recurrent Hodgkin's - dose?

[seper]

A 21 yo man had bulky stage I classic HD involving the mediastinum.
He was treated with ABVD-type of chemo alone (sigh) a had a brief remission.
Relapsed with multiple nodes, about 2-3 cm in size, involving original site, supraclav and axilla.

Had good partial response to non-myeloablative chemo (including Gemzar).
No plans for transplant.
RT dose /fx ?

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[cefhcl]

I would do 45 Gy to anything Deauville 4+ residual disease post-salvage chemo, 36 Gy to all sites of recurrent disease, and 30.6 Gy to all sites of initial disease that didn't recur with a sequential plan at 1.8 Gy/fx.

 

[Palex80]

Why no high dose chemo with stem cell support planned?

 

[Upgrayedd]

the answer is transplant and consolidative rt somewhere in the mix. if targeted agents change the paradigm then that is great; but usually ice chemo or equivalent as first line

 

[seper]

No transplant is because the treatment team believes we can do better with lighter chemo + definitive RT.
Agree, a debatable point.
transplant can be done next if RT fails.

So 45 Gy / 25 fx if some FDG avidity remains?

 

[Palex80]

No transplant is because the treatment team believes we can do better with lighter chemo + definitive RT.
Agree, a debatable point.
transplant can be done next if RT fails.

So 45 Gy / 25 fx if some FDG avidity remains?

What is the Deauville status in the current post-chemotherapy PET? "Some FDG avidity" is likely a 3?

Will the patient also receive post-RT treatment, for instance Brentuximab-maintenance or will RT be the last treatment component?
I would cover all disease areas with 17 x 1.8 Gy, then boost Deauville 3 sites up to 45 Gy.

If he is Deauville 4, I would seriously rediscuss high-dose chemo and further consolidation.

 

[evilbooyaa]

No transplant is because the treatment team believes we can do better with lighter chemo + definitive RT.
Agree, a debatable point.
transplant can be done next if RT fails.

So 45 Gy / 25 fx if some FDG avidity remains?

lolwut

are transplants done at your center/hospital or would patient have to be referred out for it?

honestly, I think if he recurred outside initial volumes this is very bad prognosis for you to chase with RT and would favor high dose chemo and transplant with consideration of consolidation RT

I would do 45 Gy to anything Deauville 4+ residual disease post-salvage chemo, 36 Gy to all sites of recurrent disease, and 30.6 Gy to all sites of initial disease that didn't recur with a sequential plan at 1.8 Gy/fx.

If forced to treat without transplant consideration I think this is very reasonable.

 

[Upgrayedd]

What is the Deauville status in the current post-chemotherapy PET? "Some FDG avidity" is likely a 3?

Will the patient also receive post-RT treatment, for instance Brentuximab-maintenance or will RT be the last treatment component?
I would cover all disease areas with 17 x 1.8 Gy, then boost Deauville 3 sites up to 45 Gy.

If he is Deauville 4, I would seriously rediscuss high-dose chemo and further consolidation.

If he was in remission with a negative PET does it matter if is 3 or 4? I thought this was only important for teasing out sluggish responders who cannot be candidates for chemo de-escalation?

Agree with everything else in regards to brentuzimab as being a possible alternative in the salvage setting

 

[Palex80]

If he was in remission with a negative PET does it matter if is 3 or 4? I thought this was only important for teasing out sluggish responders who cannot be candidates for chemo de-escalation?

I was asking what the current Deauville after the "non-myeloablative chemo (including Gemzar)" is.
Seper mentioned "Had good partial response" but then "some FDG avidity remains".
I am a strong believer in quantifying these PET-responses on an established scale to guide treatment recommendations.

Deauville assessment can work both ways: de-escalation and escalation.
Some protocols, for instance, call for ABVD as treatment for advanced disease and if not favorable PET-response after 2 cycles is obtained, then escalation to BEACOPP esc.

In this case, a deescalated salvage approach is being attempted by the treating physicians. Standard of care in recurrent hodgkin's lymphom eligible fpr high-dose chemotherapy with stem cell support is high-dose chemotherapy with stem cell support. Thus, a Deauville 3 or 4 after a "non-myeloablative chemo (including Gemzar)" can aid you in your decision to still not offer s.o.c.

For what it's worth (from the European perspective): My hem-onc colleagues would have never agreed to RT only for a Deauville 4 after non-myeloablative chemo, they would have called this case a poor chemo-responder and go for an escalated approach, likely high-dose chemo with stem cell support and Brentuximab maintenance.

 

[evilbooyaa]

I was asking what the current Deauville after the "non-myeloablative chemo (including Gemzar)" is.
Seper mentioned "Had good partial response" but then "some FDG avidity remains".
I am a strong believer in quantifying these PET-responses on an established scale to guide treatment recommendations.

Deauville assessment can work both ways: de-escalation and escalation.
Some protocols, for instance, call for ABVD as treatment for advanced disease and if not favorable PET-response after 2 cycles is obtained, then escalation to BEACOPP esc.

In this case, a deescalated salvage approach is being attempted by the treating physicians. Standard of care in recurrent hodgkin's lymphom eligible fpr high-dose chemotherapy with stem cell support is high-dose chemotherapy with stem cell support. Thus, a Deauville 3 or 4 after a "non-myeloablative chemo (including Gemzar)" can aid you in your decision to still not offer s.o.c.

For what it's worth (from the European perspective): My hem-onc colleagues would have never agreed to RT only for a Deauville 4 after non-myeloablative chemo, they would have called this case a poor chemo-responder and go for an escalated approach, likely high-dose chemo with stem cell support and Brentuximab maintenance.

I would argue the bolded is SOC even in the US, but OP is in a tough situation b/c he can't force heme-onc to proceed down this path and can only try to do what is best for the patient within the limmitations of the disease process.