Hodgkin lymphoma: Late effects of treatment and guidelines for surveillance
Introduction
After the introduction of modern radiotherapy (RT) and combination chemotherapy (CT) in the 1960s, Hodgkin lymphoma (HL) has become the prototype of a curable malignancy [1]. However, over the past decades it has been clearly demonstrated that both RT and CT can increase the risk of second malignant neoplasms (SMNs), cardiovascular disease (CVD), and other treatment complications [1], [2], [3], [4]. Excess mortality from SMNs and CVD has been demonstrated to substantially reduce the life expectancy of HL survivors [5], [6].
Section snippets
Risk of second malignancy
Increased risks of solid tumors in irradiated HL patients and of leukemia in CT-treated patients have been reported consistently in the literature [4], [7]. In a recent study that included HL patients treated from 1965 to 2000 [8], the excess risk of second malignancy remains significantly increased beyond 35 years after HL treatment (Fig. 1), with a 40-year cumulative incidence of second cancer estimated at 43.6% (Fig. 2). The largest standardized incidence ratios (SIRs) are observed for
Risk of cardiovascular disease
Both RT involving the heart and anthracycline-containing CT can increase the risk of CVD in HL survivors. Radiation-induced CVD includes coronary heart disease (CHD), valvular heart disease (VHD), myocardial dysfunction, electrical conduction abnormalities, and pericardial disease [2], [24]. Anthracyclines can, depending on the cumulative dose, lead to both acute cardiomyopathy and chronic cardiac complications (especially HF) [25], [26], [27]. RT- and anthracycline-associated cardiac damage
Pulmonary dysfunction
Both mediastinal RT and bleomycin are associated with acute lung toxicity, but can also lead to persistently reduced pulmonary function and long-term pulmonary fibrosis. Several studies have documented decline in pulmonary function in HL patient after adriamycin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy and mediastinal irradiation, with persistently reduced function up to 3 years post-treatment. In a study on HL survivors beyond 5 years after treatment [46], almost 30% of the
Current guidelines for surveillance
Several organizations offer surveillance guidelines for HL survivors, with special attention to key late effects such as second malignancy and cardiovascular disease. The National Comprehensive Cancer Network (NCCN) provides guidelines for monitoring for late effects specifically for HL survivors 5 years after initial treatment, including types of testing and their timing [70]. The long-term follow-guidelines from Children’s Oncology Group (COG) present detailed recommendation according to
Conclusions and future directions
Decades of successful HL therapy has allowed the elucidation of an array of long-term complications among the survivors. The study of late effects is critical as it guides patient counseling and development of follow up strategies for survivors, and motivates development of new treatments aimed to mitigate the side effects. However, late effects of treatment and the surveillance guidelines are moving targets. As new agents and novel techniques are introduced for HL, additional time is needed
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2020, Clinical Lymphoma, Myeloma and LeukemiaCitation Excerpt :In recent decades, owing to the improvements in diagnostic techniques, advances in molecular biology, and in the development of therapeutic options, the survival of these patients has significantly increased.10,11 This has led to the need to monitor the occurrence of late complications, such as the appearance of second tumors or cardiovascular events, dramatically affecting the morbidity and mortality of these patients.2-5 We performed a retrospective analysis of 96 patients with HL diagnosed between 2005 and 2008.
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2019, Physica MedicaCitation Excerpt :Radiation therapy (RT) has a key role in the management of HL patients [3,4]. However, the use of RT has been associated with late effects, including the development of secondary malignancies [5–7]. HL patients present statically significant increased risk of developing second cancer for at least 40 yrs after irradiation [8].