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153-1
HODGKIN LYMPHOMA
The Firefighter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level I
Cindy L. O’Bryant, PharmD, BCOP
CASE SUMMARY
A 27-year-old man presents with night sweats, fever, fatigue, and
a chest mass that has grown progressively larger over the past
few weeks. Further workup leads to a diagnosis of HL (nodular
sclerosis), early stage IIB, unfavorable with bulky disease. The
patient has the following unfavorable prognostic factors: mass
>10 cm (bulky disease), ESR (erythrocyte sedimentation rate)
>50 mm/hour, and B symptoms. Unfavorable prognostic factors
have been shown to increase the risk of relapse. This patient has
early-stage disease, and cure is the primary goal of therapy. The
standard treatment recommendation for this patient is ABVD
(doxorubicin, bleomycin, vinblastine, dacarbazine) for 4–6 cycles
based on PET five-point scale (Deauville Criteria), followed by
involved-site radiation. The Stanford V regimen (mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin, etoposide,
prednisone) for 12 weeks plus radiation has also been shown to
improve progression-free survival. Escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine,
procarbazine, prednisone) for two cycles followed by ABVD for
two cycles with involved-site radiation therapy is also an option
for select patients <60 years old. The ABVD regimen has a favorable toxicity profile and causes fewer cases of acute leukemia, sterility, and myelotoxicity than many previous treatment programs
containing alkylating agents. The acute and long-term toxicities of
chemotherapy and radiotherapy must be monitored. Appropriate
supportive care measures must be initiated to prevent and treat
nausea and vomiting, mucositis, and myelosuppression among
other toxicities. Cardiac and pulmonary function should also be
monitored based on the treatment regimen selected. Fertility preservation must be discussed with this patient, as he has an interest
in having children.
• Stage II was determined because the patient has involvement
of two or more lymph node regions on the same side of the
diaphragm.
• Subset “B” indicates the presence of B symptoms (fever, night
sweats, and weight loss).
Desired Outcome
2.What are the goals of therapy in this case?
• The main goal of therapy is to cure the HL. The majority of
patients achieve cure with first-line treatment; 92–95% of
patients with stage I/II disease, and 80–85% of patients with
stage III/IV disease.3
• Minimize cost and inconvenience.
• Reduce acute treatment toxicities.
• Prevent long-term treatment toxicities.
• Preserve reproductive ability.
Therapeutic Alternatives
3.What treatment options are available for managing this
patient’s Hodgkin lymphoma?
Problem Identification
• Combination chemotherapy with consolidative radiotherapy
to bulky sites of disease is the standard of care for the treatment of early stage I–II unfavorable-prognosis HL.4 The ABVD
regimen (doxorubicin, bleomycin, vinblastine, dacarbazine) is
considered the standard of care because it is as effective and has
a more favorable toxicity profile causing fewer cases of acute
leukemia, sterility, and myelotoxicity than the previous alkylating agent-containing MOPP (mechlorethamine, vincristine,
procarbazine, and prednisone) regimen that was the standard
of care for almost 20 years. The Stanford V regimen (mechlorethamine, doxorubicin, vinblastine, vincristine, bleomycin,
etoposide, prednisone) with involved-site radiation is also a
possible treatment option in patients with bulky mediastinal
masses or B symptoms. A dose-intensified approach can also
be employed in select patients with early unfavorable disease
by administering escalated-dose BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) for two cycles followed by ABVD for two
cycles and involved-site radiation.
1.a. What clinical and other information is consistent with the
diagnosis of Hodgkin lymphoma?
• Unfavorable prognostic factors for early-stage HL may influence
the type of treatment chosen, especially in early-stage disease.4
• Signs: painless supraclavicular adenopathy; mediastinal and
hilar nodal involvement.1
✓In early-stage disease, four adverse prognostic factors have
been identified: (1) bulky mediastinal disease (mediastinal
mass ratio [MMR] >0.33) or bulky disease >10 cm; (2) ESR
>50 mm/hour; (3) more than three nodal sites of disease;
and (4) B symptoms. These prognostic factors influence the
risk of disease relapse.
QUESTIONS
• Symptoms: fatigue and B symptoms (fever, drenching night
sweats, and weight loss).
• Pathology: identification of Reed–Sternberg cells classifying this
as classical Hodgkin lymphoma, nodular sclerosing subtype.
• Scans: positive PET/CT scan of the chest and clavicular area.
