Hodgkinlymfoom (HL)
Inhoudsopgave
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1 onderzoek
- PET-CT, tenzij zekerheid hoog-stadium liefst in stralingshouding via radiotherapie
- bij vroeg-stadium Hodgkinlymfoom consult radiotherapie voor start chemotherapie
- geen beenmergonderzoek
2 therapie
- ook bij vroeg stadium vruchtbare vrouw verwijzen naar de fertiliteitpoli
2.1 therapie eerste lijn
- vroeg stadium
- stadium II-B en bulky: gevorderd HL!
- na 2 kuren ABVD mag de bleomycine weggelaten worden indien de ABVD gecontinueerd wordt
- in principe schema met radiotherapie
- interim-PET na 2 kuren ABVD: indien D4+ ipv 2x AVD over op 2x escBEACOPP
- EORTC/GHSG favourable: 2x ABVD + 20 Gy INRT
- GHSG unfavourable
- EORTC favourable: 3x A(B)VD + 20 Gy INRT
- EORTC unfavourable: 4x A(B)VD + 30 Gy INRT
- infradiafragmaal is geen reden om af te wijken van protocol1
- zonder radiotherapie (indien <35 jaar en mammae in veld: mediastinaal en bilateraal axillair):
- non-bulky: 4x A(B)VD
- bulky: 6x A(B)VD
- therapie gering inferieur
- proefplanning te overwegen (bij bv. bulky mediastinal, mediastinaal en 1 klier in oksel, proximaal in hals)
- daarna eindevaluatie als bij gevorderd RT op residual disease
- 60-70 en fit: als <60 maar zonder escBEACOPP
- >70 (of >60 en niet fit): 3x CHOP-21 + IN-RT
- gevorderd
- geen escBEACOPP: >60
- argumenten voor escBEACOPP: stadium IV, hoge tumorload (tumor >7 cm), IPS >1, voorkeur patient
- argumenten voor ABVD: fertiliteit, PS >2 boven 40 of co-morbiditeit
- begin met ABVD
- 2x ABVD
- PET-CT
- D1-3: nog 4x AVD
- D4-5: 4x escBEACOPP
- begin met escBEACOPP
- 2x escBEACOPP
- PET-CT
- D1-3: 2x escBEACOPP
- D4-5: 4x escBEACOPP
- >70 (of >60 en niet fit): 6x CHOP-21
- interimevaluatie
- planning-PET
- geen PET noodzakelijk bij negatieve interim-PET-CT
- minimaal 2 weken na laatste chemotherapie
- eindevaluatie
- na chemoradiotherapie
- na 3 maanden
- niet nodig bij beperkt stadium en negatieve interim/plannings-PET-CT
- na behandelplan zonder radiotherapie
- na 4-6 weken
- indien nieuwe lesies of groei na eerdere afname, en <65 tot 70
- PA-bevestiging: tweedelijns therapie
- geen PA-bevestiging mogelijk: na 2 maanden PET-CT herhalen
- indien "nog resterende FDG-avide afwijkingen" >1,5 cm: aanvullende RT, 36 Gy op FDG-avide afwijkingen
- PET-CT in bestralingspositie bij grote kans op noodzaak aanvullende radiotherapie
- na chemoradiotherapie
2.2 recidief
- <65-70: DHAP / VIM / DHAP / BEAM met curatieve intentie
- bij PR: 50% curatiekans
- indien mogelijk RT
- ook monotherapie radiotherapie kan curatief zijn, met name bij vroeg stadium ziekte
- CD30-positief: brentuximab
- na AuSCT of 2 eerdere therapieen
- indien niet fit genoeg voor AuSCT eerst chemotherapie
- na brentuximab: nivolumab (AMC)
- chemotherapische opties
- 3x DHAP / VIM
- IGEV
- ChlVVP
3 prognose
3.1 getallen
3.1.1 vroeg stadium
- HD14 OS-5jr 4x ABVD 97% (en HD10 94%)
3.1.2 gevorderd
- IPS - Hasenclever: curve
- Serum albumin <4 g/dL
- Hemoglobin <10.5 g/dL
- Male gender
- Age >45 years
- Stage IV disease
- White blood cell count ≥15,000/microL
- Absolute lymphocyte count <600/microL and/or <8 percent of the total white blood cell count
3.2 timing recidief
- tot 20 jaar na initiele diagnose (Brockelmann, JCO, 2017: curve)
3.3 GHSG-risicofactoren
- indien 1 aanwezig: intermediate stage (indien geen aanwezig early stage)
- Large mediastinal mass, size at least one third of the maximum thorax diameter
- Extra-nodal disease
- Involvement of three or more nodal areas
- Elevated erythrocyte sedimentation rate
- > 50 mm/h for stages IA, IIA and
- > 30 mm/h for stages IB,IIB
3.3.1 Nodal area's
- Area A: right cervical + right infra-/supra-clavicular/nuchal lymph nodes
- Area B: left cervical + right infra-/supra-clavicular/nuchal lymph nodes
- Area C: right/left hilar + mediastinal lymph nodes
- Area D: right axillary lymph nodes
- Area E: left axillary lymph nodes
