RISK FACTORS: Immunodeficiency (inherited or acquired), Autoimmune disorders, HIV infection
APPROPRIATE HEALTH CARE
. Initial staging is critical to therapy
. Cotswold classification :
. Stage I - single lymph node group
. Stage II - two or more node groups on same side of diaphragm
. Stage III - Node groups on both sides of diaphragm
. Stage IV - dissemination involving extra-nodal organs (not the spleen which is considered lymphoid tissue)
. Subclass designations
- A = no symptoms
- B = systemic symptoms (fever, night sweats, weight loss >10% body weight)
- X = bulky disease (widened mediastinum >1/3 intrathoracic diameter or >10 cm nodal mass)
- E = single extra-nodal site involvement in proximity with known nodal site
GENERAL MEASURES
. Treatment aimed for cure with minimum toxicity, including treatment-induced late mortality
. Treatment can be radiation therapy (RT), chemotherapy, or combined radiation and chemotherapy (CMT),
based on stage and tumor burden
. Early stages - favorable prognosis - low amount (2-3 cycles) chemotherapy plus involved fi eld RT; or
extended field RT
. Early stages - unfavorable prognosis - moderate chemotherapy (.4 cycles) plus RT
. Advanced stages - extensive chemotherapy (.8 cycles) with or without RT
. Autologous bone marrow transplant for selected patients who fail conventional therapy
DRUG(S) OF CHOICE
. Note: Must be monitored by experienced oncologist
. ABVD chemotherapy - 4 week cycles
. Doxorubicin (Adriamycin) - 25 mg/m2 IV days 1 and 15
. Bleomycin 10 mg/m2 IV days 1 and 15
. Vinblastine 6.0 mg/m2 IV days 1 and 15
. Dacarbazine 375 mg/m2 IV days 1 and 15
ALTERNATIVE DRUGS
. MOPP chemotherapy - 4 week cycles
. Mechlorethamine (nitrogen mustard) 6.0 mg/m2 IV days 1 and 8
. Vincristine (Oncovin) 1.4 mg/m2 IV days 1 and 8
. Procarbazine 100 mg/m2 po days 1 through 14 (avoid vanilla, cheese and wine)
. Prednisone 40 mg/m2 po days 1 through 14 during cycles 1 and 4
. Alternate cycles with MOPP/ABVD to minimize toxicity
. BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone)
. Stanford V regimen (nitrogen mustard, doxorubicin, vinblastine, vincristine, bleomycin, etoposide, prednisone)
PATIENT MONITORING
. CBC, nutrition and hydration during therapy
. Post-treatment monitoring (at least yearly)
. CBC, ESR
. TSH, if RT to the neck
. Chest x-ray
PREVENTION/AVOIDANCE
. Pneumococcal vaccine, if splenectomy is planned for staging
. Consider vaccines for Haemophilus and Neisseria species as well
POSSIBLE COMPLICATIONS
. Secondary malignancies following therapy
. Sterility, gonadal dysfunction
. Hypothyroidism
. Bone marrow suppression
. Immunosuppressed infections, including herpes zoster
. Anemia
. ITP, TTP
. Coronary artery disease, cardiomyopathy
. Radiation pneumonitis, pulmonary fi brosis
. Transient radiation myelopathy (Lhermittefs sign)
EXPECTED COURSE/PROGNOSIS
. Overall 5 year survival 83%
. 75% long term survival
. 10 year survival rates correlate with stage at diagnosis
. Stage IA, IB, IIA non-bulky 85-95%
. Stage IIA bulky, IIB 80-85%
. Stage IIIA 75-90%
. Stage IIIB 60-65%
. Stage IV 55-60%
. Unfavorable prognostic factors in advanced disease
. Sed rate > 70
. Age > 45
. Male gender
. Albumin < 4g/dL
. Hemoglobin < 10.5 g/dL
. Lymphopenia < 600 cells/MICROL
. Leukocyte count . 15,000 cells/MICROL