Striving for Consensus: The Application of Existing and Emerging Research Findings to the Practical Management of Hodgkin and Non-Hodgkin LymphomaCase presentation: A young woman with bulky mediastinal HL and a BRCA germline mutation
6:52 minutes.
TRANSCRIPTION:
DR FLOWERS: This is a rather challenging case of a woman that I saw actually just a week or 2 ago, who is a patient of one of my colleagues. She’s a young woman with nodular sclerosing Hodgkin lymphoma, with a bulky mediastinal mass. It was about 14 to 15 centimeters in her chest, also had disease in her abdomen and pelvis, but had no disease in her bone marrow, so had Stage III disease, but with a bulky mediastinal mass. DR LOVE: How old? DR FLOWERS: She is in her early thirties. Was started on ABVD therapy that went very well, tolerated therapy well, and now has completed 6 cycles of therapy and comes to see me with questions about what to do about the radiation. Of note, the physician who saw her initially took a good medical history and found out that her mother had breast cancer, which actually turned out to be a bilateral breast cancer with a third breast cancer recurring after she’d already had bilateral mastectomies. DR LOVE: So had she been BRCA tested? DR FLOWERS: And so she was BRCA tested and her mother was BRCA-positive. This patient with Hodgkin lymphoma also underwent BRCA testing, and she was BRCA-positive as well and now is coming to discuss what to do about — DR EVENS: You just made it easier. DR VOSE: Yes. DR FLOWERS: So I think the first questions are, what additional information would you want about the treatment of her Hodgkin lymphoma? And then secondly, what would you do in terms of discussing the role of radiation with her? DR LOVE: Let’s give this to Julie. DR VOSE: So at diagnosis, her IPS score was…? DR FLOWERS: I think it was relatively low. It was around 1 or 2. DR VOSE: One or 2. Okay. And her PET scan after treatment was completely negative? DR FLOWERS: So her PET scan after treatment now shows a 5-cm mass that is not FDG avid. She does have a new area of a nodule in her left upper lung field that is also not FDG avid. DR VOSE: Okay. In that type of patient, I would obviously discuss the pros and the cons of all those issues, but given her mother’s history of breast cancer and she’s BRCA-positive, PET scan’s negative, I would probably observe her but discuss the pros and the cons of that. DR LOVE: Has the topic of prophylactic mastectomies come up? I’m sure it must have. DR FLOWERS: It did last week. So she’s now going to a high-risk breast cancer clinic for a discussion and getting bilateral breast MRIs as well. DR LOVE: And so Julie, if she elects to have bilateral mastectomies, how would that affect the way you approach this? DR VOSE: I think that changes it a bit, and then you can a little bit more safely give the radiation. However, I have more recently been leaning toward trying not to do radiation, especially in young people, to try to decrease the risk of overall complications, cardiac/pulmonary complications. So I still might even consider that, even if she did have bilateral mastectomies, to consider not doing that. DR LOVE: So Andy, what are your thoughts about this case and, also, in general about this issue and the data that’s come out over the last year or 2 in that regard? DR EVENS: To me, if the BRCA was negative, that would have really been a hard decision. I mean, you look at NCCN guidelines. The most common recommendation would be for bulky mediastinum to consolidate with radiation. But if you really go back and look at that data, how did we get there to irradiate? I mean, obviously, it’s intuitive; it’s bulky, radiate. There is some PFS data, but there actually, if you dig deep into the data, has never been shown to be an overall survival advantage to radiation in Hodgkin’s to a bulky mediastinal mass. There’s PFS data. And so I think that’s one important backdrop point. Obviously, there are the concerns of second malignancies, arterial disease, albeit likely less in the current era with more refined IMRT and better radiation. But I would submit it’s still not zero. And it is individualized. And I practice similar to Julie, looking for ways and data not to give radiation. And there is data moving towards that end. British Columbia has looked back for PET-negative patients, much less bulky patients in their data. But those patients might do fine without radiation. And there’s other data looking at that. Although, still, in most of the European studies for bulk, there’s some form of radiation being given, whether 20 or 30 Gray. But there obviously is somewhat of a movement towards looking to avoid it, if possible, especially for young females. DR LOVE: So Mike, do you want to weigh in with your thoughts on this and how you approach this right now in your own practice? DR WILLIAMS: Right. So the approach at our place is basically to avoid radiation wherever possible. So in a patient who is PET-negative post-treatment, even if they had a bulky mass up front, we don’t radiate those patients. Points are well taken about what’s in NCCN guidelines, what’s been standard of care. But the data from British Columbia that you mentioned are very encouraging in that regard. DR LOVE: Andy? DR EVENS: What do you consider PET-negative/PET-positive? What cut points are you using? Because that is an issue. DR WILLIAMS: Right. DR EVENS: I mean, a lot of times a busy community oncologist doesn’t have time, like we probably do, to sit down and analyze every PET scan, whether alone or together with the nuclear medicine physician. DR WILLIAMS: Right. DR EVENS: And are they using the newer Deauville material? Or the older — a lot of times in most communities, it’s SUV. And sometimes that’s not always applicable. DR WILLIAMS: Right. So yes. The Deauville criteria are the ones that are, I think, probably the best to use at this point. And look, we put a lot on our PET scans, but when you try to do PETs in a clinical trial setting, they can be, as ECOG found out, they can be tough and the interpretation can be an issue. So I think these are cases where if they’re being evaluated in the community, I think — as a second opinion, a consultation at a center that does a lot of lymphoma work, where you can get the PETs reviewed carefully, I think that’s an important thing to offer patients, because it is tough in the community to make those decisions sometimes. |