1.b. Explain what system of staging was used and how his stage
of disease was determined.
• The staging system used is the Cotswolds modification of the
Ann Arbor Staging Classification for Hodgkin lymphoma.2
✓In the advanced HL setting, seven adverse prognostic factors have been identified, each of which decreases survival
by 7–8% per year: (1) serum albumin <4 g/dL; (2) hemoglobin <10.5 g/dL; (3) male sex; (4) stage IV disease;
(5) age ≥45 years old; (6) white blood cell (WBC) count
>15,000/mm3; and (7) lymphocyte count <600/mm3.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Hodgkin Lymphoma
Ashley Glode, PharmD, BCOP
• The following staging procedures were performed to determine
the extent of disease: complete history and physical examination; detailed history of lymphadenopathy; laboratory tests;
Chest x-ray; PET/CT scans of chest, abdomen and pelvis, and
neck; excisional biopsy; and bone marrow biopsies if PET is
negative and the patient is cytopenic.
CHAPTER 153
153
Refer to the textbook chapter on lymphomas for more detailed
information.
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SECTION 17
Oncologic Disorders
• In 1992, a Cancer and Leukemia Group B (CALGB) study
compared three chemotherapy regimens for newly diagnosed
advanced stage HD: MOPP, ABVD, and MOPP alternating
with ABVD.4 The overall results showed similar complete
remission (CR), failure-free survival (FFS), and OS rates for
ABVD and MOPP/ABVD and that both regimens were superior to MOPP. Since that time, ABVD has been compared to
a variety of multidrug regimens and has maintained similar
outcomes with a better toxicity profile.
• The individualized drug regimen for this patient is as follows:
• The addition of radiation to combination chemotherapy in
stage I–II HL patients improved progression-free survival and
overall survival in several different studies.4
• The Deauville Criteria is a five-point scale to assess end-oftreatment PET scans based on the determination of fluorodeoxyglucose (FDG) uptake in the involved sites compared to the
mediastinum and liver.4 Typically, patients with a score of 1 or 2
are considered negative, a score of 3 may be considered positive
or negative, and patients with a score of 4 and 5 are considered
positive. For patients with stage I/II unfavorable bulky disease
and a Deauville score of 1–3 after four cycles of ABVD, the
patient may receive two more cycles of ABVD for a total of
six cycles followed by involved-site radiation or involved-site
radiation alone after the four cycles of ABVD. Patients with a
Deauville score of four should receive ABVD for two additional
cycles (six total) followed by involved-site radiation. A Deauville score of 5 requires a biopsy to be performed. If the biopsy
is negative, the patient receives the same treatment as if they
had a Deauville score of 4, and if it is positive a second-line
treatment regimen should be initiated.
• The Stanford V regimen is a dose-intensive regimen, but overall
the total cumulative doses of the agents is less than ABVD and
may thereby reduce the risk of infertility, cardiac and pulmonary toxicity, and secondary cancer. Stanford V with involvedfield radiation when compared to the same regimen with
extended-field radiation has shown at 8 years 92% freedom
from progression in patients with stage I–II bulky stage disease
with a better tolerated toxicity profile.4 Stanford V was compared to ABVD in one study in patients with intermediate
and advanced stage HL. The results showed that ABVD was
superior to Stanford V, but the results are controversial because
of difficulty in interpreting the data due to timing of response
evaluation and modification in radiation protocols. The E2496
Intergroup trial comparing ABVD plus radiation to Stanford V
plus radiation in bulky stage II and stage III–IV disease demonstrated no significant difference in overall survival between the
two arms, confirming that ABVD continues to be the standard
of care for HL patients with advanced disease.5
• The HD14 trial randomized patients with early-stage unfavorable disease to four cycles of ABVD or two cycles of dose
escalated BEACOPP followed by two cycles of ABVD.6 Both
treatment plans were followed by 30 Gy of involved-field
radiation as consolidation. Freedom from treatment failure
and progression-free survival were superior in the BEACOPP/
ABVD arm, but not overall survival. In the combination arm,
more acute toxicity occurred, but there was no overall difference in treatment-related mortality or second malignancies.
This regimen may be considered in select patients <60 years old.
Optimal Plan
4.a. What drug regimen, dose, schedule, and duration of chemotherapy are best for treating this patient’s Hodgkin
lymphoma?
• The standard treatment for early-stage, IIB unfavorable with
bulky disease, classical HL is ABVD for 4–6 cycles. The decision to treat for four or six cycles is based on the patient’s Deauville score on the restaging scan after four cycles of ABVD, as
discussed below.
