Prognosis for Stage IV Hodgkin's Lymphoma & Patient Expectations

Jonathon B. Cohen, MD, MS:Today’s case is that of a 32-year-old gentleman who presented to their primary care physician with fevers up to about 101°, as well as itching and some abdominal pain. They underwent an evaluation including cross-sectional imaging, which ultimately showed a large mediastinal mass, as well as intra-abdominal disease and other potential areas of organ involvement. Ultimately, they had a biopsy, which confirmed the diagnosis of classical Hodgkin’s lymphoma. They had some additional evaluation, including lab work, which was generally unremarkable with a relatively normal hemoglobin and other hematologic parameters. Eventually they were diagnosed with classical Hodgkin’s lymphoma stage IVb.

They were initiated on chemotherapy with the ABVD [doxorubicin (Adriamycin) bleomycin vinblastine dacarbazine] regimen using a PET [positron emission tomography]-adapted approach. After 4 treatments or 2 cycles of ABVD, they achieved a complete remission with a Deauville score of 1. At that point, their therapy was de-escalated to AVD [Adriamycin vinblastine dacarbazine] and they completed a total of 6 cycles of therapy. Again, at the end of therapy, they were in complete remission. They were monitored at that point and subsequently did exhibit recurrent lymphomatic symptoms. A repeat scan revealed some mediastinal lesions—and a repeat biopsy confirmed the presence of relapse.

This is a case that I see quite frequently: the young patient exhibited constitutional symptoms of Hodgkin’s lymphoma, which included unexplained fevers [and] sweats and unaccountable weight loss.

Fortunately, most patients with classical Hodgkin’s lymphoma will achieve remission after initial therapy. In this case, despite the patient’s advanced-stage setting, with some high-risk features—including the presence of constitutional symptoms—we still expect a 50% margin, or greater, of remission. Among those patients who ultimately achieve a complete response, that number is probably closer to 80%.

However, the discussion about prognosis in patients with any type of lymphoma is challenging, especially regarding Hodgkin’s lymphoma. This is often because these patients are young—many of them are beginning their families or are just starting out on their career. Many of them have been told that Hodgkin’s lymphoma is “the good lymphoma” to have—and so I spend a lot of time discussing the positives and negatives of this particular diagnosis. Fortunately, most patients will be cured of their disease with currently available therapies; however, that’s not 100%—so I try to be realistic with patients but also provide some hope and recognition that the majority are cured.

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