Intermediate Risk Hodgkin Lymphoma

Dr. Mahmoud Motaz Mohammed

South Egypt Cancer InstituteAssiut University

EASO Course on Paediatric Oncology17-18 May 2013

Cairo, Egypt

History• Female patient, 12years old, presented on 10/2009 .• The condition started 2 weeks ago with sever diffuse abdominal

pain,abdominal distenstion, absolute constipation so patient saught medical advice and was diagnosed as acute intestinal obstruction.Urgent exploration done with intestinal mass found and completely excised moderate to high grade fever mainly by night, partially responding to medical treatment.

• The condition was associated with small right neck swelling of lemon size surgical removal of which showed a non malignant nature.

• On 5/2010, patient developed multiple painless neck swellings with gradual onset progressive course associated with night fever and weight loss - no drenching night sweating.

• Surgical removal of cervical swelling was done and patient was referred to us.

• No manifestation of other system affection was apparent.

Examination & WorkupLymphatic system: - Right upper deep cervical LN about 3*2 cm - Multiple small left upper deep cervical LNs the largest one about 1 cm in diameter - RT axillary LN about 1,5 cm in diameter in the apical group -All of the above described lymph nodes are firm to rubbery in consistency, non tender,

freely mobile and with normal overlying skin. - No other enlarged LN groups Laboratory workup:

ESR: 1st hr 25 Imaging Workup: • CT neck : Multiple bilateral upper and lower deep cervical LNs the largest one on

RT side about 3*2.5 cm, the largest one on the left side about 1 *1 cm.• US axillae: Multiple bilateral axillary LNs the largest one on the RT side about 1.6*0.8 cm

most of them show loss of the central hilum mostly pathological LNs • Echo: FS 36 with MR grade1 • PFT : Free Pathology report• Suggestive of Hodgkin lymphoma, nodular lymphocytic predominant type with tumor cells

positive for CD20• BMB Free

histolopathological appearance of nodular lymphocytic predominant Hodgkin lymphoma with characteristic popcorn cells adopted from www.webpathology.com

ManagementFinal Diagnosis: Hodgkin lymphoma, nodular lymphocytic predominant type stage 2B,

non bulky disease

Treatment plan:• 4 courses of ABVD /COEP then IFRTH 25 gy/17 settings on neck and axillae

Evaluation after 2 courses:• CT neck : multiple enlarged cervical LNs the largest one about 1cm • Axillae US: RT LN with eccenteric hilum largest 1cmEvaluation after another 2 courses and IFRTH:• CT neck : multiple enlarged cervical LNs the largest one about 1cm.• Axillae US: RT LN with eccenteric hilum largest one about 1 cm.• Other imaging investigations, Echo, PFT, BMB were free

Prospective ApproachWhat is the current situation?

- Patient finished treatment on 11-2010

- Patient is in CR up till now and on follow up for 2,5 years now

What is the future plan ?

- Patient is under regular follow up in our outpatient clinic

Case 1QUESTIONS FOR DISCUSSION WITH FACULTY

1. As PET-CT is not available in my center, Can we finish treatment in the presence of residual enlarged LNs? IF so, What's the size of acceptable LN residual after chemotherapy and radiotherapy to finish chemotherapy on?

2. Taking into consideration the good prognosis of HL in general. In this case can we use only ABVD instead of alternating ABVD/ COEP to avoid the late effect of cyclophosphamide on fertility& puberty especially the female child is 8 years old (pre pubertal)? Does this will affect overall survival?

3. What’s the rule of PET-CT in the management of HL in such a case ?

THANK YOU