• The specific drug regimen is as follows:
✓Adriamycin (doxorubicin) 25 mg/m2 IVPB on days 1 and 15
✓Bleomycin 10 units/m2 IVPB on days 1 and 15
✓Vinblastine 6 mg/m2 IVPB on days 1 and 15 (the dose is not
capped like vincristine)
✓Dacarbazine 375 mg/m2 IVPB on days 1 and 15
• Calculation of the patient’s body surface area (BSA) using the
Mosteller formula:
BSA (m2) = Square root of (height in cm × weight in kg/3600)
BSA = Square root of (180.3 × 87/3600) = 2.1 m2
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✓Adriamycin (doxorubicin) 52.5 mg IVPB on days 1 and 15
✓Bleomycin 21 units IVPB on days 1 and 15
✓Vinblastine 12.6 mg IVPB on days 1 and 15 (the dose is not
capped like vincristine)
✓Dacarbazine 787.5 mg (round to 788 mg) IVPB on days 1
and 15
✓The regimen is repeated every 28 days for 4–6 cycles.
4.b. Are additional treatment modalities other than chemotherapy indicated for treating this patient’s Hodgkin lymphoma?
• The patient should also receive involved-site radiation at doses
of 30–36 Gy as part of the combined modality treatment.4
Involved-site radiation is used to decrease the size of the radiation fields and minimize the exposure of adjacent, uninvolved
organs, as well as to mitigate the long-term toxicities associated with radiation exposure. This method of radiation focuses
on the initial involved nodal sites and possible extranodal
extensions.
Outcome Evaluation
5.a. What clinical and laboratory parameters are necessary to
evaluate the therapy for achievement of the desired therapeutic outcome for treatment of Hodgkin lymphoma?
• Response is determined by follow-up radiologic PET/CT studies that initially showed positive findings. The timing for repeat
radiologic PET/CT imaging is based on the treatment regimen
chosen and the initial stage and presentation of disease. For
early-stage (stage I/II) HL, PET/CT should be performed after
2–4 cycles of ABVD, after 8–12 weeks of chemotherapy with
Stanford V, or after two cycles of escalated BEACOPP and two
cycles of ABVD depending on whether disease is stage I or II
and favorable or unfavorable.4 Unfavorable factors include large
mediastinal adenopathy, more than two to three nodal sites of
disease, presence of B symptoms, extranodal involvement, or
significantly elevated ESR (ESR ≥50 mm/hour), and advanced
stage disease (stage III/IV).
• Treatment response should also be assessed by monitoring
the following signs and symptoms: (1) presence of B symptoms; and (2) extent of supraclavicular, mediastinal, and hilar
adenopathy. These signs and symptoms can be monitored
every cycle as well as laboratory studies such as complete blood
count (CBC) with differential, and chemistry. ESR should only
be monitored for early-stage disease if initially elevated at
baseline.
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• Myelosuppression (doxorubicin, dacarbazine, and vinblastine).
• Nausea/vomiting (high emetic risk with dacarbazine, moderate emetic risk with doxorubicin, minimal emetic risk with
vinblastine and bleomycin).7
• Stomatitis/mucositis (doxorubicin, vinblastine).
• Cardiotoxicity (doxorubicin).
5.c.What clinical or laboratory parameters are necessary to
detect and prevent acute and long-term adverse events commonly associated with treatment of Hodgkin lymphoma?
Acute adverse events:
• Myelosuppression: Obtain CBC, differential, and platelets
one to two times per week after each course of chemotherapy.
The patient should monitor himself for signs of infection or
bleeding. If infectious complications occur after chemotherapy
cycles or if prolonged myelosuppression prevents the timely
administration of subsequent cycles, growth factor support
with granulocyte colony-stimulating factor (G-CSF; filgrastim, tbo-filgrastim, filgrastim-sndz, or pegfilgrastim) maybe
considered to maintain dose intensity.8 G-CSF support is a
controversial risk factor for development of bleomycin pulmonary toxicity. If G-CSF is administered concomitantly with
bleomycin-containing chemotherapy, patients and clinicians
should be highly aware of the development of signs and symptoms of pulmonary toxicity such as cough, dyspnea, chest pain,
tachypnea, and hypoxemia.
