Hodgkin Lymphoma
Diagnosis & Staging

Updated: March 2011

Management of Relapsed & Refractory Hodgkin Lymphoma

The diagnosis and management of Hodgkin Lymphoma at initial presentation is covered in some detail on the BC Cancer Agency website. The scope of this management guideline will focus on the role of stem cell transplantation in the management of relapsed and refractory Hodgkin lymphoma.

Diagnosis & Staging

Definitions

Relapsed Hodgkin lymphoma is defined as relapse of previously treated Hodgkin lymphoma more than three months following completion of all planned chemotherapy and/or radiation therapy.

Primary refractory Hodgkin lymphoma is defined as disease which has failed to respond to initial standard therapy OR disease which has been shown to progress within three months of completion of a standard course of treatment.

Background:

High dose chemotherapy and autologous stem cell transplant  improves progression free survival in patients with relapsed and primary refractory Hodgkin Lymphoma as demonstrated in two randomized controlled trials (Schmitz N et al, Lancet 2002; Linch DC et al Lancet 1993). Multiple subsequent trials have demonstrated long term disease free survival in the order of 50% for patients with HL in first relapse/progression treated with HDC/ASCT (Yuen et al Blood 1997; experience from here Lavoie et al Blood 2005). For patients treated in first relapse, progression free survival is in the order of 62%. For primary progressive disease, progression free survival of 31%-39% has been reported, even in patients who did not respond to salvage chemotherapy pre HDT/ASCT (31% PFS at 5 years - Josting et al Blood 2000, 39% PFS at 15 years Lavoie et al Blood 2005). These results are clearly superior to survival historically reported with chemotherapy salvage alone 17% at 20 years for relapsed Hodgkin Lymphoma (Longo et al JCO 1992; Yuen AR et al Blood 1997 89; 814-22 Stanford non randomized experience)

Diagnosis of Relapse or Progression:

Disease relapse is, when possible, confirmed by biopsy. Biopsy confirmation of relapse is especially important for late cases of relapse (greater than 5 years), where secondary malignancy is in the differential diagnosis. Restaging CT scans of neck, thorax, abdomen and pelvis should also be part of the relapse/ progression workup.

Bone marrow aspirate and biopsy is performed in all cases as part of restaging.

Referral of the patient to the Leukemia and BMT Program of BC for assessment is made at the diagnosis of relapse.

PET scanning has been shown to be predictive of outcome post HDT/SCT when performed after salvage chemotherapy and before autologous transplant. Timing of the PET scan is important - these should not be performed less than 3 weeks from the most recent cycle of chemotherapy (Juweid ME et al, JCO 2007 Consensus statement). GCSF used for stem cell collection can alter the bone marrow signal on PET scan and similarly, PET scans should be interpreted with caution if performed within <3 weeks of high dose GCSF. (Kazama et al Eur J Med Mol Imaging 2005)

The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use.