Dear OncoLink "Ask the Experts,"
We want know your opinion about a Hodgkin's Disease (HD) case. L.G., female, age 28, European, Medical Doctor (Surgeon). In December 1995 she was given a diagnosis of HD scleronodular type (SN 1) by cervical lymph node biopsy. The staging demonstred mediastinal and retroperitoneal nodes involvment. Liver and spleen were free of disease. The disease was classified stage III B. The patient underwent chemotherapy with MOPP plus ABV (Vancouver hybrid program):
mecloretamina 6 mg/mq
procarbazina 100 mg/mq for 7 days
prednisone 40 mg/mq for 14 days
doxorubicina 35 mg/mq
vinblastina 6 mg/mq
-for 6 + 2 cycles.
After the 4th cycle, total remission of the disease was obtained (late remission?). The re-staging of the disease on November 1996 (CT scan total-body) demonstred a retrosternal residual that was considered as fibrotic outcome (about 20 mm diameter). A second CT scan on February 1997 demonstrated a little increase of retrosternal image that seems to be about 25 to 30 mm in diameter, at the moment. A Scintiscanning with Gallium 67 citrate demonstrated a pathological radioactive capture of radiogallium in the restrosternal area.
The first problem is: the lesion is a residual of HD? or is a fibrotic involvment? Which of these different therapeutic approaches are the most indicated: 1)intensification of chemotherapy with bone marrow transplant? 2)Mediastinic area RT? 3)Surgical biopsy (thoracoscopy, mediastinoscopy biopsy)?
Ken Blank, MD, and John Han-Chih Chang, MD, OncoLink Editorial Assistants, respond:
Thank you for your question.
Gallium scans and CT scans can be nonspecific. Residual abnormalities on these studies following therapy of HD may represent residual cancer, inflammatory/infectious etiology, or fibrosis. Distinguishing cancer from the other entities is a fairly common therapeutic dilemma and, unfortunately, short of a biopsy there is no sure method to resolve this conundrum. Each such case must be handled individually. However, in general, management options include re-biopsy, observation, or treating empirically by giving more chemotherapy or radiation and then re-scanning (gallium or CT) for a response. Please see further information at:
OncoLink's Hodgkins Disease section
For a case on gallium studies and Hodgkins see:
A case history from Washington University Medical Center