• Nausea/vomiting: Record the number and severity of nausea
and vomiting episodes. Monitor electrolytes one to two times
per week after each course of chemotherapy. Several prevention
options exist for highly emetogenic chemotherapy regimens;
serotonin (5-HT3) receptor antagonist, corticosteroid, and neurokinin (NK)-1 antagonist (eg, ondansetron, dexamethasone,
and aprepitant; or netupitant/palonosetron and dexamethasone), or olanzapine, palonosetron, and dexamethasone should
be given before each course of chemotherapy.7 Medication for
breakthrough nausea and vomiting should also be prescribed
(eg, prochlorperazine). To avoid anticipatory nausea and
vomiting, administering a benzodiazepine such as lorazepam
before the chemotherapy may be beneficial.
• Stomatitis/mucositis: Mucous membranes should be examined
for erythema, ulcers, or breakdown daily by the patient and
by a clinician during each physical examination. Good oral
hygiene should be encouraged. Oral rinses with saline and soda
solutions can help maintain a clean mouth. To prevent irritation, teeth should be cleaned with a soft-bristle toothbrush or
mouth swab and alcohol-free oral solutions. Topical management of mucositis may also include the use of viscous lidocaine; sucralfate suspension; or extemporaneously prepared
suspensions containing combinations of viscous lidocaine,
diphenhydramine, and magnesium/aluminum hydroxide.
• Cardiotoxicity: Acute cardiotoxicities of the anthracyclines
are usually self-limiting and rarely life threatening. During and shortly after administration, transient nonspecific
Long-term adverse events:
• Peripheral neuropathy (mild with vinblastine): Peripheral neuropathy is typically a cumulative effect that occurs after several
cycles. It may or may not be reversible. Neurologic examinations should be done at baseline before chemotherapy and then
before each subsequent course.
• Secondary malignancies: Secondary malignancies are a major
cause of late morbidity and mortality after treatment for HL.
Treatment with combination chemotherapy (especially alkylating agents) and radiation increases the risk of acute myeloid
leukemia (AML). The 30-year cumulative standardized incidence ratio (95% confidence interval [CI]) of leukemia is 1.3
(0.9–1.7).9 Secondary leukemia is often refractory to therapy.
Other secondary malignancies associated with the treatment
of HL include cancers of the gastrointestinal tract, lower
respiratory system, breast, and non-Hodgkin’s lymphoma. The
30-year cumulative standardized incidence ratio (95% CI) of a
secondary malignancy, excluding myelodysplastic syndrome
(MDS) is 32.5 (30.4–34.6), and appears to increase over time.
• Sterility: ABVD is associated with a low risk (0–10%) of infertility and premature ovarian failure. Women attempting to
conceive after treatment with ABVD have similar success rates
to age matched controls, with 75–80% of females becoming
pregnant.10 The majority of males (50–75%) will have normal
sperm counts and/or follicle-stimulating hormone (FSH) levels
after treatment with ABVD. This risk can be up to 50% with
other regimens used to treat HL. Treatment with alkylating
agents or gonadal radiation leads to dose-dependent infertility
in male and female HL survivors. Fertility preservation should
be discussed before starting therapy if the patient desires to
have children in the future.
• Cardiotoxicity (doxorubicin): Chronic anthracyclineassociated cardiotoxicity is characterized by cardiomyopathy and is frequently life threatening. Patients present with
typical symptoms of ventricular failure. The frequency and
severity of this chronic toxicity are related to the cumulative dose. Doxorubicin-associated cardiac injury is unusual
at cumulative doses <450 mg/m2 but increases at doses of
450–550 mg/m2. Risk factors that increase the frequency and
severity of anthracycline-induced cardiotoxicity include hypertension, preexisting cardiac disease, prior thoracic radiation,
and very young or very old age. An echocardiogram should
be obtained at baseline before starting therapy to evaluate the
ejection fraction. Follow-up examinations at appropriate intervals are important, especially in patients with risk factors for
cardiotoxicity or for those who require >450 mg/m2 of doxorubicin. Few clinicians would continue therapy with doxorubicin
if the left ventricular ejection fraction (LVEF) is <40% without
a cardiology evaluation, as additional therapy could result in
irreversible heart failure. Radiotherapy, if given along with chemotherapy treatment for bulky disease, is also associated with
cardiomyopathy and pericarditis. Long-term HL survivors who
received mantle-field radiation are also at risk for developing
coronary artery disease (40–50% of patients). Cardiac effects
are radiation dose-related and significant heart disease can be
seen in up to 35% of survivors at 30 years.10
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Hodgkin Lymphoma
• Other adverse effects of the regimen include alopecia (bleomycin, doxorubicin, dacarbazine, vinblastine); sterility (vinblastine); constipation (vinblastine); flulike syndrome (bleomycin,
dacarbazine); anaphylactoid reactions (bleomycin); skin hyperpigmentation and erythema of skin and nail beds (bleomycin);
photosensitivity (dacarbazine); and red urine discoloration
(doxorubicin). Doxorubicin and vinblastine are vesicants.
