenberg Professor of Medicine
Harvard Medical School
Dana-Farber Cancer Institute
Boston, MA
I would say you did the right thing by giving ABVD to complete
the chemotherapy regimen. Because the patient is only 23 years
old, I would be cautious about radiation therapy – given the high
risk of long-term cardiac toxicity. If he is indeed PET-negative,
there is a chance that he is already cured.
However, there is a 10 to 20 percent chance of disease recurrence. But, being that he has stage IIIb disease, the patient’s disease could recur anywhere.
I would follow the patient closely with CT or PET/CT scans repeated at six months. If the disease recurs only
in the mediastinum, then a cycle of ABVD followed by radiation therapy to the mediastinum – if this is the only
site of relapse – would be advisable. In a PET-negative circumstance, I would say six months is a liberal interval
of time, but I assume the patient will be seen sooner on a clinical basis. In fact, one could say that the longer the
PET remains negative, the less likely a relapse will occur.
It would worry me if an early mediastinal relapse occurred because it was not confined to that site and the
disease may recur in other sites over time.
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.
Next Month’s Clinical Dilemma:
I have a 32-year-old male patient with no
cardiovascular risk factors who had what
looks to be an idiopathic renal infarct. The
radiologist feels that the infarct was likely
arterial in origin, but no source of the clot
has been found. Results from the CT angiography of the entire aorta and embolic
work-up (including 48-hour Holter monitoring for atrial fibrillation) have been
negative to date – so have the results
from my APLA/PNH/MPN work-up.
In this instance, how long should
anticoagulation last? I am unsure what
duration to recommend because the
infarct was arterial and idiopathic. Data
for this circumstance seem to be scarce,
and I have read that the duration should
be anywhere from 6 to 12 months to
indefinitely. While I am worried about
recurrence – given he had this thrombosis
at such a young age – I am also cognizant
of the burden that lifelong anticoagulation will bring.
How would you respond? Email us at
[email protected].
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and th eir 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).
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
April 2015