Treatments stratified by risk for relapsed or refractory Hodgkin lymphoma

Some Hodgkin lymphoma patients either do not respond to treatment (refractory disease) or relapse soon afterwards. These patients can be treated with high-dose chemo-radiotherapy, followed by stem-cell surgery. This approach, however, only cures 40-50% of patients.

There are three major risk factors predicting poorer outcomes in these patients. These are: tumors located outside the lymphatic system; initial remission lasting less than one year; and the presence of weight loss, excessive sweating and fever.

When patients receive salvage therapy (a second course of chemotherapy before high-dose chemotherapy) with ICE (ifosfamide, carboplatin and etoposide), five-year event-free survival (EFS; time from treatment until an event such as disease progression) is 55%. These rates vary (76%, 35% and 8%) depending on the number of major risk factors the patients have. It is not clear whether adjusting salvage therapy based on the number of risk factors could improve outcomes.

This study examined whether patient survival improved if salvage therapy was adjusted to individual risk level.

This study examined 105 patients with relapsed- (55%) or refractory disease (45%). All patients received salvage chemotherapy with ICE (two cycles). The intensity of the therapy depended on the number of risk-factors (0-3) the patient had. All patients had functional imaging scans after the therapy. Scans were either positive ( showing cancer activity) or negative (showing no cancer activity). Patients were followed for an average of 7 years. 

18% of patients had 0 risk factors. 27% had 1 risk factor. 41% had 2 risk factors and 14% had 3 risk factors. There were no treatment-related deaths. 10.5% of patients failed salvage therapy. 

Four-year overall survival (time from treatment until death from any cause) was 72% and four-year EFS was 56%. 90% of patients were sensitive to the salvage chemotherapy. In these patients, 4-year overall survival was 79%, and 4-year EFS was 63%. There was no difference in rates between the risk groups.

Patients with negative scans after salvage therapy were 4.61-fold more likely to have a better 4-year EFS than patients with positive scans, regardless of risk level.  The 4-year EFS for negative scans was 77%. This was compared to 33% for positive scans.

The authors concluded that treating patients based on their number of risk factors improved outcomes. This study also concluded that those with cancer-free scans after risk-adapted salvage therapy had better survival outcomes than those with cancer activity after the therapy.

Larger studies are needed.