This presentation covers the guidelines for follow up of patients with Hodgkin's lymphoma after they achieve complete remission and complete their therapy.

1. Follow up of Hodgkin’s
lymphoma after treatment
Prof. Ahmed Zeeneldin
Prof Medical Oncology
NCI, CU

2. HL
• High cure rates ≥ 80%
– 20% relapse
• Long-term complications
• Heart & Lungs
• Thyroid & Breast
• Fertility
• Other secondary malignancies

3. Follow-up After CR and end of TX
• Aims:
– Detect relapse  earlier treatment  ? Better
outcome
– Follow acute and chronic toxicities
• Myelospuression, Immunesupression
• Heart
• Lungs
• Thyroid
• Breast
• Fertility
• Other secondary malignancies

4. Characteristics of an ideal FU
• Patient
– Positive impact on patients
• Survival
• Quality of life
– Minimal bothering to patients
• Less invasive
• Acceptable cost
• Health care system
– Cost/effective
– Acceptable burden on care-givers

5. FU triad
• Regular
• Purposeful (to check for)
– Disease recurrence (local and metastasis),
– Complications of therapy (short- and long-term)
– Other malignancies and precancerous lesions,
• Individualized (frequency & procedures):
– Type of Cancer (and its stage)
– Treatment,
– Possible treatment related problems,
– Person’s overall health,

6. How frequent
• General rule
– Q 3-4 MONTHS in the first 2-3 YEARS
– Q 6-12 MONTHS after that
– Is there a stopping time?

7. 5-y Freedom from progression:
early stages
• 20% recurrence/progression
• 15% in the first 5 years
• 10% thereafter with plateau at year 8

8. 10-y Freedom from progression
advanced stages

9. Late therapy effects
• What:
– Secondary cancers,
– cardiovascular disease,
– hypothyroidism, and
– fertility issues
• When:
– increases with longer follow-up time
• Regimens
– Less with current treatment programs (ABVD, Stanford
V) compared to those used more than 10 years ago
(MOPP, COPP)

10. Risk of 2nd malignancies in HL
Thus, follow up should be long-term

11. Frequency in HL
• Q3-6 months in first 1-2 years
• Q6-12 months in next 3 years
• Q 12 months annually
Year1 Year2 Year3 Year4 Year5 Years≥6
3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12
X (X) X (X) X (X) X (X) X X X X X X X

12. Procedures
• Clinical: H&P
• Lab:
– Simple: CBC, biochemistry, serum markers
– Complex/invasive:
• Imaging
– Simple: CXR, US
– Complex: CT, MRI, PET/CT
• Special procedure
– Biopsies
– BMA
– Endoscopies

13. Procedures in HL
• Clinical (H& P) : every visit
• Lab:
– CBC and plateletes + ESR and LDH every visit
– Thyroid function tests: at least annulaly
• Imaging:
– Initially positive imaging
– CT chest and abdomen
– Breast mammo/MRI
• Vaccination:
– Influenza: annually
– Pneumococcal, meningococcal, and H-flu: in splenectomy
or splenic RT every 5 years

14. Role of PET (PET/CT)
• Recommended:
– Initial staging (before therapy)
– Interim assessment of response (during TX)
– at the end of TX to assess residual masses
• Controversial in post-therapy surveillance
– False positive

15. Frequency and procedures
in HL
• Q3-6 months in first 1-2 years
• Q6-12 months in next 3 years
• Q 12 months annually
Year 1 Year 2 Year 3 Year 4 Year 5 Years ≥ 6
3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12
H&P X (X) X (X) X (X) X (X) X X X X X X X
LAB X (X) X (X) X (X) X (X) X X X X X X X
Imag X X X X X X X X

16. Who
• Oncologist
– Surgical
– Medical/pediatric/hematologist
– Radiation
– Others
• Specialized clinics
• Primary care
• Patient

17. Who
Outcome Cost
Oncologist
Surgical
Medical/pediatric/hematologist
Radiation
Others
Best
++++
Highest
++++
Specialized clinics +++ +++
Primary care ++ ++
Patient Least
+
Least
+

18. Who in HL
• Oncologists:
– Medical
– Pediatric
– Radiation
– Due to the long-term risks of therapies (including
secondary cancers and cardiovascular diseases)
– Need for some one aware
– Especially in first 5 years then annually

19. Follow-up After CR and end of TX
• Aims:
– Detect relapse  earlier treatment  ? Better
outcome
– Follow acute and chronic toxicities
• Heart
• Lungs
• Thyroid
• Breast
• Fertility
• Other secondary malignancies

20. Follow-up After CR and end of TX
• Aims:
– Detect relapse  earlier treatment  ? Better
outcome [H&P, ESR, CT (PET?CT), biopsy]
– Follow acute and chronic toxicities
• Heart [H&P, BP, echo]
• Lungs [H&P, PFT, CT Chest]
• Thyroid [H&P, T3, T4, TSH, Neck US, thyroid scan]
• Breast [H&P, mammogram, US, MRI]
• Fertility [serum hormones, semen analysis, US ovaries]
• Other secondary malignancies: breast and lungd

21. Secondary Cancers
• Solid tumors are the most common especially breast and lung
• Mostly >10 years after the completion of treatment.
• Highest risk when RT is used as a component of first-line treatment.
– lower risk with combined modality treatment than with RT alone as
– marginally higher risk with combined modality treatment when
compared with chemotherapy alone.
– No significant differences in the risk with IFRT vs. EFRT,
• Risk of breast cancer was substantially higher for EFRT.
• Risks for secondary lung cancer, non-Hodgkin’s lymphoma (NHL),
and leukemia were significantly higher after treatment with
chemotherapy alone, whereas combined modality therapy was
associated with a higher risk for these and several other cancers.

22. Screening
• Breast cancer:
– High risk patients: women who received chest or
axillary irradiation
– Procedures
• Monthly self-breast examination
• Annual breast examination by a health care professional
• Annual breast screening [mammography ± MRI]
– MRI women who received irradiation to the chest between 10
and 30 years of age,
– When:
• Age of 40 or 8-10 years after therapy completion
(whichever first)

23. Screening
• Lung cancer
– High risk patients: chest irradiation or alkylating
agent chemotherapy, and those with a smoking
history
– Procedure: Chest imaging (low-dose spiral CT)
– Frequency: Q 6 months
– Stop after 5 years when there is no increased risk

24. Cardiovascular Disease
• Risk factors: Mediastinal irradiation and
anthracycline-based chemotherapy
• May develop years after therapy
• Procedures
– annual blood pressure monitoring (even in
asymptomatic individuals) and
– Echo 10 years after therapy w prior chest irradiation
– Carotid ultrasound (for patients treated with neck RT
– Aggressive management of cardiovascular risk factors
is recommended

25. Hypothyroidism
• 50% of long-term survivors who received neck
or upper mediastinal irradiation
• Procedure:
– Thyroid examination with every visit
– Thyroid function tests at least annualy

26. Pulmonary Toxicity
• Risk:
– Bleomycin-induced pulmonary toxicity (BPT)
• Other risk factors : older age, cumulative bleomycin
dose, pulmonary irradiation, and prior history of lung
disease, growth factors

27. Myelosuppression
• uncommon to continue for very long beyond
completion of the primary treatment program
• Mostly with HDT/SCT
• Increase risk for infections
• Pneumococcal, meningococcal, and H-flu
revaccination is recommended every 5 years
for patients treated with splenic RT or
splenectomy