Case Review: Newly Diagnosed Stage IV Hodgkin Lymphoma

Jonathon B. Cohen, MD, MS:So today we’re discussing the case of a 22-year-old female patient with a recently diagnosed classical Hodgkin lymphoma. This was a young woman who was completing her college coursework and noted some cervical lymphadenopathy over the period of a few weeks to months. She was initially evaluated by her obstetrician-gynecologist who initially observed her, but ultimately, she started developing more symptoms while consuming alcohol. And so as a result, she was referred for a biopsy and ultimately was found to have Hodgkin lymphoma.

As part of her staging evaluation, we completed a PET CT, which identified several areas of enlarged lymph nodes as well as some possible bone lesions. In addition, she had an elevated white blood cell count [and] an elevated platelet count, whereas the rest of her labs were generally within normal limits. She ultimately had her pathology reviewed at Emory where it was confirmed to be a classical Hodgkin lymphoma, nodular sclerosis subtype, and with a fairly typical immunophenotype. As a result, she was diagnosed with a stage IV classical Hodgkin lymphoma.

So this is a case of a fairly typical patient with classical Hodgkin lymphoma. We frequently see this in young people, especially young women, and often patients will feel well up until the point their disease starts to cause more symptoms, and that’s when they come to [seek] medical attention.

When I saw this case and completed the staging evaluation, I was somewhat concerned about the fact that she had some uptake on her PET in the bones. This is not entirely uncommon with Hodgkin lymphoma but certainly suggests that this is a more advanced-stage disease.

This is not uncommon to have patients with advanced-stage disease at the time of diagnosis. Certainly, the fact that she is a young woman would support this diagnosis, and interestingly, the fact that she had some symptoms that developed while consuming alcohol has been a classic symptom associated with Hodgkin. Although we don’t always see that in real life, it’s something that has been described.

Fortunately, most of our patients with classical Hodgkin lymphoma can look forward to responding to therapy and many of them will be cured of their disease. So out of all patients with classical Hodgkin lymphoma that presents at [an] advanced stage, our historical expectation was that roughly 75% would be cured. In recent years, there’s been new therapies that have been developed, including one which includes brentuximab vedotin, which appears to be improving that by about 5% to 7%.

So all of my new patients with classical Hodgkin lymphoma will have a PET CT as part of their staging evaluation. I feel that the PET CT is important as it’s not entirely uncommon to have extra nodal sites of disease, including the bones like we saw in this patient. And the PET really helps identify those sites. In addition, the PET CT at baseline is important because we frequently rely on an interim PET as well as a posttreatment PET, and it’s important to have a baseline. In addition, I typically will have patients complete a battery of laboratory assessments, including assessment for HIV. It is not uncommon for a new diagnosis of HIV to be identified in a patient with a new diagnosis of lymphoma.

One thing that I don’t typically require of my patients, unless there’s a specific indication, is a bone marrow biopsy. In the past, this was typically done for all new lymphoma patients. But it turns out that it’s exceedingly uncommon to have marrow involvement that ultimately impacts treatment. So the only time I really will have a patient obtain a bone marrow biopsy is if they have some sort of hematologic abnormality or something else going on that makes me worry that there might be an additional process going on in the bone marrow.

Transcript edited for clarity.

A 22-Year-Old Woman With Stage IV Classical Hodgkin Lymphoma

History & Physical

• A 22-year-old female presented with right cervical nodes developing over several months
• Initially evaluated by her OB/GYN who recommended observation. She subsequently developed neck pain while drinking wine
• Referred for lymph node biopsy -> classical Hodgkin lymphoma
• Past medical history: unremarkable
• Social history: No tobacco use; occasional ETOH; Division 1 swimmer, NKDA
• Family History:
  • Maternal grandfather — Squamous cell cancer
  • Maternal grandmother — Melanoma
  • Aunt — Breast Cancer
  • 2 healthy siblings

Laboratory Values

• WBC 19.8 (85% PMN’s)
• Hgb 12.0
• Plts 571
• ESR 30
• Cr 0.76
• Albumin 4.2
• HIV/Hepatitis Negative

Staging PET/CT

• Intrathoracic adenopathy
  • R cervical 2.3 x 1.9 (SUV 9.3)
  • L cervical 2.2 x 1.8 (SUV 8.8)
  • Ant Mediastinum 4.8 x 2.9 (SUV 21.3)
  • R axillary 2.8 x 2.8 (SUV 12.2)
• Spleen SUV 2.9 with normal size
• Diffuse uptake in the axial skeleton (SUVs 4.9-5.5)
• Mediastinum SUV 1.8 / Liver 2.4

Pathology

• Nodular sclerosis classical Hodgkin Lymphoma
• Per IHC, Hodgkin cells express CD30, CD15, PAX5 (weak); negative for CD3, CD20, CD45

Treatment:A(BV)VD x 6

• Interim PET/CT with Deauville 3
• Tolerated well with GCSF support