Frontline Treatment Options & Chemotherapy Response

Jonathon B. Cohen, MD, MS:There are a number of benefits to PET [positron emission tomography]—directed therapies that have been seen in a series of clinical trials, both in advanced-stage and early Hodgkin’s lymphoma. These trials were done as a follow-up to a prior retrospective study, which highlighted the importance of a negative interim PET in Hodgkin’s lymphoma. It’s important to remember that, for physicians, it is different caring for patients on a clinical trial [in which] regulations are increasingly stringent, and radiology reports are generated in a standard fashion, as opposed to taking care of a patient in real life.

Patients frequently do not receive a PET scan at the effective time interval, which is, typically, the repercussion of a physician being unfamiliar with the Deauville score—an essential tool for making a determination. Therefore, it’s important that physicians, who will be treating a patient with a PET-directed approach, collaborate with radiologists who can provide real-time feedback on patient response. An additional challenge is ensuring that physicians do not forgo escalating patients to a more intensive therapy if, after 2 cycles of ABVD, there is a positive PET scan.

We found that patients being treated outside the larger centers, who may have positive PET scans, are not being escalated, which is an improper treatment based on data provided by clinical trials. Making sure that interim PET scans are interpreted quickly and accurately, with an appropriate, reactionary treatment, is one of the biggest challenges faced to date. Subsequent follow-up is, generally, a standard across Hodgkin’s lymphoma approaches. I typically follow patients, at minimum, quarterly—despite the overwhelming lack of data surrounding surveillance imaging for patients who achieved complete remission—for a couple [of] years following remission with an interim and concluding PET/CT scan—after which, if the patient has sustained complete remission, [they] will only receive scans as clinically indicated.

If this patient had yielded a positive PET/CT scan, the standard approach would be a progression to escalated treatment like BEACOPP. It’s important to recognize, however, that in reality, there are numerous potential approaches: it depends on the level of FDG [fluorodeoxyglucose] uptake and PET/CT activity. If the patient is progressing after the first 4 ABVD cycles, instead of administering BEACOPP, I would give them a standard salvage therapy and consider an autologous stem-cell transplant.

Conversely, if a patient has a positive PET scan but the clarity of the candidate’s lesion is indicated above the liver, I’d be inclined to issue another couple [of] cycles of ABVD treatment and then reevaluate them. Again, it’s important for the individual physician caring for the patient to consider the clinical scenario instead of focusing on the PET-scan readings. In most cases, however, where there’s explosive progression or residual disease, I would consider escalating to BEACOPP.

Transcript edited for clarity.

A 32-Year-Old Man with Stage IV Hodgkin's Lymphoma

• History & Physical:
  • A 32-year-old man presented to his PCP in January 2017 complaining of abdominal pain, pruritus, fevers of over 101⁰ F, and weight loss
• Imaging
  • PET scan showed avid mediastinal mass
• Labs
  • HgB 12.2 g/dL
  • WBC 7,500 mm²
  • ALC 3,200 mm²
  • Albumin 3.9 mg/dL
  • ANC 4,200/mm³
  • Liver and renal function tests WNL
• Biopsy confirmed mixed cellularity classical Hodgkin’s lymphoma (HL)
• Normal lung and cardiac function
• Final Staging: Stage IVB, cHL, IPS score 2
• ECOG PS 2
• He received 2 cycles of ABVD. PET/CT restaging showed Deauville (1-). He received 4 additional cycles of AVD
• He achieved a CR
• 2 years after completion of therapy, the patient complained of a persistent cough and fatigue
• PET/CT showed bilateral mediastinal masses
• Biopsy confirmed cHL