Observation after Surgery for Stage IA Nodular Lymphocyte-Predominant Hodgkin Lymphoma

Abstract

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) frequently presents with limited stage IA disease and has a relatively indolent course. Although definitive radiation therapy (RT) is the standard treatment in this setting, national guidelines suggest that observation may be appropriate for stage IA patients with a completely excised solitary lymph node. As this is a rare histology (∼5% of Hodgkin lymphoma cases), there are few prospective studies characterizing present-day clinical management. We hypothesized that RT is being omitted frequently, particularly in younger patients to limit long-term toxicity and risk of secondary malignancy. We used the National Cancer Data Base (NCDB) to interrogate patterns of care for stage IA NLPHL. In particular, we sought to evaluate how often RT is omitted and if there are factors that can predict for patients that receive surgery followed by observation. The NCDB was queried for patients with stage IA NLPHL who received surgery followed by observation or RT. Multiple logistic regression was used to identify factors that were significantly associated with receipt of surgery followed by observation. Variables examined included facility type, age, sex, race, insurance status, distance to treatment facility, Charlson-Deyo comorbidity scores, median household income and year of diagnosis. 441 patients treated from 2004 – 2013 were identified with a median follow-up of 50.4 months. Median age was 40 years old (range, 4-86 years). 40% (175/441) did not receive RT after surgery with a median age of 35 (range, 4-86 years). 68% (54/80) of pediatric patients (<21 years) did not receive RT after surgery. Observation after surgery in age groups 21-40, 41-60, and >60 years was 37% (53/144), 27% (40/149) and 41% (28/68), respectively. Median time from diagnosis to receipt of RT was 2.3 months. Under multiple logistic regression, receipt of RT was significantly associated with increasing age (ρ = 0.011, odds ratio 1.030, 95% CI: 1.007 – 1.053) and lower income (median household income < $38,000/year) (ρ = 0.012, odds ratio 2.454, 95% CI 1.222- 4.927). Patients with Medicare (ρ = 0.007, odds ratio: 0.155, 95% CI 0.040 – 0.598) and a higher Charlson-Deyo comorbidity index of 1 (ρ = 0.049, odds ratio: 0.510, 95% CI 0.261 – 0.998) were more likely to be observed following surgery. Facility type, sex, race, distance to treatment facility and year of diagnosis were not significantly associated with receipt of RT or observation. In this analysis, a large percentage of stage IA NLPHL patients (including more than 2/3 of pediatric patients) were observed following surgery. Increasing age was significantly associated with receipt of RT after surgery. Our results suggest that omission of RT (“watch and wait”) is occurring frequently in contemporary clinical practice, especially for younger patients, and may be a reasonable consideration in select patients with stage IA NLPHL.