A recurrence of Hodgkin’s lymphoma, known as a relapse, means the cancer has reappeared after a period of being undetectable. This is different from refractory disease, where the lymphoma did not respond to the initial therapy. While facing the disease again is a challenge, there are established and effective treatments available for relapsed Hodgkin’s lymphoma. Understanding why relapses happen, how they are detected, and the available treatments can help in navigating the path ahead.
Causes and Risk Factors for Relapse
A relapse of Hodgkin’s lymphoma is linked to the biology of the cancer cells, not a patient’s actions. Some lymphoma cells may survive initial treatment, remaining in the body in undetectable numbers. Over time, these residual cells can multiply, leading to a relapse. The likelihood of this is influenced by several factors from the original diagnosis.
Several factors present at the initial diagnosis are associated with a higher risk of relapse:
- Advanced disease (Stage III or IV) at diagnosis.
- The presence of a large tumor, known as “bulky” disease.
- Systemic “B symptoms” like unexplained fever, night sweats, or significant weight loss.
- The patient’s age and overall health.
The timing of the relapse is a major factor. An early relapse, occurring within 12 months of completing treatment, suggests a more aggressive form of the disease. A late relapse, happening more than a year after treatment has finished, may indicate a different biological behavior. Most relapses of classical Hodgkin’s lymphoma happen within the first three years after the initial diagnosis.
Detecting a Recurrence
Detecting a relapse often begins with the patient noticing familiar signs, as many symptoms are the same as the initial illness. This can include the reappearance of painless swelling in lymph nodes in the neck, armpits, or groin. The return of systemic “B symptoms” like unexplained fevers, drenching night sweats, and weight loss are also common indicators, along with fatigue that does not improve with rest.
When a relapse is suspected, medical tests are performed to confirm the diagnosis. A Positron Emission Tomography (PET) scan, often combined with a CT scan (PET-CT), is used to identify metabolically active cells that indicate lymphoma. These scans help determine the location and extent of the recurrence. Blood tests, like a complete blood count (CBC), are also done to assess overall health.
The definitive step in diagnosing a relapse is a new biopsy. A small tissue sample is surgically removed from a suspicious area and examined by a pathologist to confirm the presence of Reed-Sternberg cells. This biopsy confirms the relapse and also ensures the cancer has not transformed into a different type of lymphoma.
Treatment for Relapsed Disease
The standard treatment for relapsed Hodgkin’s lymphoma often begins with “salvage chemotherapy.” This uses a different combination of drugs than the initial treatment, with common regimens including ICE or GDP. The goal of this second-line chemotherapy is to reduce the cancer in the body and achieve a second remission.
Following successful salvage chemotherapy, the next step is high-dose chemotherapy followed by an autologous stem cell transplant. In this procedure, the patient’s own stem cells are collected and stored. The patient then receives very high doses of chemotherapy to eliminate remaining lymphoma cells, after which the stored stem cells are infused back to restore the bone marrow. This approach is a standard of care that can lead to long-term remission for many patients.
Targeted therapy, such as brentuximab vedotin (Adcetris), is another treatment option. It is an antibody-drug conjugate that seeks out the CD30 protein on lymphoma cells and delivers a chemotherapy agent directly to them. This medication may be used after a transplant to reduce relapse risk or for patients who are not transplant candidates.
Immunotherapy, specifically checkpoint inhibitors like nivolumab (Opdivo) and pembrolizumab (Keytruda), has also changed treatment. These drugs help the body’s immune system recognize and attack cancer cells by blocking the PD-1 protein that cancer uses to hide. Checkpoint inhibitors are often used for patients whose lymphoma returns after a stem cell transplant or for those ineligible for one. In some cases, these agents are combined with chemotherapy before a transplant.
Prognosis and Life After Treatment
The outlook for relapsed Hodgkin’s lymphoma has improved, though it depends on several factors. The timing of the relapse is a primary element influencing prognosis, with late relapses having a more favorable outlook than early ones. The response to salvage chemotherapy is another indicator; achieving a complete response before a stem cell transplant is associated with better long-term outcomes.
While statistical averages, studies show that high-dose chemotherapy and autologous stem cell transplant can result in long-term, disease-free survival for about half of patients. For those who relapse after a transplant, newer agents like brentuximab vedotin and checkpoint inhibitors offer further options for controlling the disease.
Long-term follow-up care is an important part of maintaining health after treatment for a relapse. This continued monitoring helps manage any late effects from treatments like high-dose chemotherapy and radiation. Regular check-ups allow the healthcare team to watch for any signs of the cancer returning and to address any secondary health issues that may develop.