- Area F: lymph nodes of the upper abdomen (spleen hilum, liver hilum, coeliacal)
- Area G: lymph nodes of the lower abdomen (spleen hilum, liver hilum, coeliacal)
- Area H: right iliac lymph nodes
- Area I: left iliac lymph nodes
- Area K: right inguinal + femoral lymph nodes
- Area L: left inguinal + femoral lymph nodes
3.4 EORTC-risicofactoren
- indien alle aanwezig favorable, anders unfavorable
- age 50 or under
- without large mediastinal adenopathy (>=0,35 MT ratio: op Th5 ratio tumor/thorax diameter op staande X-thorax)
- with an ESR of less than 50/h with no B symptoms
- with an ESR of less than 30 mm/h in those who have B symptoms
- disease limited to three or fewer regions of involvement
3.4.1 Klierregio's
3.5 Ann-Arbor2
- Stage I: single lymph node region (e.g. cervical, axillary, inguinal, mediastinal) or lymphoid structure as spleen, thymus and Waldeyer's ring.
- Stage II: two or more lymph node regions or Iymph node structures on the same side of the diaphragm. Hilar nodes should be considered to be "lateralized" and when involved on both sides, constitute stage II disease. The number of anatomical regions involved should be indicated by a subscript (e.g. II3). For the purpose of defining the number of anatomical regions, all nodal disease within the mediastinum is considered to be a single Iymph node region. Hilar involvement constitutes an additional site of involvement.
- Stage III: lymphoid structures on both sides of the diaphragm. This may be subdivided stage III1 or III2, stage III1 being described for patients with spleen or splenic, hilar, coeliac or portal node involvement and stage III2 for those with paraaortic, iliac or mesenteric node involvement.
- Supradiaphragmatic disease with splenomegaly also.
- Stage IV: extensive extranodal disease will be designated stage IV.
- Example: Asymptomatic clinically staged patient with bilateral neck and axillary nodes, bulky mediastinum, enlarged left hilar node and extension into chest wall: CSII6XEA.
3.5.1 "B" symptomen
- (a) Unexplained weight loss of more than 10% of the body weight during the 6 months before initial staging investigation
- (b) Unexplained, persistent, or recurrent fever with temperatures above 38°C during the previous month
- (c) Recurrent drenching night sweats during the previous months
3.5.2 Bulky disease (X)
- largest dimension (cm) of the largest node or conglomerate node mass in each region of involvement 10 cm or greater: "bulky".
- mediastinal mass: "bulky" on PA chest radiograph when maximum width is equal or greater than one-third of the internal transverse diameter of the thorax at the T5-T6 level maximal inspiration in the upright position at a source-skin distance of 2 m.
3.5.3 Extranodaal (E)
- Involvement of extra Iymphatic tissue on one side of the diaphragm by limited direct extension from an adjacent nodal site will be classified as extranodal extension (E) with the implicit expectation of a prognosis equivalent to that for treatment of nodal disease of the same anatomical extent. The E category may also include an apparently discrete single extranodal deposit consistent with extension from a regionally involved node. Multiple extranodal deposits will not be included: stage IV. A single extralymphatic site as the only site of disease should be classified as IE.
3.5.4 Spleen (S)
4 voetnoten
Voetnoten:
1
- prognose slechter door associatie met slechtere prognostische factoren
- maar geen reden om van radiotherapie af te zien
- https://www.sciencedirect.com/science/article/pii/S0167814003000549?via=ihub
- Iannitto, Haematologica, 1997
2
- Carbone PP, Kaplan HS, Musshoff K, et al. Report of the committee on Hodgkin's disease staging classification. Cancer. Res. 31:1860-1861, 1971.
- Lister TA, Crowther D, Sutcliffe SB, et al. Staging for Hodgkin's disease. Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin's disease: Cotswolds meeting. J. Clin. Oncol. 7:1630-1636, 1989 (Erratum J. Clin. Oncol. 8:1602, 1990).