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Active surveillance shows benefit for rare Hodgkin lymphoma subtype
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ATLANTA — Active surveillance appeared to be a feasible strategy for the management of nodular lymphocyte-predominant Hodgkin lymphoma, according to results of a retrospective study presented at the ASH Annual Meeting and Exposition.
“Because this is a very rare subtype and a rare disease, there haven’t been any large randomized controlled studies, and treatment is somewhat controversial,” Sven Borchmann, MD, of the German Hodgkin Study Group and department of internal medicine at University of Cologne in Germany, said during his presentation. “Depending on how you see this disease and in what sort of box you want to put it, you will arrive at a different treatment.
“We know treatment outcomes are excellent and very few patients actually die of this disease, so that led us to ask the question: What is the outcome of patients who are actively monitored and underwent surveillance as a first-time approach?” Borchmann added.
Borchmann and colleagues evaluated 163 consecutive patients aged 16 years and older diagnosed with nodular lymphocyte-predominant Hodgkin lymphoma and followed at Memorial Sloan Kettering Cancer Center between 1974 and 2016.
Researchers compared patient outcomes between those who underwent active surveillance and those who received active treatment with radiotherapy alone, chemotherapy with or without rituximab (Rituxan; Genentech, Biogen), a combined modality with or without rituximab, or rituximab monotherapy.
Researchers defined PFS as biopsy-proven disease progression or relapse, clinician’s choice to initiate further treatment or patient death. Second PFS included time to second biopsy-proven disease progression or relapse, initiation of third-line treatment or death.
“We considered active surveillance actually as a first-line treatment approach, meaning if a patient had a PFS event in the active surveillance group, they then went on to receive their first active-agent treatment, and not if a patient, for example, had been treated with radiotherapy as first-line treatment, experienced a PFS event and went on to a second active treatment,” Borchmann said.
Median follow-up was 5.7 years. Forty patients were followed for 10 years or longer.
Among all patients, 46% received radiotherapy, 22.7% received active surveillance, 15.9% received chemotherapy, 11.7% received combined modality treatment and 3.7% received rituximab monotherapy.
Researchers reported a 10-year PFS rate of 71.2% (95% CI, 59.3-80.1), second PFS rate of 92.5% (95% CI, 83.7-96.6) and OS rate of 96.6% (95% CI, 87.6-99.1).
Seven patients died. Researchers determined three of these deaths likely related to treatment.
Patients who received active treatment demonstrated higher 5-year PFS (87.2%; 95% CI, 79.2-92.2) than patients in the active surveillance group (76.5%; 95% CI, 55.7-88.5); however, researchers observed benefit largely in early-stage disease.
A combined modality of chemotherapy and rituximab (P = .038) and radiotherapy (P = .032) appeared superior to active surveillance for extended PFS, but not to chemotherapy alone.
After correcting for treatment, multivariate analysis showed bulky disease 5 cm or larger (HR = 3.1; 95% CI, 1.3-7.21) and extranodal disease (HR = 7.7; 95% CI, 2.1-28.5) were risk factors for shorter PFS.
Researchers observed 12 transformations to aggressive lymphoma after a median of 7 years (range, 0.4-15.6), which included 10 treated patients and two who underwent surveillance. The transformation rate was 0.99% per patient-year.
Researchers observed 12 secondary cancers after a median of 7.8 years (range, 1.1-24.8). Ten patients who underwent treatment developed a secondary cancer compared with two patients who underwent surveillance. The secondary cancer rate was 1.03% per 100 patient-years.
Active surveillance is an applicable management strategy for nodular lymphocyte-predominant Hodgkin lymphoma, due to the fact most patients on surveillance did not require treatment after multiple years of observation, according to Borchmann. Further, patients who did need treatment were managed with established treatments.
However, Borchmann noted the study was limited as a retrospective analysis and that the results need to be validated.
“It is important these data are validated and prudent now to prospectively evaluate patients [to determine] whether this treatment approach ... can be used in the future for patients more often,” Borchmann said. – by Melinda Stevens
Reference:
Borchmann S, et al. Abstract 654. Presented at: ASH Annual Meeting and Exposition; Dec. 9-12, 2017; Atlanta.
Disclosures: Borchmann reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.