Fever, Night Sweats, and Weight Loss

Peter W. Marks, MD

Yale University School of Medicine, New Haven, CT

Copyright of the American Society of Hematology, 2012. ISSN: 1931-6860.

VI. PROGNOSIS/CLINICAL COURSE

Along with pediatric acute lymphoid leukemia, Hodgkin disease was one of the first cancers to be effectively cured by modern therapy. Extended field radiotherapy was found to provide cure for patients with Stage I and II disease, particularly when there were no associated symptoms. Combination chemotherapy regimens were developed through clinical research, and eventually, one consisting of mechlorethamine (a nitrogen mustard), vincristine (Oncovin is a brand name), procarbazine and prednisone (MOPP) was used in combination with radiotherapy and associated with a high cure rate of more advanced disease. However, due to its high rate of associated side effects, including secondary leukemias, other less toxic approaches were developed.

Modern therapy for Hodgkin lymphoma involves radiotherapy or chemotherapy for early stage disease (usually IA or IIA) and chemotherapy for all other stages, either alone or with radiotherapy to the involved areas. Careful consideration is generally given to the use of radiotherapy in Hodgkin lymphoma because it is so responsive to chemotherapy and because radiation therapy is associated with long-term side effects, including therapy-related cancers such as breast cancer in a woman treated to the mediastinal region.

The most common combination chemotherapy regimen used in the United States includes doxorubicin (Adriamycin is a brand name), bleomycin, vinblastine and dacarbazine (ABVD). This is associated with an approximately 80% remission rate, even in advanced disease. However, there are significant toxicities. Cumulative doses of doxorubicin can be associated with cardiac toxicity, particularly when above a threshold. Bleomycin is associated with the development of pulmonary toxicity in some patients, and therefore, close patient monitoring of pulmonary function is required.

Other combination regimens exist and may be appropriate in high-risk patients. When patients relapse, they are generally treated with salvage chemotherapy regimens in order to achieve a second remission and then may proceed to autologous hematopoietic stem cell transplant.

In this patient’s case, a bone marrow aspirate and biopsy was performed as part of the staging evaluation. However, it should be noted that in current practice, it is often omitted from the evaluation, particularly in individuals with normal blood counts.

Following documentation of normal baseline cardiac and pulmonary function, this patient received treatment with two cycles of ABVD chemotherapy. PET-CT restaging scans after this showed no evidence of uptake in any of the lymph node regions, nor in the mediastinum. A small residual mass observed on the CT scan in the mediastinum was not felt to represent active disease, but rather to represent fibrotic scar tissue (this is not uncommonly observed in the treatment of Hodgkin disease with mediastinal involvement). After this, two more cycles of ABVD chemotherapy were administered, followed by radiation therapy to the region of the chest involved with the mediastinal mass. After completion of therapy, she was followed every three months and had repeat scanning performed at regular intervals for two years. Five years out, she is disease-free. The 5-year survival of the overall population of patients with Hodgkin lymphoma is now about 85%. Survival is even better than this today for patients with favorable prognostic features independent of the exact treatment regimen administered.


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