Long Term Follow-Up Results for Patients with Hodgkin Lymphoma after First Remission of Longer Than Ten Years: A Population Based Study of 954 Patients from the British Columbia Cancer Agency.
Authors: Ramadan Khaled M. , Connors Joseph M. 
Published: October 2019

Background Little information is available regarding the long-term follow-up results in patients with Hodgkin lymphoma (HL) after a first remission for 10 years or longer. The aim of this study is to evaluate the risk of disease relapse, secondary malignancy and causes of mortality in this cohort of patients.

Results 954 patients with HL were identified by searching the BC Lymphoid Cancer Database for all patients diagnosed between 1960 and 1995 who had maintained a first remission of greater than 10 y. Median age at diagnosis was 27 y (range 3–73 y) with 83% of patients less than 44 y. Male:female ratio was 1.2:1. The clinicopathological characteristics of the whole cohort are summarized in table 1. The 20- and 30-year OS for the whole cohort were 84% and 64%, respectively. The 20- and 30-year DSS for the whole group were 99% and 98%, respectively. Significant risk factors for lower OS were male gender (20-year OS for males 81%, females 87%, p=0.03), age >44 at diagnosis (20-year OS for age >44 was 51%, <44 was 93%, p<.00001) and mixed cellularity (MC) (20-year OS 81%) compared with nodular sclerosing (NS) (20-year OS 90%), p=0.007. Those factors (sex, age and histological subtype) had no significant impact on the 20-year DSS or PFS. Disease stage and B symptoms had no impact on survival (OS, DSS and PFS). There is no significant difference in the 20- and 30-year OS, DSS or PFS between patients initially treated with radiotherapy alone, chemotherapy alone or a combination of both.

Only 24 patients (2.5% of the whole group) had a HL relapse. Six patients had been treated with radiotherapy only, one with radio-chemotherapy and 17 with chemotherapy only. Twelve of these patients have died due to various causes (HL: 7, cardiac disease: 4, lung cancer: 1). There were no risk factors predictive for late relapse (age, stage, histologic type, initial treatment).

Secondary cancer was observed in 169 patients (17%) with a median age at cancer diagnosis of 52 years. Extended field radiotherapy (n=108, 64%) and MOPP-like chemotherapy (n=72, 43%) were the most prevalent 2 factors in this group. Breast cancer was the most common malignancy (n=31, median age at diagnosis 47 years), followed by lung (n=25), gastrointestinal (n=21), gynecological (n=20), genitourinary (n=16), hematopoietic (n=15), and thyroid (n=6).

In total, 165 patients (17% of the whole group) died after remission of more than 10 y of whom 113 (13% of the whole group) died due to potential complications of primary treatment. The two most common causes of death were secondary malignancies (n=79) and heart diseases (n=34). Only seven patients (0.7%) died due to HL relapse.

Conclusion HL relapse is a rare event (< 3%) and death from HL very rare (< 1%) in those who remain in first remission for more than 10 y. Treatment related complications, such as secondary malignancy or ischemic heart disease, are the major causes of mortality.

Summary of clinicopathological parameters of patients with HL in first remission for longer than 10 y Parameter Number (954)(%) *Limited: stage I/II, non-bulky (<10 cm in diameter) and no B symptoms. Histology Classical HL 858(90) Nodular sclerosing 610(65) Mixed cellularity 193(20) Lymphocyte-rich/depleted 42/13(4/1) Nodular lym. pred. 11(1) HL not specified 85(9) Stage:Limited*/advanced 445/509(47/53) B symptoms 239(25) Treatment Radiotherapy alone 357(37) Chemotherapy alone 258(27) Combination 337(35)