electrocardiographic (ECG) abnormalities, arrhythmias, and
vasospasm may occur. Routine monitoring of the ECG is not
required unless the patient exhibits symptoms. Transient congestive heart failure (CHF), pericarditis/myocarditis syndrome,
and myocardial infarction have also been described as acute
toxicities.
CHAPTER 153
5.b. What acute adverse effects are associated with the chemotherapy regimen?
153-4
SECTION 17
Oncologic Disorders
• Pulmonary toxicity (bleomycin): Pulmonary fibrosis is a doselimiting toxicity for bleomycin. Pneumonitis is manifested
by a dry cough, rales, pulmonary infiltrates, and dyspnea; it
may progress to fibrosis. This complication is more common
in patients older than age 70 and those with a prior smoking history, prior or concurrent pulmonary radiotherapy,
oxygen therapy, renal insufficiency, underlying lung disease,
and cumulative doses of >400 units. Pulmonary fibrosis may
be only partially reversible and can be fatal. Treatment with
corticosteroids may be beneficial. Obtain baseline pulmonary
function tests before starting therapy and repeat every two to
four cycles or if pulmonary symptoms occur.
• Hypothyroidism: The incidence of hypothyroidism after radiotherapy ranges from 10 to 20%.
Patient Education
6.What information should be provided to the patient to
enhance compliance, ensure successful therapy, and minimize
adverse effects for treatment of Hodgkin lymphoma?
Doxorubicin:
1. This drug interferes with the growth of cancer cells. Because
the growth of normal cells may also be affected, side effects
will occur. The drug is administered intravenously (injected
into a vein).
2. The most common side effects include nausea and vomiting,
sores in the mouth and on the lips, red urine, and possible
sterility.
3. Contact your doctor immediately if any of these less common
side effects occur: fast or irregular heartbeat, cough or hoarseness, shortness of breath, or swelling of the lower legs or feet.
These symptoms may represent heart failure.
4. This drug can lower the number of platelets in your blood,
which are needed for proper blood clotting. This may increase
your risk of bleeding. Contact your doctor immediately if you
notice any unusual bleeding or bruising, blood in the urine or
stools, black/tarry stools, or pinpoint red spots on your skin.
5. This drug temporarily lowers the number of white cells in your
blood, increasing your chance of getting an infection. Try to
avoid coming into contact with people who have infections.
Contact your doctor immediately if you experience any of the
following symptoms: fever (>38°C) or chills, lower back or side
pain, painful or difficult urination, or cough or hoarseness.
6. If this drug accidentally seeps out of the vein into which it is
injected, it may damage the adjacent tissue and cause scarring.
Contact your doctor immediately if you notice redness, pain,
or swelling at the site of injection.
7. There is a chance that this drug may cause birth defects if it
is taken during pregnancy or if either the male or female is
receiving it at the time of conception. A reliable form of birth
control should be used while receiving the drug.
8. Temporary hair loss will occur typically with the first few weeks
of treatment; normal hair growth should return after treatment
has ended.
• Contact your doctor immediately if any of these less common
side effects occur: shortness of breath, dry cough, or swelling
of the throat, which may be a sign of a severe allergic reaction.
Vinblastine:
• Side effects 1, 4, 5, 6, 7, and 8 as with doxorubicin.
• The most common side effects include mild nausea, temporary
loss of hair, mouth sores, and muscle pain.
• Less common side effects include numbness and tingling in
fingers or toes, difficulty walking, weakness, and dizziness.
• This drug may cause constipation. Exercise, increased dietary
fiber, and hydration may help prevent this side effect.
• It may decrease your ability to have children in the future.
Dacarbazine:
• Side effects 1, 4, 5, 7, and 8 as with doxorubicin.
• The most common side effects include nausea and vomiting, a
flulike syndrome, and sores in the mouth.
• This drug may irritate the vein into which it is injected. Contact
your doctor immediately if you notice redness, pain, or swelling at the site of injection.
