We investigated a recent (January 1999 to December 2009) cohort of 95 elderly Hodgkin lymphoma subjects. At diagnosis, median age was 67 years (range, 60-89 years), whereas 61% had significant comorbidity, 26% were unfit, 17% had a geriatric syndrome, and 13% had loss of activities of daily living. Overall response rate to therapy was 85%, whereas incidence of bleomycin lung toxicity was 32% (with associated mortality rate, 25%). With 66-month median follow-up, 2-year and 5-year overall survival were 73% and 58%, respectively (advanced-stage, 63% and 46%, respectively). Most International Prognostic Score factors were not prognostic on univariate analyses, whereas Cox multivariate regression identified 2 risk factors associated with inferior overall survival: (1) age more than 70 years (2.24; 95% CI, 1.16-4.33, P = .02) and (2) loss of activities of daily living (2.71; 95% CI, 1.07-6.84, P = .04). Furthermore, a novel survival model based on number of these risk factors (0, 1, or 2) showed differential 2-year OS of 83%, 70%, and 13%, respectively (P < .0001) and 5-year OS of 73%, 51%, and 0%, respectively (P < .0001).
"These figures are significantly inferior to those reported in the adult patient.3 However, HL survival for all age groups increased in the last two decades, even in the age subset over 60, where no major advances in treatment efficacy were recorded, indicating an overall improvement in patient care.1,3 "
[Show abstract][Hide abstract] ABSTRACT: Hodgkin Lymphoma HL can be cured in the large majority of younger patients, but prognosis for older patients, especially those with advanced-stage disease, has not improved substantially. The percentage of HL patients aged over 60 ranges between 15% and 35%. A minority of them is enrolled into clinical trials. HL in the elderly have some specificities: more frequent male sex, B-symptoms, advanced stage, sub diaphragmatic presentation, higher percentage of mixed cellularity, up to 50% of advanced cases associated to EBV. Very old age (>70) and comorbidities are factor of further worsening prognosis. Like in younger patients, ABVD is the most used protocol, but treatment outcome remains much inferior with more frequent, severe and sometimes specific toxicities. Few prospective studies with specific protocols are available. The main data have been published by the Italian Lymphoma Group with the VEPEMB schedule and the German Hodgkin Study Group with the PVAG regimen. Recently, the Scotland and Newcastle Lymphoma Study Group published the SHIELD program associating a prospective phase 2 trial with VEPEMB and a prospective registration of others patients. Patients over 60y with early-stage disease received three cycles plus radiotherapy and had 81% of 3-year overall survival (OS). Those with advanced-stage disease received six cycles, with 3-year OS of 66%. The role of geriatric and comorbidity assessment in the treatment's choice for HL in the elderly is a major challenge. The combination of loss of activities of daily living combined with the age stratification more or less 70y has been shown as a simple and effective survival model. Hopes come from promising new agents like brentuximab-vedotin (BV) a novel antibody-drug conjugate. The use of TEP to adapt the combination of chemotherapy and radiotherapy according to the metabolic response could also be way for prospective studies.
Mediterranean Journal of Hematology and Infectious Diseases 01/2014; 6(1):e2014050. DOI:10.4084/MJHID.2014.050
"Bleomycin leads to frequent incidence of pulmonary toxicity in the elderly. In a recent report, the incidence of bleomycin lung toxicity was 32% with a 25% mortality.14 Intensified regimens as the BEACOPP-dose escalated regimen are not recommended for patients with advanced-stage HL over 60 years.15 "
[Show abstract][Hide abstract] ABSTRACT: Hodgkin lymphoma (HL) is among the neoplastic diseases that has the best long-term outcome after cytotoxic treatment. Cure rates approach 80-90%; however, 15-20% of patients will be resistant to therapy (primary refractory) or relapse after treatment. Prognostic factors should help to stratify treatment according to the risk profile and identify patients at risk for failure. Significance of prognostic factors partly depends on the efficacy of the treatments administered, since new effective therapies can variably counterbalance the adverse effects of some unfavorable clinical determinants. As a consequence, some prognostic factors thought to be important in the past may become meaningless when modern successful therapies are used. Therefore, the value of prognostic factors has to be updated periodically, and then adapted to new emerging biomarkers. Besides the prognostic role of PET imaging, tissue and circulating biomarkers, as the number of tumor-infiltrating macrophages, cytokine and chemokine levels and profiling of circulating nucleic acids (DNA and microRNAs) have shown promise.
Mediterranean Journal of Hematology and Infectious Diseases 01/2014; 6(1):e2014053. DOI:10.4084/MJHID.2014.053
[Show abstract][Hide abstract] ABSTRACT: In advanced Hodgkin’s disease, a new standard of therapy was defined by the results of the HD15 trial where 6 cycles of therapy according to the BEACOPPescalated regime translated into an impressive superior longterm survival compared to more intensive alternative approaches due to reduced toxicity and less secondary malignancies. Furthermore, PET guided allocation of consolidating radiotherapy to residual masses avoided unnecessary radiation in two-thirds of patients in the HD15 trial. Excessive radiotherapy was also proofed to be detrimental in early stage disease in the framework of the NCIC CTG/ECOG HD.6 trial. Rituximab was shown to be an effective, although not curative treatment in the early “Nodular lymphocyte predominant Hodgkin’s Lymphoma” (NLPHL) subtype in several series. The remaining challenge in Hodgkin’s disease is the optimisation of therapy in elderly patients, the only patient subgroup still underperforming. In aggressive lymphomas, no definite changes of therapeutic standards could be deduced from this year’s ASH meeting while multiple new therapeutics are still in phase I and II studies.
memo - Magazine of European Medical Oncology 09/2012; 5(3). DOI:10.1007/s12254-012-0028-x
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