Hodgkin lymphoma in specific subgroups of patients

Haema 2012; 3(3):321-327

by Katerina Pyrovolaki, Maria Psillaki, Helen A. Papadakis

Hematology Clinic, University Hospital of Heraklion, University School of Medicine Crete, Creece

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Hodgkin lymphoma sometimes presents coincident with certain other major conditions, including pregnancy, infection with human immunodeficiency virus (HIV) or older age, which complicate treatment and make management considerably more challenging. Between 0.5% and 1.0% of cases of Hodgkin lymphoma present coincident with pregnancy. Treatment should mimic that of nonpregnant patients as much as possible, taking into consideration the gestational age at presentation, the clinical stage of disease, and the preference of the patient. Whenever possible, treatment should be deferred at least until the second trimester, after the completion of organogenesis, as chemotherapy in the first trimester can induce a spontaneous abortion or significantly increase the risk of congenital abnormalities. Some patients may be candidates for deferred therapy after the first trimester. However, disease that seriously threatens the immediate well-being of the mother (eg, acute airway obstruction, spinal cord compression) requires emergent treatment at any time. In general, the majority of pregnant women diagnosed with Hodgkin lymphoma have good pregnancy outcomes and their prognosis does not differ significantly from nonpregnant women. The availability of highly active antiretroviral therapy (HAART) has led to improvements in immune status among HIV-infected persons, reducing AIDS-related morbidity and prolonging survival. However, despite the impact of HAART on HIV-related mortality, malignancies remain an important cause of death in the current era. Hodgkin lymphoma in the HIV-positive population is characterized by frequent B symptoms (ie, fever, weight loss, night sweats), extranodal disease, and involvement of unusual locations. The most common sites of extranodal involvement are the gastrointestinal (GI) tract, bone marrow, liver, lung, and central nervous system. The treatment of systemic Hodgkin lymphoma in the setting of HIV is complicated by the patient’s immunocompromised state and also requires specific treatment for the HIV. Supportive care should also include prophylaxis for Pneumocystis jiroveci pneumonia and antibiotic prophylaxis for enteric organisms. Given the high incidence of recurrent Herpes simplex, Herpes zoster, and Candida infections in this population, many clinicians also advise instituting antiviral and antifungal prophylaxis. Older Hodgkin lymphoma patients defined by chronological age represent a heterogeneous population in terms of life expectancy, comorbidities, and functional status. Older patients have lower remission rates, but relapse-free survival is less impaired. No standard treatment recommendations exist. In older fit patients less than 65–70 years – go for ‘young’ treatment. The thoroughly estimation of the individual patient’s frailness/comorbidities is mandatory in order to properly adjust treatment, thus saving patients from over/under treatment. Representativeness of large clinical trials including evaluation of functional status and comorbidity remains crucial.