Hodgkin Lymphoma
Treatment Options & Assessment of Response
wwwUpdated: March 2011
Salvage Chemotherapy
Salvage chemotherapy is generally recommended to achieve some disease control and to prevent progression while arrangements for stem cell collection and pre-transplant organ function workup are underway. This process takes about 6 weeks in total, for non urgent cases. Standard salvage chemotherapy – usually GDP (gemcitabine, cisplatin and dexamethasone) is given at the local BC Cancer Agency unit. (See protocol)
For the purposes of follow up post HDT/SCT, either a CT scan or CT PET should be performed post salvage chemotherapy and pre transplant. Ideally CT scans should be performed in the referring centre where comparitive scans are easily available for interpretation of response criteria. 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 Nucl Med Mol Imaging 2005)
Where possible, PET CT scan will be arranged in Vancouver prior to transplantation.
The assessing Bone Marrow Transplant physician will arrange workup investigations prior to high dose chemotherapy and autologous stem cell transplant. These investigations are performed to ensure that HDT can be administered without excessive toxicity. These investigations include: creatinine clearance, pulmonary function tests, ECG and echocardiogram or MUGA scan and routine viral serology. The bone marrow transplant physician assessing the patient may require further investigations based upon clinical history and examination.
Presentation of cases at BCCA Lymphoma Conference is recommended particularly to guide local oncologists with respect to post transplant assessment and the early consideration of post transplant radiation therapy assessment in certain cases. The modality of repeated imaging can also be discussed.
Stem Cell Collection
Stem cell collection is performed in the Centennial Pavillion at Vancouver General Hospital. The patient is provided with a prescription for high dose GCSF (10mcg/kg) for a total of 5 days. This medication is administered by subcutaneous injection and the first dose is given by Hematology/ BMT nursing staff. Subsequent doses may be self administered by the patient or by a local practitioner. Side effects of GCSF include low back/pelvic pain which can at times be quite severe.
Stem cell collection is carried out on day 4 and 5 of GCSF therapy. This procedure takes place in the Apheresis Unit at VGH. Apheresis nurses assess every patient prior to this procedure to assess the suitability of the patients peripheral veins for the apheresis procedure. In certain cases, insertion of a central line (vascath) is required for this procedure.
The Bone marrow transplant physician will review all organ function workup criteria and ensure that an adequate number of stem cells (CD34+ cells target >2 x 106/kg body weight) is collected. Arrangements are made for the patient to have a Hickman line inserted prior to hospital admission for the delivery of this therapy.
The patient is then admitted to the VGH Leukemia and BMT Unit to undergo the procedure of HDT/ASCT.
High Dose Chemotherapy with BEAM or CBV
High dose chemotherapy with BEAM or CBV (see protocols) is given as an inpatient at Vancouver General Hospital. 24 hours following the last dose of chemotherapy, the patients’ autologous stem cells are reinfused. Side effects of high dose chemotherapy include GI upset, mucositis, a period of pancytopenia lasting about 2 weeks with associated need for blood transfusion support and risk of serious or life threatening infection.
Mortality associated with this procedure is less than 5%. Following recovery from the initial toxicity of the transplant course, the patient is discharged for follow up at the Bone Marrow Transplant Day Ward. When the patient has had satisfactory recovery of hematological parameters and is free of fever, the patient is discharged home. All patients are given a follow up appointment with their primary BMT physician at this point. Arrangements will be made for transfer back to the primary oncologist at this review appointment. The primary oncologist will be responsible for ordering repeated imaging to assess response to transplantation, ideally in the referring centre. For most patients, repeated imaging should be performed no earlier than 6 weeks post transplantation and ideally before 12 weeks post transplantation.
Carmustine/ BCNU given as part of BEAM and CBV protocols can cause pneumonitis, which may occur following initial recovery from stem cell transplant. Any patient who presents with respiratory symptoms at this point should undergo CT of chest and pulmonary function testing and should be treated empirically with high dose prednisolone.
Long term side effects of high dose chemotherapy include infertility, an increased risk of cardiac and thyroid disease and an increased risk of secondary malignancy (Lavoie et al Blood 2005; Forrest D et al JCO 2002).
Long-term Follow Up
All patients who receive HDT/ASCT should undergo repeated vaccination programs ONE YEAR following the date of transplantation. The guidelines for the vaccines required are available on the BC Centres for Disease Control website.
| 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. |