• You may be more prone to getting sunburned or a rash from
sun exposure. Do not stay out in the sun for prolonged periods,
protect your skin with sunscreen (sun protection factor [SPF]
15 or higher), and wear protective clothing and a hat when you
are outside.
■■ FOLLOW-UP QUESTION
1.What follow-up and long-term monitoring should this patient
receive after completion of his cancer treatment?
• Patients should receive a cancer treatment summary and survivorship care plan to monitor for late effects from their cancer
treatment.4 At the completion of treatment, patients should
receive the following:
✓Interim medical history, physical examination, and laboratory studies (CBC with differential, serum chemistries,
ESR) every 3–6 months for the first 1–2 years, then every
6–12 months until year 3, then annually up to 5 years after
treatment.
✓Annual influenza vaccine.
✓TSH annually if radiation to the neck was received.
✓Imaging studies: CT scan once during the first 12 months,
then as clinically indicated for the first 5 years.
✓Counseling on reproduction, health habits, psychosocial
issues, cardiovascular risk, breast self-exam, skin cancer risk,
and end of treatment discussion.
• After 5 years, patients should receive the following:
✓Annual medical history and physical examination to
assess cardiovascular risks (baseline stress test/echocardiogram at 10-year intervals; also carotid ultrasound if neck
radiation).
• Side effects 1, 4, 5, 7, and 8 as with doxorubicin.
✓Annual influenza vaccination and revaccination with pneumococcal, meningococcal, and influenza after splenic radiation or splenectomy.
• The most common side effects include mild nausea, a flulike
syndrome including fever with or without chills, and sores in
the mouth.
✓Laboratory studies to assess CBC with differential, serum
chemistries, TSH (if radiation received to the neck) annually,
and fasting lipid profile biannually.
• You may experience darkening or thickening of skin, skin redness or tenderness, or skin itching.
✓Low-dose chest CT for patients at increased risk for lung
cancer.
Bleomycin:
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153-5
✓ Colonoscopy every 10 years if 50 years of age or older (begin
at age 40 if high risk).
✓Consider referral to survivorship clinic and transfer of care
to primary care provider.
REFERENCES
1. Eichenauer DA, Engert A. Advances in the treatment of Hodgkin lymphoma. Int J Hematol 2012;96:535–543.
2. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for
initial evaluation, staging, and response assessment of Hodgkin and
non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol
2014;32:3059–3068.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Hodgkin Lymphoma
✓Counseling on reproduction, health habits, psychosocial
issues, cardiovascular risk, breast self-exam, and skin cancer
risk.
3. Connors JM. Hodgkin lymphoma: special challenges and solutions.
Hematol Oncol 2015;33:21–24.
4.CCN Hodgkin Lymphoma Clinical Practice Guidelines in Oncology (Version V.2.2015). Available at: http://www.nccn.org. Accessed
January 14, 2016.
5. Gordon LI, Hong F, Fisher RI, et al. Randomized phase III trial of
ABVD versus Stanford V with or without radiation therapy in locally
extensive and advanced-stage Hodgkin lymphoma: an intergroup
study coordinated by the Eastern Cooperative Oncology Group
(E2496). J Clin Oncol 2013;31:684–691.
6. von Tresckow B, Plutschow A, Fuchs M, et al. Dose-intensification in
early unfavorable Hodgkin’s lymphoma: final analysis of the German
Hodgkin study group HD14 trial. J Clin Oncol 2012;30:907–913.
7. NCCN Antiemesis Clinical Practice Guidelines in Oncology (Version
V.2.2015). Available at: http://www.nccn.org. Accessed January 14,
2016.
8. NCCN Myeloid Growth Factors Clinical Practice Guidelines in Oncology (Version V.1.2015). Available at: http://www.nccn.org. Accessed
January 14, 2016.
9. Schaapveld M, Aleman BM, van Eggermond A, et al. Second cancer
risk up to 40 years after treatment for Hodgkin’s lymphoma. N Engl
J Med 2015;373:2499–2511.
10. Hodgson DC. Long-term toxicity of chemotherapy and radiotherapy
in lymphoma survivors: optimizing treatment for individual patients.
Clin Adv Hematol Oncol 2015;13:103–112.
CHAPTER 153
✓Annual breast screening according the American Cancer
Society starting 8–10 years post screening or at age 40,
whichever comes first. Breast MRI may be done in addition
to mammography for women who received irradiation to
the chest between 10 and 30 years of age.